Where does an overburdened mental health system leave patients diagnosed with ADHD? | Nicholas Hudson
IIt seems almost everyone has a friend who has recently been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). As a GP working in suburban Melbourne, what used to be an occasional topic brought up by patients is now a conversation I have several times a week.
So what has changed and what does it mean for our health and our healthcare system?
ADHD is a developmental condition, present from childhood, largely involving problems with inattention, hyperactivity and impulsivity. There is an increasingly recognized subtype characterized by inattention without the other characteristics. The stereotypical presentation is of a restless and somewhat chaotic child struggling to achieve his or her potential in school.
Where I see growth is not so much in children, but more in adults. The accepted wisdom is that highly functioning adults can make up for their ADHD until something upsets the apple basket. This might come up against a task that goes beyond their organizational strategies; a shift from secondary school to the more self-directed learning of higher education; an abandonment of the support structures of family life; or a loss of environmental landmarks and the structures that had supported them.
Over the past three years, the classroom, workplace, and home have coalesced into a porous, ill-defined singularity, with added mental, financial, and social stress. It’s no wonder people started to withdraw into themselves when they didn’t immediately “bounce back” with the end of the lockdowns.
There may also be a snowball effect of symptom recognition. With swathes of algorithmic social media where people tell their experiences, or talking to friends and listening to their stories, it’s easy to see why people might identify with signs such as reading sentences on a page without absorbing any of them, forgetting a PIN that’s been in use for a decade, or feeling overwhelmed by noise, sights, and smells returning to the grocery store, school or in the office.
As with most mental health issues, the determining factor for diagnosis is the degree of dysfunction the person is dealing with. Is their education failing? Does this have an impact on their work? Are their relationships hurting?
Don’t get me wrong: most people who want to explore an ADHD diagnosis meet the criteria, and then some. But where does this lead them? And where does that leave a mental health system where wait times to see a psychiatrist were already unsustainable, before living through a global pandemic made us all feel a little more vulnerable?
The conventional wisdom is that the mainstay of ADHD management is behavioral and psychological strategies, but when patients are interested in a diagnosis, they’ve often followed these avenues and are considering medication options – and that’s where we run into a problem.
Legislative requirements vary by state and territory, but in a Victorian context, drugs require diagnosis by a psychiatrist (retrospective before age 18, if scenarios are to be subsidized under the Pharmaceutical Benefits Scheme), and either initiation of medication by the psychiatrist or back-up by a GP through a written plan, which the GP can then use as supporting evidence to seek authorization to prescribe. These permits can be held for up to two years.
In good times, I could provide a referral to a psychiatrist with the certainty that it was someone whose opinion I valued and trusted, with whom I had corresponded professionally and received the most invaluable approvals: positive feedback from patients.
Now, if my patients have any hope of being seen, I increasingly need to refer to someone I’ve never worked with before. The path of least resistance for patients is to pursue a diagnostic examination via Medicare Article 291, in which the psychiatrist provides their diagnosis and a plan of action to enable the GP to treat. To meet this demand, a number of telehealth services have emerged.
The “regular rate” for most of these single-appointment assessments seems to be a $200-400 cost, which already puts it out of reach for many patients. Depending on the service, costs can exceed $1,100. Some of these reviews provided me with not a clear overview of the patient’s situation and the medication options best suited to them, but rather a list of medications used for ADHD, with a seemingly somewhat cynical view of ticking off the box for prescription requirements. .
I’m not sure that always leaves me or my patients better off.
So what advice can I offer? First, caveat emptor – do your research and ask your GP or psychologist which services they trust. Second, the sense of urgency to act in the “I think I might have ADHD” presentation can lead to hasty decisions. I encourage you to consider laying the groundwork by working with a psychologist and to consider waiting to see a specialist that we can vouch for.