Frequently asked questions

ADHD stands for Attention Deficit Hyperactivity Disorder. It is an umbrella term that covers three different presentations:

  • inattentive type (formerly known as ADD),
  • hyperactive/impulsive type, and
  • combined type (a combination of both of the other types).

There are a range of symptoms that are noted in those who struggle with ADHD symptoms. These include but are not limited to:

  • Listening difficulties
  • Losing / misplacing items
  • Easily distracted
  • Forgetfulness
  • Short attention span
  • Struggling to see tasks through to completion
  • Procrastination
  • Making ‘silly mistakes’
  • Fidgeting / restlessness
  • High energy
  • Talkativeness
  • Interrupting and unable to wait ones turn
  • Impulsive

Yes – the traditional, stereotyped view is of hyperactive boys with behavioural disturbances. Inattentive ADHD can easily be missed and is frequently noted as the predominant presentation in women/girls. In other words, girls can often present as ‘daydreamers’ or known for ‘zoning out’. This is less likely to come to the attention of teachers, parents and subsequently mental health professionals as there is usually no evidence of any disruptive behaviour. A child who sits at the back of a class zoning out is more likely to ‘slip through cracks’.

Awareness of ADHD has certainly risen in recent years. Various social media platforms have raise this awareness and many people have reflected, realising that they too could have ADHD. The reality is that whilst some have thought that ‘ADHD is overdiagnosed’ this is far from the truth. The prevalence of ADHD is thought to be up to 5% in the adult population. Only a small fraction of these are actually diagnosed and treated. Therefore in fact, it is certainly reasonable to opine that ADHD is underdiagnosed. There are many adults with inattentive ADHD pushing through their struggles for many years, who have finally realised that ADHD could explain their mental health journey.

Initially, please book in for your initial consultation. To book in this appointment, a referral from your GP is required which is sent to admin@wapsychiatry.com.au. This is then reviewed by the psychiatrist named on your referral (if there is one named). If this psychiatrist is unable to accept the referral, it will be circulated to the other psychiatrists in the clinic in case another may be able to accept. You will advised whether the referral has been accepted within several weeks and advised of the outcome via email. There are many reasons that referrals can be rejected so please do not take this personally – this can range from the psychiatrists’ preferred case-mix, the complexity of your case or whether the psychiatrists’ books are open are close.

The initial consult covers a full psychiatric history which including information like previous treatments trialled, any other explanations for your symptoms, any medical conditions you may have, and much more! Some psychiatrists can make a diagnosis of ADHD on your initial appointment however it is also not unusual for this process to take another 1-2 follow ups (up to 20 minutes in duration) to clarify.

There is nothing specific that you must bring. However, it can help if you bring a support person to clarify some of the symptoms you have been experiencing. If possible, this is best someone who has known you since you were a child (eg a parent). We understand however that this is not always possible!

It can help to bring in school reports to your appointment. This can give your psychiatrist an indication of what symptoms you had growing up. Often, reports from later years can be the most useful (years 9 to 12) as the dysfunction caused by ADHD can be more evident.

Sometimes you may be requested to undertake neuropsychological testing. This is done by a clinical neuropsychologist and can be used to clarify the diagnosis of ADHD or sometimes recommended to explore possible diagnoses of Autism Spectrum Disorder (ASD).

It is not usually a compulsory part of diagnosis.

The gold standard for the treatment of ADHD is generally with the use of stimulant medications. Whilst there is certainly some societal stigma associated with the prescription of stimulants, most of the concerns that the general public have had about these medications is not based in reality.

There are also non-stimulant options that can be used which your psychiatrist can go through with you, especially if you are not suitable for a trial of a stimulant.

Medications are not the only option and various non-pharmacological approaches do exist. Often these are overseen by what is known as an ‘ADHD coach’. These are usually psychologists who have a special interest in ADHD and work with you to trial various methods to compensate for the dysfunction caused by ADHD symptoms.

Nevertheless, regardless of your desired treatment option, your psychiatrist will be happy to answer any questions you may have. Sometimes it is worth having a consult in order to have an open discussion regarding any thoughts you have – there will be no pressure to commence a particular treatment pathway!

In some cases, even if the psychiatrist wishes to start stimulant medication they are not able to without prior approval. These cases are termed (unofficially) as Complex ADHD cases. In these cases we must seek permission from the Department of Health rather than simply commencing a stimulant.

There are a range of reasons why permission must be sought, some (but not all) reasons are as below:

  • Substance misuse or dependence within the last 5 years – this can be anywhere from methamphetamines, marijuana to legal substances such as alcohol.
  • A diagnosis of bipolar affective disorder
  • A diagnosis/history of psychosis (e.g. schizophrenia, depression with psychotic features, drug induced psychosis etc)

The Department of Health require this because:

  • Using stimulants poses a small long term risk of psychosis, but combining stimulants with other psychoactive substances (particularly marijuana) can increase the overall risk of psychosis.
  • A previous history of psychosis predisposes a patient to having a higher risk of psychosis when prescribed a stimulant (eg it may trigger off a psychotic episode)
  • Those with bipolar affective disorder may have a relapse of their condition if a stimulant is prescribed, therefore risking a manic episode.

