Implementation and Results of a Protocol Created by Amaha for ADHD Assessment in Adult Psychiatric Practice: A Quality Check Study

Abstract

Objective:

This study aimed to evaluate the implementation and adherence to a standard operating protocol for the assessment and initial management of Attention-Deficit/Hyperactivity Disorder (ADHD) in adults within a large mental health organisation in India (Amaha).

Material and Methods:

A retrospective clinical audit was conducted on 200 client cases assessed for Adult ADHD using the Diagnostic Interview for ADHD in Adults (DIVA-5) between January and September 2024. Data regarding adherence to protocol steps were collected via a structured questionnaire completed by 10 treating psychiatrists based on clinical notes in the electronic record system. A random 8% sample was verified for accuracy, revealing a 12.5% discrepancy rate.

Results:

High adherence was observed for several protocol steps: 92% (n=184) of initial consultations were conducted by the treating psychiatrist, an informant was present in 98.5% (n=197) of DIVA assessments, and 94% (n=188) of clients received psychoeducation post-assessment. 87% (n=174) of assessed clients met criteria for ADHD. Comorbidity was present in 54.5% (n=109), with depression (47.7% of comorbid cases) and anxiety (31.8% of comorbid cases) being the most common. Current substance misuse was reported in 20.5% (n=41). Methylphenidate was the most common prescribed medication (52.9% of prescriptions). Therapy was recommended in 64.8% (n=130). Areas for improvement included timeliness of DIVA assessment (30% >1-month post-intake) and completeness of report uploads (16% missing from the system).

Discussion & Conclusion:

The standardised protocol demonstrates generally strong implementation in key areas of adult ADHD assessment within this setting. Findings highlight high rates of diagnosis and comorbidity. Key recommendations and directions for the future are discussed.

Introduction

Attention-deficit/hyperactivity disorder (ADHD) has been increasingly recognized and diagnosed in adulthood in recent years.^1,2 Meta-analyses have shown that this might not be reflective of any actual increase in prevalence but rather due to an improvement in the understanding of adult ADHD and its diagnosis. The prolific spread of mental health information on social media in recent years, particularly around buzzwords such as “trauma” and “attention-deficit,” has led to many people previously unaware of their challenges being linked to actual symptomatology, now seeking clarification and treatment. ³ A recent review focused on the Indian population indicates that India has a high prevalence of childhood ADHD, and this will very likely pose a burden on the mental healthcare system in the coming decades, with a large portion of these cases growing into adult ADHD. ⁴ However, diagnosing adult ADHD has not been an easy task for clinicians; the intricacies of differential diagnoses for adult ADHD, clinical blindness, inexperience, clinical prejudice, and treatment hesitancy are among many reasons why, ⁵ as well as challenges arising from medication weaknesses. ⁶ Considering these issues, a clear protocol for identifying, diagnosing, and treating adult ADHD would be a significant aid for clinicians in an organizational setting, seeing a high volume of cases.

Recognizing this, Amaha, a large-scale mental health organization based in India, implemented a standardized protocol outlining guidelines for assessing and managing adult ADHD (Nallur, this issue, 2025). This study aimed to conduct a clinical quality audit of the protocol’s implementation within the organization. The primary objective was to assess the degree of psychiatrists’ adherence to the established clinical guidelines, evaluate the consistency of diagnostic practices (specifically the use of the Diagnostic Interview for ADHD in Adults [DIVA] and informant involvement), and examine the application of key initial management steps (comorbidity assessment, psychoeducation, medication considerations, therapy referral, and documentation).

Material and Methods

A retrospective clinical audit design evaluated psychiatrist adherence to the organization’s standardized protocol for adult ADHD assessment and treatment initiation. The audit focused on the clinical practice of 10 psychiatrists employed at Amaha between January 2024 and September 2024 (9 months duration). Data pertained to adult clients (≥18 years old) who underwent a DIVA-5 assessment conducted by these psychiatrists during the specified timeframe. For one psychiatrist who had exited the organization before data collection, data were extracted from clinical records and entered by their supervisor and another audit team member. The organization’s data team generated a comprehensive list of unique client identifiers for all individuals who completed a DIVA-5 assessment between January 1, 2024, and September 30, 2024, stratified by the assessing psychiatrist. This list served as the sampling frame. All identified cases within this period (N = 200) were included in the audit, representing a census of DIVA assessments conducted during the timeframe.

