A significant proportion of those treated in childhood for ADHD will require on going treatment at 18yrs+ though this requirement tends to decline with increasing age.
Prescribing and management can be continued in primary care alone as the risks of disordered growth are no longer applicable. Continue the last CAMHS dosage.
Regular monitoring of BP is required.
Usual treatment is as follows (see BNF for dosage guidance):
1st line – methylphenidate (Concerta XL or Medikinet XL) CD – only Concerta is licensed for adult use
2nd line – atomoxetine – not a CD and is licensed for adult use
3rd line – dexamfetamine – rarely used, now extremely expensive and most abuse potential
Also - Lisdexamfetamine – new pro-drug of dexamfetamine (less potential for abuse), for treatment of children, may be licensed for adults soon.
On going need for treatment should be reviewed annually through assessing the response to treatment breaks or missed doses. There is no need to wean down medication to do this except with atomoxetine (reduce dose over 3weeks prior to stopping).
New Adult Diagnosis
NICE guidance recommends that new diagnoses in adulthood should be made in secondary care, medication initiated and stabilised before transferring back to primary care for on-going prescribing and monitoring.
The referral route is via the SAT form to PCP who will transfer the referral to the ABT Team. A psychiatrist will review the referral in ABT. If it appears complex, an assessment will be carried out in ABT. Otherwise, the referral will be passed to the specialist CNWL ADHD clinic. Unfortunately, there is often a wait of 6-9mths for assessment there and it requires IFR funding approval from the CCG (applications done by the ADHD clinic).
Online questionnaires are NOT a reliable diagnostic tool due to very poor specificity. Diagnosis also needs to take into account the patients mental state, childhood history, substance misuse and social factors.
Response to stimulant medication is also not indicative of the diagnosis as many patients with depressive or personality disorders feel better on stimulants.
1st line – methylphenidate (though it is not licensed for new diagnosis treatment in UK)
2nd line – psychological treatment (not available on NHS)