May 2026 - AMAQ President, Financial Advice and ADHD

Dr Nick Yim - Hervey Bay GP and Immediate Past President of AMA Queensland - gives an overview of medical politics during his tenure. 

Cutcher & Neale Accounting and Financial Services - Sav Angi and Nicole Brown give advice on maximising wealth in retirement and update us on important changes following the recent Federal Budget. 

Professor Shuichi Suetani - psychiatrist - talks about adult ADHD in primary care - "If you've got a hammer - everything looks like a nail"

Transcript

SPEAKER_00 0:04

Welcome to the Sunshine Coast Local Medical Association's Monthly Clinical Education. This is an audio recording of the evening's clinical presentations. You should also find the slides of the presentations on the SCLMA website so you can have a look through those as you listen.

SPEAKER_05 0:24

Good evening and welcome to the May meeting. I wanted to start by thanking our sponsors tonight, AMA, and we are very privileged to hear from the Queensland president. Past president. Here we've got Dr. Nick Yim, and we are also supported by our co-sponsors. And you can see their table over there, Kucha and Neil. And we'll be hearing from them tonight as well, getting some updates after the changes that we saw come through with the budget. And then we've got a fantastic presentation as well from Professor Shuchi Sutani from the Queensland Brain Institute about a very topical subject being adult ADHD. And I hear it's well worth waiting for the at the end of the night, very entertaining. I wanted to introduce Dr. Nick, who's going to have about 10 minutes or 15 minutes to have a chat about some updates, and then we'll be taking some questions. So make him feel welcome.