  • Once your psychiatrist has confirmed the diagnosis of ADHD and is agreeable with the use of stimulants to treat this, permission is sought by completing an application for the stimulant panel. In addition to the application, your psychiatrist must complete a detailed report outlining your psychiatric history, as well as steps your psychiatrist (and you) will take to ensure that the risk stimulants pose to you is minimal/minimised.
  • Prior to accepting the application and report, it is essential to be able to demonstrate a clean supervised Urine Drug Screen – note that this is a requirement for all those requiring permission and not just those with a history of drug use/misuse.
  • In addition to the above, the stimulant panel will generally NOT accept applications until a non-stimulant medication has been trialled for the ADHD. In some cases, an exception can be granted to this rule but this is only in specific circumstances and will be guided by your psychiatrist.

TMS (transcranial magnetic stimulation), sometimes referred to as rTMS (repetitive transcranial magnetic stimulation) is a non-invasive and well tolerated treatment method for depression.

It is a mild form of brain stimulation using a magnetic field. It has been extensively studied for over 30 years with large clinical trials establishing that is an effective treatment for patients with depression. There is also a growing evidence base for its use in other psychiatric and neurological disorders, such as pain management, bipolar disorder, obsessive compulsive disorder, smoking cessation, addictions and post traumatic stress disorder.

Depression is the leading cause of disability worldwide. While there are many effective treatments for depression, first-line approaches such as medication and psychotherapy do not work for everyone. Research into medication options for depression has not significantly progressed over the past few decades and some individuals experience side effects to antidepressants or lack of effective response in terms of their depressive symptoms. In fact, up to two-thirds of people with depression do not achieve adequate relief from the first antidepressant they try. After two months of treatment, research shows that some symptoms can remain for these individuals and each subsequent medication tried is actually less likely to help than the one prior. The field of neurostimulation has therefore become a focus of research and treatments such as electroconvulsive therapy (ECT), transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS) are becoming more popular. ECT was considered the gold standard for treatment-resistant depression, however, for many people ECT can be too difficult to tolerate due to side effects on memory and cognition. ECT is also not a convenient treatment for some people as it involves having a general anaesthetic. For individuals who have had an inadequate response to medications and therapy alone, TMS is a newer treatment option.

TMS devices operate completely outside of the body and affect central nervous system activity by applying a magnetic field to specific areas of the brain that we know are involved in depression. TMS does not require anaesthesia and is generally exceptionally well tolerated compared to the side effects often seen with medication and ECT. The treatment targets the parts of the brain shown in brain-imaging studies to be abnormally low in activity in depressed patients. The severity of the depression often correlates with the extent of the decline in activity in this part of the brain. The magnetic fields produce small electrical currents (pulses) which then go on to activate cells within the brain which release neurotransmitters (brain chemical messengers) that are known to have an important role in mood regulation. As TMS is non-invasive, it generally does not have any negative effects on thinking, memory and normal brain functions.

Approximately 50-60% of people with depression can experience a clinically meaningful response with TMS. About one third of these individuals can experience a full remission, meaning their symptoms go away completely. It has been shown that by combining TMS with psychotherapy the patient is more likely to achieve remission from depression. A large study in 2017, showed that after an average of 21 sessions, 66% of patients responded well to the combined approach with lasting effects after 6 months in 65% of the group.

A typical course of TMS consists of 5-7 treatments per week over a 3-4 week period, for an average of 20 sessions in total. Each treatment lasts for approximately 20-40 minutes. You may start to notice an effect within the first 5 sessions. An individual treatment plan will be discussed in detail during your initial consult but for TMS to have the best effect sessions need to be frequent.

Generally speaking, the beneficial effects of TMS may last at least 6 months for the majority of clients. However, a number of clients opt to return for follow up treatment once a month or once every 2-3 months to maintain the effects or to prevent a relapse of depression. Research shows that after six months depressive symptoms are significantly lower than at intake.

TMS has the advantage of not inducing side effects common with antidepressant medications. Unlike other methods of neurostimulation (such as vagus nerve stimulation or deep brain stimulation), TMS does not require surgery or implantation of electrodes. And, unlike ECT, TMS has a much lower risk of seizures and does not require sedation with anaesthesia.

TMS is very well tolerated, but with any medical treatment there are potential side effects. Side effects are generally mild and improve after an individual session and decrease over time with additional sessions. They may include headache; scalp discomfort at the site of the stimulation; muscle twitching of the facial muscles; and light headedness. The treatment parameters can be adjusted to reduce such symptoms. More serious side effects are rare, but may include seizures (<1% risk overall), mania (particularly in people with bipolar disorder) and hearing loss (if there is inadequate ear protection during treatment).

