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Opinion

The answer to psychiatric and child development waitlists


Andrew Leech


12/04/2024 4:15:26 PM

Allowing trained GPs to initiate stimulant prescriptions for ADHD would help families and clinicians, writes Dr Andrew Leech.

Doctor talking to upset child
Many patients cannot access paediatric care due to extensive waitlists.

As I reflect on another week of seeing families stuck in a circle of trying to find a paediatrician or psychiatrist to help their child, only to end up on a waitlist or be told to call back in a year, I now realise one key element in this giant puzzle that would potentially improve the entire health system.
 
We urgently need to de-regulate stimulant prescribing for GPs and provide a clear, consistent guideline nationwide for the treatment of ADHD.
 
It’s confusing – I can easily prescribe morphine and all of its various substitutes, medicinal cannabis, benzodiazepines and other highly addictive medications, with little to no training. But after years as a GP working with families in child and adolescent health, I’m unable to prescribe medication that we know from research is at least 70% effective for children with diagnosed ADHD.
 
With the advances in technology and the inception of ‘safe script’, we’re far better off than we have ever been in making sure both GPs and patients are acting safely with medications that could be potentially at risk of abuse.
 
It’s appalling to think that we’re delaying a diagnosis and treatment purely because only two types of medical specialists can do it. How is this fair to families?
 
We already have a workforce of GPs interested in neurodevelopment, child development and mental health, potentially in the thousands across Australia, ready and able to support families.
 
Recent child health webinars hosted by RACGP Specific Interests have had around 1000 GPs attending, which demonstrates considerable interest in wanting to be supported and trained.
 
Many who have reached out to our ADHD working group are willing to be involved in any way possible but are limited by the rigid state prescribing rules.
 
I propose that the RACGP be funded to provide training and accreditation to GPs under the guidance of primary health alliances around the country.
 
This should not be a ‘free for all’ process and GPs would need similar approvals to other potentially risky medications such as methadone, Yellow Fever vaccination and hepatitis C treatments.  
 
But what doesn’t seem to be acknowledged is that this seemingly cheap, accessible, ready-to-go-now option continues to be delayed.
 
Anecdotally, I’ve heard these barriers are in place due to the risk of over-prescribing and over-diagnosing, the lack of knowledge and training that GPs might have, and the fact that ADHD is far more complex than what it may seem on the surface.
 
I don’t dispute any of these concerns. ADHD never exists on its own, and there are usually precipitants such as mental health or trauma, genetic elements, and other comorbid conditions.
 
But I have to ask – who is better placed to help these patients than a GP?
 
We see the whole family.
 
We understand the impact of disease on the child and the siblings and parents, and we see children over a lifespan.
 
We’re also trained to recognise disease patterns early on and have a long-term relationship that gives us a unique lens into what might be happening.
 
Whether it’s ADHD, bullying, anxiety, or, more importantly, whether we are missing a health condition such as obstructive sleep apnoea, epilepsy (which was a cause in one of my paediatric patients), endocrine disorders, malnutrition and iron deficiency or hearing deficits to name a few, GPs can look at all possible causes of the child’s symptoms and broadly consider why there are difficulties with learning or development.
 
Even after an ADHD diagnosis and treatment initiation, most paediatricians send children back to the GP for monitoring of side effects. We are well equipped to do this; it’s not hard work.
 
It’s also revealing to hear from parents that diagnosis and treatment consultations are often quick due to how busy the paediatrician is, to the point where they didn’t know how the medication worked and what to look out for. While the above may not be true for all paediatric specialists, the pressure on them to see patients is so high right now that there’s less time than ever for education or follow-up.
 
This is not to say paediatricians and psychiatrists don’t do this work. They do and are necessary in caring for children with neurodevelopmental or complex health needs.
 
The problem is many patients can no longer access paediatric care because unnecessary regulatory rules disempower primary healthcare providers from providing a diagnosis and treatment of what is an increasingly common concern for parents.

Waitlists-article.jpg
Dr Andrew Leech has proposed that the RACGP be funded to provide training and accreditation that would allow GPs to initiate stimulant prescriptions for children with ADHD.
 
Rather than overwhelming paediatricians and psychiatrists with patients who could be safely managed in general practice, we need them to be more available for those with concerns beyond our scope.
 
I’d like to finish with an example of this. I’ve been helping a 15-year-old girl, Charlotte*, whose mental health has been deteriorating, with severe symptoms of OCD, body dysmorphia and depression with anxiety.
 
I needed secondary support, but the six referrals sent to private psychiatrists were all rejected as Charlotte sits in the difficult category of being too old for a paediatric psychiatrist and too young for adult psychiatry, where many won’t start seeing patients until 17 or 18.
 
