Research published today highlights that allowing GPs to prescribe ADHD medication isn’t enough.
A February rule change expanded the prescribing of ADHD stimulant medication beyond psychiatrists and paediatricians to GPs and nurse practitioners.
Earlier research estimated that only 60% of Kiwi kids with ADHD are prescribed medication.
The proportion was lower among adults, falling to a third of 18 to 49-year-olds and just 9% of 50 to 70-year-olds.
Adult ADHD assessments have often involved long wait times.
Allowing more doctors and nurses to prescribe medication for ADHD was intended to reduce bottlenecks and help meet the demand, but a viewpoint article published today in the New Zealand Medical Journal says there has been “limited discussion of the practical requirements”.
The researchers state the clinical framework for ADHD “provides high-level guidance”, but “lacks operational detail”.
They write: “Recommendations that clinicians possess ‘expertise’ in ADHD assessment or be supervised by an experienced clinician are not supported by mandatory training requirements, competency standards or quality assurance mechanisms.
“Further, reference to ‘validated diagnostic tools’ is not accompanied by guidance ... how clinicians should be trained to administer them or what constitutes adequate assessment.”
One of the authors, academic GP Steven Lillis, told the Herald: “It’s an immense change in the prescription framework.
“And personally I just don’t think it was thought through quite sufficiently. The bottleneck of getting an assessment remains.”
Lillis told the Herald it was not simply a matter of having a standard 15-minute GP consultation and emerging with a bottle of Ritalin.
The paper notes a comprehensive ADHD assessment usually takes a couple of hours – time that is difficult to come by in a primary healthcare system under strain.
Internationally, GPs aren’t confident to diagnose and prescribe for ADHD and the researchers note it is likely New Zealand doctors feel the same.
Diagnosing ADHD can be challenging. More than 60% of adults with ADHD have other psychiatric or neurodevelopmental conditions, such as PTSD and anxiety, and many of those conditions have symptoms similar to ADHD.
Publicly funded psychiatric services rarely have capacity for adult ADHD assessments.
Lillis told the Herald the lowest-cost pathway at present is a psychological assessment combined with a GP who is willing to prescribe on the basis of that assessment – a process that costs around $800 or $900.
“I think that there should be an agreed and shared pathway,” Lillis said, adding the process should be consistent whether someone lived in Northland or Southland, and whether they were Māori or Pākehā.
“The second that you have that, you can suddenly do lots of research because you know everyone’s come through the same pathway. Now you can start to figure out how are we doing with our ADHD.
“But the other thing that happens is, if there’s an agreed pathway, it stops what has happened in the UK, where you get cowboy clinics being set up, where, you know, everybody who goes to the clinic gets a diagnosis of ADHD and gets put on medication, which is not good.
“If there is agreement around those things, it means that a group of psychologists could say, ‘Hey, we can streamline this’.
“A big practice can say ‘We can train one of our practice nurses to do these assessments’. And suddenly the cost starts to go down.”
Lillis told the Herald that seeing patients with untreated ADHD motivated him to get involved in the research.
“There’s a lot of people out there who actually deserve better than what’s happened.
“Everything that’s happened has been well-meaning, but I’ve seen so many people with untreated ADHD and I am so aware of just how difficult it is.”
Lillis said improved prescribing was just one part of the puzzle.
“We need to look at the others.
“It’s having the assessment, getting the assessment done at a decent price, getting the psycho-education and getting the medications.”
Chris Knox is a scientist turned data-journalist who investigates the stories behind the numbers and creates interactives for Herald readers to explore them.