Abstract
ADHD care demand surge: A stress test of mental health system capacity
The rapid rise in attention deficit hyperactivity disorder (ADHD) presentations and prescribing over the past decade has become one of the most visible indicators of sustained and unresolved pressure across mental health systems in Australia and Aotearoa New Zealand.
In Australia, the dispensing rate of ADHD medications has increased approximately eleven-fold since 2004–05, rising from around two per 1000 people to 22 per 1000 in 2023–24. Approximately 2% of the Australian population received ADHD-related medication in the past year, with the steepest growth occurring among adults particularly women. Comparable trends are evident in Aotearoa New Zealand, where adult ADHD medication dispensing has increased ten-fold since 2006, with an estimated 68,500 people (around 1.3% of the population) receiving ADHD-related medicines in 2023–24.
These trends reflect genuine clinical need. They also reveal mental health systems operating under significant and prolonged strain.
The challenge before us is not simply about ADHD. Rather, ADHD functions as a lens that magnifies broader structural failings within mental health care: fragmented service design, variable prescribing and regulatory frameworks across jurisdictions, workforce shortages across both specialist and primary care, and long waiting times that disproportionately affect already marginalised populations. Without addressing these systemic constraints, attempts to reform ADHD care risk being piecemeal at best and at worst, clinically unsafe or inequitable.
In this sense, ADHD has become a stress test of how Australia and Aotearoa New Zealand organise, fund and prioritise mental health care. It highlights vulnerabilities that clinicians, people with lived experience, families and advocacy groups have been drawing attention to for many years.
Rising demand against a backdrop of unmet need
In Australia, approximately 4.3 million people experience a mental disorder each year, yet around half receive no formal mental health care. For those living with severe and persistent mental illness, the gaps are even more pronounced, with longstanding shortfalls in community-based psychosocial supports, inpatient beds, subacute services and supported housing.
In Aotearoa New Zealand, the 2022/23 New Zealand Health Survey reported that over 20% of young people aged 15–24 years experienced high or very high psychological distress, a four-fold increase compared with 2011–12. Despite increased investment following He Ara Oranga, the Mental Health and Wellbeing Commission’s Te Huringa monitoring series and the Auditor-General’s 2024 review of youth mental health services found no consistent improvement in access, waiting times or outcomes, particularly for young people with complex needs.
It is within this environment of rising demand, unmet need and widening inequity that ADHD care is now unfolding. Women, First Nations peoples, people from culturally and linguistically diverse backgrounds, those living in rural and regional areas, and young people navigating education and employment transitions continue to face substantial barriers to timely, high-quality ADHD assessment and care.
Medication growth reflects need but also system strain
Stimulant medications play an important role in ADHD treatment and are often highly effective. However, they are not a standalone solution. Medication should follow comprehensive assessment and be considered alongside non-pharmacological strategies, psychosocial supports and, where appropriate, non-stimulant options. Medication alone cannot address the developmental, educational, occupational or social factors that frequently underpin difficulties with attention, activity and regulation.
Australian data illustrate both rising demand and shifting patterns of care. Over the past two decades, ADHD medication dispensing increased approximately eleven-fold. The number of ADHD prescriptions more than doubled over a recent 5-year period, from around 1.4 million in 2018 to over 3.2 million in 2022. PBS utilisation data show that between 2021–22 and 2022–23, the number of people treated with PBS-listed ADHD medicines increased by 28% overall, with 40% growth among adults compared with 20% among younger people. The proportion of adults among all people receiving ADHD medicines rose from approximately one-third in 2019–20 to nearly half by 2022–23, marking a substantial shift towards adult ADHD care.
In Aotearoa New Zealand, national dispensing data demonstrate a ten-fold increase in adult ADHD medication use between 2006 and 2022, with new adult dispensing doubling between 2011 and 2022. Dispensing to children and adolescents also increased approximately three-fold over the same period, though adult growth has been proportionally greater.
These trends should be understood as a signal of longstanding under-diagnosis, delayed access, and unmet need now colliding with constrained system capacity.
Why comprehensive psychiatric evaluation matters
ADHD rarely presents in isolation. Across the lifespan, ADHD symptoms overlap with anxiety disorders, mood disorders (including bipolar disorder), trauma-related conditions, autism and other neurodevelopmental conditions, substance use disorders, learning difficulties, sleep disorders and physical health problems. For many individuals, ADHD is the entry point into a much broader pattern of psychological distress and functional impairment.
For this reason, comprehensive psychiatric evaluation is not optional, it is a safety requirement.
A robust assessment is developmental, longitudinal and contextual. It requires time to gather collateral information from family, whānau, schools and other services; examine temporal relationships between symptoms, trauma, substance use and medical conditions; evaluate comorbidity and differential diagnoses (including psychotic disorders, bipolar disorder, personality vulnerabilities, etc.); understand cultural identity, social supports and risk; and translate this information into nuanced formulation and collaborative treatment planning.
