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CHHS18/135

Canberra Hospital and Health ServicesClinical Guideline Adult Attention Deficit and Hyperactivity Disorder (ADHD) – Managing referrals for assessment of ADHD and prescription of psychostimulants (MHJHADS)Contents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................2

Background........................................................................................................................... 2

Key Objective........................................................................................................................ 3

Scope........................................................................................................................................ 3

Section 1 – Prescribing psychostimulants.................................................................................3

Controlled medicines prescribing standards.........................................................................4

Psychostimulants under the PBS...........................................................................................5

Section 2 – Managing referrals from GPs for ADHD assessment..............................................5

Initial assessment and diagnosis of ADHD.............................................................................6

Referrals for subsequent controlled medicine authorities....................................................7

Continuation of psychostimulants within inpatient units.....................................................7

Continuation of psychostimulants within custodial or detention settings (adult and young people)..................................................................................................................................7

Implementation........................................................................................................................ 7

Related Policies, Procedures, Guidelines and Legislation.........................................................8

References................................................................................................................................ 8

Search Terms............................................................................................................................ 9

Attachments..............................................................................................................................9

Attachment 1 – Flow chart – management of GP referrals for initial assessment of ADHD10

Attachment 2 – ADHD Letter to GP.....................................................................................11

Attachment 3 – ADHD Letter to person..............................................................................15

Doc Number Version Issued Review Date Area Responsible PageCHHS18/135 1 27/04/2018 01/05/2022 MHJHADS 1 of 19Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Guideline Statement

BackgroundAttention Deficit and Hyperactivity Disorder (ADHD) is a heterogeneous behavioural syndrome characterised by core symptoms of inattention, hyperactivity and impulsivity. ADHD is a common childhood disorder, however it often persists through adolescence into adulthood. Symptoms of ADHD are evenly distributed throughout the population and vary in severity; only those who experience at least a moderate degree of psychological, social and/ or educational or occupational impairment in multiple domains should be diagnosed with ADHD. ADHD is most commonly diagnosed in childhood, affecting 5 – 10% of children and approximately 3 – 4% of adults.

Determining the severity of ADHD is a matter for clinical judgement, taking into account severity of impairment, pervasiveness, individual factors and familial and social context. Symptoms of ADHD can overlap with other disorders, and ADHD cannot be considered a categorical diagnosis.

Psychostimulants are a first line treatment of moderate to severe ADHD and are among the most effective and well-studied psychotropic medications available, despite ongoing misinformation and stigma surrounding their use. Overall, psychostimulants are well supported by clinical research and a have a history of a robust response, good tolerability and safety across the lifespan. Over the last two decades, an increase in the understanding and acceptance of ADHD in the medical community has led to more widespread use of psychostimulants.

The Royal Australia and New Zealand College of Psychiatrists (RANZCP) supports the appropriate use of these drugs in the treatment of ADHD, for which there is a sound evidence base. Methylphenidate, Dexamphetamine and other stimulant medications enhance the presynaptic release of catecholines, in particular dopamine. Although the precise mechanisms underlying the actions of these drugs are not completely understood, they appear to increase the availability of dopamine and noradrenaline via stimulation of their release (dexamphetamine) or inhibition of their re-uptake (methylphenidate). Clinically, these pharmacological actions manifest as increased attention, concentration, impulse control, learning and memory.

Psychostimulants are noted to be drugs of dependence, meaning that whilst there is a recognised therapeutic need for these medicines, they also have a high potential for misuse, abuse and dependence. The issues relating to the prescription of psychostimulants are complex. The past few decades have seen a significant increase in the prescription of methylphenidate in particular, and an associated increase of accidental and non-accidental poisonings. Furthermore, increased misuse of stimulants and amphetamine based drugs both licitly and illicitly has been widely documented. Patterns of greater rates of prescribing of psychostimulant medications which subsequently go on to be misused or diverted has also been dramatic and led to rescheduling and greater restrictions placed on these medicines. Finally, it is noted that some people experiencing drug dependency may attempt


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to access psychostimulants through their general practitioners (GPs), making the need for more comprehensive assessment of referrals necessary.

Methylphenidate and Dexamphetamine are Controlled Medicines under Schedule 8 of the Commonwealth Standards or Uniform Scheduling of Medicines and Poisons (SUSMP) and a number of factors including the reduced availability of private psychiatrists has led to an increase in referrals into Adult Community Mental Health Teams (ACMHTs) from GPs for the diagnosis of ADHD and subsequent psychostimulant prescriptions.

