ADHD: Initiation, modification and continuation of psychostimulants by specialist GPs

3.1 Specialist GPs can improve access to ADHD diagnosis

The current access to ADHD diagnosis and management for many patients is inadequate. There are several barriers to patients receiving timely diagnosis, including difficulty in accessing non-GP specialists (psychiatrists and paediatricians), costs to patients, and unclear referral pathways.

Most public sector mental health services do not provide ADHD services, resulting in an over-reliance on private sector care and services.¹⁷  GPs referring patients for diagnosis report significant delays in appointments to see non-GP specialists including paediatricians, psychiatrists, and psychologists, and often several appointments are needed before diagnosis can be confirmed. These delays exceed 6 months in urban areas and can be 12-16 months in rural and remote areas, compounded by long travel distances. Longer waiting times of 12 -24 months have been reported, even in urban areas.

Receiving a diagnosis for adult patients with ADHD may be even more difficult as they don’t have access to the paediatric services which can support children. Adult ADHD can often be more difficult to recognise compared to childhood presentations.

There are financial barriers to receiving a diagnosis, with patients often paying significant out-of-pocket costs, and many patients (particularly those living in rural and remote areas) needing to travel long distances, sometimes interstate, to see a specialist with availability. Many adults cannot afford to pay to see a psychiatrist, so they are unable to have their diagnosis confirmed and are unable to access pharmacological treatment. Children whose parents are unable to afford the costs may wait longer for assessment and diagnosis, which can lead to poorer educational outcomes¹⁸. This cost barrier increases health inequity. People on low incomes are unable to access care and are disproportionately affected by poor access to care. Given there is a social gradient in ADHD and that it is more common in people with low incomes, it is crucial that this cost barrier is addressed or many patients will be missed. Enabling GPs to manage more of these patients will free up psychiatrists to manage more severe mental health issues.

The RACGP-endorsed Australian Evidence-Based Clinical Practice Guideline for Attention Deficit Hyperactivity Disorder (ADHD) identifies that there can also be delays to patient diagnosis due to unclear referral pathways (for example, from GPs to other specialists and back again). 

3.2 Specialist GPs can already provide support after an ADHD assessment and can do more

Specialist GPs are highly qualified medical practitioners with more than a decade of training and are experts in managing uncertainty, complexity and prescribing. They are already frequently managing ADHD in an informal and unsupported way when they manage the co-existing mental, physical and preventive health concerns for patients with ADHD.

People living with ADHD require lifelong, individualised support. The support they need will depend on factors including any co-existing conditions and their external environment. GPs are well placed to provide the holistic care that tackles the biopsychosocial nature of ADHD.

More than two thirds of individuals with ADHD have at least one other co-existing condition.¹⁹ Common co-existing conditions include anxiety, bipolar affective disorder, behaviour disorders, Tourette Syndrome, autism spectrum disorder, sleep disorders, and depression. This list is not exhaustive. People living with ADHD require individualised care which also diagnose and manage these conditions alongside the ADHD.

The environment the patient is living in influences the supports available to that patient. Coordination of care is vital and specialist GPs are the best placed healthcare professional to undertake this role through chronic condition management plans and relevant Medicare items. It is essential that people living with ADHD have a comprehensive care plan which is regularly reviewed and has input from a multidisciplinary team.

Psychostimulant medication is a Schedule 8 medicine and allows for maximum script durations of six months. This creates additional barriers for those living in rural and remote areas who need to travel to major centres to access a non-GP specialist to renew their prescriptions.

Specialist GPs should seek individual advice from their medical indemnity insurer when making significant changes to the nature of their practice.

3.3 Diagnosis of ADHD in Aboriginal and Torres Strait Islander People

Prevalence of ADHD in Aboriginal and Torres Strait Islander people is unclear, but it is likely to be more common because of the clear social gradient seen worldwide in ADHD. Culturally safe identification, diagnosis and treatment of ADHD in Aboriginal and Torres Strait Islander people is important. The National Aboriginal Community Controlled Health Organisation (NACCHO) recommends the development of culturally appropriate ADHD diagnostic tools for Aboriginal and Torres Strait Islander people and building the capacity of the ACCHO sector to support culturally safe diagnosis.^20,21,22,23

Some Aboriginal and Torres Strait Islander people may fear and be reluctant to access services for assessment and treatment of ADHD because of discrimination, racism, and ignorance that may have influenced their past experiences of accessing mental health support.

Assessment needs to consider physical, mental, emotional, social, cultural, family, and Country connections. Cultural factors associated with psychosocial and environmental functioning, cultural elements, and power differentials in the relationship between the person and the practitioner must be taken into consideration in an overall cultural assessment.^24,25,26,27

Consideration of cultural, pharmacological, and non-pharmacological interventions need to occur, and the wishes of families, parents, and people with ADHD must be considered in the choice of treatment options so that they are culturally sensitive and tailored to the people involved. Pharmacological interventions need to be explained carefully with an awareness of potential cultural issues.

