Q: How can I find information about the latest approaches to diagnosis and treatment of Adult ADHD? Thank You.

Thanks for the question. Adult ADHD (attention deficit hyperactivity disorder) has only been well recognised in the last decade or so. Previously it was thought to exist only in children. As a consequence the evidence base is still developing and debate continues about the diagnostic criteria, how to separate it from other disorders (especially bipolar disorder) and how best to treat it.

I’m no expert when it come to ADHD! But I can give you some general advice.

Medicine has a problem with all new disorders – they attract controversy! This is a normal part of the scientific process – scientists collect evidence and debate. Inevitably there will be those who are fanatical proponents and those who are fanatical opponents, and others who sit in the middle. This presents a problem for people who want good, sensible, balanced advice.

The fanatics speak the loudest, and most frequently, and so attract the most attention – when you go looking for advice, they will be the ones you find first. But, of course, they are not usually in the best position to give balanced information and advice.

The best way to avoid the fanatics is to seek your advice from sources that are as independent from influence & conflicts as possible. So websites that are ‘peer reviewed’ – these are usually government funded, or set up by big research bodies like the NH&MRC in Australia, NICE in the UK, etc. They should not have any funding from groups that sell treatments (like clinicians offering their services, or drug companies).

Most of the government health sites are pretty good. Here is the Victorian governments Better Health Channel – http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Attention_deficit_hyperactivity_disorder_and_adults
Here are the NICE guidelines for ADHD from the UK – https://www.nice.org.uk/guidance/cg72

Once you have the information, the next step is to find a balanced clinician to help guide you through diagnosis & treatment – this can be tricky because of the same problem, you don’t want to begin with a fanatic.

You need a general psychiatrist or psychologist, who can work through the symptoms, separate normal variation from the actual disorder (we all have a little of everything!) develop a ‘differential diagnosis’ of alternative things to consider, and then discuss all the treatment options. In particular, you don’t want to jump straight onto the medications (Ritalin and it’s variations) because they carry risks that you need to carefully weigh up. There are plenty of other treatment options to consider.

Finding the right clinician is not always simple. Start by asking your GP. Check the referral directories of the psychiatry and psychology governing bodies (RANZCP & APA in Australia) and then when you find someone, question them to make sure they consider all options. You sometimes have to knock on a few doors until you find someone who is right for you.

Hope this helps. Good luck.
Steve

Q: I've got depression and my GP says I should get some counseling or therapy. She asked would I prefer a psychologist or psychiatrist. Is there much difference?

This depends on a number of factors, and your GP will guide you.

In a nutshell, we treat depression according to its severity:
Mild – usually support and advice, wait and see, and address the 5 key factors for good mental health – sleep, exercise, nutrition (including caffeine, alcohol), relationships and stress levels. Mild depression usually gets better without specialist help.
Moderate – either psychological help or medications (you choose)
Severe (usually means suicidal ideas) – usually we recommended all of the above. Plus we think about hospital admission.

If you’ve been told therapy – yes, you have a choice of a psychiatrist of psychologist. Both are highly trained. Psychiatrists are trained as doctors, then specialise in psychiatry. So they can prescribe medications and do therapy. Psychologist (in Australia) don’t prescribe, but they have longer training in the therapies, and so some would argue they are more skilled in the area (at least at the time of qualification, some psychiatrists only do therapy so quickly gain the experience and skills needed).

Which you choose probably depends more on who your GP works with and recommends, and which you can get an appointment with. In the long run, I don’t think it matters much, the main thing is that you give therapy a try, with someone. And you have to give it a decent try – you can’t judge it in a few sessions.

Also, it depends a little on who you ‘click’ with – make a phone call first and chat to the therapist to see if they sound reasonable. And I tend to prefer people with more experience.
One more thing – the costs are different – so ask before you book in.

In my own practice, when I have to refer someone for therapy for moderate depression (I work in a hospital and so mostly refer outside for therapy), I tend to let the patient decide and give them options for each – but they mostly end up choosing the psychologists as they are easier to get into, a bit cheaper, and often more experienced in specific forms of depression psychotherapy.