Procedure

Key parameters for the audit were defined based on the essential components outlined in the organization’s adult ADHD assessment and management protocol (Nallur, this issue, 2025), which was informed by standard clinical guidelines and relevant literature. ⁷ A structured questionnaire was created using Google Forms to capture data related to the defined parameters. The questionnaire covered the clinical pathway from the initial consultation through diagnosis and initial intervention steps. Specific questions that were assessed:

Clinician conducting the first session (treating psychiatrist vs. other).

Time elapsed between initial client intake or registration and the DIVA assessment.

Duration and mode (online or in-person) of the first meeting and the DIVA assessment session.

Presence and relationship of an informant during the DIVA assessment.

Outcome of the DIVA assessment (ADHD diagnosis: Confirmed, not confirmed, or inconclusive).

Assessment and identification of psychiatric or medical comorbidities.

Provision and documentation of psychoeducation following the assessment.

Assessment and documentation of current and past substance use history.

Uploading of the completed DIVA assessment report to the organization’s electronic health record system (TWA).

Provision of the assessment report to the client.

Medication prescription decisions (type of medication, if any; ADHD-specific vs. other).

Clinician-reported medication compliance (if prescribed).

Referral for psychotherapy (yes or no, reason if no).

Client attendance or engagement in therapy (if referred within the organization).

Each participating psychiatrist (or the designated personnel for the exited psychiatrist) received the list of their respective client identification numbers (IDs). They completed the online questionnaire by reviewing the clinical notes documented in the therapist web application (TWA) system for each case. To assess the accuracy of the data entered via the questionnaire, a random sample of 16 responses (8% of the total N = 200) was selected. A senior clinician not involved in the primary care of these specific 16 cases independently reviewed the corresponding clinical records in TWA and compared them against the questionnaire responses. Discrepancies were identified in 2 of the 16 verified responses, resulting in a 12.5% discrepancy rate in this verification sample.

Data Analysis

Data exported from Google Forms were analyzed using descriptive statistics. Frequencies and percentages were calculated for each categorical variable corresponding to the audit parameters. Results were summarized to describe adherence rates to the different protocol components and to characterize the diagnostic outcomes, comorbidity patterns, and initial treatment steps for the audited sample.

Results

A total of 200 client cases assessed via DIVA-5 between January and September 2024 by 10 psychiatrists were included in the audit. The caseload distribution varied, with one psychiatrist accounting for 25% (n = 50) of the audited assessments.

Adherence to Assessment Protocol

1. Initial Consultation: In 92% (n = 184) of cases, the initial consultation was conducted by the same psychiatrist who subsequently performed the DIVA assessment, adhering to the protocol.

2. Timeliness of DIVA Assessment: Thirty percent (n = 60) of clients had their DIVA assessment more than 30 days after their initial intake or registration with the organization. In 5.5% (n = 11) of cases, the DIVA was conducted on the same day as the intake or served as the first session. The majority (96%, n = 192) had at least a 30-minute evaluation session before the DIVA assessment.

3. Mode of Assessment: The DIVA assessments were conducted online in 40.2% (n = 80) of cases and in-person in 37.7% (n = 75). The mode was not documented or retrievable for 22.1% (n = 44) of cases (primarily those handled by the exited psychiatrist).

4. Informant Presence: Adherence to the protocol requirement of having an informant present during the DIVA assessment was very high, occurring in 98.5% (n = 197) of cases. Documentation regarding informant presence was missing for the remaining 1.5% (n = 3).

5. Informant Relationship: Among the 197 cases with an informant, the informant was a primary caregiver (e.g., parent) in 83.5% (n = 167). Other informants included direct observers from childhood (e.g., sibling, relative, friend; 10.5%, n = 21) or a spouse or partner (3%, n = 6). The relationship was not specified in 3% (n = 6).

