ADHD: dilemmas for doctors and patients

A 26-year-old woman recently immigrated to Ireland from the US attended her GP for the first time. The reason for attending was to request a repeat prescription for lisdexamfetamine for her pre-existing diagnosis of ADHD. She brought background documentation from her previous doctor, and also the relevant specialist, from the US. 

She had received her diagnosis eight months previously, based on two screening instruments, clinical interview and including collateral history. Her background included difficulty concentrating, with completing more tedious tasks, and difficulty in following conversations in company. She described herself as ‘always on the go, and having difficulty sitting still’. She described herself as having poor social skills, and challenging experiences throughout her education, where she advised she had always been characterised ‘as difficult.’ She recollected these circumstances broadly, and extending throughout her childhood. 

Following her diagnosis, she was commenced on lisdexamfetamine 40mg OD, which she associated with an immediate marked improvement in many of her symptoms, and in both her social and occupational experience. She found the medication easy to take, with no appreciable side-effects, including no palpitations, sweats, tummy upset or weight loss. In consultation, she was worried that she now only had 15 tablets remaining from her last prescription.

Past medical history was unremarkable. Family history was significant in that it included two relatives with a diagnosis of ADHD, including her own father and a paternal aunt. There was no previous personal or family history of significant anxiety, depression, eating disorder or substance misuse.

She recounted settling in well to her new routine in Ireland, describing good levels of social support, and good engagement with her new job.

The doctor’s dilemma

The GP advises her there are two options, including referral for evaluation through public psychiatry (very long delay), or referral for evaluation through private psychiatry (less delay, but substantial expense). Her GP advises her that they are currently constrained from prescribing lisdexamfetamine in the absence of guidance and direction from an Irish consultant psychiatrist.

Focused literature review

Recent systematic reviews indicate the prevalence of ADHD in the adult population range from 2.5-6.7%.^1,2,3 Of these, it has been estimated that fewer than one in five as yet have a formal diagnosis.^4,5 In the Republic of Ireland it is estimated that there are over 110,000 people with ADHD, of whom as few as less than 10% are receiving ongoing support or formal treatment.⁶ A recent study conducted on those attending adult mental health services in Sligo (n = 634), indicated as many as 16.7% were diagnosed with ADHD.⁷ This is in keeping with a recent systematic review examining ADHD prevalence among adult attendees at outpatient health clinics, indicating a prevalence of 14.6%.⁷

People with ADHD experience lower educational achievement than the general population,⁸ have a doubled lifetime risk of premature unnatural death,⁹ and as a sub-group in society, experience a higher lifetime prevalence of substance and alcohol misuse, ranging from 20-43%.¹⁰ They experience a relative 10-fold increased risk of incarceration and custodial sentencing, in comparison to the general population.¹¹ An estimated cost of ADHD-related morbidity to the Republic of Ireland was recently given as €1.8 billion per annum.⁶

In the Republic, costs of private psychiatric evaluation for a diagnosis and outline management plan among commercial clinics can involve out-of-pocket costs ranging from €900 to €1,650. This is a major barrier, particularly for an often economically marginalised sub-group of people. 

Critical appraisal of the current HSE Model of Care for ADHD indicates that there is no direct pathway identified for people who have been diagnosed outside the Irish health system, which is relevant to our case. 

Despite previous diagnosis, our patient here, and people in similar circumstances, require to either enter the very slow public referral route, currently defined as initial referral to adult mental health services, with a further wait for onward referral from there to a local ADHD clinic. This care ‘pathway’ is further contingent on living within a defined catchment area, which compounds the difficulties for people who may initially be resident in different and changing locations as they settle in Ireland. 

If the individual can complete either the expensive referral via private care, or the excessively delayed pathway via the public service, then their GP can, subject to explicit direction from psychiatry, support prescribing at the practice level.

How difficult is this?

Review of screening tools for the diagnosis of ADHD was included in our literature review. Two screening instruments are of particular relevance, including the Wender Utah Rating Scale (a patient self-administered scale, available in several versions)¹² and the Adult ADHD Self Report Scale.¹³ These are briefly compared in Table 2. Neither are difficult to administer and used together offer a good reliability in confirming diagnosis.¹⁴

The current care pathways available to our patient and their GP now appear overly restrictive and dysfunctional. Sifting through the relevant literature, it is evident that there is a view that supports the enabling of GPs and people attending with symptoms indicative of ADHD to take a more expedited and autonomous approach at the practice level. 

In the absence of clear evidence to support alternative mental health diagnoses (for example bipolar affective disorder, schizophrenia, severe underlying depression, or significant substance misuse), if a standardised screening tool together with a strongly indicative history point towards a diagnosis of ADHD, then arguably a trial of treatment could be undertaken on this basis, at the practice level. This would be with the proviso that treatment is withdrawn in the absence of a reasonable response to trial of therapy or in the presence of adverse reaction to prescribed medication. These steps could be undertaken even while the GP and patient await the formal response from secondary care mental health services.

The HSE has identified, communicated (and therefore tacitly recommended) UK-based training, enabling GPs to diagnose and prescribe in this common and important condition. The courses recommended by the HSE are those already endorsed by the UK Adult ADHD Network, and are costed for GPs at £660 for a two-day workshop, enabling those completing the course to both diagnose and provide bridging prescriptions for people with defined and uncomplicated presentations of ADHD. See www.ukaan.org/pharmacological-treatment-2024/

Naturally, given the extent to which this important condition is frequently seen in primary care, it is not surprising therefore that there are many studies which positively identify the training needs for GPs and GP teams,¹⁵ and this aspect of providing more timely care could usefully be pursued by professional bodies.

A compelling case to be made for task-shifting

ADHD is an epidemiologically important condition, with a growing prevalence, and clear and large costs associated where treatment is suboptimal. Costs are evident for the individual, their household, and social networks, as well as large societal costs, in terms of opportunity costs arising from loss of educational potential, excess rates of incarceration, and health system costs.

More positively, sustained advances in diagnosis and in treatment are clearly encouraging. Close consideration of our case would strongly support a greater role for GPs and GP teams in order to make a more timely diagnosis, support the diagnosis, and provide more accessible and timely community based care and treatment. A compelling case can be made for task shifting much care for this troublesome condition into GP-led primary care, with proper resourcing.

Key advantages to this approach include the prospect of marked improvement in outcomes, and in destigmatising this difficult condition, by having more routine care provided as part of community-based mainstream GP-led primary care, with a more selective input from specialist/secondary care psychiatry. 

All of this is in keeping with the Slaintecare policy framework in Ireland. Given the importance of this condition, we suggest that both the Irish College of GPs and The College of Psychiatry Ireland conduct a critical review of current care pathways, and develop new e-learning modules on ADHD, together with scoping out the possibility of synchronised online consultations between GPs, psychiatrists and advanced nurse practitioners for the management of complex cases. Concurrently, this strand of GP-led primary care will need to be costed and funded, so that it is sustainable at the general practice level. 

Authors: Nyka Riego, Madeline Haines and Jonathan Vaantaja are final-year medical students at TCD and Brendan O’Shea is in practice in Co Kildare and is assistant adjunct professor at the Department of Public Health and Primary Care, TCD

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