Dr Nick Yim - AMAQ President

SPEAKER_06 1:34

All right, good evening, everyone. So it's great to be on the Sunshine Coast again. I think usually I'll pop down every 12 months to have one of these meetings, and it's great to see so many familiar faces. Firstly, I'd like to acknowledge the traditional cassoons of the lands that we meet, and I'd like to pay my respects to elders, past, present, and emerging, and also acknowledge any First Nations people here with us tonight. So I'm going to keep my AMA Queensland update relatively brief because I prefer to take questions from the floor. But as we alluded, I'd like to thank the LMA for inviting me to present tonight. We've recently completed our elections, and for those of you who aren't aware, our newly elected president is Associate Professor Eric Gannon. She's an emergency physician at the Capulture Hospital, and our vice president is Dr. Sarah Cole, an orthopedic surgeon up in Cairns. I'd also like to acknowledge all the councillors that's been re-elected. I see that Wayne's here tonight, and thank you for your time and counsel as well. Contributions have been amazing, and the advocacy for this region has been impeccable. Likewise, I'd like to acknowledge Dr. Eleanor Chu who's here tonight. A great friend. She's completed her six long years as board chair for AMA Queensland. And now we have a new board chair as well coming forward. So a few updates. There's a UR code, uh QR code up there. So we've had some great wins over the past 12 months, and we've also been working very, very hard for our members. So one of the big things for those of you who are members, we've worked very hard for the AMA Queensland Medical Cost Guide. So the medical cost guide has been developed from the grassroots, taking account from GPs, specialists, surgeons, and etherists in the private sector from Brisbane, metropolitan areas, Sunshine Coast, and all the way out to the regions. We know that the delivery of costs is increasing, and unfortunately, at the moment, there have been challenges with our Federal Health Minister. I guess interfering with the market, saying that specialists are charging too much, saying that GPs must bulk bill, but without acknowledging what is the true cost of delivering of that health care to our patients. And those costs is going to be variable for one doctor to another. Maybe it's group practices, solo practitioners, some may have fly-in-flight services, different technology systems. That's the reason why there's going to be that cost variability. And this is where this cost guide is so important. So we can demonstrate to our patients, to our colleagues, and also to stakeholders as to why the current Medicare rebate just has not kept up with the times. From an advocacy point of view, we have um advocated hard over the past 12 months. Many of your members on the Sunshine Coast spoke to me and also via email and also on phone about e-scooters. Who's witnessed an e-scooter accident or had to treat someone with a fracture, laxeration? Yep? Carpal? Carpal? It was actually the Sunshine Coast. There was a lot of their research we utilized in our submission with the increased presentations, not just affecting emergency departments, affecting pediatrics, surgeons, anethatists, general practice. And it's really positive just recently, some of the recommendations were taken on board, and that includes the aid restrictions, speed limitations, and also we advocated hard on the need for investment in infrastructure and also education in this space. We are a little bit disappointed with some of the recommendations proposed by government, putting the onus on parents. One of the challenges, I know many of you who do have kids, it can be quite challenging knowing what kids do. But what we're calling for is the fact that we need to put restrictions on what they're selling, what they're importing. And at the same time, if they're knowingly selling these e-scooters to people under the age of 16, that's where the repercussions should be placed on hand. The other big thing is uh the drug diversion repeal. AMA Queensland with the previous Labour government worked hard to, we advocated to treat drugs as a health issue. As a GP, I know people don't deliberately go out there to use medicine cannabis, methamphetamines, cocaine, the illicit drugs that we see. We know that many people who do get pulled up by police, they might only have personal quantities. We are calling for people to go down the education route to treat it as a healthcare issue, as opposed to going down the criminal route and clogging up our court system. These policies were devised actually in conjunction, ironically, with the police union in the past, with the legal experts, and also with multiple specialties as well. So this is something that we are keeping a watchful eye on. I think this is probably going to go down to that one strike as opposed to three strikes rule. Um so I think this is something that we'll have to be cautious on. And for the colleagues in the community, I think this is something where it's really important to continue educating our patients to go down the education route. Um, we have a great advocate in Wayne here with treating the people with um, I guess, drug issues, addiction issues. We need to get more people in this space because this is an area, unfortunately, that's really under-resourced and underfunded. Upcoming in the Queensland budget, um, this is going to be an interesting budget for Queenslanders. We know across the whole state, and Sunshine Coast is not exempt to this. Um I think Sunshine Coast, you do take a lot of the workforce with this amazing area. Um a lot, I don't think you have challenges in recruiting, but I think workforce is going to be a big, big part. The state government wants to have an additional $6,000 for the state of Queensland by 2032. Um we need a training pathway that includes medical students. We need training pathways for our doctors and training to complete their fellowship, but at the same time, we need retention pathways as well to keep doctors that are in Queensland working in Queensland. We're also calling for investment in mental health. We've unfortunately seen closures of beds in the private sector in mental health. We've seen a reduction in services in mental health for Queenslanders, and this is something that's really important to prevent hospitalizations, presentations to emergency department, and also the added strain for our hospitals. It's really positive that the Queensland government has committed to free influenza vaccines for all Queenslanders, and just recently there's a commitment for increasing the age for the volumists to 17 for those who are scared of needles. I think this is a great commitment from the Queensland government to highlight that immunization is paramount. Unfortunately, last year, I believe the statistics showed that was approximately only 28% of Queenslanders had the flu immunisation. And we'd really need to increase those numbers this year. We don't want a repeat of putting elective surgery on hold in the public sector because that adds additional pressures to our system. I'm sure many of you who saw the federal budget recently, I think most of us were a little bit underwhelmed. There wasn't huge amounts of investment into the healthcare sector. There was investment into urgent care clinics and there was a commitment in New South Wales to fund general practice, 100% bulk billing, and government funded in areas when there's market failure. I, and along with AMA Queens, and we do have concerns with these funding models because it's creating, I guess, market pressures on existing practices in those areas. I think this highlights one of the challenges, not just in general practice, but also in the specialist area, that the Medicare rebate just has not kept up with the times. The patient's Medicare rebate is less and less when you look into inflation, and that's something that we do need to address, and that's something that it's key that we focus on. But I'm going to pause there. Um, thank you for the Sancho LMA for the opportunity to chat tonight, but I'm happy to take any questions. Um, as we alluded to, we really appreciate the support from Catch O'Neill, Sav and Nicole's here tonight, they're great sponsors, and they're gonna be here tomorrow as well. We know that we've got the private practice series tomorrow. If you have a spare moment tomorrow, if you don't have any plans on, I believe it might be wet. Um there's still plenty of seats available. It's being hosted at Pier 33. If you have any questions or interest on that event, um come across to the stand, and I'm sure um just staff from AMA Queensland are happy to take any questions. But I'm happy to take any questions from all of you tonight.

