It seems like almost everyone has a friend who has recently been diagnosed with attention deficit hyperactivity disorder (ADHD). As a GP working in suburban Melbourne, what had been an occasional topic patients broached is now a conversation I’m having multiple times a week.
So what has changed, and what does it mean for our health and health system?
ADHD is a developmental condition, present from childhood, broadly involving issues with inattention, hyperactivity and impulsivity. There is an increasingly recognised subtype characterised by inattention without the other features. The stereotypical presentation is a child who is restless and a bit chaotic in their behaviour and struggling to meet their potential at school.
Where I’m seeing growth is not so much among children, but rather among adults. The accepted wisdom is that highly functional adults can compensate for their ADHD until something upsets the apple cart. This might be running up against a task that surpasses their organisational strategies; a move from high school to the more self-directed learning of tertiary study; a shift away from the support structures of living with family; or a loss of the environmental cues and structures that had borne them along.
The last three years have seen the classroom, workplace and home amalgamated into one porridgy, ill-defined singularity, with added mental, financial and social stress. It’s no wonder people started looking inwards when they didn’t immediately “bounce back” with the end of lockdowns.
There can also be a snowball effect of symptom recognition. With swathes of algorithmic social media where people relate their experiences, or by talking to friends and hearing their stories, it’s easy to see why people might identify with signs such as reading sentences off a page without absorbing any of it, forgetting a pin number that’s been used for a decade or feeling overwhelmed by the noise, sights and smells returning to the grocery store, school or office.
As with most mental health conditions, the defining factor for diagnosis is the degree of dysfunction the person faces. Is their education faltering? Is it impacting their work? Are their relationships suffering?
Don’t get me wrong: most of the people who come in wanting to explore an ADHD diagnosis meet the criteria and then some. But where does that leave them? And where does it leave a mental health system where wait times to see a psychiatrist were already teetering on untenable, before living through a global pandemic made us all feel that bit more vulnerable?
The conventional wisdom is that the mainstay of management of ADHD is behavioural and psychological strategies, but when patients come in interested in a diagnosis, they’ve often pursued these avenues and are looking at medication options – and that’s where we hit a snag.
Legislative requirements vary between state and territories, but from a Victorian context, medication requires a diagnosis by a psychiatrist (retrospective to before 18 years of age, if scripts are to be subsidised under the Pharmaceutical Benefits Scheme), and either initiation of medication by the psychiatrist or deputisation of a GP through a written plan, that the GP can then use as supporting evidence to apply for a permit to prescribe. These permits can be held for up to two years.
In the halcyon days, I could provide a referral to a psychiatrist with confidence that it was someone whose opinion I valued and trusted, who I had corresponded with professionally and received that most invaluable of endorsements: positive patient feedback.
Now, if my patients have any hope of being seen, I’ve increasingly needed to refer to someone I haven’t worked with before. The path of least resistance for patients is to pursue a diagnostic review through a Medicare item 291, whereby the psychiatrist provides their diagnosis and a plan of action to allow the GP to treat. To meet this demand, a number of telehealth services have sprung up.
The “going rate” for most of these single-appointment assessments appears to be an out-of-pocket cost of $200-400 – already placing it out of the reach of many patients. Depending on the service, costs can be in excess of $1,100. Some such assessments have provided me not with a clear insight into the patient’s situation and the medication options best suited to them, but rather a list of the medications that are used for ADHD, with a seemingly somewhat cynical view to ticking the box for prescribing requirements.
I’m not confident this always leaves me or my patients any better off.
So what advice can I offer? Firstly, caveat emptor – do your research, and ask your GP or psychologist which services they have confidence in. Second, the feeling of urgency for action in the “I think I might have ADHD” presentation can lead to hasty decisions. I encourage you to consider laying your foundation through work with a psychologist, and consider waiting to see a specialist we can vouch for.