Assessment and application of diagnostic criteria
15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen.
16. Mr E says the Clinic applied the criteria too stringently meaning Mr E did not receive a confirmed diagnosis of ADHD. Mr E feels the psychiatrist did not take into account that some people can ‘coast’ through school with a supportive home or higher academic ability, so difficulties may be less obvious in earlier life.
17. The Clinic says it conducted Mr E’s assessment and review in accordance with guidance for ADHD in adults, set out by the Royal College of Psychiatry.
18. In forming our view, we considered the records of the assessment completed on 24 February 2021 (report 21 April 2021) and the face-to-face review on 23 May 2022 (report 8 July 2022), alongside NICE NG87 and the DSM-5 diagnostic criteria for ADHD; this includes the need for several symptoms before age 12 and evidence that symptoms affect day-to-day life in two or more settings (for example work and home). The 2022 review used a structured questionnaire (Diagnostic Interview for ADHD in adults (DIVA)) alongside clinical interview, which records childhood and adult symptoms against the published rules.
19. The February 2021 assessment took place in a specialist service and was completed by a consultant psychiatrist. The records show a comprehensive clinical interview and review of Mr E’s mental state, relevant medical, educational, and occupational history, and questions about childhood and school functioning. The psychiatrist also considered Mr E’s sleep and mood.
20. The psychiatrist’s report provides a documented rationale for not diagnosing ADHD as Mr E did not meet the criteria for ADHD as there was not enough evidence that several symptoms before age 12 and across more than one area of life. The psychiatrist noted that other factors such as Mr E’s sleep and mood could better explain the reported difficulties.
21. Our adviser noted the records do not show enough childhood symptoms were present from youth to meet the published rules (which look for several symptoms before age 12). The DIVA scores recorded for childhood were below that threshold. The notes consider how difficulties affected Mr E at work and in study, but our adviser said the lack of clear evidence of difficulties before age 12 meant the diagnostic rules were not met even though adult-life difficulties were clearly described.
22. We asked our adviser if this assessment was conducted and documented in accordance with the expected standards. Our adviser told us the assessment was specialist-led, correctly sought and obtained a full history including current symptoms, education, work, enquiries about Mr E’s childhood, and considered other explanations such as mood and sleep.
23. In giving this view, the adviser pointed to the specialist setting, the use of DIVA in 2022, information from Mr E’s parents about school years, and the written reasoning that considered other possible explanations such as low mood, sleep problems and existing diagnoses. The adviser said using DIVA helped ensure the right questions were asked about both childhood and adult life and supported a clear written record of why the rules were or were not met.
24. From advice sought we understand the psychiatrist set out clear reasons to clinically justify not diagnosing ADHD at that time and they did not identify any process gaps or any signs that criteria were applied more strictly than as set out in NICE NG87 and DSM-5. From the same advice we note adviser the documentation did not evidence there were enough childhood symptoms or consistent impact across different parts of Mr E’s life to meet the criteria set out by DSM-5.
25. Taking this advice into account, we consider the assessments were carried out and written up to the expected clinical standard and that the diagnostic rules were applied as set out.
26. In May 2022, Mr E attended a review after he asked for his position to be looked at again. The records show the psychiatrist undertook a structured re-assessment using a DIVA interview. This is tool recognised by the Royal College of Psychiatry ADHD in adults good practice guidance; it helps specialists gather information consistently against the published diagnostic criteria and make sure key areas such as childhood history and day-to-day impact are covered.
27. The records show the psychiatrist noted Mr E’s difficulties at work and study but considered whether these were better accounted for by other factors discussed in the records (for example, mood or sleep), and explained the basis for the diagnostic position reached on each occasion. The records also show Mr E’s parents’ account recorded difficulties emerging around AS-level years (age 16–17) rather than in primary school, which is relevant to the “before age 12” requirement. The psychiatrist’s reasoning for their conclusions were clearly recorded.
28. We asked our adviser if this review was conducted and documented in accordance with the expected standards. Our adviser told us that this review was conducted and documented in accordance with the expected standard set out in NICE NG87; a structured questionnaire (DIVA) was used alongside a clinical interview and this was clinically appropriate.
29. From advice sought we note the records show the DIVA and narrative entries record adult-life symptoms but did not identify or account for sufficient evidence of symptoms before age 12 to meet DSM-5 thresholds. We have seen the records show the clinician sought information from Mr E’s parents about his childhood and explored the impact in more than one area of Mr E’s life. Our adviser told us the psychiatrist explained why the material available did not demonstrate childhood-onset criteria and this is consistent with the way NG87 and DSM-5 expect the diagnostic criteria to be applied.
30. Having reviewed the records and sought independent clinical advice, we consider the Trust’s assessments in 2021 and 2022 were carried out and recorded in line with expected guidance. We have not seen indications that the diagnostic criteria were applied more strictly than set out in guidance.
31. We recognise Mr E later obtained a private diagnosis and reports improvement with prescribed medication. This subsequent outcome does not, by itself, show the earlier NHS assessments were conducted improperly. Our adviser told us that response to medication is not itself a diagnostic test and can occur in conditions other than ADHD, so does not demonstrate the earlier NHS assessments were done improperly.
32. We recognise Mr E considers the clinicians who conducted the assessments were unduly strict in their application of the diagnostic criteria. We can understand why Mr E feels the lack of diagnosis lead to many years of challenge and financial hardship. Having sought independent specialist advise and reviewing the records we are unable to say the assessment were conducted unduly strict. We have identified the approach, and reasoning was aligned to what we would expect to see in terms of the relevant clinical standards. Therefore, we have not identified a failing and take no further action.