Cutcher & Neale - Financial advise and Budget implications

SPEAKER_05 11:20

We're ready for our next speaker, and it's my pleasure to introduce Sav Angie and Nicole Brennan, who are both partners from Kutcher and Neil, who are our co-sponsors tonight, and they've taken their Thursday night, and they're also taking their Friday all day tomorrow to help educate us and answer our questions. We've got a couple of presentations from them tonight. Firstly, Sav's gonna talk about um retirement and wealth, hopefully, those two things together. Um, so we're gonna be maximising wealth sooner. That's the plan. And then um we're gonna have a little bit more information from Nicole about updates from the budget. So we're gonna have questions after. Um, so make sure that you're popping your hand up at the end of both presentations and we'll come around with the roving mics. But join me in welcoming Nicole and Sally.

SPEAKER_01 12:16

Thank you very much. And thank you to all of you braving the weather on the not-so-sunny coast tonight and uh being here for this. Just a bit of a snippet of some of our team. So Nicole and I that look after the uh medico accounting and uh financial, well, wealth creation, I guess. Um Josh from our finance team and Andrew from our general insurance team. Okay, so the firm's been around since 1953, um, headquartered in Newcastle with offices now in Brisbane, Sydney, and Melbourne. Um a lot of what we do is tailored towards medical professionals and helping them create and preserve their wealth. As you can see, we've got clients sort of spread all over the country with a big focus on the eastern seaboard there. Some of our services. I'll be touching on a few of those a little bit more specifically. So this is what we call our seven pillars for success. So in the middle where it says wealth, it's actually you, if you want to interchange the word wealth with you, because a lot of what we do, as I said, is helping you create wealth but preserving that wealth at the same time. So, in terms of the services that we that we offer, um obviously big focus on income and taxation, so doing accounting and tax returns and financial statements and so on, making sure you're structured the right way to put you in the best tax position. Um key performance indicators, making sure your business is is running successfully and actually operating viably, superannuation and financial planning. So we we do uh have a strong focus on both of those areas as well. So, both from a wealth creation from an investment services team point of view. We look after about $1.3 billion of client monies, um, and a number of our clients have got self-managed super funds, so that's also quite a big area. Um, risk and general insurances. So I mentioned preserving your wealth before, so making sure you've got the right insurances like income protection. For example, if something happens to you and you can't work, then you need to make sure that's covered. But from a general insurance point of view, also having things like your medical indemnity and your business and your cyber and so on, too. So we offer free consultations for you know uh quotes and comparisons on all those sorts of things. Finance and cash flow. So we have an in-house finance team that has a lot of medico-specific um lending policies that we can certainly assist with. Um, and cloud systems, I guess, for those of you running your own businesses where you're using things like zero accounting software to make it easier from a financial reporting point of view, and also timely lodgement of BASEs and so on as well. The only thing we really don't do is legal, so we've got estate planning there as a bit of a I guess a checklist item, but we're not lawyers. Um, we can certainly put you in touch with some lawyers that look after estate planning and wills and so on, but also very part, a very important part of protecting your wealth. Okay, so tonight we're gonna um I guess briefly go over the power of compounding and how that can make a fairly um decent impact on your end goal. Um, the the three tax freeze of superannuation, I'll go into those individually. Using property uh as an investment and also allowing that to help boost your retirement plan, and then Nicole's going to touch on the recent budget updates. So power of compounding small fiction microphone.

unknown 15:55

Okay.

SPEAKER_03 16:01

Okay. Perfect. Okay.

