The NSW Government recently announced reforms that will allow GPs with additional training to diagnose and treat ADHD, in line with similar policies in WA and Queensland.

Six in 10 GPs believe this could help solve underdiagnosis and treatment access issues, a Healthed survey of over 1200 GPs has found. But more than half said it could also contribute to overdiagnosis.

It seems many GPs can see the potential for both outcomes—and have mixed feelings about expanding their role in ADHD management.

Conflicting views on the changes

With many people waiting months or years to see a specialist, the policy aims to make it easier for those with ADHD to get diagnosed and start treatment sooner – and 60% of surveyed GPs agreed this outcome was moderately or extremely likely.

Some commented that GPs typically know their patients better than specialists, so are well-placed to provide this type of care, while others saif they’re already managing patients with ADHD.

However, 56% of respondents said expanding the role of GPs was moderately or extremely likely to contribute to overdiagnosis.

“It will worsen the situation,” one GP commented. “Too many inappropriate diagnoses will then lead to under supply of medications for those that actually need them.”

An over-emphasis on overdiagnosis

Another GP noted that good training and assessment tools would make overdiagnosis less likely, and paediatrician Dr Alison Poulton, a senior lecturer at the University of Sydney who has been running a clinical trial training GPs to manage ADHD, agrees.

She says having a “limited number of GPs who are committed to ADHD and know what they’re doing” will mitigate overdiagnosis risk.

Clinical psychologist Professor Adam Guastella, Michael Crouch Chair in Child and Youth Mental Health at the University of Sydney, says the key lies in the program’s execution.

“The reality is that if the process is implemented really well, then we will see GPs empowered to correctly diagnose ADHD and provide the right supports to the people that need them.”

Done less well, however, there is a risk it will contribute to misdiagnosis—both of missing the diagnosis in people who do have ADHD, and of ascribing the diagnosis to people who do not, he says.

That’s why evaluation of the program—and ensuring GPs who take part have adequate support from specialists—will be crucial, he stresses.

Dr Poulton adds that rhetoric about overdiagnosis is a “bit more hyped up than it needs to be.”

While diagnostic tools are not perfect, using them along with the clinical guidelines, does help ensure that only people experiencing significant functional difficulties are diagnosed with ADHD.

“Everyone is going to tick some of these boxes some of the time,” she explains. “But the critical thing is that people who have ADHD are having more problems than you would expect someone of their ability, training, and education to be having.”

Professor Guastella says social media is driving a lot of misguided public conversations about overdiagnosis.

“There’s this talk about ADHD as if it’s normalcy being diagnosed as a problem,” he says. “I think that undermines the value of the diagnostic criteria and the impact that ADHD has on people’s lives.”

The cost of underdiagnosis

Importantly, Dr Poulton says underdiagnosis remains more of a problem in some populations, particularly among professional women. While most of these women have never been hyperactive, their inattention and disorganisation symptoms can cause more problems when work demands increase.

“And at that point, ADHD is holding them back,” she says.

However, their apparent success means women in this group are often told they could not possibly have ADHD.

“And yet, this woman is anxious, depressed, worrying about missing appointments, forgetting meetings,” Dr Poulton says. “Yes, she’s functioning, but at an enormous personal cost.”

Diagnosing more people earlier could also reduce the comorbidities that are commonly associated with ADHD in adulthood, she adds.

Pressure to diagnose and prescribe

Many surveyed GPs expressed concerns that they’d be pressured by parents or adult patients to diagnose ADHD and prescribe stimulant medications.

“There will be a flood of people – those that have the problem and have never been diagnosed, those that think they have it and have been told they haven’t and those that want to abuse the medication for exams and for recreational use,” one summed up.

But Dr Poulton says these fears are largely unfounded, noting only trained GPs will be able to manage ADHD under the new system.

“And also the community needs to know that they can’t just roll up to any GP and expect ADHD diagnosis and management,” she adds.

Professor Guastella says this concern is justified given stimulant medications have a reputation for supporting cognition, but notes GPs already have experience managing drugs that can be misused, like benzodiazepines.

Tight prescribing regulations will help, he adds.

Remuneration needs to reflect added complexity

The government also needs to remunerate GPs fairly for the increased time and complexity involved in managing ADHD, Dr Poulton says.

“And I think you’ll find that if Medicare recognises the good work that GPs can do in ADHD, you’ll find there’s less kickback from GPs—because there’s no question that these patients are more challenging to treat.”

Several surveyed GPs made the same observation, stressing they would only participate in the training on the proviso that Medicare rebates reflect the increased workload.

Dr Poulton hopes the government will also review the onerous regulations that currently account for much of the time it takes to prescribe ADHD medication.

“When you look at the level of regulation, you would think these must be really dangerous drugs,” she says. “Actually, they’re not.”

“Regulations need to be simplified and no more arduous than is absolutely necessary.”

What your colleagues are saying:

• “Access to GPs who can adequately deliver a service will significantly reduce the burden, but also increase responsibility on the GP.”
• “Due to the lack of psychiatrists, I am left prescribing for most of my patients with ADHD, very few see a psychiatrist for this. As I often see the patients more than the psychiatrist would, I think I am in a good position to manage their medications well.”
• “GPs are likely to significantly over-diagnose and over-treat a supposed ADHD diagnosis, particularly due to lack of detailed knowledge and sophistication with their diagnostic processes and likelihood of rushing the consultations.”
• “I see this as a difficult and demanding medical condition that is not easy to assess nor easy to treat and manage and I am concerned that general practitioner may become involved in this while being underprepared.”
• “I think often GPs who have done psychiatry in their training rotations are invaluable in providing these services.”
• “I do think it will be helpful to increase access to ADHD medications and I currently prescribe for some patients after they have been assessed by a psychiatrist. However, I plan to retire soon so will not be undertaking further training.”
• “I think this move will bring about a lot of risk and many inappropriate prescriptions. Already too many people on ADHD treatment. It seems to be the latest fad at the moment and we seem to be playing into public demand.”
• “There is a dire need to get the help out to people. I hope advocacy will be loud and clear to provide ideally online, easy access learning programs, and that after completion I can diagnose ADHD but also take on the management.”
• “There is a great need for more capacity to deal with patients with ADHD, and I already prescribe with relevant permit for many of my patients.”