By contrast, brief, narrowly focused or abbreviated online-only assessments, particularly those relying solely on screening tools or self-report, risk over-diagnosing ADHD, missing other mental illness, or initiating stimulant treatment without adequate understanding of context, complexity, or risk. While such models may increase throughput, they can undermine clinical safety and erode public confidence.
Recognising complexity across the spectrum of mental illness
ADHD exists within a broad spectrum of mental health presentations, from mild and situational difficulties to severe, complex and enduring mental illness. Safe and equitable care depends on the system’s ability to distinguish levels of need and respond appropriately. Too often, however, systems fail to do so.
When timely access to psychiatric care is constrained by affordability and workforce shortages, and when multidisciplinary community services are stretched beyond capacity, people with increasingly complex needs are channelled into models of care never designed for such complexity. Specialist psychiatric services are then left managing only the most acute crises, with limited capacity for early intervention, comprehensive assessment, or longitudinal care.
This mismatch disproportionately harms people with severe mental illness and reinforces a discriminatory assumption made at times that all mental health presentations can be addressed through generic or low-intensity interventions. It also risks diminishing the distinctive contribution of psychiatry to diagnostic clarity, formulation, risk assessment, and integrated biopsychosocial care.
Stimulant medicines remain an important and often highly effective component of ADHD treatment, but the psychiatric risks cannot be ignored, particularly the risk of new or worsening psychotic or manic symptoms. Clinically, risk appears higher in the context of dose escalation or high doses, comorbid substance use, sleep deprivation, and personal or family vulnerability to psychosis or bipolar disorder which underscores the importance of careful screening, conservative titration, and proactive monitoring.
Beyond the risk of psychosis or mania, stimulant medications are associated with a range of physical adverse effects including reduced appetite and weight loss, sleep disturbance, tachycardia, increased blood pressure, headache, and gastrointestinal symptoms, with rarer but clinically significant cardiovascular risks in individuals with underlying cardiac disease.
From a psychiatric perspective, stimulants may exacerbate anxiety, irritability, emotional lability, agitation, and insomnia, and in some individuals contribute to mood destabilisation, particularly where there is underlying bipolar vulnerability. There is also evidence of increased risk of misuse, diversion, and non-medical use, especially in adolescent and young adult populations, and in contexts of comorbid substance use disorders.
Market responses and professional reflection
In the absence of accessible, comprehensive public ADHD services, a range of market responses has emerged. Most clinicians across psychiatry, psychology, paediatrics, general practice and allied health continue to provide ethical, thoughtful care under considerable pressure. However, a small but visible subset of services now offers rapid, high-fee ADHD assessments, sometimes at significant personal cost to individuals, with limited collateral information, minimal follow-up, and poor integration with broader care pathways.
These practices understandably generate community concern. They should be understood primarily as symptoms of structural failure, not merely individual shortcomings. High-fee, low-depth models thrive where governments have not invested sufficiently in accessible, multidisciplinary ADHD and neurodevelopmental services.
As a profession, it is timely for us to reflect on how our practices are perceived particularly when some assessments are delivered at very high cost yet lack the depth and quality our patients rightly expect. These instances, though not reflective of the majority, can shape public trust in ways we must take seriously.
A challenge to governments
This leads to an unavoidable conclusion: no Australian state or territory, and no region of Aotearoa New Zealand, can currently say hand on heart, that its mental health system is meeting population need. The data are unequivocal: rising prevalence, widening inequities, prolonged delays, constrained specialist capacity, and persistent gaps in community-based and psychosocial care.
If governments cannot confidently assert that their systems are functioning adequately, the next question must be asked: why not?
ADHD reform should not be treated as a narrow issue of prescribing policy or individual clinical behaviour. It is an opportunity to repair system foundations to integrate multidisciplinary care, strengthen data and monitoring systems, embed lived experience in service design, and create pathways that genuinely match levels of clinical need.
RANZCP position statement
Our position statement, developed through extensive member input, charts a clear path forward: comprehensive assessment, structured shared care models, expanded GP roles with mandatory accredited training, specialist oversight for complex or high-risk presentations, safe prescribing practices and, critically, genuine engagement with people with lived experience in designing and evaluating reforms.
It calls for substantial investment in a nationally coordinated system to monitor diagnosis patterns, prescribing trends, adverse events, and service utilisation, and the impact of policy reforms across settings.
Conclusion
ADHD care is not an isolated policy challenge. It is a mirror reflecting the deeper fragilities of mental health systems in Australia and Aotearoa New Zealand. The current moment is precarious, as rapid change risks amplifying inequities and undermining safety. Yet, it is also generative, offering an opportunity to build systems in which comprehensive psychiatric evaluation, multidisciplinary care, equity, cultural safety, and timely access are core commitments rather than aspirational ideals.
If we are serious about delivering safe, comprehensive and equitable ADHD care, we must be equally serious about sustained investment in both public and private mental health systems, and about preserving and strengthening the depth, integrity, and expertise of specialist psychiatric practice.
Only then can we move towards mental health systems that truly serve our communities, systems that are accessible, safe, equitable, culturally responsive and evidence informed.