4. Discussion
To the best of our knowledge, this is the first evaluation of the effectiveness of a specialist adult ADHD service in relation to improvements of functional impairment, pre- and post-titration onto ADHD medication. The results indicate that overall, ADHD medication is effective at reducing the functional impairment of adults with ADHD in all domains of the WFIRS, which is consistent with similar research in this area20. This evidence has contributed to longer term commissioning of the service. However, the large proportion of service users either disengaging from treatment (19.5% of the sample), being assessed as not suitable for medication (12.4% of the sample) or choosing not to have medication (2.7% of the sample), highlights a significant service gap and the need to offer an alternative intervention for the management of ADHD. This endorses NICE guidelines11, which recommends non-pharmacological treatment for adults with ADHD who have either made an informed choice not to have medication, have difficulty adhering to medication; or found medication to be ineffective/intolerable.
The present study also found that the level of functional impairment reported by people that disengaged from the service did not significantly differ to those that completed titration, suggesting that this was not a factor in people disengaging from treatment. It is possible that those who disengaged could have done so due to unmanaged ADHD symptoms (e.g. the organisational skills needed to attend regular appointments over several months). This further strengthens the need for psychosocial support, as “CBT for adult ADHD aims to set up early success experiences that help improve engagement in treatment and hopefulness”21 (p.67). Further research into this area is needed to understand the reasons for disengaging in treatment and what the service could do or offer to help people to remain engaged in treatment.
Disparity in the levels of disengagement between those that were recently given an ADHD diagnosis (25.6%), compared to those diagnosed prior to the present episode of care (15.7%) highlights a potential avenue for exploring reasons for disengagement. Due to the relatively small sample size used in this evaluation, caution is needed with drawing conclusions from this finding. However, the psychological impact of both the consequences of untreated ADHD across the life span, as well as the emotional impact of receiving a diagnosis later in life, have been well documented. Matheson et al.22 highlighted that adult patients with a delayed diagnosis of ADHD have many unmet needs regarding treatment. Young23 found the delay in diagnosing ADHD until adulthood may contribute to a sense of feeling misunderstood by others, uncertainty, and dissatisfaction because the underlying cause of their problems went unidentified, misdiagnosed, and untreated for so long. He suggested a six-stage model of psychological acceptance of a diagnosis of ADHD: (a) relief and elation, (b) confusion and emotional turmoil, (c) anger, (d) sadness and grief, (e) anxiety, and (f) accommodation and acceptance. This indicates an important role for psychological treatment, which should begin at the point of diagnosis23. Comparison with a matched site that can provide this level of support could offer valuable insight as to the short- and long-term benefits and cost-effectiveness of offering this.
The present findings, along with the evidence discussed, highlights the wide gap between NICE guideline policy in England and clinical practice, in terms of the support that adults with ADHD receive. More investment is needed to help people to not only deal with the symptoms of ADHD they face, but to adjust to and accept a diagnosis. Having an adult diagnostic service inherently brings about a responsibility to offer an appropriate, comprehensive response to the needs of the population they serve.