SPEAKER_01 16:06

So even the smallest action can make a big difference. So everyone's heard of compounding simple interest versus compound interest, reinvesting to help things grow more quickly. So the smallest actions can make a big difference. Oops, hang on. Let me go back a step. Okay. For those of you that have got longer time frames on your side, you can make it obviously work more effectively for you. And a difference of five years can make a big difference. So, for example, those the younger ones in the room who are just starting out, I guess, who, if you start investing, say more seriously at say 35 compared to 40, it can actually make a fairly big difference by the time you get to retirement. Now, compounding can work across all asset classes, not just um cash. Uh, it can work with things like superannuation, property, and shares, and so on. And the idea is to be disciplined to be consistent with your savings and contributions into your investments. Compounding isn't a new thing, it's been around for a very long time. Referred to by Albert Einstein as the eighth wonder of the world. Uh just a bit of a, I guess, an update on the recent superannuation limit changes for those of you that um I guess are wanting to use this as a tool for retirement planning. The um limits have all been or will be changing, sorry, as of 1st of July. Um so all of the caps are increasing, tends to go up sort of with CPI. Typically, it's it happens every three years, but it's happened fairly quickly this time. So we may not see it happen again next year straight away, but for this year at least we've had an increase there, which obviously affects your non-concessionals and your and your um your three-year bing bring forward um provisions there as well. So with your employees, 12%. We basically maxed out now at what the government introduced probably more than a decade ago. We started out at 3% for the employees with um superannuation guarantee. We've now slowly achieved that 12%. Um for those in the public hospital system. I know Quincent Health tends to pay 12.75, so slightly above that. Um, but the thing to keep in mind that superannuation is still the best taxed environment with a tax rate of 15%. So here's a bit of an example. We've got a young couple here earning similar money, slightly uh different age gap there, but they're trying to aim for a reasonable amount in their retirement, um, starting with 250,000 in superannuation. Now, this example is done on the 27,500 cap that went up until last year. But um, here we if we look at the two of them at the moment, if we project that forward with those assumed earning rates and inflation, we've got a $2.6 million retirement balance. If we look at adding in the maximum concessional contributions each year instead of just their superannuation guarantee amounts, we jump up to a massive 4.8%. So obviously, it's going to give them a much bigger pot at retirement, make their I guess their lifestyle more comfortable, but would also last a lot longer in retirement. I guess one thing that is a bit of a concern these days is with people living longer, is how quickly will you run out of money in retirement? 2.1 million. Now we don't see this as a limit, we see it as a target, but this amount relates to the transfer balance cap and how much a member can have in superannuation before starting a pension and essentially being tax free. And I'll elaborate a little bit more on the tax-free. So I mentioned there's there's three different tax free of super. The first one is tax-free going in. Well, technically it's not, it's 15% going in, but I'll give you an example to show how it does work out to be tax-free. Tax-free while it's growing in pension phase up to that transfer balance cap of 2.1 million that I mentioned before, and then tax-free coming out as pension. So I'll give you a bit of an example of each here. So this is an investment portfolio where we've got in accumulation phase in superannuation, we've got half of our investment pool sitting in either cash or hybrids, earning roughly, say, 5%. Currently, a fairly reasonable rate in things like term deposits at the moment, earning $25,000. And let's say we've got the other half in shares that are fully franked in shares, and so we've got our 30% tax that gets paid by the public companies on each of those. So we take into account the $17,500 in the franked dividend plus the imputation credit of $7.50. So we have total taxable income of $50,000 in this example, taxed at 15% in the super fund, seven and a half thousand, less the imputation credit you've received on your shares there, and essentially you work out to pay zero tax. Let's take it a step further and say, well, once we're in pension phase, there's a bit of a different example with rent and dividends and so on that are fully franked as well. When you're in pension phase, if you're under that $2.1 million cap and you switch to pension from accumulation, you can essentially be a hundred percent exempt from tax. So therefore, you can earn in this case $150,000. But because your tax is going to be zero because you're in pension phase, you're going to get 100% of those imputation credits back. So you end up with quite a nice refund of $15,000. Pension payments. So between $55 and 60, you can start what's called a transition to retirement pension. While you're still under 60, though, you do. Get taxed, and there is a tax rebate that you get back. But basically, once you're over 60 and you're in pension phase, so you have had to have met a condition of release to actually be able to start that pension. Any pension or lump sum that you draw out is tax-free to you, doesn't even get included in your tax return. Property can often be a really good tool for retirement planning as well, so it can assist with a passive income, so rental property trickling away nicely, adding to any income, I guess, from other investments and so on as well. It can help cover your living expenses depending on what sort of passive income you've got there. It can help with credit card and help debt and car loans. But by the time you get to retirement, ideally you're not going to really have any car loans or help debt, but I guess it's something that can help pay those off. The other thing we can look at is if you do have borrowings on those, what sort of interest rates and what sort of loan periods come into play there. So we can use the power of leveraging earlier on in life to build up our property pool that will help us later on in retirement. So the beauty about property though is we can hold it both inside and outside super. You've got some flexibility there. Superannuation is still obviously the best tax environment, being 15%. At the moment, under the current budget announcements, it's also been exempted from the changes that they're talking about with negative gearing and capital gains. So still quite an attractive investment entity. And the other thing, I guess, is when you're getting closer to retirement age, you've got the option of do you hold or do you sell. So if you hold the property, as I said, you've got a nice passive income stream. Some people may say, Well, I want to sell it off, gives me a nice big pool of cash that I can then go and do other things with. So it's obviously a fairly important part there of overall retirement planning. Bit of an example here, I guess, growing your asset base more quickly. If you're saying, well, okay, we've got $50,000 to invest. What can we do a little bit differently? Well, as medical professionals, you can borrow up to 95% of the value of the property with no lender's mortgage insurance. Um, so you could use that $50,000 as a deposit towards a million-dollar property, or you could invest it in shares, um, and both with 5% growth. Property obviously is going to give you a better long-term growth when you're comparing the two directly with that, but obviously you've got to take into account the debt that's in place there at the same time. Now we're actually going to hand over to Nicole to discuss the um recent budget measures, and we'll have some time for questions uh after this.

