Adult ADHD Diagnosis in a Family Medicine Clinic

THE INNOVATION

Adult patients seeking diagnosis and treatment of previously undiagnosed ADHD can wait 20 to 56 weeks for formal diagnosis in behavioral health clinics locally. We wanted to greatly decrease wait times for uncomplicated adult ADHD diagnosis and treatment.

WHO & WHERE

Within a suburban Family Medicine Residency clinic, clinicians completed a set of 2 standard length clinical visits—the 1st visit is for initial screening for ADHD and potential alternative and/or comorbid conditions. If uncomplicated ADHD is suspected, a second visit is scheduled to formally diagnose and initiate treatment.

HOW

Under the guidance of a psychiatrist, we chose self-administered instruments for screening adult patients concerned about ADHD symptoms. Comorbidity screening includes depression (PHQ-9), bipolar disorder Rapid Mood Screener (RMS), anxiety (GAD-7), substance abuse (TAPS part 1), sleep apnea (Epworth Sleepiness Scale), and ADHD symptoms (ASRS-v1.1). Scoring of these instruments can be completed by any clinic staff. Lunchtime learning sessions with a psychiatrist helped us to gain comfort with use of behavioral health medications including ADHD psychostimulants and DSM-5 diagnostic criteria for ADHD.

During the 1st clinic visit, the patient completes the 6 self-administered screening surveys and discusses their ADHD concerns with the clinician. If the patient screens positive for 1 or more comorbidities (present in approximately 75% of patients with ADHD), it does not mean that the patient does not have ADHD, but does indicate that the clinician should treat underlying conditions. If the clinician suspects adult ADHD, the patient is given a copy of the DIVA-5 diagnostic interview and an educational handout about self-care behavioral strategies to manage ADHD symptoms during the diagnostic process. Patients are instructed to review and annotate the DIVA-5 at home before the follow-up visit, adding detail about symptoms and functional impairment. In complex cases, the patient is referred to behavioral health for evaluation.^1,2

The 2nd visit includes clinician review and scoring of the DIVA-5, a structured, symptom-based, diagnostic interview that reviews adult and childhood ADHD symptoms corresponding to the DSM-5 criteria. The DIVA-5 is available for clinic (non-research) usage through the DIVA foundation for a 1-time minimal payment (not a per patient charge).³ If previously undiagnosed adult (aged 18+ years) ADHD is confirmed, we offer to initiate pharmacotherapy, including stimulants, during this 2nd visit. In our pilot, 80% of 48 patients were diagnosed with ADHD (72% elected medication treatment during the 2nd visit), 12% complex cases were referred for behavioral health care, <0.5% had no ADHD, and <0.5% were lost to follow-up. This process decreased patient complaint to treatment time by 46% to 96% (1.7–11 weeks; mean 3–4 weeks) when compared with behavioral health evaluation. Patient comments indicate a preference for being seen in “their” clinic and that treatment options are offered through a timelier process. Pairing a standardized assessment process with pre-implementation teaching has increased clinician confidence with diagnosis and medical management of ADHD.

LEARNING

We have been able to speed diagnosis and treatment initiation for ADHD and also for depression, complex psychiatric conditions, and substance use disorders, improving patient care quality. The process is low-cost, and fits within any family medicine clinic’s standard visits.