Key People: Professor Steven Marwaha
Background: Attention-Deficit/Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder involving inattention, hyperactivity and impulsivity that starts in childhood and frequently persists into adulthood. Stimulant and non-stimulant medication are the mainstay of treatment in adults. ADHD in adults is commonly comorbid with bipolar disorder (bipolar) and psychosis. There is substantial uncertainty over the effectiveness of stimulant and non-stimulant medication in adults with ADHD and comorbid psychosis or bipolar. There is also concern that they could trigger psychotic or manic symptoms. A randomised controlled trial (RCT) is needed to address this evidence gap.
Aims and Objectives: The aim of the study is to evaluate the clinical and cost-effectiveness of stimulant compared with non-stimulant medication for adults with ADHD and a history of either psychosis or bipolar. Primary objective: To evaluate separately in adults with 1) ADHD and a history of psychosis and 2) ADHD and a history of bipolar, whether stimulant vs. non-stimulant medication reduces ADHD symptom severity at 12 months. Secondary objectives: To evaluate separately in adults with 1) ADHD and a history of psychosis and 2) ADHD and a history of bipolar the impact of stimulant vs. non-stimulant medication: a] on ADHD symptom severity at 6 months; b] on the emergence of symptoms of bipolar or psychosis over 12 months; c] on health-related quality of life, occupational, functional, substance misuse and other outcomes at 6 and 12 months; d] on cost-effectiveness
Methods: We will complete a pragmatic, observer-blind, multi-centre, stratified, 2-arm, parallel group, RCT comparing Lisdexamfetamine (stimulant) with Atomoxetine (non-stimulant). Strata are defined according to a history of: (1) bipolar or (2) psychosis. 648 participants will be recruited in total, meaning there will be 324 participants with ADHD and bipolar, and 324 with ADHD and psychosis. We include an internal pilot with clear progression criteria that will be independently assessed for each stratum. Participants will be recruited from mental health Trusts / Health Boards in the Midlands, London and South East, the North East and Scotland. A PPI co-applicant and lived experience advisory panel will aid the study throughout. The analysis will be on an intention to treat basis and use ADHD symptoms measured at 12 months post-randomisation as the primary outcome. The primary analysis of all outcomes will be based on the separate treatment effects for each stratum. A health economic trial-based analysis of the cost-effectiveness of Lisdexamfetamine vs. Atomoxetine medication will be undertaken for each stratum. The trial will take 58 months to complete.
Impact: We will provide definitive evidence as to the clinical and cost-effectiveness of Lisdexamfetamine vs. Atomoxetine in the treatment of adults with ADHD and a history of psychosis or bipolar, as well as the risks of adverse events associated with each medication. The results will provide clear guidance to NICE, clinicians and service users. Given that untreated ADHD is associated with poor clinical outcomes, unemployment and criminal justice system involvement, clear effectiveness evidence in this area is likely to improve recovery for individuals with ADHD and a history of psychosis or bipolar, reduce costs for the individual, the NHS and society