SPEAKER_04 24:48

Thanks, Sav. So I've got here top 15 budget measures. Um I'm probably only going to give you a brief overview of one to four, which is we're talking about the CGT discount changes, discretionary trusts, negative gearing, and some changes to do with small business depreciation. I'm not going to pretend I know more than you about five, six, seven, and all of these ones focused specifically on medical professionals and so on. No doubt you know you understand more about that than what I do, and I know Nick mentioned that a little earlier on in the evening too, about some of these things. Um, so all important to consider, but I guess I'm gonna wear my tax hat. And talk through first capital gains tax and changes are coming, and and this could impact all of you in many different ways. Um, what is capital gains tax? So, capital gains tax is a tax that you pay when you sell an investment. You don't pay tax on your main residence that you live in, and historically you've never paid capital gains tax on an asset if you purchased it prior to September 1985. However, under the budget changes, um the traditional, and sorry, let me go back a step. Um, if you held an investment for more than 12 months and you still hold that investment now, so up to 30 June 2027, you will still get a 50% discount on any capital gains that are made, and then you pay tax at your marginal rate if you hold that asset for more than 12 months. However, the rules are proposed to be changing. So, what's changing? The traditional 50% capital gains tax discount is going to be replaced with an inflation-adjusted model, which is fairly complex, is what I will say, with a minimum 30% tax being paid on gains that are made. It's proposed it will take effect from 1 July 2027, and who's it going to impact? Any investors that hold shares, property, unless it's a new build, which I'll cover in a little bit more detail. Um, and you know, even if you think about we we know medical practices, service entities and so on, um they're carried on through, it could be through a company. So even holding shares within that medical practice company, that's seen as being an investment. So there's so many different ways that this really impacts everyone. Um the the key takeaway is don't rush and do anything because this legislation there's been no legislation passed. Um, we did get a bit of notice today that it's progressed, and um around I think it was the 22nd of June, we might hear some more, so it's making its way through the House of Representatives, and um there's meant to be some feedback later on in June. Um the one thing I will say is they have a very short timeline in terms of announcing this in the federal budget a couple of weeks ago and really a 30 June 2027 deadline. Um, there were some changes in the superannuation space, and it took them probably close to three years to get it across the line. So, um anyway, it's been put forward, it's in front of us. We've got to consider uh how this could impact everyone and ensure that you seek proactive advice if or when we get confirmation of the changes. Also giving you a little bit of a I'd say an intro, a bit of a taster of the federal budget changes because we are covering these in more detail in tomorrow afternoon session with some actual practical examples that align with each of these key budget changes from a taxation perspective. So, discretionary trust, another one that's been impacted. We've heard for many, many years the tax office doesn't really like trusts, and why is that? What's a trust? A trust has historically been and still is an effective investment vehicle, so a separate legal entity where you can carry on a business activity, you can hold investments, really good asset protection, but at the same time there's been it's a legitimate way to split income with family members. So you think about your family tree, that's typically who you can distribute income to, and even children over the age of 18 where they're receiving financial support from their parents. The proposal is from 1 July 2028 that there's going to be an introduction of a 30% minimum tax rate. That's tax that the trust will pay. 30% is the amount of tax that an individual pays at the moment on $200,000. So if you think about there's lots of family trusts that are running, where it might be that there's adult children, spouse, and so on that's not working, that's receiving a distribution of income. This is going to mean that every single family trust is going to pay more tax. It's impacting all discretionary family trusts. There is a proposal that there could be some rollover relief made available for those that are impacted to consider restructuring. In the background, what do we think that's about? It's an opportunity to restructure without tax implications from a family trust to possibly a company. A company pays tax at 25% or 30%. We don't know enough about it yet, but what we do know is that there could be stamp duty implications and so on that you go, that's a state tax, and we're dealing with a federal tax change here, so no different to really what we went through with payroll tax, where it was the states imposing a tax, and you get a tax deduction for it, which decreases your income tax from a federal perspective. So stay on top of this one if you've got family trust. Negative gearings, probably the biggest one. And yeah, you know, why's why is this one being put forward is to really improve housing affordability, reduce those investors that keep buying properties and so on. I'm not a property expert. Um I don't know, I don't know how this is going to all play out, but