Key Objective To provide Adult Mental Health Teams and prescribing Psychiatrists within MHJHADS

with a framework for managing referrals from GPs for assessment and diagnosis of adult ADHD or requests for psychostimulant prescription

To provide Psychiatrists with current prescribing information of psychostimulants including authority, schedule and restrictions.

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Scope

This clinical guidance document pertains to medical and clinical staff within MHJHADS under the clinical governance of the Chief Health Officer and the Chief Psychiatrist.

Non-pharmacological therapies such as psychological therapies are available for the treatment of ADHD both as primary and adjunctive therapies. However, these therapies are out of scope for this document and pertain to referrals from GPs requesting psychostimulant initiation and continuation.

Child and Adolescent Mental Health Services or patients aged under 18 years are out of scope for this clinical guideline.


Section 1 – Prescribing psychostimulants

Under the Controlled Medicines Prescribing Standards, a GP or other prescriber is unable to initiate or continue psychostimulants without support from a psychiatrist or neurologist. A psychiatrist is required to provide support for the use of psychostimulants to the Chief Health Officer (CHO). Following authority from the CHO the GP can continue to prescribe maintenance psychostimulants for up to 3 years with the exclusion of dosage increases, whereby at this time a psychiatrist is again required to provide support for the ongoing treatment and gain authority from the CHO.


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Restricted psychostimulants for the treatment of ADHD include the following drugs: Dexamphetamine sulphate– all preparations Lisdexamphetamine – all preparations Methylphenidate hydrochloride – all preparations

Controlled medicines prescribing standardsUnder the Controlled Medicines Prescribing Standards, category 5 refers to Controlled medicine to treat a person with Attention Deficit and Hyperactivity Disorder.

For a paediatrician (for persons aged 4 – 18 years), psychiatrist or neurologist or any other specialist considered appropriate.

Under this category approval a specialist (as listed above) may prescribe a controlled medicine to a non-drug dependant person with ADHD, up to a maximum of 3 years for:

Category 5CPersons aged 4 to 18 yearsThis category approval is only inclusive of the total daily dosage below: 40mg daily of dexamphetamine (dexamfetamine) 70mg daily of lisdexamphetamine 72mg daily of controlled release methylphenidate 60mg daily of conventional methylphenidate

Category 5DPersons aged 19 years or olderThis category approval is only inclusive of the total daily dosage below: 40mg daily of dexamphetamine (dexamfetamine) 70mg daily of lisdexamphetamine 72mg daily of controlled release methylphenidate 60mg daily of conventional methylphenidate

Other information:The above categories permit a prescriber to prescribe one long acting and one short acting controlled medicine to treat a person with ADHD provided that the maximum daily dose does not exceed the above.

The CHO may ask for further information when considering this application, including but not limited to seeking evidence of specialist support.

When considering an application the CHO may choose to refuse, amend or place a condition on an application if the CHO believes that it is in the best interest of the patient or the public to do so.


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Subsequent applications for continuing treatment with psychostimulants may be: Submitted by an appropriate psychiatrist or neurologist; or Submitted by a general practitioner where:

o The efficacy of the prescribed treatment has been reviewed by a psychiatrist within the previous 3 years; and

o There is no prescribed increase in dose.

Subsequent or continuing treatment applications are made under Category 5A (aged 4 – 18 years) or Category 5B (aged 19 years or older).

Psychostimulants under the PBSIt should be noted that although methylphenidate is recommended as the first line treatment of ADHD, all modified release preparations are not subsidised under the Pharmaceutical Benefits Scheme, with the exception of dexamphetamine, unless the person was diagnosed with ADHD between the ages of 6 – 18 years. This significantly restricts the capacity for subsidisation of this drug. Therefore the person’s capacity to pay for their methylphenidate treatments must be taken into account when determining the appropriate treatment plan.


Section 2 – Managing referrals from GPs for ADHD assessment

There are a number of reasons that a person may be referred through their GP to the public system for ADHD diagnosis. These include a lack of available private psychiatric specialists, lack of private health insurance, inability to pay private fees or a preference to be seen in the public system.

It is important to note that people with undiagnosed and untreated ADHD in adulthood may experience severe distress, agitation, education and occupational disadvantage, and poor biopsychosocial functioning. A lack of childhood diagnosis does not negate a person from having ADHD.