It is also important to note that neurodevelopmental disorders such as ADHD may be underdiagnosed in Aboriginal and Torres Strait Islander communities due to cultural and systemic barriers in accessing appropriate healthcare services. This underdiagnosis could contribute to the over-incarceration of Aboriginal and Torres Strait Islander children who may be struggling with unmanaged symptoms. The RACGP recognises that 63% of young people aged 10-17 in detention are Aboriginal and/or Torres Strait Islander people and that they experience detention at relatively younger ages than non-Indigenous young people.²⁸

4.1 State and territory variations

The barriers to a greater role for GPs in providing expanded ADHD healthcare are primarily regulatory. Stimulant medications are Schedule 8 (controlled) medicines and each state and territory in Australia has their own laws and regulations surrounding the prescription of stimulants. This creates confusion and challenges for people moving interstate, living in border areas, and where access to non-GP specialists is difficult. Departmental administrative workloads can affect the timely review of GP prescribing authority requests; meaning patients can be initiated on a medicine by a GP and then be required to stop it months later when the GP hasn’t received their authority approval.

Restrictive models of care.

State regulations regarding ADHD diagnosis and assessment vary. Generally, this is limited to paediatricians, psychiatrists and psychologists. In some jurisdictions:

• GPs can apply for a permit to initiate stimulants in children (by implication, diagnose ADHD)
• GPs can apply for a permit to prescribe under delegation from a paediatrician/psychiatrist.

In Queensland, GPs have been safely initiating and continuing stimulant medications to patients aged 4 to 18 years since 2017. In other jurisdictions, GPs cannot provide a diagnosis or prescription of stimulant medication for a patient with ADHD.

This is a rapidly changing landscape as other jurisdictions review their models. More information is available on the Australasian ADHD Professional’s Association’s webpage on ADHD Stimulant Prescribing Regulations & Authorities in Australia & New Zealand or click on the state/territory below for more specific information about prescribing restrictions in each area:

• Australian Capital Territory
• New South Wales
• Northern Territory
• Queensland
• South Australia
• Tasmania
• Victoria
• Western Australia

Shared care models

Shared care models vary by jurisdiction because regulations on whether GPs can diagnose ADHD or prescribe stimulant medications vary in different States and Territories.

The development of shared care arrangements, for example in the form of clinical protocols and funding systems, would ensure GPs can access timely assistance from other non-GP specialists and allied health professionals, to support diagnosis and management and mitigate risk of both over and under treatment.

Maximum dose limits and Real Time Prescription Monitoring

The maximum dose limits vary from state to state (some have no limits), with Queensland being more restrictive than most jurisdictions. The RACGP is not aware of any evidence base for establishing these limits.

When specialist GPs prescribe Schedule 8 stimulants, they must also abide by the requirements of Real Time Prescription Monitoring in their jurisdiction. This is a safety mechanism for both prescribers and patients. Over time, there should be a review to consider transitioning these stimulants from Schedule 8 to Schedule 4 (with real time prescription monitoring).

4.2 Funding

Patient rebates are lower per minute for longer consultations, disadvantaging people who require more time with their GP, including patients with ADHD. Increased investment in longer consultations is a simple way to build additional support for these patients.

Higher patient rebates for relevant Medicare-subsidised services would improve access by reducing costs for individual patients. Relevant Medicare Benefits Schedule (MBS) items include: Standard attendances (items 36, 44, 123, 91801, 91802, 91900, 91910 and 91920), GP Chronic Condition Management Plans (items 965, 92029,967 and 92030), GP Mental Health Treatment Plans (items 2700-2701, 2712, 2715, and 2717), mental health attendances (item 2713), multidisciplinary case conferences (items 735-758) and mental health case conferences (items 930, 933, 935, 937, 943 and 945).

A general practice (or an Aboriginal Community Controlled Health Organisation) in a disadvantaged area will have more ADHD patients, due the social gradient observed internationally with ADHD.²

There are a variety of opportunities available in terms of the models for training, education and support to enable

GPs to help address the bottleneck of diagnosis and treatment, and to provide timelier, coordinated care for patients. A combination of local, state, and Commonwealth funding is likely to be needed to enable this approach. Shared care models show how GPs can work alongside other medical professionals to improve access for patients. Funding is needed to support GPs in this work and to support effective shared care models. ²

Pharmaceutical Benefits Scheme (PBS)

Medications are often more costly for adults as there are fewer medication options listed on the PBS for those who are diagnosed with ADHD in adulthood. Only two of the three long-acting stimulant medications are eligible for PBS prescribing for ADHD patients diagnosed after the age of 18 years. This means that if a medication doesn’t work for a patient, they need to pay much more to find one that works for them. This cost barrier is hardest on those on low incomes.

Medication shortages create more urgency for patients who may need their medication changed. Enabling specialist GPs to initiate, modify and continue medications will address this. The Therapeutic Goods Administration will still need to address the medication shortages issues which have been ongoing for some time.

Research

Potential areas for further research including screening tools, shared care models, effective non-pharmacological therapies and longitudinal studies. Further research into the prevalence of ADHD in Aboriginal and Torres Strait Islander populations is required, as well as a more accurate estimate of prevalence of persistence of ADHD into adulthood within the Australian context is required, together with broader research into any variations in how it might present or be more effectively managed.

5. Related policies and documents

• RACGP submission to the Senate Inquiry into assessment and support services for people with ADHD
• RACGP endorsed clinical guideline – Australian evidence-based Clinical Practice Guideline for ADHD
• RACGP submission to the Senate Inquiry into Australia’s Youth Justice and Incarceration System.
• RACGP submission to Tasmania Government ADHD Inquiry