Reducing overdiagnosis and disease mongering in ADHD in Lombardy

In practice, clinicians’ subjectivity plays a role in mental health diagnosis1 and in the wide variation in prescription rates by country, region, and even in the same city.2 As Thomas and colleagues point out,3 practice guidelines on attention-deficit/hyperactivity disorder (ADHD) recommend performing a medical, psychosocial, and developmental evaluation to define severity, but leave it up to individual clinicians to rate impairment. Unfortunately, classifications (such as mild, moderate, and severe) are academic rather than useful approaches in practice.

In June 2011, an ADHD registry was set up in Lombardy, and each of the 18 reference centres accredited by the regional health authorities must guarantee a strict diagnostic assessment of the disorder before treatment, as well as systematic monitoring during treatment. A working group defined an evidence based pathway consisting of six mandatory steps. These include a complete psychopathology overview using the schedule for affective disorders and schizophrenia for school age children (K-SADS), as well as quantification of symptoms and global functioning severity using the clinical global impressions scale for severity (CGI-S) and children’s global assessment scale (C-GAS), respectively. It was agreed, approved, and shared by all centres. Training sessions and discussion meetings were organised for the reference centres’ clinicians, and educational events were also provided for community paediatricians, families, and other health professionals.

In this context, the prevalence rate of ADHD was stable at around 0.5% in 6-17 year olds, and from 2011 to 2012 drug use decreased—from 24% to 16% of patients. Thus, “overdiagnosis and disease mongering” can be limited if adequate resources are available, appropriate training is undertaken, and patients’ interests in care guide decisions.