Why we should prioritise adult ADHD

14 October 2020

Authors: ADHD Subgroup, The Royal College of Psychiatrists in Scotland

“No one is always busy. It all depends on what number you are on their priority list”  lifehack.org

COVID-19 has disrupted the world and in particular the provision of healthcare. Mental health services in Scotland are now in remobilisation after an initial period of pause on non-urgent care. A “second wave” of mental health problems in the wake of the pandemic has been described. In addition a “digital first” response remains in place where feasible, representing a new way of working presenting opportunities to work differently in addition to challenges.

Before the pandemic it was established that ADHD in adults was under recognised and under treated. It is a common condition affecting 2.5 % of the adult population, with some partial genetic contributing factors. Core traits are normally distributed within the population. Services across Scotland are in variable and early stages of understanding how best to meet this need.

National ADHD Pathway

In January 2020 the Cabinet Secretary for Health and Sport, therefore, requested that a National ADHD pathway be developed through scoping current practice in Scotland. The Royal College of Psychiatrists in Scotland had formed an adult special interest group and worked with national services to review guidance (RCPsych in Scotland, 2017) and build an up to date National ADHD Adult Pathway. The team taking it forward will now complete a feasibility study to understand the implications of rolling out the pathway nationally. Regional meetings will now take place to review the pathway and understand implications for local services. Please contact MBoilson@qmu.ac.uk for more information. The Programme for Government reaffirms that commitment to introduce a national adult ADHD pathway.

Impact of the Pandemic

COVID-19 required an urgent focus on priorities across the country. Increased demand for mental health treatment as a consequence of the pandemic now requires optimal organisation and streamlining of resources to enable remobilisation.

ADHD untreated is associated with considerable increase in morbidity and mortality. It has recently been described as a “seriously impairing, often persistent neurobiological disorder of high prevalence” (Faraone et al 2015). Numerous studies have described an increase in injuries associated with this condition, injuries being a substantial cause of ADHD associated death (APSARD 2016). Obesity, one of other associated morbidities, has clear medical consequences and now is of even greater significance with an increased risk of adverse outcome with COVID-19 infection in this context.

Further COVID-19 related risks have been described as a consequence of disorganisation and disinhibition, for example making the ability to consistently adhere to social distancing and implement Personal Protective Equipment (PPE) guidance, considerably more challenging, (European ADHD guideline group, April 20).

Anxiety disorders are present in 50% of adults with ADHD. Anxiety is now inherent to living in the times of a pandemic and in part helps us prepare to respond in a more adaptive and healthy way to threats in our environment. For those with pre-existing anxiety disorders this anxiety can become overwhelming preventing adaptive measures.

The loss of external scaffolding provided by schools, institutes of higher education and office working poses even greater challenges for patients with ADHD. The most recent NICE guideline (NICE, 2018) has an increased focus on environmental modification as a first approach. Reasonable adjustments that had been put in place and structures supporting their implementation will have been disrupted with lockdown. Increased home working, whilst providing some with opportunities, places more responsibilities on the individual to structure their day.

ADHD is a treatable condition with good treatment responses and has some of the best pharmacotherapy effect sizes for treatment of psychiatric disorders.

Access to Services

The Scottish government is committed to ensuring that people in Scotland have access to services, and that services are joined up (Mental Health Strategy 2017-2027). Increased demands on resources means that there is now an even more compelling need for a stepped, coordinated multidisciplinary approach to delivery of assessment, diagnosis and treatment of adult ADHD. There are potential significant roles for the use of tools that support information gathering ahead of appointments and opportunities for wider involvement of the range of disciplines found within community mental health teams. The development of pathways can ensure duplication is excluded and consistent standards adhered to.

A digital first approach presents opportunities as outlined in a recent review of Attend Anywhere/ Near me video consulting service evaluation 2019-2020 (Scottish Government, Jul 2020). Scheduling of appointments can at times be easier to coordinate, patients report feeling more relaxed in their “natural “ environments as opposed to clinical ones, with no need for travel required. The collateral history, a core component of gathering contextual evidence in an ADHD assessment, in particular can be easier to obtain. The National Autism Implementation Team have collated guidance on providing patient contact remotely.

Assessment and Treatment

The European ADHD guidelines group flagged in particular that a digital first response should not prevent assessment and treatment of adult ADHD rather a careful evaluation of risks and benefits needs to be undertaken (European ADHD guidelines group, June 2020). Physical health assessment, a necessary component prior to initiation of medication, can be completed in a shorter specific appointment by a member of the MDT, reducing the face to face time required, important from a resource perspective in addition to being a component of infection control.

Adult ADHD is a serious mental health condition that left untreated causes significant impairment in many domains of an individual’s life, increases the likelihood of additional co-morbid mental health conditions, is associated with an increase in physical health morbidity and in adults increased mortality. It has significant economic, social and relational adverse impacts. Treatment is effective. It needs to be a priority area for services to attend to.