Diagnostic Outcomes and Comorbidity

• DIVA Outcome: Based on the DIVA-5 assessment, 87% (n = 174) of clients were diagnosed with ADHD; 12.5% (n = 25) did not meet the criteria, and 0.5% (n = 1) had an inconclusive result documented.

• Comorbidity: A comorbid mental or physical health condition was identified and documented in 54.5% (n = 109) of the audited clients. Among these 109 clients with comorbidities:

• Depressive symptoms or disorder were noted in 47.7% (n = 52).

• Anxiety symptoms or disorder were noted in 31.8% (n = 35).

• Non-psychiatric medical conditions were present in 14% (n = 15).

• Features suggestive of autism spectrum disorder were noted in 6.5% (n = 7).

• Substance Use: A history of substance misuse (past or current) was reported in 33% (n = 66) of clients. Specifically, 20.5% (n = 41) reported current substance misuse, and 12.5% (n = 25) reported past misuse. The majority (65.5%, n = 131) reported no history of substance misuse, and status was unknown or not documented for 1.5% (n = 3).

Adherence to Post-Assessment Procedures

• Psychoeducation: Psychoeducation regarding the assessment results and diagnosis was documented as provided in 94% (n = 188) of cases. It was documented as not done in 1% (n = 2) and incomplete (pending follow-up) in 1% (n = 2). Documentation was missing or unclear for 4% (n = 8).

• Report Documentation and Sharing: The completed DIVA assessment report was successfully uploaded to the internal electronic record system (TWA) in 84% (n = 168) of cases, indicating a 16% gap in documentation compliance. Reports were shared with the client (electronically or physically) in 93% (n = 186) of cases.

Treatment Initiation

• Medication Prescription: Following the DIVA assessment, ADHD-specific or other psychotropic medication was prescribed by the assessing psychiatrist in 51.8% (n = 104) of the audited cases. Of these 104 clients who received a prescription:

• Methylphenidate was prescribed in 52.9% (n = 55).

• Atomoxetine was prescribed in 27% (n = 29).

• Other non-ADHD-specific psychotropic medications (e.g., antidepressants, anxiolytics) were prescribed in 19.6% (n = 20).

• Medication Compliance: Among the 104 clients prescribed medication, compliance was reported as “good” by the psychiatrist in 60.6% (n = 63). Non-compliance was noted in 15.8% (n = 16), and compliance status was unknown or not documented in 23.6% (n = 25).

• Therapy Referral and Uptake: Referral for psychotherapy was made in 64.8% (n = 130) of the 200 cases. Reasons documented for not referring included the client seeking assessment only (10%, n = 20), client unavailability or declining ongoing treatment (9%, n = 18), or the client already being engaged in therapy elsewhere (11%, n = 22). Documentation was missing for 5.2% (n = 10).

• Therapy Attendance (Internal Referrals): Of those referred for therapy within Amaha, the clinician’s report indicated that 59% attended at least one session. Regular attendance was reported for approximately 70 clients. Non-attendance after referral occurred in 20% of referred cases, and irregular attendance was reported for 23 clients.

Discussion

This clinical audit provides a quantitative evaluation of the implementation of a standardized protocol for adult ADHD assessment and initial management within Amaha. The findings indicate that the protocol has been largely adopted, with high rates of adherence observed for several critical components designed to ensure thorough and evidence-informed practice.

The strengths of the implementation include the consistent involvement of psychiatrists in the initial consultation (92%) and the near-universal inclusion of an informant during the DIVA assessment (98.5%). These practices align strongly with expert recommendations emphasizing the need for comprehensive psychiatric evaluation and the crucial role of collateral information in validating self-reported symptoms and developmental history in adult ADHD diagnosis.^7,8 The high rate of primary caregivers serving as informants (83.5%) likely enhances the reliability of the childhood history obtained. Furthermore, the provision of psychoeducation following assessment was commendably high (94%), reflecting a commitment to patient engagement and shared understanding, which is vital for treatment adherence. ⁸

The diagnostic yield of 87% among individuals undergoing the DIVA assessment suggests that the organization’s initial screening or referral pathways effectively identify clients with a high likelihood of having ADHD. The substantial rate of documented comorbidity (54.5%), predominantly depression and anxiety, is consistent with extensive literature on adult ADHD ⁹ and highlights the clinical reality of managing complex presentations. The significant proportion reporting current substance misuse (20.5%) further underscores the necessity of routine screening and integrated treatment planning, as recommended by the protocol.

