Access to adult ADHD treatment under scrutiny

For Perth GP Dr Sean Stevens, this week’s Four Corners on the ABC made for essential viewing.
 
Fronted by Dr Norman Swan, the program reported new prescription data to estimate the rate of adult attention deficit hyperactivity disorder (ADHD) diagnoses across the country.
 
It found dramatic rises in many areas, most notably in Western Australia, where Fremantle showed the highest proportion of prescriptions for ADHD treatment anywhere in the country.
 
As of June 2024, that stood at 4.4% of adults and more than 6% for women aged 44 and under – a level that Dr Swan speculates could now ‘be getting beyond the accepted ADHD prevalence’, which is defined by the program at between 2.5% and 3%.
 
Prescription rates in other areas, including swathes of south-west Sydney, were much lower than the estimated prevalence of ADHD, suggesting that missed diagnoses may be more of an issue.
 
Dr Stevens, who is Chair of the RACGP WA ADHD working group, found the ABC program ‘reasonably balanced’ and raised important concerns.
 
‘They point out that your postcode and your income is a determinant of how likely you are to get an ADHD diagnosis, which is very true, particularly in the adult space,’ he told newsGP.
 
For the high rates in Fremantle, he notes the data pre-dates GPs’ involvement in diagnosing and prescribing for ADHD patients and believes its wealth, along with good awareness of the condition, are likely to have contributed.
 
‘Western Australia has for decades had the highest rates of stimulant prescribing. There were some forerunners, adult psychiatrists and paediatricians, in Western Australia that led the nation in the identification and management of ADHD,’ he said of the trends more broadly.
 
‘We’re still seeing some of the effects of that.’
 
He notes the Australasian ADHD Professionals Association (AADPA) includes a different adult prevalence rate of between 2–6%.
 
The Four Corners episode also considers the likely impact of recent changes across many jurisdictions, which have paved the way for GPs to continue ADHD medications, as well as undergo training to diagnose and initiate prescriptions.
 
Dr Tim Senior, the Chair of RACGP Specific Interests Poverty and Health who works at the Tharawal Aboriginal Corporation in an area of Sydney where diagnoses are notably low, appears in the Four Corners episode expressing concerns around equity of care.
 
‘The Medicare system funds shorter consultations quite well, but longer consultations much less well,’ he said.
 
‘So, I worry that the incentives aren’t there and that will worsen the gap.
 
‘GPs taking it on in better-off areas will be able to charge co-payments to patients and not hit practice viability.
 
‘In areas where most patients can’t afford a co-payment, that can be a big hit to practice revenue for employing practice nurses, receptionists, practice managers, and could affect the viability of a practice in areas where patients can’t afford to pay a co-payment.’
 
Those concerns are ‘a very real issue’ for Dr Stevens, although he notes that in Western Australia, GPs working in regional, rural, remote and lower socioeconomic areas, along with Aboriginal-controlled health services, ‘had been deliberately prioritised’ in the rollout of ADHD training.
 
‘Speaking to my colleagues in Queensland who have been doing this for some time, they say that an initial diagnosis is usually made over two one-hour appointments,’ he said.
 
‘So even if you use [MBS] item 123, that’s a lot lower than doing four or five level B consults, particularly when you add the bulk-billing incentive.
 
‘It does provide a disincentive to this slow, comprehensive medicine.
 
‘It just adds weight to the college’s call for better remuneration for longer consults, because otherwise you are going to see a lot of GPs steering away from this or having to charge large gaps, which goes against the idea of increasing the number of diagnosticians and continuing prescribers.’
 
Telehealth was also put under the Four Corners spotlight, particularly online clinics largely dedicated to ADHD treatments – another ‘valid concern’, according to Dr Stevens.
 
‘Not all telehealth providers are bad and sometimes for remote patients, telehealth is the only option,’ he said.
 
‘But unfortunately there are some operators that are relying too much on questionnaires.
 
‘You really need a detailed assessment, running through all of the 18 DSM-5 criteria for ADHD, and you have to have evidence of impairment or disability as a result of those symptoms. 
 
‘If you’re relying just on questionnaires and it’s a quick tick-and-flick and only looking at ADHD and none of the other criteria, then you’re doing the patient a disservice.’
 
In a separate segment, Dr Swan probes the main existing clinical guideline, produced by AADPA, pointing out more than 100 consensus-based recommendations, as well as the use of studies funded by pharmaceutical companies.
 
Dr Stevens says like many areas of medicine, the science behind ADHD diagnoses and treatment is evolving.
 
‘The guidelines that the AADPA put together are a summation of the best evidence that’s out there at the moment,’ he said.
 
‘Where the evidence is not clearcut or you don’t have a randomised control trial, then you do need to build by consensus. 
 
‘And their guidelines are very open and honest about that, they’re not trying to hide that fact. That’s not to say that they’re not going to change over time. 
 
‘No doubt they will review as more evidence comes out, both in Australia and internationally. 
 
‘It’s a very good start.’
 
In the meantime, he calls for consistency to make changes to GPs’ scope of practice work as effectively as possible – an area the RACGP has been strongly advocating for.
 
‘One of the key things that needs to happen is national harmonisation,’ he said.
 
‘We really need to see the rules right across Australia having the same age of initiation, the same training, and we need to see some funding for training for GPs to be able to do this. 
 
‘If we look at Queensland, any GP has been able to diagnose and initiate down to the age of four since 2017, but very few have taken it up because they haven’t had the training. 
 
‘We need state and federal governments to step up and really help with robust training for GPs to be able to do this job well.’ 
 
The Federal Government has set a target of 30 June this year for setting nationally consistent prescribing rules to enable GPs to initiate, change and continue ADHD medications for both adults and children.

 
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