1. Introduction: Treatment Does Not End at the Right Dose
For adults receiving medication for ADHD, treatment does not end once the right medication and dose have been established. ADHD is a long-term neurodevelopmental condition, and treatment should continue to be reviewed to make sure it remains effective, appropriate and safe as a person’s health, circumstances and treatment goals change.
Regular review gives patients and clinicians an opportunity to look beyond the repeat prescription and consider the wider picture: whether symptoms remain adequately controlled, whether medication is lasting for the required part of the day, whether adverse effects have emerged, and whether changes in physical health, mental health, work, education or family life mean that the treatment plan should be reconsidered.
In Ireland, the HSE ADHD in Adults Model of Care includes continuity of care and annual review of ADHD-specific medication as part of the recommended adult ADHD pathway. NICE guidance similarly recommends that ADHD medication is reviewed at least annually by a healthcare professional with appropriate expertise in ADHD. [1,2]
NICE recommends that ADHD medication is reviewed at least once a year by a healthcare professional with appropriate expertise in ADHD.
2. Why Regular ADHD Medication Review Matters
ADHD medications can provide substantial improvements in attention, impulsivity, organisation, emotional regulation and day-to-day functioning for appropriately selected patients. However, the clinical response to medication can change over time.
A medication or dose that worked well when treatment began may not always remain the best option several years later. Changes in employment, education, family responsibilities, sleep, physical health, mental health or other medication can all affect how ADHD treatment works in everyday life.
ADHD medication includes stimulants such as methylphenidate and lisdexamfetamine, as well as non-stimulant treatments such as atomoxetine and, in appropriate circumstances, guanfacine. These medications require ongoing assessment of both benefit and potential adverse effects.
An annual review is therefore much more than a prescription renewal. It is an opportunity to ask a fundamental clinical question: is the current treatment still providing the right balance of benefit, tolerability and safety for this individual?
3. What Is an ADHD Annual Review?
An ADHD annual review is a structured clinical review for somebody who has already been diagnosed with ADHD and is established on treatment. It is different from the original ADHD diagnostic assessment and is also different from medication initiation or titration, where appointments may be considerably more frequent while the appropriate medication and dose are being established.
The annual review does not normally involve repeating the entire diagnostic process. Instead, the clinician considers the person’s current ADHD symptoms, functional impairment, medication response, adverse effects, physical and mental health and ongoing treatment goals.
NICE recommends reviewing ADHD medication at least once a year and discussing whether treatment should continue. The review should take account of the individual’s clinical circumstances rather than follow a one-size-fits-all approach. The HSE Model of Care for adults with ADHD similarly describes annual review as part of continuity of treatment for people who remain on ADHD medication.
4. What Does an ADHD Annual Review Cover?
A comprehensive review considers both how well the medication is working and whether it continues to be safe and appropriate. The clinician will usually explore the person’s current ADHD symptoms and how these affect everyday functioning. This includes whether medication is providing adequate benefit during work, education, family life and other daily activities, how long the benefit lasts during the day, and whether there are periods of breakthrough symptoms or rebound as the medication wears off.
The current dose and formulation should also be considered. Some people remain stable on the same treatment for many years, while others may benefit from an adjustment in dose, timing or medication preparation as their circumstances change.
Functional improvement is particularly important. Successful ADHD treatment is not measured simply by a reduction in symptom scores. The wider clinical question is whether treatment is helping the person function more effectively in areas that matter to them, including employment, education, relationships, organisation, emotional regulation and everyday responsibilities.
5. Monitoring Side Effects and Physical Health
An annual review should also consider potential adverse effects of ADHD medication. Depending on the medication and the individual, this may include appetite changes, weight change, sleep disturbance, headaches, gastrointestinal symptoms, cardiovascular symptoms, anxiety, agitation, mood changes or other medication-related concerns.
Physical-health monitoring is not something that should occur only once a year. NICE recommends monitoring heart rate and blood pressure before and after clinically relevant dose changes and at least every six months during ADHD medication treatment. Weight should also be monitored regularly in adults, with further assessment where clinically significant weight change occurs.
This distinction is important. The annual specialist review and routine physical-health monitoring are complementary parts of care, rather than the annual appointment replacing monitoring throughout the rest of the year.
Further investigation, including cardiovascular assessment, may be appropriate when indicated by symptoms, medical history, examination findings or other clinical concerns. Routine ECG testing is not required for every person simply because they are taking ADHD medication.
6. Mental Health and Comorbidity
ADHD frequently occurs alongside other mental-health or neurodevelopmental conditions, and these can change independently of the ADHD itself. An annual review therefore provides an opportunity to consider whether there have been changes in anxiety, depression, mood, emotional regulation, sleep, substance or alcohol use, or other psychiatric symptoms.