In the time since those referrals were rejected, Charlotte’s condition has deteriorated to the point where she is now self-harming and having suicidal thoughts. She fears needing to go to the emergency department, but we have spoken about this possibility and emphasised that if she is in acute crisis, she does need to go.
 
Her family even increased her insurance coverage to allow private admission, but despite my phone calls, no private hospital could admit this age group.
 
Charlotte is fortunate enough to have family support, but is still isolated and cannot leave her home or go to school. I’m not skilled enough to handle her complex mental health on my own, but I can’t access psychiatric care for her.
 
How is this happening in a country with so many resources and dedicated health workers?
 
My theory is in addition to Charlotte’s age, psychiatrists and paediatricians are so inundated with referrals for ADHD and autism they can no longer deal with other mental health issues, which further backs my argument and solution: empower GPs to help with ADHD.
 
Ironically, allowing GPs to prescribe stimulants will make us also less busy.
 
The repercussions and repeated attendances of non-diagnosed children and teenagers currently occupy a significant amount of my time. Presentations are all too common now and range from non-school attendance, defiance, bullying, being misunderstood in the classroom, and lack of engagement with psychology or OT as they cannot sit or focus on therapy, through to family dysfunction from a child who is emotionally dysregulated and challenging to deal with.
 
What about those minors in detention or prison who have untreated ADHD? Could this have been prevented? I’m currently treating adolescents post-incarceration who clearly have untreated ADHD, and the impulsiveness of their condition has contributed to them making poor decisions and imprisonment.
 
I’m not exaggerating, just passing on what I see.
 
ADHD treatment is effective and evidence based. Whether we like it or not, the rates of diagnosis are rising.
 
A consequence of our current generation or an increase in awareness? More research is still needed.
 
But knowing that we have medication which does help children and improves lives should be enough to at least get started.
 
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Dr Anna   13/04/2024 8:04:29 AM

I still think ADHD is a difficult one. It’s one of the only diagnoses that a lot of parents are actually very eager to get. I feel that this means the diagnosis is likely to be problematic in primary care.
I’ve had parents who are very unaccepting of other diagnosis such as anxiety.
The whole issues of Telehealth diagnosis is adults is also a minefield with little or no onus on the diagnosing psychiatrist to make the ‘difficult’ decision of not diagnosing ADHD. I’ve never seen a negative result in any patient who has requested an ADHD diagnosis despite some people who had the diagnosis rejected in the past by a face to face psychiatrist.
Really difficult area. We need more face to face psychiatrists and paediatricians.


Dr Brendan Sean Chaston   13/04/2024 9:20:00 AM

I agree with appropriate training we should be able to prescribe stimulant medication. However I don’t believe it should be their regular GP. There needs to be a therapeutic separation. This model could be applied to many areas of limited medical access. Essentially referring within general practice. Many benefits - meets demand, removes treating in isolation, allows sub-specialty consolidation within general practice, allows more definitive management within general practice hence improves society perception of general practice. Improves Gp satisfaction. Society values special skills not general skills. I think some degree of sub specialisation would go a long way in rectifying the current crisis we now face. This would not be hard to achieve within a reasonably quick timeframe.


Dr Henry Arthur Berenson   13/04/2024 9:34:07 AM

Better still, take ADHD out of the DSM and manage it like any other GP condition. Refer when you need a second opinion, not because you are deemed untrustworthy to prescribe.


Dr Duncan MacWalter   13/04/2024 10:15:38 AM

We need 'top of scope' prescribing for GPs.


Dr Tavia Goodison   13/04/2024 10:21:50 AM

Agree 100% Andrew. I mainly manage adults with ADHD as often children we are just filling scripts between paediatric appointments. I'm very fortunate to have a partnership arrangement with one of the local psychiatrists who does the official diagnosis and then I takeover management and do all ongoing monitoring. I do tend to send more complex patients to psychiatrists with availability for ongoing care but I see far too many simply managed patients on stable long term medication having their care managed entirely by a specialist when this is entirely within our scope, and we are cheaper and more easily accessible for the often inevitable forgotten appt or late script. Also we are able to closely monitor and react to cardiovascular risk that the literature suggests can be worsened with stimulant use. It is also disappointing that some of our colleagues refuse to prescribe stimulants. It is in our scope and it is in our patients best interests.


Dr Rebecca Helen Monahan   13/04/2024 11:26:00 AM

Yes! Wholeheartedly agree. How can we make this happen?
Even adults who we can assess and commence on treatment while they are on waitlist for psychiatry assessment. They would also benefit.


Dr James Andrew Best   13/04/2024 12:01:36 PM

entirely agree Andrew. I hope the colleges back you on this, and eventually the regulators. Families are suffering unnecessarily because of this.


