Clinicians fear over-diagnosis of ADHD as GPs, nurse practitioners allowed to prescribe medication

New rules allowing GPs and nurse practitioners to prescribe drugs to treat ADHD increase the risk of over-diagnosis, over-prescribing, addiction, psychosis and other harms, some clinicians are warning.

Christchurch hospitality worker Caity became increasingly anxious in the month after starting on ADHD medication.

"I just couldn't shut my brain off at night, so I went 11 days without sleeping, which was definitely not fun."

Then the TV started talking to her.

Caity had been prescribed atomoxetine by her GP while on the waiting list for an ADHD assessment.

It is not a controlled stimulant drug like Ritalin - but in rare cases, it can also trigger psychosis.

Admitted to Hillmorton Psychiatric Hospital, she was discharged too quickly.

"At that point I still believed probably about 50 percent of my psychosis, but I wasn't a danger to myself or others so they didn't really have a place for me.

"I was back within a month, and they were like 'What happened? Why did you stop taking your meds?' And I was 'I don't know'."

Caity has since been diagnosed with ADHD but does not currently take medication, and has not had another psychotic episode.

The move to bring in GPs has been driven by long-standing concern about lack of access to ADHD diagnoses for most people in the public system, and long wait lists to see private psychiatrists.

People with untreated ADHD have 13 years' less life expectancy, due to higher rates of unintentional injuries, road accidents, substance abuse, suicidality and imprisonment.

Stan* believes he would not be alive today without his ADHD diagnosis four years ago.

"Prior to being diagnosed, my life was an absolute train wreck - the number of car accidents I've been in is ridiculous, the number of drink driving convictions, even before being able to legally purchase alcohol."

ADHD medication - trialled after several sessions with a psychiatrist - had a life-changing impact.

"It allows me to hold one thought - I certainly couldn't have done that before."

Prescriptions rising

Since GPs lost their authority to prescribe stimulants in 1999 - due to worries about the potential for abuse - only psychiatrists and paediatricians have been able to initiate treatment.

Yet prescriptions for ADHD medications increased more than tenfold in the last two decades.

Wellington psychiatrist and addiction specialist Dr Sam McBride said it was "inevitable" that having more prescribers (GPs and nurse practitioners) would lead to more prescribing - and more negative impacts.

As happened now, some drugs would end up being "diverted" into the hands of people who had not been prescribed them, he said.

"A certain number of people come to harm from abusing them. A small proportion will develop addiction in the context of exposure to stimulants.

"We can expect a small number of people to have psychosis precipitated by these medications. And we can also expect some people will have physical effects due to exposure to stimulants."

Those physical reactions could be short-term, like an irregular heartbeat, or become chronic, long-term problems.

There was also a risk to the wider health system: high demand for ADHD services could take "scarce medical resource" away from other parts of the health system.

"We'll see the development of private providers meeting the need. And I'm unclear whether we'll see the equity gains that were intended from the changes."

Accused of 'drug-seeking'

The lack of capacity in the public health system in the last few years has forced many people to pay hundreds or even thousands of dollars for an ADHD assessment.

Bella* waited more than nine months and paid nearly $1000 for an ADHD assessment by a psychiatrist - but felt "let down" by the experience.

"He said something along the lines of 'a lot of people come in and try to get diagnosed so they can re-sell the medication'. It was like he had an idea of what I was trying to do that was completely inaccurate."

Bella said she had already told the doctor she was not interested in medication, she just wanted a diagnosis.

"I cried throughout most of that session because I thought I was finally in a space where I was going to get answers and support, and to be put down in that way ... I wasn't expecting that at all."

Three years on, she remains "really hurt" by the experience.

"I haven't gone for a second opinion because I'm honestly worried that I won't be seen for who I am or the mental hurdles that I overcome each day."

However, she has researched widely and found her own ways to mitigate some of the problems, including turning off social media notifications, exercise, proper sleep and good food.

"It's a lot of work and can be tiring, but the results have really paid off. I've also gone to therapy to work through some of the more ingrained habits and thought patterns, and I'm learning to accept myself and encourage the positive aspects of ADHD."

She thinks she will "most likely" go to her doctor for a second opinion at some point, but is in no hurry.

No evidence drugs being misused - advocate

An advocate for adults with ADHD said claims that stimulant medications prescribed by GPs could end up on the black market unfairly "stigmatised" people with the condition.

Aroreretini Aotearoa convenor Kent Duston said there was no evidence to support the claim that drugs were being misused.