If I was choosing for myself, I’d probably choose a psychologist as my first option, but it is a line ball and there is no correct single answer.
(Note – there are also social workers very skilled in therapy of various types with training in specific therapies. I consider well trained social workers as the same as psychologists and psychiatrists when it comes to therapy, so consider them too).

At the end of the day, ask your GP, try to find someone you like and trust, and give it a go. If it doesn’t work out, go back to your GP and try someone else or consider other options.

Cheers,
Steve

Q: What's your opinion on health insurance? Is it worth it? Isn't the public system fine in Australia? Why bother?

This is probably more of a financial than medical question – as it depends on your income and the rebate from government. But from a health perspective, what insurance gets you is access to private hospitals (plus extras – but again, you decide on those based on your finances and need). Private hospitals are great for NON life threatening things like less-major surgery, fixing up chronic medical conditions, getting various treatments that are expected to go well etc. You get fancier facilities, better food, & choice of doctor. If your illness is life threatening I think public is better. There are more staff (& usually less ‘agency’ or temporary staff), better night coverage, bigger ICUs, & access to more specialists if other opinions are needed. Also I think public has better protocols for care, so in my opinion less mistakes are made and your more likely to get evidence based opinions rather than one doctors view. Public clinicians (doctors and nurses) work in teams. To be fair, my opinion isn’t universal – some in private disagree!



BUT for mental health, I think the private system has some distinct advantages – and I DO NOT work in private psych (so I don’t think this is a biased view). The advantages are that it is FAR easier to get admitted when you need it. The public mental health system is area based (so you must go where you area dictates, regardless of whether it is has a good reputation), and it is a bit overcrowded, so it’s hard to get admitted unless you are very unwell (usually that means suicidal). If you have a chronic condition, or are at risk of one (things that put you at risk – past psych problems or past trauma or a family history of psych probs) then I’d get private insurance just to be safe and to give me choice around future admissions. I’m not saying the public system is bad, but it is not as well funded as the public general health system. For psych, the lack of decent public funding means less beds, and useful less adds on’s (like group therapy, psychology programs etc) compared to the private system. Sad, but true.



So in summary:  for general health, get it if you can afford it, but the public system is perfectly fine. For psych problems, I think having private insurance is a distinct advantage.

Hope this helps.

Q: Hi Steve, my sister has had a problem with drugs (originally heroin, now ICE and others) on and off for years. She has tried to get help, but it has only worked for a short time, and she ends up back where she started. What can I do? I've tried to help but been pushed away. I hate seeing this happen to her.

Thanks for the question. It’s a biggie! It’s also one of the most frequent and important questions I get asked in everyday practice. Of course, there is no simple answer. Here are some tips, in no particular order. Of course there are many great places to get advice – my favourite is Direct Line – http://www.directline.org.au/ This is Victorian, but an Australian version is http://www.druginfo.adf.org.au/contact-numbers/help-and-support


  • Be consistent, calm and supportive. Don’t try to push your ideas. You usually can’t convince someone to get help, you can only facilitate it once they ask. If you push too hard you can damage your relationship.
  • Educate yourself to be ready when asked. Read the websites above.
  • Don’t respond to crises – respond BETWEEN crises. By this I mean, don’t get caught up in the various crises like court, police, relationship problems. They are usually the times you are asked for help, to solve urgent issues. But the real gold in helping comes when there are no crises, and the person is genuinely interested in tackling their drug problem, rather than the consequences of their drug problem.
  • Beware of burnout. It’s easy to help and help and help, and then get burnt out, and when the person is ready for real change, to be sick of them. You prevent burn out by setting limits. Keep your approach simple and to the point. Offer advice, offer support – but beware of trying to do it all for them – that’s when you risk burn out. Choose your battles wisely.
  • Stay positive. Most people eventually overcome their problems. The basic plan works – encourage them to see a clinician (there are many many services), keep trying till they find the one that’s right for them, consider different alternatives, don’t give up too soon (all approaches feel crappy in the first few weeks, because giving up drugs in hard!), if they do drop of, don’t be judgemental, be realistic, and let them know when they are ready to try again to give you a call if help is needed.



There’s lots more I could say, but hope this is a start.

Cheers,
Steve