Dr Scott David Arnold   13/04/2024 1:53:17 PM

I agree, in so many fields of medicine a lot of specialist time and expertise is consumed by conditions that could have been managed by GPs who had cultivated a special interest. It would be nice to see specialist time freed up so that cases that can't be managed by a GP can receive the care they need promptly.


Dr Kwan Leung Chia   13/04/2024 4:58:11 PM

ADHD and ASD are far too common nowadays. GPs see a lot but cannot make diagnosis even there are clear criteria from DSM. If there are accreditation programs for GP to become qualified ADHD and ASD diagnostician then things become simplified. Allied health professionals can train to become qualified ASD diagnostician so why GPs cannot?


Dr Wai Lee   13/04/2024 8:09:06 PM

The ADHD management issue is a huge problem, with more patients and psychologists being aware of it and asking for support. I see the problem with trying to get kids into paediatricians here in North Qld, with waiting lists of 18 months for private specialists probably as long if not longer than the public system. Don't bother trying to get an adult into a private psychiatrist locally. Telehealth options that patients have to pay generally $1000 for the process still take at least 3-9 months.
I can understand the children in incarceration having ADHD. I work in drug and alcohol rehab and see many of our clients treating themselves for years unknowingly with drugs (mainly ice) and wondering why it doesn't affect them the way it does their friends. I too wonder if they had managed to get treatment earlier, would their life trajectory be much different.
I also believe GPs are well placed to manage this with some upskilling and we could save people time and improve their lives.


Prof Max Kamien, AM. CitWA   13/04/2024 11:44:09 PM

In the 1970s I was the sole psychiatrist in the Far-West of NSW and I made this diagnosis twice. In the 1990’s I was a GP providing medical services to a nearby private school. One in six of the senior students were on amphetamines or Ritalin. The paediatric diagnosis of ADHD had become an epidemic. For some parents it provided an explanation for their child’s poor scholastic performance.

GPs are not idiots and it is demeaning to be told by single discipline specialists, that we cannot be trusted to prescribe Ritalin or amphetamines. Especially so, when some specialist s started the epidemic but cannot cope with the specific needs of the population.

One hundred GPs could clear the waiting lists in my state in three months to the medical and financial satisfaction of their patients with the bonus of ongoing care from the doctor who knows them.


Dr Paul Michael Coughlan   14/04/2024 9:24:39 AM

Thanks for a thought provoking article .Much as per RACGP response to scope of practice review I think we need to be wary of convenience over quality. If we prescribe , we will b expected to be able to diagnose.Without access to Ed Psych , PaedsOT , Social work or Paeds Psych this risks over medicalising a complex multifactorial issue.Give us a multidisciplinary team , and we may function as consultants , but be very wary of extending the Community Intern role.We are already having to wean kids started on psychostimulants trials with minimal multidisciplinary input.We need to avoid a Tavistock-like situation with neurodiversity. Access to appropriate multidisciplinary resources in Primary Care Practice must come first .


Dr Sanjeevan Nagulendran   14/04/2024 10:03:22 AM

Following the murder of shoppers in Bondi Junction and the shooting of a mentally unwell patient who held up practice staff in Nowra we can see our healthcare system is in utter chaos- especially the mental healthcare system.
Some of my patients have had to fly to India as the care they have received in our mental health system is so poor.
Urgent training is required for GP's and psychiatrists to improve outcomes and keep the community safe.
Australia has double the suicide rate of the UK and events such as those above and the rampant failure of the courts to deal with the growing illicit drug trade in Australia which is behind the mental health pandemic is a national disgrace.
According to the ABC's four corner episode 'cocaine nation' Judges are taking cocaine. Its also worth watching the ABC's 4 corners 'please dont judge'.
Someone needs to clean up this whole rotten system for the rest of of us who want to live safely in a law abiding country.


Dr Paul Michael Coughlan   14/04/2024 6:26:57 PM

https://www.psychiatrictimes.com/view/conversations-critical-psychiatry-allen-frances-md
" The easiest, and most mindless, part of psychiatry is prescribing meds; be good at it, but not limited by it".

Wisdom from the Author of DSM IV , no less. (NOT a fan of DSM V)


Dr Tim Jones   15/04/2024 5:27:52 PM

Hi Andrew. Thank you for raising so many valid points and I certainly concur that families are suffering. In my specific interest work in a public paediatric neurodevelopmental/behavioural clinic I am struck by the complexity of presentations and in particular the social and structural overlaps. I certainly think that general practice can be a major part of the solution here but would hope that taking on more and more management of stable paediatric patients with ADHD and agreeing on discharge criteria from public and private clinics for this patients could allow diagnosis to remain with our paediatric colleagues and enable them to do their jobs better also.