"What the studies say, both in New Zealand and internationally, is that the risk of diversion is low, that ADHD medications have limited interest in terms of an illicit drug market, and that New Zealand police say that Ritalin and related ADHD medications are not drugs of interest, as far as police are concerned," he said.

"It's concerning that these anecdotes and tropes are being repeated while the evidence that this is not a major problem is not being brought forward."

Ritalin was "not physically addictive", he said.

"We are not prescribing meth here, no-one taking Ritalin is physically addicted to that drug."

Characterising people with ADHD as "drug-seeking" only "perpetuated harmful stereotypes", in his view.

It's 'big business' - psychologist

A psychologist who worked at a private clinic specialising in neurodiversity said she left after witnessing "unethical and lazy practices".

There were clinicians who treated it like "a box ticking exercise" or ignored red flags.

"I saw people being diagnosed that I am confident did not have ADHD and when I raised it, it was like I was stepping out of line," said the woman, whom RNZ has agreed not to name.

In one devastating case, a teenager died of suspected suicide within weeks of being diagnosed with ADHD.

The psychologist believes no one adequately explored what was really going on for him.

A proper assessment should involve digging deep into family history, home-life, school, relationships, what trauma (even intergenerational trauma) could be involved.

"I don't want to discredit it as a genuine diagnosis but I am really skeptical about the diagnostic framework, particularly as used by clinicians who claim to specialise in this area.

"It's being used as an explanation for people's difficulties too easily without considering other things."

It was hard to say "no" to a client or parent who was desperately seeking a diagnosis, she said.

"There's also a financial incentive to give people the answers they want.

"You're talking about a private business that's incentivised to keep clients on, send them onto the psychiatrist. It's big business, and it's concerning that the public don't know that, you've got very vulnerable people coming in.

"It's very frightening because the consumer has to come in with a lot of knowledge if looking for a diagnosis for themselves or their child."

Furthermore, the huge pressure on mental health services meant there was also political pressure to get people seen quickly, she said.

"I'm really concerned about this pathway of making it easier and faster for less qualified people to diagnose ADHD."

McBride said when a diagnosis was correct and properly managed and people were "well supported", stimulants were useful.

They could even reduce the risk of people engaging in other addictive and risk-taking behaviour, he said.

However, they did not work for everyone, and treating ADHD was often much more complicated than just popping a pill.

"And I'm concerned that at present there's been really little consideration given to monitoring any of these issues, educating the public about these issues, educating clinicians about these issues, and looking to contain some of these harms."

'Key to providing access'

Wellington father Darrin Bull, who helped set up the family advocacy group ADHD New Zealand, said more health professionals being able to diagnose and treat the condition was huge.

"It's the key to getting our community the help they need and providing easier access. This is the first step of that."

"Previously, seeing a specialist was an obstacle. Many of them were in Auckland, and if you were outside Auckland or a main centre like Wellington or Christchurch, you had to go there.

"And public health care only helps those in our community who are in crisis. In many regards, it's too late for them, and that meant many people had to go privately. The cost of going privately ranged from $1300, and the most expensive we've heard was $5000.

But he said there were still barriers to getting an ADHD diagnosis, particularly for those living outside in more remote areas where there would not be a GP specialising in ADHD.

"There are barriers if you're in a community that has nobody who's able to diagnose and prescribe to be able to have better access."

"We've got some way to go. I would like to see some of these GP visits publicly funded. But we have to do first steps."

But he expected the cost of getting a diagnosis through the private health care system would be far less.

"I've heard it range from $400 to $700 through private. That's a significant reduction."

Ministry to monitor

The Ministry of Health's chief medical officer, Dr Joe Bourne, told Morning Report that health professionals would be careful to avoid over-diagnosis of ADHD and over-prescription of stimulants.

"We've got a situation where many people are saying they can't access treatment and assessment. At the same time, the medications used, stimulant medications, are still controlled drugs, which, like any medication, have the potential for side effects as well as benefits.

"We have to get the balance right, where people who need access can get access while requiring the clinicians prescribing to take a cautious approach."

Bourne said health professionals would need specific training to be able to treat ADHD.

"Although we are enabling GPs and nurse practitioners to undertake assessments and initiate treatment, this isn't going to be something every GP or nurse practitioner picks up."

He appreciated the new system would increase workloads, but said there would not be any additional funding to cover the cost of training.

"The course the GP college has done is reasonably priced and should be accessible to most GPs."

He said it would be up to GPs how much they charged for assessment, but that it would likely cost hundreds of dollars.

"It will be up to clinicians how they're going to price it. Our hope is that creating opportunities for others to provide these assessments, that will increase the number of clinicians who are in the market."

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