The Senate inquiry into the diagnosis and treatment of ADHD has again put the spotlight on the role of GPs in helping people access care.
By Eric Martin
The Senate inquiry into attention deficit hyperactivity disorder has found what many GPs and patients have discovered the hard way – that there is a stark lack of services, and those that are available are invariably costly.
The RACGP has welcomed recommendations in the inquiry’s report for GPs to have a greater role in the diagnosis and management of ADHD, which affects over one million Australians.
The inquiry drew on 700 submissions and the evidence of 79 witnesses across Australia, including Perth, drawn from professional and advocacy organisations, medical professionals, people with lived experience and the WA Department of Health.
While no single cause of ADHD is known, the report noted that to the best of clinicians’ knowledge, ADHD was an interaction of genetic, social and environmental factors – and was ‘highly heritable’, with an estimated rate of transmission between 70% and 80%.
Significantly, most people are diagnosed with ADHD before 12 years of age by a paediatrician, psychiatrist or psychologist, but through learned behaviours such as masking, many people are diagnosed much later in life or not at all.
The investigating committee found that barriers to assessment, diagnosis and support services included:
- Lack of services – limited availability and long wait times for healthcare professionals to diagnose and provide medication and other supports; there was also a lack of services in the public health system, especially for adults with ADHD, and insufficient services in rural, regional, and remote areas
- High costs of services – including insufficient coverage under Medicare, the Pharmaceutical Benefits Scheme and the National Insurance Disability Scheme
- Poor consumer experiences – caused by lack of reliable information about ADHD, overly bureaucratic processes, fragmented care, inconsistent prescribing regulations, stigma and variable quality of healthcare associated with ADHD.
Access to healthcare, supports and other environmental and social factors were repeatedly highlighted as some of the most important factors in determining the impact of ADHD in adulthood.
“Throughout this inquiry the committee has heard how peoples’ experiences of accessing an ADHD medical diagnosis are generally long, difficult, expensive and time consuming, causing significant stress, anxiety and pressure on family relationships and school systems,” the report said.
“… if children can be diagnosed early and treated, they are much better able to adapt and learn strategies to manage and work with their condition, and treatments have greater impact while the mind is more malleable. Treatment from a young age is irreplaceable and will yield ongoing benefits for the rest of their life.”
The committee heard that for around 65% of people with ADHD, it coexists with another physical or mental condition, potentially increasing the complexity of a diagnosis and adding to its impact.
Common comorbidities in children included oppositional defiant disorder, learning disabilities, autism, conduct disorder, anxiety, depression and speech problems.
The Royal Australia College of Physicians noted that “poor understanding of comorbidities and contributing factors can lead to poor quality assessment, relevant assessments not being undertaken, no assessment of learning ability, or alternative issues not considered in referrals.”
All this could result in higher caseloads for health professionals, and further delays in assessment and diagnosis.
Research provided to the committee indicated that stimulant medication could reduce ADHD symptoms for 70-80% of people, but, in some cases, medication was not effective, while some people experienced undesirable side effects.
However, there were some positive experiences shared, with some attributing their experience to luck or to individual support people who helped them to access services, such as an “amazing” doctor or psychiatrist, or a “fantastic social worker”.
As one person with lived experience explained:
“Thanks to an understanding GP who said: ‘let’s look into it’ instead of ‘oh, everyone thinks they have ADHD now’ I was able to finally understand myself. After lost jobs, years of incorrect medications, a stay at a mental health hospital and so many changed jobs, I could finally understand myself.”
WA Health acknowledged that while paediatric workforce modelling showed that WA still had capacity, if the current model of service provision for ADHD were to continue, it would be inadequate to meet the growing demand for services.
“It is imperative that alternative models of care be explored, tested, and supported to assist individuals and families waiting for a diagnosis and further management,” it said in its submission.
The RACGP WA’s ADHD working group agreed:
“ADHD medicine involves taking a careful history, getting collateral histories, screening for other commonly occurring conditions, mental state and physical examinations, psycho-education, and shared decision-making. All of these are vital but time-consuming and spending longer in a GP consultation is not economically viable for GPs.”
The committee heard of cases in which clinicians would not accept an existing formal diagnosis of ADHD, instead forcing people to undergo screening and assessment multiple times by a range of health professionals.
Another key issue addressed by the report was that not all adult ADHD medications were subsidised under the PBS, and there were limitations based on both age and dosage.
The report noted that under State and Territory laws, ‘prescription of psychostimulants is generally limited to psychiatrists and paediatricians’, with varying state-based requirements. GPs and other primary care practitioners were permitted to prescribe psychostimulants in some jurisdictions, under limited conditions.
RACGP vice president Dr Bruce Willett said that many GPs were ready to help families who needed support with ADHD in a shared-care model with psychiatrists, paediatricians and allied health professionals.
“The RACGP would also welcome reducing regulatory barriers so GPs with an interest in the area and appropriate training can commence and continue prescriptions for stimulant medicines for people living with ADHD,” he said.
There was also scope for increasing rebates for longer consultations because currently it is lower per minute than shorter consultations which disadvantaged people requiring longer with their GP, including patients with ADHD.
“Increased investment in longer consultations is a simple way to build additional support for these patients,” he said.
WA Health highlighted the urgent need for comprehensive training of GPs and was in favour of greater emphasis and investment in specific training of registrars in psychiatry, paediatric and general practice, and upskilling of qualified specialists in the areas of neurodevelopmental issues, especially ADHD.
Undergraduate training and integrated and multidisciplinary care could better support more contemporary models of care.
These observations were supported by Dr Tim Leahy from the RACGP WA ADHD working group, who noted that several elements would need to be put in place for this to be successful.
These included upskilling for GPs, federal and state policy and funding, including MBS items, funding for collaboration, and communities of practice between GPs and specialists to discuss patients and to upskill, timely assistance from specialists, and the availability of other allied health and mental health supports.
The WA working group suggested that GPs should provide the majority of care for the more than 50% of patients whose care is ‘relatively straightforward.’
“There will never be enough paediatricians and specialists to address the unmet need,” the group said. “There is a real cost too, GPs not being used to their full scope. A significant number of GPs want to do more. About 1000 college GPs recently attended an ADHD upskilling course, not the usual 40 or 50.”
The Royal Australasian College of Physicians urged the Federal Government to implement the key recommendations, including supporting specialist physicians to work closely with GPs to improve the efficiency of ADHD assessments.
RACP also wants a review of specific PBS items to help improve the safety and quality of medications prescribed. President and paediatrician Dr Jacqueline Small said specialist physicians, especially paediatricians, played a critical role in delivering assessments and support for people with ADHD, and it was encouraging to see that the inquiry had adopted the college’s advice.
“As the inquiry rightfully identifies, people with ADHD across Australia continue to face many challenges and hurdles, and it is imperative that these are addressed,” she said.