personally I really felt they needed to do something in the negative gearing space to really try and get first home buyers into the property market. Their proposal is that negative gearing will be limited to new builds only from budget night. So that was on the 12th of May. So anyone that held an investment property prior to the 12th of May, 7:30 pm, you will still get the benefit of negative gearing into the future. If you purchase an existing house that's on a block of land and so on, or an existing apartment, townhouse, whatever, post-budget night, you will get the benefit of negative gearing only until 30 June 2027. Um it's going to impact, I say, everyone, unless you're looking at a new build. The biggest issue with investing in a new build, and again, not a property expert, but construction costs are so high at the moment. So to enter into that market, you've got to consider well, what are you paying for that property and what's the likelihood of capital growth? So will there be slower capital growth? You know, who knows? Um, you know, I live in Brisbane. Um, how much spare land is there available and so on for these new builds? A new build is classified as you know, work that's completed on a block of land where you increase housing supply. A granny flat does not count. So if you knock down a house and put two townhouses on, you've increased supply. So it's all these things that are going to come into play with all of this. Um, one thing we do know from new builds though is there's some really, really good tax depreciation that you get the benefit of. So a pretty good tax deduction there from that, um, because you do get to write off construction costs over 40 years. So that does go, that does work in your favour. For anyone that's carrying on a business activity, so that could be you as a sole trader with an ABN, maybe you've got a company or trust that's carrying on a business activity, you would have heard over time that there's this immediate deduction for plant equipment and so on that's purchased once upon a time on the back of COVID. Um there was a government stimulus measure whereby you could pretty much go and buy anything and claim an immediate deduction for it. Um, that's no longer the case. Um, this they've permanently approved the $20,000 instant asset right off instead of dropping it down to $1,000 every single year and then increasing it back up. So that's $20,000 per item. So you know, if there's some machine that you meet that you need and it's $18,000, and then there's a computer that's $5,000 and something else that's $5,000, all of those items are immediately deductible. So really you're bringing forward a tax deduction. That's all that is, because without this rule being in place, historically you would have depreciated that over a number of years. Um it's already in place. It says here it's taking effect from 1 July, that's just because it's permanently going to be there. And and you know, most of our medicos will benefit. It's relevant to all businesses with turnover less than $50 million. There is also this two-year loss carry back rule. Um, what does that relate to? It's really anyone that carries on a business activity through a company. So, where do we typically see this? It's in, I say, the growth phase, um, or maybe there's been a bit of a change that's that's happened, and for whatever reason, there's a loss in you know, your third or fourth year. There's an opportunity to really carry back that loss to one of the earlier years and get a refund of tax that had previously been paid. Um, we don't see this one really being a big deal in the medico space that we work in. Um there's lots of other industries where it can be very seasonal and and so on, good years, bad years. So just to finish off, um, a bit of a financial roadmap, and I guess some key key takeaways. Um one that's not on there is if you've got some free time tomorrow, come along to the event that's being held here. Um, you know, we attended the the Brisbane event um a few weeks ago now, and lots of great speakers and so on, lots of good networking. Um in terms of the key takeaways from what Sav and I have spoken about tonight. Eliminate bad debt, so try and focus on non-deductible debt, is what we call bad debt. Um, protect your income in the event that you're unable to work tomorrow. You know, what would your personal circumstances look like? Um, you want to make sure that you've got protection in place to stay in your own home and meet the commitments that you have personally or as a family. So that's more so thinking about your income protection, insurance, um, life insurance and so on. Start investing now, you know, even a small amount, it's the power of compounding and how that can help you through through your stages of your career and into retirement. Superannuation contributions, um, you know, Sav mentioned that the three tax frees of super. Um, you know, there is a there is a pretty good tax deduction that comes if we put in some extra super away. The biggest danger in it is it can be a long time until you get access to that. So just ensure you obtain appropriate advice in relation to that. Um consider diversifying your investments, like if you own a home with some debt, like maybe there's an opportunity to diversify and invest elsewhere. Um, and I guess even more importantly, with the federal budget updates, seek proactive advice. Umsure that you understand your structure and that you've got your trusted advisor. Um, because if some of these changes come to light, there could be some pretty quick moves that need to be considered. So that's all from us.