The clinician should also review significant changes in physical health and other prescribed or non-prescribed medication. This is particularly important because new medical conditions or medications can alter the risk-benefit balance of an existing ADHD treatment. Where new symptoms have developed, the aim is not automatically to attribute them to ADHD or to medication. They should be assessed in their wider clinical context.
7. The Patient’s Experience and Treatment Goals
One of the most important parts of an annual review is understanding the patient’s own experience of treatment. Some people may be very satisfied with their current medication and wish to continue without changes. Others may feel that the medication does not last for long enough, causes unwanted adverse effects or no longer fits their daily routine.
The review provides an opportunity to discuss whether the patient wishes to continue their existing treatment, adjust the dose or formulation, consider an alternative medication, explore non-pharmacological interventions or, where clinically appropriate, consider a supervised reduction or treatment break.
These decisions should be made collaboratively. The goal is not simply to keep somebody on medication indefinitely, nor is it to stop medication simply because treatment has continued for a long time. The decision should be based on clinical benefit, impairment, adverse effects, safety, individual preference and overall treatment need.
8. Who Should Have an Annual ADHD Medication Review?
Adults with ADHD who remain on pharmacological treatment should receive regular clinical follow-up, including at least annual review of their ADHD medication. This includes people prescribed stimulant medication such as methylphenidate, lisdexamfetamine or dexamfetamine, as well as non-stimulant treatment such as atomoxetine or guanfacine where clinically appropriate.
The principle applies regardless of whether the original ADHD diagnosis was made through an HSE service or by an appropriately qualified private provider. The HSE Adult ADHD Model of Care specifically describes people whose medication has stabilised being followed by their GP for prescribing and physical-health monitoring, with those remaining on ADHD medication recalled for specialist review.
If medication has continued for a prolonged period without specialist review, it is reasonable to discuss with the treating clinician or GP whether an updated ADHD medication review is appropriate.
9. ADHD Annual Reviews and Primary Care in Ireland
The HSE Adult ADHD National Clinical Programme has established a model for specialist adult ADHD services in Ireland. The HSE Model of Care describes a pathway in which specialist ADHD services initiate and stabilise medication and, where appropriate, patients subsequently receive continued prescribing and physical-health monitoring through their GP. The same model includes annual specialist review for people who remain on ADHD-specific medication, with the outcome communicated to the GP and other relevant treating services.
Access to specialist adult ADHD services, however, remains variable across Ireland. The HSE continues to develop and implement its national adult ADHD programme, and the availability of specialist assessment and follow-up can differ according to geographical area and local service capacity. For patients who cannot readily access specialist follow-up through the public pathway, appropriately governed private specialist services can provide another route to clinical review.
10. Should ADHD Tests Be Repeated Every Year?
An annual medication review does not mean repeating the entire ADHD diagnostic assessment every year. Standardised rating scales can nevertheless be useful when they answer a specific clinical question. NICE recommends considering the use of standard symptom and adverse-effect rating scales during treatment, but these measures should complement clinical assessment rather than replace it.
10.1 Adult ADHD Self-Report Scale — ASRS
The Adult ADHD Self-Report Scale, or ASRS, is a widely used measure developed in collaboration with the World Health Organization. It can help quantify current ADHD symptoms and, when used appropriately, may provide useful information about change over time. The ASRS is best viewed as one source of information within a wider clinical assessment. A score by itself does not determine whether medication should be continued, altered or stopped.
10.2 QbTest
QbTest is a computer-based objective assessment that measures aspects of attention, impulsivity and motor activity. It may be useful in selected patients when an objective longitudinal measure could provide additional information about symptom burden or medication response.
Research in adults has demonstrated measurable changes in QbTest parameters during stimulant treatment, while a systematic review of studies using QbTest for treatment monitoring concluded that it can provide useful objective information about medication response in both short- and longer-term treatment.
However, QbTest should be used as an adjunct to clinical assessment, not as a standalone measure of whether treatment is successful. Subjective experience, everyday functioning, adverse effects, physical health and the clinician’s overall assessment remain essential.
The decision to use the ASRS, QbTest or another instrument should therefore depend on the clinical question and circumstances of the individual patient rather than simply repeating every assessment annually.
