How to safeguard against overdiagnosis when more GPs treat ADHD

The proportion of people diagnosed with and treated for attention-deficit hyperactivity disorder (ADHD) is growing. Prescription rates have increased 11-fold in 20 years.

But the growth isn’t uniform across the country. This week, ABC’s Four Corners found higher rates of ADHD prescribing in some regions, while other areas were much lower, suggesting ADHD was being missed.

Previously, only paediatricians or psychiatrists could diagnose and start treatment for ADHD. But in most states and territories, GPs can or will soon be able to do this as well.

This is a welcome step to improve access to care, reduce wait times and cut the number of missed diagnoses. But as we show our new paper in the Internal Medicine Journal, we need better safeguards to prevent overdiagnosis.

Read more: More GPs will be able to diagnose and treat ADHD – and experts say it’s a positive step

Where diagnosis can go wrong

It’s important GPs are adequately trained and have appropriate time to make the right diagnosis. They also need clear pathways to refer more complicated cases to specialists.

But changes to enable GPs to diagnose and treat ADHD haven’t been standardised across the country. Each state and territory has its own rules and has different requirements about the level of training GPs need.

In Queensland, currently GPs can start and continue ADHD treatment for adults and children aged four and over. In Victoria, a GP can’t currently prescribe stimulant medications without specialist involvement. But this will change later this year.

There is no requirement in Queensland to complete specific training modules, while training requirements vary in other states.

This lack of a uniformity risks creating more disparities, where your diagnosis and treatment depends on where you live rather than your symptoms and their impact.

GPs with less training may be more likely to diagnose and initiate medication when it’s not indicated. ADHD can appear similar to other conditions or occur alongside another condition. One study found 77.9% of children with ADHD also had another disorder.

Assessing someone for ADHD is time-consuming. It includes taking a thorough history, getting information from others and assessing other mental health or psychological conditions that can mimic or occur alongside ADHD.

But Medicare doesn’t adequately reimburse GPs for this time. There is no dedicated MBS item for GPs to diagnose ADHD. And longer consultations don’t attract as high a rebate as shorter consultations, per unit time.

Under time-pressure to diagnose, stimulants are sometimes considered the only treatment option. However, a range of non-medication interventions can also be used to manage ADHD, including lifestyle changes, cognitive behavioural therapy (CBT) and ADHD coaching, as well as non-stimulant medications.

Public ADHD clinics are rare in Australia, resulting in many people seeking private specialists. But these can still have significant wait times and the costs can be prohibitive.

Avoiding the path of medicinal cannabis

Without more stringent guidelines and processes, ADHD medication prescribing could follow the lead of medicinal cannabis.

In this commercial model, medicinal cannabis is often prescribed without clear evidence-based indications.

There are clear financial incentives to provide a script within “vertically-integrated” medicinal cannabis clinics, where the same business prescribes and dispenses the medication.

Safeguards and monitoring will be essential to ensure ADHD care is not similarly reduced to a simple script service, rather than one based on accurate diagnosis and treatment.

There are already concerns about poor prescribing from telehealth prescribers with online prescribing business models. This prompted the Australian Health Practitioner Regulation Agency to update it’s telehealth guidelines late last year.

Similarly to medicinal cannabis, there are also concerns ADHD medications could be diverted for recreational use. One study estimated 18% of people prescribed stimulants for ADHD had given their medication to other people. Increased availability of these medications could exacerbate this problem.

Read more: Should clinics prescribe medicinal cannabis that they also supply? We asked 5 experts

So what needs to happen to safeguard patients?

We have an opportunity to shape how ADHD care is delivered throughout Australia, and minimise unintended consequences, by supporting a national, co-ordinated approach.

In our new paper, we propose a framework to ensure patients receive high-quality care when they see a GP for ADHD assessments or management. This includes:

• mandatory training for all ADHD prescribers

• formalised shared care pathways across GP, paediatric and psychiatric care. This ensures consistency and coordination of practice and the ability to escalate care when people require specialist input

• structured templates for GPs, including minimum information required before stimulant scripts can be prescribed. This would include complete health summaries, current and previously prescribed medications, psychiatric history and substance use history

• periodic review of medications, side effects, effectiveness and whether they are still needed

• stronger regulation of the advertising and business models of prescribing services. Greater penalties are also needed for breaches

• research, evaluation and monitoring of the changes to ADHD prescribing including any adverse impacts or medical complications.

Living with ADHD has a substantial impact on people’s ability to work, socialise, maintain relationships and function in society. Enabling GPs to provide ADHD will improve access to diagnosis and treatment, particularly in areas facing an access crisis.

But clear, national guidelines and practising frameworks are needed to ensure people with ADHD receive high-quality, evidence-based care and not just more prescriptions.

Read more: Half of psychologists assessing for ADHD don’t follow the diagnostic guidelines, new study shows