A survey of adult referrals to specialist attention-deficit/hyperactivity disorder clinics in Canada

Abstract

Background

Canadian guidelines encourage family physicians to diagnose/manage adults with uncomplicated attention-deficit/hyperactivity disorder (ADHD); specialist referral is recommended only for complex cases. This retrospective case review investigated adults referred to Canadian ADHD clinics.

Methods

Adult ADHD specialists reviewed referral letters/charts of patients (aged ≥18 years and no family history/known/expressed childhood ADHD) from family physicians/psychiatrists over 2 years.

Results

Data on 515 referrals (mean age 33 years, 60% males) were collected (December 2014 to September 2015); 472/515 (92%) were made by family physicians. No psychiatric comorbid symptoms were noted in 344/515 (67%) referrals. ADHD was confirmed by a specialist in 483/515 (94%) cases, whether comorbid symptoms were noted at referral (155/171 [91%]) or not (328/344 [95%]). ADHD was reported to impact “work” (251/317 [79%]), “school” (121/166 [73%]), “social/friends” (260/483 [54%]), and “spouse/family” (231/483 [48%]). Overall, 335/483 (69%) patients had more than or equal to one comorbid symptom (diagnosed by referring physician or specialist). Stimulant monotherapy was recommended for 383/483 (79%) patients, non-stimulant monotherapy for 41/483 (8%) patients, and stimulant plus non-stimulant monotherapy for 39/483 (8%) patients. Almost half of patients were returned for referring physician’s follow-up, either before treatment initiation (102/483 [21%]) or after treatment stabilization (99/483 [20%]). Follow-up was by a specialist for 282/483 (58%) patients.

Conclusion

ADHD diagnosis was specialist confirmed in most cases. Although most referrals (67%) noted no psychiatric comorbid symptoms, 69% of patients had ≥1 such symptom (diagnosed by a referring physician or specialist), so comorbid symptoms although not always noted at referral, may have contributed to the decision to refer. ADHD has a wide-ranging impact on patients’ daily lives. It is possible that greater confidence of family physicians to diagnose and treat adult ADHD could help to meet patients’ needs.

Keywords:

• attention-deficit/hyperactivity disorder
• adult
• Canada
• diagnosis
• comorbid symptoms
• family medicine/general practice/primary care

Supplementary materials

Table S1 CRF

Table S2 Categories and predefined list of words used to list the symptoms for each patient

Acknowledgments

The authors wish to thank the ADHD specialists who contributed case information for this survey. Under the direction of the authors, Joanna Wright, DPhil, Caudex, Oxford, UK, and Denise Graham, PhD, Caudex, Oxford, UK, provided writing assistance for this publication, funded by Shire International GmbH. Editorial assistance in formatting, proofreading, copyediting, fact checking, and coordination and collation of comments was also provided by Caudex, funded by Shire International GmbH. The authors wish to thank Carol Heggie (formerly of Shire) for her contribution to the study. Tamara Werner-Kiechle of Shire International GmbH also reviewed and edited the manuscript for scientific accuracy. Although employees of Shire were involved in the design, collection, analysis, interpretation, and fact checking of information, the content of this manuscript, the interpretation of the data, and the decision to submit the manuscript for publication in International Journal of General Medicine were made by the authors independently. This research was funded by Shire Development, LLC. Shire International GmbH provided funding to Caudex, Oxford, UK, for support in writing and editing this manuscript. Data from this manuscript were presented at the 12th Annual CADDRA ADHD Conference, Ottawa, Canada, 2016.

Author contributions

James G Burns and Samuel Schaffer contributed to the conception and design of the study. All authors contributed to the analysis and interpretation of the data and revised the article critically for content. All authors reviewed and approved the final draft of the manuscript and have agreed to act as guarantors of the work.

Disclosure

Larry J Klassen has received research support from Shire and has been on advisory boards and speaker bureaus for Shire, Ironshore, Janssen, Lundbeck, Pfizer, Purdue, and Sunovion. C Matthew Blackwood has been on advisory boards and speaker bureaus for Shire and is on the Board of Directors for CADDRA. Christopher J Reaume and James G Burns are employees of Shire. Samuel Schaffer was an employee of Shire at the time of the study. The authors report no other conflicts of interest in this work.