Bupropion hydrochloride recommendation
33. Mr E says the Clinic suggested he trial bupropion, but he was unable to get this prescription on the NHS, leaving him worried about access to treatment.
34. The Clinic says bupropion was discussed in July 2022. As this medicine was limited to specialist prescribing, and because there was no neurodevelopmental diagnosis, the Clinic says it was not commissioned to initiate or follow it up. It asked the GP to make an urgent referral to the Community Mental Health Team (CMHT) so a specialist team could consider prescribing and monitoring.
35. We reviewed the Clinic letter of 8 July 2022 proposing bupropion hydrochloride modified release (MR) 150 mg once daily, the GP Practice’s reply of 11 July 2022, and the Clinic’s response of 21 July 2022.
36. The 8 July 2022 letter set out a plan, recommending bupropion hydrochloride MR 150 mg once daily and stating that arrangements would be required for follow-up and monitoring during treatment.
37. The same letter explained that, because of Mr E’s recurrent depression and comorbid eating-disorder history, input from CMHT would be required and the Clinic asked the GP to make a referral. It also recorded that Mr E was discharged from the Clinic’s service, and that the Clinic would provide further advice to the GP if needed.
38. The reply from the GP Practice on 11 July 2022 confirmed bupropion hydrochloride was being treated as specialist-only on the local formulary and asked the Clinic to manage prescribing/monitoring; the Clinic’s 21 July 2022 response explained it was not commissioned to do so and again asked for an urgent CMHT referral.
39. We asked our adviser whether the advice/prescribing of bupropion hydrochloride and the plan and communication about ongoing NHS supply and monitoring were in line with expected practice and local position in July 2022.
40. From our independent clinical advice we note having regard to the BNF (2022) entry for bupropion (licensing and cautions) and the local formulary in July 2022 classifying bupropion for depression as amber, specialist initiation on advice of the CMHT with possible GP continuation once stable, a GP would not be expected to start bupropion and ongoing supply/monitoring should sit with a specialist service.
41. On that basis, the steps shown in the letters, proposing a trial, confirming with the GP that local rules required specialist prescribing, and asking for an urgent CMHT referral so a specialist team could consider initiation and monitoring were consistent with the standards in place.
42. The adviser did note the GP referred to bupropion hydrochloride as ‘red’, which differs from the formulary’s ‘amber’ classification, but considered the Clinic’s written plan and handover remained appropriate and clear as the correspondence set out the status of the medicine, who could prescribe, and the next steps. Our adviser told us this a difference in interpretation rather than a breach of policy.
43. After considering the information we have received, we consider the Clinic set out an appropriate plan from the outset. In its 8 July 2022 letter it proposed a trial of bupropion hydrochloride MR 150 mg daily, explained that the medicine required specialist monitoring, and asked the GP to refer Mr E to CMHT. When the GP replied on 11 July 2022 to say bupropion hydrochloride was being treated locally as specialist-only in primary care, the Clinic’s 21 July 2022 letter reiterated its commissioning limits and again asked for an urgent CMHT referral.
44. We understand this created confusion and led to Mr E feeling as though he had been passed between services without an immediate outcome. This appears to have resulted from the GP Practice’s interpretation of the medication being classified as ‘red’ compared with the local formulary classification of ‘amber’. However, after speaking with out adviser, we consider the Clinic’s actions were appropriate to avoid unsafe prescribing outside commissioning limits.
45. Therefore, we have not identified any indication that anything has gone seriously wrong in how bupropion hydrochloride was advised, communicated, or handed over for ongoing NHS supply and monitoring. We will not take any further action on this complaint point.
Wrongly review by same psychiatrist
46. Mr E says the Clinic conducted a review using the same psychiatrist which he feels was unfair. Mr E feels a different psychiatrist would have been more impartial.
47. The Clinic says a clinician-led review by the original assessor is usual in that situation because the clinician already knows the history and can consider any new information efficiently.
48. We considered the complaint correspondence and the records for the 23 May 2022 face-to-face review (report 8 July 2022). These show the review was arranged with the same consultant psychiatrist, who documented the additional information and set out the reasons for the position reached. We have not identified any local policies that required a different clinician for this kind of review, and there is no evidence Mr E requested a formal second-opinion pathway at that time.
49. We asked our adviser whether, in these circumstances, arranging the review with the same psychiatrist was in line with accepted practice; in what situations a different clinician would usually be appropriate; and whether the review note itself showed a fair consideration of the new information.
50. Our adviser told us that a review by the original assessor is commonly used and acceptable when a service is asked to reconsider its view using additional information, provided there is no evidence of bias, and the review is properly recorded.
51. From advice received we note a different clinician is generally indicated where a formal second opinion is requested or where there has been a breakdown in the clinical relationship. Through speaking with our adviser about the review in May 2022, we note the records of this review addresses the new information and gives a clear rationale, which is consistent with a fair review.
52. We recognise Mr E would have preferred a different clinician and feels that this was unfair and resulting in a lack of impartiality.
53. After reviewing the information we have received, we consider arranging the review with the same psychiatrist was within acceptable practice from the type of request made. We have not identified indications that anything went wrong in how the review was arranged or carried out. We have reviewed both the initial assessment and the review and sought advice from a clinical adviser and consider both the assessment and review were conducted in accordance with the relevant guidelines.
54. As a result of our findings, we will not take any further action on this point of complaint.