9 Jul 2020

Cortese S. BJPsych Open 2020; 6: e43; Price A et al. BJPsych Open 2020; 6: e7

A key issue often discussed in relation to the management of ADHD in the UK is the continuity of care around the transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS), occurring between the ages of 16 and 18 years.1 This can be a particularly vulnerable period, involving significant life changes that can place extra stresses on young people with ADHD and require additional coping skills. Information on regional variations in ADHD management across the UK has been lacking but could help direct and improve the quality of care during this transition period.1 A study by Price et al. addressed this knowledge gap.2

Based upon records from the Clinical Practice Research Datalink (CPRD; a primary care database including records of approximately 11 million patients), this study had three aims: 1) to examine regional differences in the prevalence of prescriptions of ADHD medications in primary care for young people aged 16–19 years in the UK; 2) to estimate the proportion of patients referred to AMHS; and 3) to map regional variations in prescribing patterns and referral rates to the location of services for adult ADHD.1,2

Approximately 65% of young adults who have had ADHD during childhood continue to present with impairing ADHD symptoms, and up to 90% of individuals with ADHD may benefit from ADHD medications.1 It may therefore be expected that a substantial proportion of young adults with a history of childhood ADHD will be receiving pharmacological treatment.1 However, this was not reflected in the findings of Price et al.1,2 The study revealed regional variability in the prescription of ADHD medication across geographic regions in the UK but, overall, the rate of prescriptions varied from low to very low.1,2 In the area with the highest prescribing rate (Scotland), the percentage of patients with at least one prescription of ADHD medication was 47% at age 14–15 years and 27% at age 19–20 years; in the region with the lowest rates of prescription (Yorkshire & Humber), the rate dropped from to 27% to 6%.1,2 Furthermore, the mean age of termination (or interruption) of pharmacological treatment was 16.6 years (standard deviation 2.63 years; 95% confidence interval 16.5–16.7), despite the fact that impairing ADHD symptoms persist after adolescence in the majority of cases.1,2

In relation to the second objective, the authors found that the average percentage of patients referred to AMHS was only 11% (range 4–21%), and even lower when individuals with a prescription of any other psychotropic medications were excluded (average 7%; range 3–11%).

Finally, no clear associations were found between reduction in prescribing, referral rates to AMHS and the location of services specialised in the care of adults with ADHD – although it should be noted that the CPRD data were for 2005–2013, whereas the service mapping was completed in 2018.1,2

Reasons considered for these findings of low prescription rates in young adults included ADHD being deemed as predominantly an academic problem, as supported by the mean age of termination of medication coinciding with the age when young people may leave school (16 years, post-GCSEs). It may also be related to practical management issues, such as a lack of shared care plan agreements or ADHD-specialised services, or even local guidelines preventing GPs from prescribing ADHD medication in adults in some regions (e.g. Nottinghamshire). Another factor may be that young adults are not being treated as per current guidelines, but instead are accessing non-conventional or non-pharmacological approaches.1

Limitations of the study findings on regional variation include that figures are likely to underestimate the proportion of individuals with ADHD who are properly managed with pharmacological treatment. To be effective, ADHD medications need to be optimised with an accurate titration and follow-up, so these estimates based upon ‘at least one prescription’ give only a rough indication of effective treatment. Furthermore, given the limitations of real-world databases such as the CPRD, adherence to treatment could not be assessed.1

In conclusion, the rate of treatment for young people with ADHD moving on from CAMHS varies from low to very low across the UK. This indicates a need for improved education and training of individuals with ADHD, their families, GPs and other health professionals to tackle misconceptions, and improve management during this transition period. In support, there also needs to be more research into the psychosocial impact of ADHD, the efficacy and safety of pharmacological interventions for adults with ADHD, and the profile of young adults with ADHD who require transition to adult services (to help develop local protocols).1

Read more about: variations in the care of young adults with ADHD across the UK here and here

  1. Cortese S. Regional analysis of UK primary care prescribing and adult service referrals for young people with attention-deficit hyperactivity disorder: from little to very little. BJPsych Open 2020; 6: e43.
  2. Price A, Ford T, Janssens A, et al. Regional analysis of UK primary care prescribing and adult service referrals for young people with attention-deficit hyperactivity disorder. BJPsych Open 2020; 6: e7.
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