11. What Happens Before an ADHD Now Annual Review?
Before an ADHD Now annual review, patients may be asked to provide updated information about their current ADHD symptoms, medication and dose, duration of benefit, adverse effects and overall treatment response. Relevant physical-health information may also be requested, including blood pressure, pulse and weight where appropriate. The clinician will also need to know about changes in sleep, appetite, physical health, mental health, other medications and any significant changes in the patient’s personal, educational or occupational circumstances. Providing this information before the consultation allows the appointment to focus on the areas that are most clinically relevant.
12. What Happens During the Review?
During the consultation, the specialist assesses how well treatment is currently working and whether there have been any significant adverse effects or changes in physical or mental health. The clinician considers current ADHD symptoms and functional impairment, the duration and consistency of medication benefit, adherence to treatment, tolerability, cardiovascular and other relevant health information, concurrent medication and the patient’s own experience and treatment goals.
Where appropriate, standardised measures or objective assessments may be incorporated into the review. The outcome will depend on the individual. For some patients, no treatment change will be required. For others, the clinician may recommend adjustment of the dose or formulation, additional monitoring or investigations, consideration of another medication, non-pharmacological support or, where appropriate, a supervised reduction or discontinuation of treatment.
13. What Happens After the Review?
Following the consultation, the outcome can be documented in a clinical report or letter to the patient’s GP. This may confirm the diagnosis and current medication, summarise treatment effectiveness and tolerability, document relevant physical and mental-health findings, and provide recommendations regarding ongoing medication and monitoring. Clear communication between the specialist, patient and GP is particularly important when prescribing is being undertaken in primary care.
For individuals who do not yet have a formal diagnosis, the first step is a comprehensive adult ADHD assessment. To understand pricing and the wider pharmacological route, the adult ADHD medication portal sets out the full treatment pathway, and for coordinating care with your local practitioner, the GP support hub explains how shared-care arrangements work in Ireland.
14. Shared Care and ADHD Medication
Once medication has been titrated and the dose is stable, ongoing prescribing may involve primary care through an appropriate shared-care or collaborative-care arrangement.
NICE recommends shared-care arrangements with primary care after medication titration and dose stabilisation. The HSE Adult ADHD Model of Care similarly describes specialist initiation and stabilisation of medication followed, where appropriate, by continued prescribing and physical-health monitoring through the GP, alongside specialist annual review.
The exact arrangement can vary between clinicians, GP practices and healthcare services. Responsibilities for prescribing, physical-health monitoring and specialist review should therefore be clearly communicated between those involved in the patient’s care.
15. Keeping Long-Term ADHD Treatment Safe and Effective
ADHD treatment should remain active, individualised and periodically reassessed rather than continuing indefinitely without clinical review. For many people, an annual specialist medication review will simply confirm that their existing treatment continues to work well and remains appropriate. For others, the review may identify an opportunity to optimise the dose, alter the duration of medication coverage, change preparation, investigate an adverse effect or incorporate additional psychological, occupational or lifestyle interventions.
The purpose of annual review is therefore not to create another administrative hurdle for people receiving ADHD treatment. It is to make sure that treatment continues to meet the needs of the individual. Regular specialist review, combined with appropriate physical-health monitoring between appointments, provides a structured way to ensure that ADHD treatment continues to deliver meaningful benefit while remaining safe, evidence-based and clinically appropriate.
Works Cited
- National Institute for Health and Care Excellence. (2018, subsequently updated). _Attention deficit hyperactivity disorder: diagnosis and management (NG87)_. Recommendations include ongoing monitoring of ADHD medication, cardiovascular monitoring, review of treatment at least annually, and shared-care arrangements following dose stabilisation. [LINK]
- Health Service Executive. (2021). _ADHD in Adults: A Model of Care for Ireland_. National Clinical Programme for ADHD in Adults. The Model of Care describes specialist adult ADHD assessment and treatment, medication initiation and stabilisation, GP prescribing and physical-health monitoring, and annual review for people remaining on ADHD medication. [LINK]
- Kessler, R.C., Adler, L., Ames, M., et al. (2005). _The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population_. _Psychological Medicine_, 35(2), 245–256. doi:10.1017/S0033291704002892. [LINK]
- Bijlenga, D., Jasperse, M., Gehlhaar, S.K., & Kooij, J.J.S. (2015). _Objective QbTest and subjective evaluation of stimulant treatment in adult attention deficit-hyperactivity disorder_. _European Psychiatry_, 30(1), 179–185. doi:10.1016/j.eurpsy.2014.06.003. [LINK]
- Gustafsson, U., & Hansen, M. (2023). _QbTest for Monitoring Medication Treatment Response in ADHD: A Systematic Review_. _Clinical Practice and Epidemiology in Mental Health_, 19, e17450179276630. doi:10.2174/0117450179276630231030093814. [LINK]