GPs will be a great help for managing ADHD medications. But many patients will still need specialists

The New South Wales government^[1] this week announced reforms that will allow some GPs to treat and potentially diagnose attention-deficit hyperactivity disorder (ADHD).

This aims to make ADHD care more accessible and less expensive and follows changes^[2] in Western Australia and Queensland, which have increased GPs’ role in diagnosing and prescribing for ADHD.

Previously, only specialists (usually paediatricians and psychiatrists) could diagnose ADHD and prescribe the most commonly used ADHD stimulant medications.

This reform comes on the back of evidence^[3] of extensive wait times for ADHD care^[4] and costs too high for many people.

But while up-skilling GPs to treat ADHD will benefit many patients, some people with more complex cases will still need to see a specialist.

What’s planned for NSW?

Under this new framework, the NSW government proposes a two-stage plan.

In phase one, around 1,000 GPs will be trained to support the ongoing prescribing of ADHD medications.

In phase two a smaller number, about 100 GPs, will receive more intensive training to conduct ADHD assessments, make diagnoses and initiate ADHD medications.

For phase two the initial focus will be on children and adolescents and then the trial will extend to adults.

Why a diagnosis is crucial for people with ADHD

The recent Senate inquiry into ADHD^[5] highlighted growing awareness about the daily struggles of people with ADHD across Australia.

People with ADHD have serious difficulties with attention, impulsivity and hyperactivity, which impact across the lifespan and many settings where people live, learn, work and play.

ADHD is linked to many poor outcomes^[6] and is even associated with higher rates of accidental injury and death.

ADHD treatments, such as stimulant medication, has been shown be safe^[7], effective^[8] and to substantially lower risks of negative outcomes^[9]. But to receive these treatments, a person needs to first receive a diagnosis.

GPs can play an important role managing ADHD

There is also no question that GPs are more accessible than specialists, both in terms of availability and cost.

They already provide ongoing management for a wide range of chronic medical conditions such as diabetes, high blood pressure and obesity. They are highly skilled in monitoring outcomes and adjusting treatments.

With the right training, they bring many transferable skills to ADHD care. Increasing their ability to take over ongoing prescribing for people diagnosed and stabilised on treatment is low risk^[10] and has shown to be effective^[11] in a range of studies.

However, although the proposal to increase the role of GPs in ADHD care is a step in the right direction, it is not without challenges.

GPs may struggle to assess complex patients

Collaborative care involves general practitioners working with specialists and specialist teams to provide care. If GPs don’t have specialists to rely on for expert advice about ongoing management, many will choose not to provide ADHD care^[12]. Ongoing support and strong links between specialist and primary care services will be essential.

GPs may also struggle^[13] to assess and diagnose complex cases.

The vast majority of people with ADHD will have other mental health conditions^[14], but some of these other conditions (such as anxiety conditions) can also result in symptoms that appear like ADHD.

For these complex situations, specialist services^[15] with multidisciplinary teams of doctors and allied health providers (such as psychologists and occupational therapists) will still be needed.

Read more: Wondering about ADHD, autism and your child’s development? What to know about getting a neurodevelopmental assessment^[16]

To ensure high-quality care and reduce the potential for misdiagnosis and incorrect treatment, it will be even more important that specialists are available to provide additional services when required.

There is little detail currently in the NSW proposal about how specialist multidisciplinary services will be supported to ensure this happens. And funding models for this will need to be established to support existing guidelines.

Bringing GPs into the assessment and diagnosis to initiate treatment is positive but comes with added pressures to manage assessment and treatment.

There are many cases in the media^[17] of poor diagnostic process, where patients were misdiagnosed with conditions such as ADHD after inadequate assessments. These practices may be driven by financial rewards and a poor application of evidence-based guidelines.

Could this lead to over-diagnosis? Or correct under-diagnosis?

In Australia, the debate about whether ADHD is under- or over-diagnosed is ongoing. There reality is that there is almost certainly a mixture of both.

The real rates of ADHD are estimated at around 7% in Australian children^[19] and 2.5% in adults^[20]. While these rates have remained stable for many years, the rates of clinical diagnosis and treatment have increased dramatically, particularly in young women.

Around 6% of children and adolescents^[21] currently receive ADHD medications, similar to the actual rates of ADHD in the population. For adults, the rates of ADHD medication use remain low for those over 45 years. For those between 18 and 44 years, rates now sit at around 2%.

One interpretation of these figures is that most children, adolescents and adults with ADHD are now getting the support they need.

However, if we remember the strong evidence that many Australians are struggling to access ADHD care, particularly in under-resourced, regional and remote areas, the more likely answer is that a combination of “misdiagnosis” and “missed diagnosis” means that sometimes diagnoses are not done correctly.

This highlights the importance of focusing on the need for accurate assessment as the cornerstone of high quality ADHD care. In its answer to the question of who should assess and diagnose ADHD, the Australian ADHD guideline^[22] focuses on training and skills rather than which profession conducts the assessment.

There is no reason that GPs cannot develop these skills, but they will require adequate training and ongoing support to do so, and they will need time to commit to these assessments.

Finally, we need to make sure medication is not the only option available. Research shows ADHD medications provide effective treatment. But they should never be the only form of treatment offered^[23].

Sadly, reports^[24] show medical treatments are relied upon more frequently in more disadvantaged communities where access to other supports can be difficult.

These reforms will do little to increase access to psychological and allied health supports to ensure the right care can be provided to people with ADHD.

Read more: GPs could improve access to ADHD treatment. But we still need specialists to diagnose and start medication^[25]

References

1. ^{^} New South Wales government (www.nsw.gov.au)
2. ^{^} changes (www.nsw.gov.au)
3. ^{^} evidence (bmjopen.bmj.com)
4. ^{^} extensive wait times for ADHD care (theconversation.com)
5. ^{^} Senate inquiry into ADHD (www.aph.gov.au)
6. ^{^} many poor outcomes (journals.sagepub.com)
7. ^{^} safe (jamanetwork.com)
8. ^{^} effective (www.sciencedirect.com)
9. ^{^} negative outcomes (journals.sagepub.com)
10. ^{^} low risk (jamanetwork.com)
11. ^{^} effective (www.sciencedirect.com)
12. ^{^} ADHD care (www.tandfonline.com)
13. ^{^} may also struggle (www.tandfonline.com)
14. ^{^} mental health conditions (theconversation.com)
15. ^{^} specialist services (theconversation.com)
16. ^{^} Wondering about ADHD, autism and your child’s development? What to know about getting a neurodevelopmental assessment (theconversation.com)
17. ^{^} media (www.bbc.com)
18. ^{^} Alex and Maria photo/Shutterstock (www.shutterstock.com)
19. ^{^} 7% in Australian children (youngmindsmatter.thekids.org.au)
20. ^{^} and 2.5% in adults (www.sciencedirect.com)
21. ^{^} 6% of children and adolescents (www.aihw.gov.au)
22. ^{^} Australian ADHD guideline (adhdguideline.aadpa.com.au)
23. ^{^} only form of treatment offered (adhdguideline.aadpa.com.au)
24. ^{^} reports (www.aihw.gov.au)
25. ^{^} GPs could improve access to ADHD treatment. But we still need specialists to diagnose and start medication (theconversation.com)