Referrals for ADHD assessment should be triaged based upon the person’s clinical need, as with all other referrals.

Referrals relating to ADHD should be first assessed based on what has been requested by the GP. That is: Initial assessment and diagnosis of ADHD Triannual psychiatric assessment as per SUSMP Controlled Medicines Prescribing

Standards for maintenance treatment Authority to prescribe continuation psychostimulants for patients who are unknown to

MHJHADS


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Refer to Attachment 1 for flow chart outlining the management of GP referrals for initial assessment of ADHD.

Initial assessment and diagnosis of ADHDIn order to accurately assess a person for ADHD, a psychiatrist will require a comprehensive snapshot of the persons functioning in the relevant domains over time, particularly when the person does not have a childhood diagnosis of ADHD. A diagnosis in an adult is made on clinical grounds and requires the presence of long-standing, high level symptoms of inattention and/ or hyperactivity/ impulsivity which have been present since childhood.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the tenth edition of the International Statistical Classification of Diseases and Related Health Problems, Australian Modification (ICD-10 AM) criteria are the minimum necessary for the diagnosis of ADHD.

Assessment of adults with suspected ADHD should include a thorough medical and psychosocial assessment. A confident diagnosis in an adult usually requires corroborative evidence from family sources, carers, educational and employment settings, both previous and current.

Given the high demands for psychiatric consultation, it is critical that as much information as possible is provided to the psychiatrist prior to the persons first appointment, as this will potentially reduce the need for unnecessary future appointments for information gathering purposes.

Where the referral is accepted, the Adult Community Mental Health (ACMH) program will provide an initial assessment and psychostimulant titration service to people with ADHD. Following titration to a therapeutic dose the person is to be transferred back to their GP for ongoing care and psychostimulant prescription within the three year period.

Upon receipt of referral from a GP for ADHD assessment, a dedicated letter as per Attachment 2, should be sent either by the administrative officer or the clinician receiving the referral to the GP. This letter outlines the requirements for diagnosis and a request for current and historical health information and records relating to educational and occupational functioning. It further provides CHO requirements for seeking approval for authority to prescribe psychostimulants and the expectations of the ACMH service that the GP will resume care for the person following initiation of psychostimulants if prescribed.

Triaging and scheduling of medical appointments cannot occur until the required information and acknowledgement is received by the GP.

A letter to the person should also be sent on receipt of referral from the GP. This is in Attachment 3 and details similar information. It is preferable that the person provides any available supporting documentation prior to their appointment. The letter to the person is


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important in reducing expectations of prescription of psychostimulants without comprehensive assessment and/ or within the first psychiatric review. The person may require a number of reviews and dosage increases before stabilisation. For people whose primary complaint is ADHD and in the absence of other ongoing comorbidity, the person should be transferred back to their GP once the person’s condition has stabilised and the person’s clinical record closed.

Referrals for subsequent controlled medicine authorities.A further psychiatric review and support for authority is required every 3 YEARS for a person receiving category 5 listed controlled medicines.

Although these referrals can be considered non-urgent, all effort should be taken to review the person prior to their authority expiring so as not to risk an abrupt cessation of their medication.

Continuation of psychostimulants within inpatient unitsDuring periods of acute hospitalisation in an inpatient ward, the treating doctor is exempt from requiring CHO approval for the period that the person is in hospital. Dose increases will require a further CHO authority with support from the treating psychiatrist.

Generally, initiation of psychostimulants should occur within the community sector.

Continuation of psychostimulants within custodial or detention settings (adult and young people)On admission assessment to a custodial or detention setting if indicated, a thorough interview process should be followed to obtain collateral information from the community prescriber and community pharmacy to corroborate the prescribing details.

Once confirmed that the prescription is current and ongoing psychostimulant medication can be continued within the custodial or detention centre with support from the Psychiatrist. Medication prescribing and administration will be in accordance with the relevant facility’s procedures.

All efforts should be made to review the person prior to their authority expiring so as not to risk an abrupt cessation of their medication.


Implementation

The contents of this guideline will be communicated throughout the Adult Community Mental Health Teams and other relevant teams where applicable through the provision of leadership and governance meetings.

GPs will be notified of the referral changes through the MH GP Liaison Nurse and the GP Liaison Unit at the Canberra Hospital.


