The debate about the role of GPs has been heated .

Professor Simon Willcock Clinical director of primary care at Macquarie University Health Sciences Centre , Sydney , NSW .

A 20-year-old biology

major , he and his tutorial group had been studying ADHD .

His accusation : “ Dad , you ’ re a GP ! How can you have missed it ? I so have all the symptoms !”

My reply was spontaneous : “ Yes , so do I . We ’ re both subsyndromal and doing well in life . You don ’ t need medication . Just make sure you have an interesting and varied job .”

My conviction in that unrehearsed response has grown stronger over the years .

In the pages of Australian Doctor , there has been a heated debate about the role of GPs : the RACGP wants the freedom for all GPs to diagnose the condition and initiate medication to end a postcode lottery .

The descriptions of what we call ADHD today have evolved over a century , with a raft of variants that have blurred the diagnostic boundaries .

Current Australian reports cite an incidence of 6-10 % of Australian children with the diagnosis , a doubling in the past decade , and a significant increase in reports of the syndrome continuing into adulthood .

As with other mental health disorders , ADHD exists along a manifestation spectrum .

The challenge is to recognise the boundary between normal variance and pathology .

Currently , the balance has shifted towards the earlier use of medication .

I believe in the diagnosis and

have witnessed the transformation in the lives of severely affected children when stimulant medication is prescribed .

I periodically suggest a diagnosis of adult ADHD , although for both children and adults , the addition of stimulant medication is only part of the treatment .

Medication alone rarely , if ever , resolves all the patient ’ s issues .

But those more obvious cases are rare in my practice . Much more common is the scenario of a 40-ish man presenting with something trivial and then sheepishly admitting there is something else to talk about .

That scenario has become so common that I often respond with , “ We ’ re going to ADHD ; aren ’ t we ?”

I am then met with a look of relief from the embarrassed patient .

When we explore the triggers behind the concern , two common themes emerge .

One , a relative ( usually a spouse or in-law ) has suggested the diagnosis . And two , the patient has completed one of the many readily available self-check tools and invariably come up with ‘ classical ’ features :

The patient insists they want to find out if medication will ‘ make me the best person I can be ’.

“ We ’ ve been in the new house for a month , and I haven ’ t hung the pictures yet , so I ’ m obviously a procrastinator .” “ I sometimes find it hard to focus at work , particularly if I ’ m not interested in what I ’ m doing .”

My attempts to contextualise the near universality of those symptoms normally fail .

PICTURE CREDIT

The patient in front of me , usually a man but increasingly a woman , whose life by any external yardstick is on track , insists that they want to find out if medication will “ make me the best person I can be ”.

After failed attempts to take the conversation in directions that I sense to be at the root of things ( mood , anxiety , relationships ), I relent and provide the referral to a psychiatrist , explaining that only specialists can make the diagnosis and prescribe the medication .

Epidemics overwhelm your usual resources . My pool of psychiatrists willing to accept these patients has pulled down the shutters on “ new patients with ADHD ”.

One patient of mine recently tried his teenage daughter ’ s medication and declared that “ it made me feel very different ”, neither better nor worse , just “ different ”.

Based on that experience , he is determined to undertake a trial of medication .

Faced with the excessive cost and lengthy delay in accessing diagnostic services locally , he identified a practitioner in another state who was prepared to undertake a telehealth assessment under an MBS item 291 psychiatric referral . I subsequently received an excellent report from the psychiatrist confirming a diagnosis of adult ADHD , with detailed instructions about the administration , titration and monitoring of the treatment . The only problem is that I don ’ t want to be his medication prescriber .

I don ’ t want to become the GP who prescribes ADHD medication during the current stampede towards a diagnosis .

Which is why I find it hard to embrace the recent exhortation by RACGP president Dr Nicole Higgins , whom I admire and respect , to get GPs more involved in diagnosing and managing ADHD .

At a time when GP resources have never been more thinly stretched , I find myself having to prioritise where I invest time and effort .

If I must choose between the needs of patients who are struggling with cancers and metabolic disease , and the existential angst of those experiencing subsyndromal ADHD , the former groups have a more valid claim .

In the early 2000s , I was cynical when the pain specialists chastised GPs for not using sufficiently strong analgesia to manage chronic pain , and here we are 15 years later being told to manage the scourge of opioid overuse .

Am I alone in foreseeing the headlines 10 or 15 years from now , when we are dealing with ‘ the curse of stimulant medication , pushed by pharmaceutical companies and doctors alike ’?

Oh , and what happened to my son ?

As predicted , he was never going to remain a lab bench researcher despite wonderful mentoring from people whose cognitive wiring was more suited to that role .

Instead , he has used the gift of his “ subsyndromal ADHD ” to forge a diverse and highly successful career , with no need for medication or labels .

Visit ausdoc . com . au for more

Australian Doctor team Chief of staff : Rachel Carter ( 02 ) 8484 0631 Editor : Paul Smith ( 02 ) 8484 0795 Medical co-editors : Dr Kate Kelso BMed FRACGP ( 02 ) 8484 0713 Dr Paul Muthiah MUDr FRACGP ( 02 ) 8484 0713 How to Treat editor : Dr Claire Berman MBBCh ( 02 ) 8484 0749

6minutes news editor : Carmel Sparke ( 02 ) 8484 0979 Political news editor : Antony Scholefield ( 02 ) 8484 0616 Clinical news editor : Kemal Atlay ( 02 ) 8484 0648 Chief reporter : Heather Saxena 0425 271 128 Senior reporter : Sarah Simpkins ( 02 ) 8484 0688 Junior reporter : Rachel Fieldhouse 0420 834 340

Production editor : Sophie Attwood ( 02 ) 8484 0786 Senior content producers : David Dombrovskis ( 02 ) 8484 0765 Robert Santos ( 02 ) 8484 0674 Senior website manager : Stacey Shipton ( 02 ) 8484 0799 Senior graphic designer : Edison Bartolome ( 02 ) 8484 0872 Managing director : Bryn McGeever ( 02 ) 8484 0650 Sales and marketing inquiries : 1300 360 126

Classified pages bookings : 02 ) 8484 0666 gpclassifieds @ adg . com . au Production manager – client services : Eve Allen ( 02 ) 8484 0764 EMAIL US @: To email staff , use the following format : first name . surname @ adg . com . au The views expressed in this publication are not necessarily those of Australian Doctor Group . Australian Doctor is an independent publication serving the needs of

Australia ’ s general practitioners . It has no affiliation with any medical organisation or association , and our editorial content is free of influence from advertisers . Australian Doctor is sent free to full-time GPs in private practice and certain prescribing and staff specialists . It is available to other readers on subscription for $ 390.00 pa including GST . Overseas rates apply . Phone 1300 360 126 . Average Net Distribution

Period ending September 2022 16,360

Australian Doctor is published 12 times a year by Australian Doctor Group , Level 12 , 117 York Street , Sydney , NSW , 2000 Ph : ( 02 ) 8484 0666 Fax : ( 02 ) 8484 0633 Email : customer . service @ adg . com . au www . ausdoc . com . au ( Inc in NSW ) ACN 132 719 861 ABN 94 615 959 914 ISSN 1039-7116

© Copyright 2023 adg . com . au Australian Doctor is printed by Fairfax Media on PEFC certified paper , meaning it originates from forests that are sustainably managed . PEFC is an international certification program which assures consumers that a forest product can be tracked from a certified , managed forest through all steps of processing and production in the supply chain by a chain of custody process . Fairfax Media source their magazine paper from mills that are FFC and PEFC certified .