This study was funded by Shire, now part of Takeda
In Canada, ADHD guidelines recommend that family physicians diagnose and manage uncomplicated ADHD in adults, with referral to a specialist recommended only for complex cases, such as those with comorbid conditions. However, many family physicians are reluctant to diagnose and treat even uncomplicated adult ADHD. This is likely due to a number of reasons, including the fact that many family physicians are inadequately trained in ADHD and comorbidities, and a perception that caution must be taken when prescribing stimulant medication. This study investigated the referral of adult patients by family physicians to ADHD specialist clinics in Canada to assess whether family physicians diagnosed and treated uncomplicated adult ADHD. In addition, the study examined the following: the presence of comorbid symptoms; the delay from referral to treatment; the impact of adult ADHD on daily life; and types of medication prescribed.
This was an open-label, non-interventional, retrospective survey of referrals of adults with suspected ADHD from family physicians to a specialist in adult ADHD. Data were collected from original referral letters* (N=515) and ADHD specialists’ charts (N=19) between December 2014 and September 2015.
Of the 515 referrals, 483 (93.8%) patients (mean age at referral=33 years; 60.2% male) had a diagnosis of adult ADHD determined by the ADHD specialist. The results indicated that most referrals (91.7% [472/515]) were made by family physicians, with many patients (59.2% [305/515]) referred due to symptoms implying ADHD with no other comorbidities. Inattention was the most common symptom, experienced by ~80% of patients. The time between referral and initial consultation with an ADHD specialist was 1–3 months for the majority of patients (36.0%), although some patients (31.0%) were seen by a specialist within <1 month.
Of the patients diagnosed with adult ADHD, 69.4% of patients had ≥1 comorbidity, which was reported by either the referring physician or the ADHD specialist. The most prevalent comorbidities were anxiety and depression, which affected 41.2% and 28.0% of patients, respectively. Almost all patients (99.6%) diagnosed with ADHD reported that it had an impact on their daily life, with school and work being the most commonly affected in 25.1% and 52.0% of patients, respectively. Pharmacological treatment was recommended for the majority of patients diagnosed with ADHD, with a stimulant monotherapy being recommended in 79.3% of cases. More than half of patients (58.4%) were retained on follow-up with the ADHD specialist, 21.1% of patients were returned to the care of the referring physician and 20.5% were returned to the referring physician following treatment stabilisation.
Due to the descriptive and retrospective nature of these data, these results should be interpreted with caution. In addition, this study may have had the following limitations: assessment of comorbid symptoms was performed in a non-standardised manner, as it was reliant on information provided by the family physician at referral; there was a lack of data on lifetime comorbid symptoms compared with current comorbid symptoms; there was insufficient information to confirm comorbid symptoms as diagnosed comorbid conditions; and patients were excluded from this study if there was a family history of ADHD.
The authors suggested that these data provide a valuable insight into the diagnosis and treatment of uncomplicated ADHD in adults in real-world practice in Canada. In the majority of cases, diagnosis of ADHD was confirmed by a specialist upon referral by a family physician, indicating that most referring family physicians were correct in their suspected diagnoses of ADHD. If family physicians were provided with more training (e.g. to improve knowledge of current pharmacological treatments and correct use of available guidelines), they may feel more confident in diagnosing uncomplicated cases of suspected ADHD in adults and managing patient follow-up once a diagnosis has been confirmed by an ADHD specialist. In the future, it is hoped that improvements in training and education of family physicians may lead to faster treatment of ADHD and could reduce the negative impact that untreated adult ADHD has on aspects of patients’ daily lives.
*Referrals were made by family physicians, non-specialist psychiatrists or “other” physicians (e.g. a psychologist)
Klassen LJ, Blackwood CM, Reaume CJ, et al. A survey of adult referrals to specialist attention-deficit/hyperactivity disorder clinics in Canada. Int J Gen Med 2017; 11: 1-10.