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Related Policies, Procedures, Guidelines and Legislation

Policies Medication Handling Policy Patient Identification and Procedure Matching Policy Patient Identification and Procedure Matching Procedure MHJHADS – Clinical Handover Procedure MHJHADS – Adult Community Teams Triaging Of Initial Presentations Procedure MHJHADS – Adult Community Teams – Duty Officer Processes Procedure

Legislation Human Rights Act 2004 Medicines, Poisons and Therapeutic Goods Regulation 2008 Medicines, Poisons and Therapeutic Goods Act 2008 Medicines, Poisons and Therapeutic Goods (Category Approval) Determination (No 3) Mental Health Act 2015 National Health Act 1953 (Cth) Poisons Standard October 2017


References

1. Adult ADHD - practice guidelines | RANZCP [Internet]. Ranzcp.org. 2012 [cited 15 November 2017]. Available from: https://www.ranzcp.org/Publications/Guidelines-and-resources-for-practice/Adult-ADHD-practice-guidelines.aspx

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th ed). Arlington, VA. American Psychiatric Publishing (2013).

3. Australian Government: Department of Health, Therapeutic Goods Administration. Standard for the Uniform Scheduling of Medicines and Poisons. February 2017 from https://www.tga.gov.au/publication/poisons-standard-susmp

4. Dunlop A, Newman L. ADHD and psychostimulants — over diagnosis and over prescription. The Medical Journal of Australia. 2016; 204(4):139.



https://www.tga.gov.au/publication/poisons-standard-susmp

https://www.ranzcp.org/Publications/Guidelines-and-resources-for-practice/Adult-ADHD-practice-guidelines.aspx

https://www.ranzcp.org/Publications/Guidelines-and-resources-for-practice/Adult-ADHD-practice-guidelines.aspx

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Search Terms

ADHD, Attention deficit and hyperactivity disorder, Dexamphetamine, Controlled medicines, MHJHADS, Psychostimulants


Attachments

Attachment 1 – Flow chart – management of GP referrals for initial assessment of ADHD.Attachment 2 – ADHD Letter to GPAttachment 3 – ADHD Letter to person

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 18/04/2018 New Document Tina Bracher, ED

MHJHADSCHHS Policy Committee

This document supersedes the following: Document Number Document Name


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Attachment 1 – Flow chart – management of GP referrals for initial assessment of ADHD


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Attachment 2 – ADHD Letter to GP

Patient name:Date of Birth:

Address: URN:

Clinic details:

General Practitioner:

[Insert date]

Dear Dr [Insert GP name]

Thank you for your referral for assessment of Attention Deficit and Hyperactivity Disorder (ADHD) for this person.

As you may be aware, there are strict criteria for making this diagnosis per the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), which are attached for your reference. Furthermore, a great number of restrictions apply to the prescription of psychostimulant medications used to treat this disorder.

We offer an initial assessment and medication initiation service which includes comprehensive assessment and screening for ADHD by a Consultant Psychiatrist, authority for prescription of psychostimulants if required, and initiation and monitoring of these medicines until a therapeutic dose is achieved.

Following this titration, the persons care will be transferred back to their GP for ongoing prescription and monitoring. Biannual psychiatric assessment as required for ongoing psychostimulant authorisation is also provided.

Generally, referrals for ADHD assessment are considered non-urgent as we work within a triage scale to ensure we are providing prompt acute care to those who require it. With this in mind, it would greatly assist us if you could provide the following information concerning this person: [Clinician to complete check list]

☐ The length of time you have known the patient.

☐ Any objective clinical evidence you have seen to support the diagnosis of ADHD. This may include reports from other specialists or your own clinical observations.

☐ Whether the patient has a childhood diagnosis of ADHD? Please provide any evidence for this.


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☐ Past and current medical history, specifically cardiovascular disease, glaucoma, tourette’s or pregnancy.

☐ Current medication list

☐ Past or current alcohol or drug dependence

☐ Past or current history of psychiatric illness

☐ Family history of cardiovascular disease or sudden unexplained death (if known)

We further require:☐ A recent ECG

☐ Any recent pathology

Your referral will only progress once we receive all of the above listed information.

