Failing those we are tasked to treat — ADHD and health inequity.
The mental health condition Attention Deficit Hyperactivity Disorder, or “ADHD” seems to be one of the most controversial for psychiatrists when it comes to recent consumer agitation and media interest. Several articles quite rightly challenge the enormous costs of seeking access to a psychiatrist to confirm a diagnosis that has been made presumptively after completing a checklist or watching TikTok videos using the hashtag #ADHD. A recent BBC article states that there have been over 20 billion views of TikTok videos using the hashtag. Videos that creators believe have helped to “spread awareness and normalise the condition”.
In Australia, there has been an uproar from these same people when they are informed of the of the cost of an appointment with a psychiatrist to obtain treatment for ADHD. In Australia, only psychiatrists and paediatricians hold the key to confirming a diagnosis of ADHD and providing the access to the medications used to treat this disorder. Medications that have not changed very much over the years, molecules that resemble amphetamines and exploit the dopamine system in the CNS, producing a paradoxical effect of slowing down the racing thoughts of somebody who has ADHD, rather than inducing a hyperactive state.
Whether ADHD is a disorder requiring treatment or a “normal variant” that still requires medication to treat it remains entirely controversial. Both arguments have great investment from consumers and health professionals alike. Regardless of the argument, there is a really sinister factor that is not being addressed. That factor is health inequity, inequity that already exists but is now being driven by the very professionals that are deemed the gatekeepers to diagnosis and treatment. Psychiatrists who engage with agencies that line their pockets to the tune of $900,000 per annum to make a diagnosis of ADHD for those who are desperate to confirm what they believe, and finding over $3000 for a consultation to do so.
Now, we all want ways to work smarter, not harder. But taking advantage of a need for those confused and concerned they may have a mental health problem after being convinced by watching TikTok influencers shouldn’t really be it. Unless you have a deficit in ethical principles. Psychiatrists have a very important role here, to reassure those who believe they have a diagnosis that in fact they don’t, or treating those who do have a diagnosis that can be treated by medication. They should not be exploiting this role by racking up the fees to see them. Especially when they request referring GPs to do a lot of the grunt work, completing pre-assessment questionnaires with the patient that don’t attract a Medicare rebate, but facilitating the psychiatrist’s ability to access their rebates.
Regardless of countless initiatives and awareness, it is irrefutable that there are two systems for people in our society with mental illness. A public, run down and largely deserted system that is funded by Medicare, and an equally run down and deserted private system that is funded by our health insurance premiums. This initiative to engage psychiatrists to work for almost $1 million per annum creates a third tier and demonstrates a really concerning approach that may see other clinics pop up to take advantage of consumer demand for other mental health diagnoses. It also engages psychiatrists who no longer work for the equally run down public or private system. Even more concerning is that this third tier will not free up demand that is stretching the public and private system. Because it remains that around $3000 doesn’t buy you anything resembling ongoing care. Pre- appointment work ups and ongoing care will most definitely be handballed back to the primary care system. That’s how the clinics have been set up, exploiting Medicare item numbers only accessible by psychiatrists.
I know from clinical practice that making a diagnosis of ADHD is largely a tick box exercise. Psychiatrists cannot order dopamine levels in CSF, or image parts of the brain that appear abnormal in people with ADHD. In fact, psychiatrists don’t even know how stimulant medications work. When I made a diagnosis of ADHD as a private psychiatrist, I took a history, perused some school reports that may have demonstrated inattention or hyperactivity in the classroom, and made sure that I ticked less boxes for an alternative mental illness that can resemble features of ADHD. But the only way I could be sure was to prescribe a short course of stimulant medication, because the only way a diagnosis can be substantiated is by gauging response to doses of amphetamines. I would meet with the patient after a course of medication and decide if it was effective, after lots of questions and hearing from the patient. I would then prescribe the medication in a longer acting form and obtain a permit to prescribe 6 months’ supply. This was super helpful for those where a diagnosis had been missed over the years, but not really rocket science. I would never consider charging any more for this work than I would for managing any other mental health condition. Other disorders that caused problems with memory, thinking and concentration, such as schizophrenia or a mood disorder were just as clinically important to me.
Many of my colleagues won’t entertain working up patients with concerns about having ADHD. They merely claim, “I don’t specialise in that”, and send their own patients off to a colleague who “does see ADHD”, has a waiting list of over 18 months and will make their patient wait. Given there is only one RANZCP fellowship, I am unable to understand that some psychiatrists “see” things that others can’t. Also, I feel for the GP who has finally found a psychiatrist for their patient to see, and then has their patient return to ask for a referral for another psychiatrist that can work in conjunction with the one managing their mental illness.
When I worked in the public system I was subjected to a blanket understanding that one must never prescribe stimulants to patients as they may be abused or make a patient vulnerable to assaults to procure their medication. Despite a paediatrician making a diagnosis of ADHD and a patient demonstrating clear cut response to treatment with obvious improvements in attention and functioning. This blanket understanding was not recorded anywhere, and not based on any evidence or clinical decision making informed by research. The inevitable decline in memory, functioning and behaviours were to be ignored or ultimately the patient was to be accused of drug seeking. I remember being bullied by a clinical director in a regional area to cease prescribing stimulant medications for a patient who had been diagnosed as having ADHD as a child, and a trajectory resembling a complete train wreck as soon as the stimulants were ceased when they were discharged from the public paediatric system at the age of 18 years. I commenced a trial of medications while they were an inpatient, believing it was a safe environment to monitor efficacy. The results were observed to be positive, the response to the news that they were unable to continue with their medication not so favourable.
This month members of the binational college for psychiatrists — the RANZCP met in Perth for their annual conference. They gathered to discuss all things contemporary psychiatry and clinical practice. In what was a jam packed agenda, there was one 60 minute session on ADHD. I mentioned this to a GP friend, because I couldn’t make sense of this. If ADHD was so widespread and so many people are seeking care, shouldn’t we be talking about it? His response was that perhaps psychiatrists were unable to concentrate for that long on a topic.
The discipline of psychiatry is well overdue for a much needed branding makeover. Psychiatrists, as medical experts should be driving the explosion of talk about ADHD, and the inability to access diagnosis and treatment in a system that is already full of inequity. If 20 billion views on a social media site are to be ignored, or worse, exploited by working in clinics that only see people with extreme amounts of cash to spend on trying to work out why they are the way they are, then perhaps psychiatrists need to get on the front foot and embrace this.
It’s too late for this year’s RANZCP congress. I hope I see some colleagues trying to educate and temper what sounds like claims that would not pass a pub test, or a welcome drinks chat at a conference attended by those who have a responsibility to help members in our society with mental illness, regardless of financial position.
Written as a freelance article for The Medical Republic, original article published here.
Dr Helen Schultz is a consultant psychiatrist in Melbourne, Australia. She is a freelance writer and an author, as well as a doctor mental health advocate. She is embarking on a writing holiday through the UK and Ireland in June/July 2023, and will be sure to write for Medium along the way.
