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PLAB 2 OSCE Guide: Managing a Patient with Suspected ADHD in GP Surgery

Updated: Aug 16

In PLAB 2, you may encounter a patient presenting with inattention, hyperactivity, or impulsivity. Once you've taken a focused history and suspect ADHD, your role in a GP setting is not to diagnose or initiate treatment, but to refer appropriately and explain the treatment pathway.


📤 Referral – What You Must Know and Say

Referral is essential ADHD is diagnosed by a specialist – typically a psychiatrist, paediatrician, or neurodevelopmental team.

🗣️ Say this:

“Based on what you’ve told me, your symptoms may be related to ADHD. To confirm this, I’ll refer you to a specialist who is trained in diagnosing and managing this condition.”

🔁 Understanding the Specialist Assessment

Assessment Components:

  • Symptom History: Exploration of current symptoms and their onset, particularly in childhood.

  • Functional Impact: Evaluation of how symptoms affect work, education, and relationships.

  • Collateral Information: Gathering information from someone who knows the patient well, such as a family member or close friend.

Outcome:

  • If diagnosed with ADHD, the specialist will discuss treatment options and support mechanisms.


💊 Treatment – How to Explain It Simply

Once diagnosed by the specialist, a treatment plan is made.


Medication Initiation:

  • Specialist Responsibility: ADHD medications, including stimulants like methylphenidate and lisdexamfetamine, are initiated by specialists due to the need for careful monitoring and potential side effects.


Shared Care Agreements:

  • GP Involvement: Once the patient's condition stabilizes, GPs may continue prescribing under a shared care agreement, ensuring ongoing monitoring and support .


🗣️ Say this:

“If the diagnosis is confirmed, treatment usually includes medication to help with attention and focus, along with practical support such as therapy or planning strategies.”

🔹 Medication

  • Initiated by specialist only (psychiatrist or paediatrician)

  • Commonly used:

    • Stimulants: Methylphenidate, Lisdexamfetamine

    • Non-stimulants: Atomoxetine, Guanfacine


🔷 Stimulants

1. Methylphenidate

  • Class: CNS stimulant (Piperidine derivative)

  • How it works:Blocks the reuptake of dopamine and norepinephrine in the brain, especially in the prefrontal cortex.→ This increases their availability in synapses, improving communication between brain cells.

  • Why it helps in ADHD:Enhances attention, focus, and impulse control by improving the function of areas in the brain responsible for executive functioning.

  • How fast:Begins working within 30–60 minutes. Available in short-acting and long-acting forms.

2. Lisdexamfetamine (Vyvanse)

  • Class: CNS stimulant (Amphetamine prodrug)

  • How it works:It is a prodrug (inactive form) that is converted in the body to dextroamphetamine, which increases the release of dopamine and norepinephrine and also blocks their reuptake.

  • Why it helps in ADHD:Improves focus, attention span, and self-regulation. Because it is a prodrug, it has a smoother onset and longer action, reducing the risk of abuse.

  • How fast:Effects last up to 13–14 hours, useful for all-day symptom control.


🟨 Non-Stimulants

3. Atomoxetine (Strattera)

  • Class: Selective Norepinephrine Reuptake Inhibitor (SNRI)

  • How it works:Selectively inhibits norepinephrine reuptake. In the prefrontal cortex, this also indirectly increases dopamine levels because dopamine is cleared there primarily by norepinephrine transporters.

  • Why it helps in ADHD:Improves sustained attention and emotional regulation. Preferred when stimulants are not suitable (e.g., history of substance misuse, tics, anxiety).

  • How fast:Takes 6–12 weeks to reach full effect.

4. Guanfacine (Intuniv)

  • Class: Alpha-2A adrenergic receptor agonist

  • How it works:Stimulates alpha-2A adrenergic receptors in the prefrontal cortex, enhancing the brain’s natural norepinephrine signalling.

  • Why it helps in ADHD:Strengthens impulse control, working memory, and attention regulation. Also helps reduce hyperactivity, aggression, and improves sleep.

  • How fast:Takes around 2–4 weeks to show effect.


🧾 GP Role:

“Once the specialist finds the right medication and dose, I can continue prescribing it under their guidance as part of a shared care agreement.”

🛠️ Other Treatments

  • Psychoeducation – understanding the condition

  • Behavioural therapy – especially helpful in children

  • Occupational/school support

  • CBT – if anxiety or depression co-exists


📚 References

  1. NHS (National Health Service).ADHD in adults – Diagnosis and treatment.Retrieved from: https://www.nhs.uk/conditions/adhd-adults

  2. Mechler K, Banaschewski T, Hohmann S, Häge A.Evidence-based pharmacological treatment options for ADHD in children and adolescents.Pharmacology & Therapeutics. 2022;230:107940.DOI: https://doi.org/10.1016/j.pharmthera.2021.107940

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