You are welcome to contact us for further information or clarification.Kind regards

[Insert clinician name and contact details]


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DSM-5 Criteria for ADHD

People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development:

1. Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level: o Often fails to give close attention to details or makes careless mistakes in schoolwork,

at work, or with other activities.o Often has trouble holding attention on tasks or play activities.o Often does not seem to listen when spoken to directly.o Often does not follow through on instructions and fails to finish schoolwork, chores,

or duties in the workplace (e.g., loses focus, side-tracked).o Often has trouble organizing tasks and activities.o Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long

period of time (such as schoolwork or homework).o Often loses things necessary for tasks and activities (e.g. school materials, pencils,

books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).o Is often easily distractedo Is often forgetful in daily activities.

2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level: o Often fidgets with or taps hands or feet, or squirms in seat.o Often leaves seat in situations when remaining seated is expected.o Often runs about or climbs in situations where it is not appropriate (adolescents or

adults may be limited to feeling restless).o Often unable to play or take part in leisure activities quietly.o Is often "on the go" acting as if "driven by a motor".o Often talks excessively.o Often blurts out an answer before a question has been completed.o Often has trouble waiting his/her turn.o Often interrupts or intrudes on others (e.g., butts into conversations or games)

In addition, the following conditions must be met: Several inattentive or hyperactive-impulsive symptoms were present before age 12

years. Several symptoms are present in two or more setting, (e.g., at home, school or work;

with friends or relatives; in other activities).


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There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.

The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on the types of symptoms, three kinds (presentations) of ADHD can occur:Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months

Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months

Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.

Because symptoms can change over time, the presentation may change over time as well.


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Attachment 3 – ADHD Letter to person

Patient name: Date of Birth:

Address: URN:

Clinic details:

General Practitioner:

Dear

You have been referred to [Insert Clinic Name] by your General Practitioner (GP) for

assessment of Adult Attention Deficit and Hyperactivity Disorder (ADHD).

You may be aware that there are strict criteria required for a diagnosis of ADHD to be made

and for ongoing treatment with psychostimulant medication (when required).

In preparation for your appointment we would like you to fill in the attached questionnaire

and bring it your appointment.

It would also be very helpful if you could bring in the following documents if you have them:

School reports

Reports from health professionals who may have made a diagnosis of ADHD (for instance

paediatrician, neurologist, psychiatrist or psychologist).

If one of your parents or a person who cared for you as a child was available to attend the

appointment with you that would also be helpful. Given that a number of medications used

to treat ADHD are only funded under the PBS if a diagnosis is made under 18 years, evidence

of diagnosis in childhood is useful in making treatment affordable.

Please note that having a further referral to a mental health service provider is not a

guarantee that ADHD will be diagnosed or medication prescribed. In addition other testing

may be needed. Because of this it is unlikely that you will receive a prescription at your first

appointment.

Thank you for your assistance. This will help us to give you the best possible care and also

comply with legislative requirements around the treatment of ADHD.


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Your problems:


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Have you been diagnosed with ADHD in the past? If so who made the diagnosis? (If you have any letters or reports from health professionals please bring them to your appointment)

Are you currently working or studying? If so please give details.

Please describe as best you can the problems that have lead you to seek assessment for ADHD.

What difference do you hope having treatment will make?

Medical History:

Please circleDo you have a history of:


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Heart disease? Yes/ No

Chest pain? Yes/ No

Fainting or collapse? Yes/ No

Heart attack? Yes/ No

High blood pressure? Yes/ No

Abnormal heart rhythms (arrhythmias)? Yes/ No

Does anyone in your family have a history of heart disease? Yes/ No

Does anyone in your family have a history of sudden unexplained death? (If so how where they related to you and how old were they when they died?) Yes/ No

Do you have a history of glaucoma (increased pressure inside the eye)? Yes/ No

Do you have a history of tourette’s syndrome, or tics? Yes/ No

For women: are you or could you be pregnant? Yes/ NoMental Health History:

Do you have a history of mental illness? (If so please provide details)


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Does anyone in your family have a history of mental illness? (If so please provide details)

Does anyone in your family have a history of ADHD? (If so please provide details)

Alcohol and drug use:Do you drink alcohol? (If yes, how much, how often?) Have you used drugs in the past? (If so, please provide details, include both legal and illegal drugs)

Do you currently use any drugs? (If so, please provide details, include both legal and illegal drugs)

Current treatments:Are you taking any prescribed medications? (If so please list them)

Do you take any over the counter medications or herbal or natural preparations? (If so please list them)

Thank you for completing this questionnaire. The answers provided will greatly assist your General Practitioner and mental health professional.We look forward to seeing you in our clinic and will forward your appointment details shortly.

Kind regards

[Insert clinician name and contact details]


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