Why is it so Hard to Get an ADHD Assessment in New Zealand?
The evidence-based treatment with the highest efficacy for ADHD is stimulant medication. Stimulant medications are safe, highly effective (for around 80% of people), and are very well-researched, as they are used for children. They have few side effects, no significant long-term negative effects, and are safe to use for children, adolescents, adults, and older adults. They are more effective than antidepressants, and with fewer side effects. But, your GP cannot prescribe them without a special authority code sourced by a psychiatrist or pediatrician, because stimulant medications are a controlled substance due to their ease of abuse. Because of this requirement, there is a huge bottleneck for ADHD assessment and treatment.
Here in New Zealand, the public health system does not have the capacity to provide assessments to all the people who need them, whatever the mental health condition. In Canterbury, referrals from GPs for adult ADHD assessment to the specialist mental health service are the second most common mental health referral! Surprising, right? The adult mental health service aims to see the top 2% of people most seriously affected by mental health problems. Most people with ADHD will not meet this criteria. There are a small number of people who do, and who can receive an assessment through the public health system. For everyone else, a private assessment will be required.
There simply aren't enough private psychiatrists and pediatricians available to perform assessments for a disorder that exists in around 5% of the adult population. And yes, some pediatricians do diagnose ADHD in adults. Clinical psychologists can assess and diagnose ADHD, but a psychiatrist or pediatrician must still be involved for accessing stimulant medication.
In the Canterbury region, the public health system will provide special authority codes for stimulant medication if a public health psychiatrist is satisfied that a person has ADHD based on a psychologist's assessment (usually a clinical psychologist). Because this requires a high level of trust on behalf of the public health psychiatrist - who will never see the patient themselves - psychologists must perform a "gold standard" assessment.
A gold standard assessment means that all criteria for ADHD in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) need to be attended to. Which means:
evidence of a minimum number out of 18 symptoms of ADHD for at least the last six months;
evidence that several symptoms were present prior to the age of 12;
evidence that symptoms exist in two or more life areas;
evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning;
that the symptoms are not better explained by another mental disorder or occur only during a psychotic disorder.
Following collection and consideration of the above criteria, a report that details all of this information must be produced and sent to a person's GP. My reports are usually around 13-15 pages long.
Sounds like a lot of work, right? It is! I estimate it would be around 8 hours of work for me to complete a relatively straightforward ADHD assessment and report. As you can imagine, not every clinical psychologist wants to be performing these assessments. You can also see why the cost of assessment with a psychologist is so high. This makes ADHD assessment a privilege mainly confined to people who can produce a sizeable chunk of money from their bank account or from the bank account of a saintly friend or family member.
Other than Canterbury, I only know of one other region that will accept a psychologist assessment - the West Coast of the South Island. People on the West Coast actually get to see a public health psychiatrist face-to-face!
The lack of access to affordable and timely ADHD assessment is a tough situation to be in for people affected by a relatively common neurodevelopmental disorder which has a range of negative consequences if undiagnosed and untreated.
What would make it better? Huge amounts of funding and staff recruitment for public mental health services. Or somehow loosening up the requirements for attaining a special authority code. I'm not holding out much hope for the first solution, but there is some work underway to review the way special authority codes operate in New Zealand. Although I wouldn't hold my breath for a timely solution.