In ECT, large electrical currents are applied in order to create seizure activity across the brain. This therapy requires sedation under medical care in hospital and may be associated with side effects including nausea, confusion and memory loss. TMS stimulation is non-invasive and targeted, so it does not affect the whole brain or create a seizure like we see in ECT therapy. It is done without sedation on an outpatient basis and you can safely return immediately to your daily activities.

Individuals diagnosed with depression, treatment resistant depression (depression that has not responded to psychotherapy and/or medication), individuals with OCD, individuals who wish to taper or cease medication for depression and are looking for therapy to support that process.

Suitability will be assessed at your initial appointment. Due to the magnetic field produced during TMS, the procedure is not recommended for some people who have the following devices:

· Aneurysm clips or coils

· Stents

· Implanted stimulators

· Implanted vagus nerve or deep brain stimulators

· Implanted electrical devices, such as pacemakers or medication pumps

· Cochlear implants for hearing

· Any magnetic implants

· Any metal fragments, metal device or object implanted in your body.

TMS may be contraindicated for patients with dental implants. Patients should seek clarification from their dental specialist. Standard dental fillings and braces are safe for undergoing TMS treatment.

Patients who are pregnant or have a history of seizures/epilepsy should not undergo TMS therapy.

Patients with facial tattoos which have metallic ink or magnetic sensitive ink should not receive TMS.

Patients are asked to remove all facial/ear piercings including tongue piercings prior to each treatment.

The initial session with your psychiatrist will determine suitability for TMS therapy. You will be asked questions regarding your medical and psychiatric history, including current and past treatments for depression. A detailed discussion will be had regarding TMS and potential alternative treatment options. The second session is called a “mapping session”. This takes approximately 20-40 minutes and various measurements are taken of your head to ensure the correct placement of the magnet over your scalp. The exact area is mapped by locating a ‘motor threshold’ by delivering magnetic pulses to the area of the brain responsible for movement. This is done by delivering a series of pulses over the motor cortex part of the brain until a slight twitch of the hand is achieved. The energy level is then lowered and the psychiatrist will prescribe an individual treatment protocol for you. During subsequent sessions, the psychiatrist or nurse will deliver your specific treatment protocol.

A qualified TMS nurse will remain with you throughout each TMS treatment. You will relax in a reclining chair for the duration of the treatment. A repetitive tapping or clicking sound can be heard from the magnet that usually lasts a few seconds followed by a pause. Patients may wear ear plugs for comfort. A tapping sensation may be felt on the scalp. Because TMS does not require an anaesthetic and is usually well tolerated without cognitive side effects, patients can generally return to their normal daily activities after treatment.

Unlike some medications, TMS does not affect your ability to drive. The experience of intensive treatment, however, may be tiring. If you would not feel comfortable driving after treatment, we advise you to ask a friend to drive you home after a treatment session.

It is generally recommended to keep medications stable during the course of a TMS treatment programme. You should inform your psychiatrist or TMS nurse of any changes in medication use.

Before commencing TMS we will conduct an intake assessment with one of our psychiatrists as well as a ‘mapping session’ to include the individualised treatment protocol. To be able to obtain Medicare benefits you will need a referral from a GP.

From November 2021, TMS has been listed on the Medicare Benefits Schedule (MBS) for the treatment of major depressive disorder. To be eligible to receive Medicare-funded TMS services you must meet the following criteria:

Be at least 18 years of age;

Be diagnosed with major depressive episode;

Have failed to receive satisfactory improvement for the major depressive episode despite adequate trialling of at least two different classes of antidepressant medications, unless contraindicated;

Have also undertaken psychological therapy unless inappropriate; and

Have not received TMS treatment previously in either a public or private setting.

If eligible, Medicare rebates will be available for:

Up to 35 TMS services for an initial course of treatment; and

Up to 15 TMS services for a course of retreatment

A course of retreatment may be undertaken where there has been a relapse after at least 4 months, and where the initial course of treatment has been successful.

Before commencing your first treatment session, your psychiatrist will plan how the treatment is to be provided including the dosage (as part of a ‘prescription and mapping’ service). A further prescription and mapping service will be required before commencing a course of retreatment. Both of these services will also attract a Medicare rebate.

Further information and patient factsheets can be found here:

http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/419674E7069172A9CA25877800803903/$File/Factsheet-rTMS-Patient.25.10.21.pdf

Our psychiatrists see a wide range of age groups. Children are welcome to be referred however for ADHD assessments, patients must be 17 and above. If you have a child who is 16 but may be 17 by the time they are seen, then they are welcome to be referred for ADHD assessment.

There is no specific upper cut-off however this will depend on the particular presentation (eg presentations more likely to be consistent with dementia processes likely will be more suitable for an old age psychiatrist) and the overall physical health of the patient.