Healthcare professionals must consider individualised treatment approaches for patients with both ADHD and bipolar disorder, depression, or psychosis.
Credit: Priscilla du Preez / Unsplash
Attention deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition characterised by inattention, hyperactivity, and impulsivity. While it is a common disorder, affecting 3 - 4% of adults worldwide, some clinicians and researchers have concerns about how valid the diagnosis is, despite the neurobiological, cognitive, clinical, and genetic evidence for the condition.
Our research at the University of Birmingham suggests ADHD often occurs with other mental health problems, particularly mood disorders and treatment plans that consider this complexity are needed to deliver better outcomes for this population.
ADHD typically begins in childhood and often persists into adulthood. The impact of ADHD extends beyond the individual, affecting relationships, employment, and even safety (such as driving accidents or criminal behaviour).
In public discourse, it is difficult to have a conversation about ADHD without someone saying: “well I’m a bit like…” or “everybody has those problems….” These remarks show a profound misunderstanding about the extent of difficulties people experience and how the condition blights the lives of sufferers and the pressures its puts on their family and others. It is similar to comments I used to hear years ago when people would say “Well I’m a bit bipolar.”
Despite the significant harms associated with adult ADHD, it remains under-recognised and under-treated. A comprehensive assessment for ADHD involves evaluating general mental health alongside a detailed account of ADHD-related difficulties. Typically, this assessment takes approximately three hours of a senior clinician’s time. Unfortunately, there is no blood test or validated automated diagnostic process for ADHD. Consequently, most NHS ADHD services face exceptionally long waiting times for assessment and treatment, often spanning 18-24 months. These delays are frustrating for all involved.
Efforts to accelerate recognition and address demand are crucial to improving care for individuals with ADHD. If you or someone you know is experiencing ADHD-related challenges, seeking professional evaluation is essential for tailored support.
While there are multiple independent providers of ADHD assessment and treatment, a BBC Panorama programme highlighted significant variability in the quality of assessments and the skill level of practitioners within this sector. Patients often face frustratingly long waits for assessment and diagnosis, whether through the NHS or private services. Unfortunately, even after this wait, frustrations can persist due to inconsistent availability of stimulant and non-stimulant medications. Some patients report rationing their supply or going without medication altogether for extended periods.
The extent to which these difficulties are apparent and tolerated within the assessment and treatment of ADHD sheds light on the broader stigma surrounding mental health problems. Addressing these challenges requires collaborative efforts and a commitment to improving care for individuals affected by ADHD.
Efforts to accelerate recognition and address demand are crucial to improving care for individuals with ADHD. If you or someone you know is experiencing ADHD-related challenges, seeking professional evaluation is essential for tailored support.
The problems are widely recognised and a new government taskforce has been set up to look at these and find practical solutions that will facilitate better care for people with ADHD.
At the University of Birmingham, we are particularly concerned with understanding the best treatment for people with ADHD who also have a diagnosis of bipolar disorder or psychosis. Of those with a diagnosis of either bipolar or ADHD, 5 - 20% also have the comorbid condition, and these patients have an earlier age of onset of their bipolar, shorter periods of wellness, greater risk of substance misuse and of other psychiatric comorbidities. Comorbidity between psychosis and ADHD occurs in 10 - 47% of cases, regardless of which condition is primary. This comorbidity is associated with poorer social and occupational functioning, as well as treatment resistance.
Regarding treatment recommendations, the most recent NICE (National Institute for Health and Care Excellence) guidelines maintain that stimulants remain the mainstay of treatment for adults with ADHD. However, it is essential to note that these guidelines are based on limited studies involving individuals with ADHD and comorbid mental disorders. Unfortunately, there are no high-quality studies specifically supporting the use of either stimulants or non-stimulants in this complex co-morbid patient group.
As research continues, healthcare professionals must carefully consider individualised treatment approaches for patients with both ADHD and bipolar disorder, depression, or psychosis.
We are conducting the SNAPPER study, a National Institute of Health Research funded trial. It is exploring the effectiveness of a stimulant medication called Lisdexamfetamine vs a non-stimulant medication called Atomoxetine, and how safe these medications are for adults with ADHD and a history of either psychosis or bipolar disorder. We are currently recruiting across eight mental health trusts across the country and anticipate this being 12 mental health trusts in the coming months. Individuals who think they may be eligible for this study are very welcome to contact Professor Steven Marwaha
Clinical Professorial Fellow
Steven Marwhaha is an academic Psychiatrist whose main interest is in early intervention and mood disorders, such as bi-polar disorder and depression.
