And that money doesn’t even begin to cover ongoing care. Psychiatry needs to remember it doesn’t exist only for the wealthy.
Attention deficit hyperactivity disorder is at the top of the controversy list for psychiatrists, to judge by recent consumer agitation and media interest.
Recent news coverage has quite rightly challenged 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 uproar at the cost of an appointment with a psychiatrist to obtain treatment for ADHD. In Australia, only psychiatrists and paediatricians – not GPs – hold the key to confirming a diagnosis of ADHD and providing the access to the medications used to treat this disorder. These medications, which have not changed very much over the years, are 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 run-down and largely deserted public 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 public or private systems.
Even more concerning is that this third tier will not free up demand that is stretching the public and private system. That’s because the roughly $3000 for diagnosis doesn’t buy you anything resembling ongoing care. Pre-appointment workups 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 fewer 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 six months’ supply. This was very helpful for those in whom 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. This held 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 was not so favourable.
Last week was the annual RANZCP congress meeting, an annual get-together for psychiatrists and trainees to discuss all things contemporary psychiatry and clinical practice. In its 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 were 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 branding makeover. We need to get on the front foot. Psychiatrists, as medical experts, should be driving the explosion of talk about ADHD – not TikTok – and the inability to access diagnosis and treatment in a system that is already full of inequity.
The fees quoted in recent coverage do not pass the pub test. It’s too late for this year’s RANZCP congress agenda. But next year it would be good to see a reminder that we have a responsibility to help members in our society with mental illness, regardless of financial position.
Dr Helen Schultz is a consultant psychiatrist and writer; she tweets @drhelenschultz.