These critical elements were identified and fostered into regular clinical practice due to the involvement of clinicians with expertise in ADHD and training in global standards of ADHD management. The larger goal of this protocol was to establish standards of practice for adult ADHD care with the in-house clinician cohort, and it has demonstrably done so.

Despite these positive findings, the audit identified specific areas requiring attention and improvement. The finding that 30% of DIVA assessments were conducted more than 1 month after the client’s initial intake points to potential bottlenecks or delays in accessing specialized assessment. A potential reason for this delay is the client identifying and then agreeing to bring an appropriate collateral historian to the DIVA session. While the reasons were not explored in this audit, other factors such as clinician availability, scheduling processes, or administrative hurdles may contribute and warrant further investigation to improve timely access to diagnosis. The organization has been served with recommendations on managing and removing some of these bottlenecks.

Documentation practices represent another area for enhancement. The 16% gap in uploading completed DIVA reports to the central electronic health record system poses risks related to continuity of care, internal communication, and future audits. Ensuring consistent and complete documentation is essential for quality assurance and clinical governance. Similarly, the lack of documentation regarding medication compliance in nearly a quarter of prescribed cases (23.6%) suggests a need for more systematic follow-up and recording of adherence information.

The audit also highlights challenges related to treatment engagement post-diagnosis. This too is a challenge that is not organization-specific, but a confounding factor from the socio-cultural context of the country as well. While psychotherapy was recommended for the majority (64.8%), the reported drop-off in attendance (only 59% of those referred internally attended at least one session, with lower rates of regular attendance) suggests the influence of well-known pre-existing barriers. These could range from patient factors (e.g., motivation, cost, time constraints) to system factors (e.g., availability of therapists, ease of scheduling). The organization recognizes that understanding and addressing these barriers is crucial for translating diagnosis into effective multimodal treatment, and is working to mitigate some of these hypothesized barriers.

Limitations

This audit is subject to several limitations. First, its reliance on clinician self-report via questionnaire, based on existing clinical notes, introduces potential for recall bias and reporting inaccuracies, as evidenced by the 12.5% discrepancy rate found during the verification process. Second, the retrospective data entry for one psychiatrist (accounting for 25% of cases) by other staff members, necessitated by their departure, may have introduced errors despite efforts to ensure accuracy, potentially impacting the overall findings. Third, the operationalization of some questionnaire items (e.g., “regular” therapy attendance, medication “compliance”) lacked strict definitions, leaving room for subjective interpretation by the reporting clinicians. Fourth, the findings are specific to one organization in India and may not be generalizable to other settings or healthcare systems. Final, this audit focused on process adherence and did not assess the clinical appropriateness of diagnoses, long-term patient outcomes, or patient satisfaction with the assessment process. Subjective bias in the original clinical encounters (e.g., clinician judgment, client reporting) could also influence the diagnostic rates observed.

Conclusion and Recommendations

In conclusion, this clinical audit demonstrated that the standardized protocol for adult ADHD assessment and initial management at Amaha is being implemented with generally good fidelity in several key areas, including psychiatrist involvement, informant use, comorbidity screening, and psychoeducation. The audit successfully identified specific strengths and areas for targeted quality improvement.

Recommendations include: (a) Investigating and addressing the causes of delays between intake and DIVA assessment to improve timeliness; (b) reinforcing protocols and potentially implementing checks to ensure consistent uploading of assessment reports to the electronic health records (EHR); (c) developing more systematic methods for monitoring and documenting medication adherence; (d) exploring barriers to therapy uptake and engagement post-referral and implementing strategies to improve linkage to care; and (e) providing ongoing training and calibration for clinicians regarding protocol components and documentation standards, potentially including clearer definitions for subjective items such as compliance and attendance. Future audits could incorporate patient-reported outcomes and satisfaction measures, as well as explore the impact of the protocol on clinical outcomes over time.