April 2009: NICE guidelines presentation at ADDISS annual conference (see bottom of this page)
March - May 2009: Website revised
March 2008: New regular clinic started at 17 Wimpole Street.
January 2008: Now fully independent [of the NHS].
October 2007: Engaged by The Priory Group to provide regular psychiatric input to residents at Rookery Hove, a specialist Asperger syndrome group home in Hove, East Sussex.
November 2006: Website started
Links
If you are just starting to look for information on Developmental Disorders I recommend the NHS Direct website's good "official" account. The BBC webpage on adult ADHD is several years old, but is still of interest.
Summary of “NICE and adult ADHD: an independent view”: presentation given at The Ninth International ADDISS Conference, London, 1st April 2009
(The full text of this talk, with notes and references, is available: please email me at neilmacf@btinternet.com)
Although the full NICE ADHD guidance is very welcome, the recommendation for medication as the first-line intervention in moderate (rather than just severe) adult ADHD is premature. My own view is that the guidelines committee could and should have left this more open to clinical judgement and patient choice.
Starting medication-based treatment in adults is still unlicensed in the UK. The premature and widespread off-licence use of medication for depression in children and teenagers led to much of the adverse public, media, regulatory and parliamentary scrutiny of prescription medications over the last few years. It is likely that this has been a key factor in the current underprovision of specialist services for this patient group.
Depression is the commonest mental health disorder in adults, so how adult depression has been dealt with in the NHS points the way for adult ADHD. The 2004 NICE guidelines for adult depression stated “severe depression…can be treated in primary care”, and did not give a detailed account of the supporting role of specialist services. In practice, risk issues determine access to those services. This is likely to be the case for people with ADHD as well, especially as the NICE guidelines do not recommend additional resources. The guidelines imply a new group of nurse specialists will undertake much of the clinical care, but there is little detail on how this will be structured. My first reason for suggesting that medication should be the recommended initial treatment only in the severe ADHD group, is that the focus can be on those patients already within the system, until resources become available.
Secondly, the NICE process is centrally concerned with cost-benefit analysis of treatments: there were only two placebo-controlled trials of methylphenidate in adults used in the NICE analysis, and neither was designed primarily to provide information on cost-benefit. Other NICE guidelines, such as those on borderline personality disorder (BPD), have been able to leave recommendations much more open to clinical judgement.
The ADHD guidelines could have had a greater emphasis on non-medication-based treatments already developed for other conditions, such as anxiety and depression, BPD, addictions, and offending, all of which overlap with ADHD. Individual clinicians and patients should be able to consider trying such interventions first, where available, in moderate ADHD.
Returning to the comparison with the premature off-license prescribing of antidepressant medication in teenagers, it does appear that relatively little short-term risk is associated with ADHD medication in any age group. What is less clear are the medium- and longer-term risks for the development of bipolar disorders and schizophrenia: it is possible that ADHD medication could even be protective against these disorders, therefore a clearer outline of how these risks will be researched in future is desirable.
The final issue relevant to how strongly medication should be recommended by NICE concerns the wider public perception of “vested interests” in mental health. The view that pharmaceutical companies unduly influence research, not just on treatment, but even on diagnosis, has moved from the fringes to the mainstream in recent years. I suggest that the NICE ADHD guidelines committee, by appearing to favour “the dominant medical scientific paradigm”, has missed the opportunity to promote a more nuanced debate, and risks being out of step with how NHS specialist mental health services are developing.