Professor Shuichi Suetani - Adult ADHD in primary care

SPEAKER_05 37:11

Uh join me in welcoming um Professor Professor Um Shu Chi Sutani from the Queensland Brain Institute. Um, who's come up from Upon? So thank you so much. Thank you. And uh we'll be taking some questions afterwards while we're all streaming.

SPEAKER_02 37:28

Right, thank you everyone. And I usually go to bed by half past eight, so I'm really tired. But I've been asked to talk about ADHD and I see some, I recognise some faces, so I'm sorry it's uh same slides. Um but um I'm Shurigium psychiatrist and I work for um the Institute for Owling Indigenous Health at my clinical job. Um and before I start, um now, can you hear me okay? No. Can you hear me okay now? Okay, right. I am gonna move around a bit, so if you can't hear me, could someone just wave your hand so I can see that you can't hear me? Oh, no, I'll probably okay. I'll I'll try to stand still. Um can I just get a show of hands? How many of you guys are medical students? That's that table, right? And a few um GPs? Yeah, and we've got a few specialists as well, is that right? Excellent, thank you. So this is really talk about um uh the changes that's been happening, as you know, in Queensland with GPs being able to diagnose and treat ADHD. So it's kind of pitched up, um, um GP colleagues in the room, but hopefully that's helpful for a lot of people um in the room. So I guess before starting to talk about ADHD, um I feel like um every man hits dog's got an opinion about ADHD and that, especially about adult ADHD. So I guess one of the take-home messages that I want to uh I want to share with you today is given that there's so much subjectivity in ADHD, it is important to have some kind of objective framework in working with people's ADHD. So there are a lot of good guidelines out there, bi-national guidelines, there are a lot of good papers. I think for um GPs in the room, Community Health Path has got a really good module on adult ADHD as well. So um I think ADHD, especially where you can't you you can't you you could get your personal opinion and professional opinion mixed up. So it's really important to be objective. And I'll kind of keep coming back to that in my talk. I want to talk about four things today. I'm gonna share with you about three different types of ADHD you see in adults, and which is not quite the same as what you find in textbooks. Um, I'm gonna talk, um, walk you through the diagnostic process we use to actually diagnose ADHD among adults. I want to talk about medications a little bit, and I'm gonna talk about uh non-pharmacological physician therapy a little bit and open up for any questions and um comments. So, to talk about different types of ADHD, I want to talk about Harry Potter. So I'm I'm old enough that I remember when the books came up, and I'm really sorry, I'm just gonna keep using Sam Jokes as the last presentation. But now I've got kids who are old enough to have read and watched the movies Harry Potter. So there are, I'm gonna talk about ADHD in terms of three main characters. So if you are a GP or a doctor seeing someone coming in for ADHD assessment for the first time among adults, you're gonna get three different types of ADHD. So you've got one that's pre-existing cases with ADHD. I'm gonna call him Ron, even though even though my daughter told me that Ron doesn't have ADHD, and it's his twin brothers, George and Fred, who's got ADHD. But that's the pre-existing case of ADHD. Then you've got Harry who's uh who had a missed diagnose of ADHD as a kid, but as an adult, you might think about diagnosing retrospective diagnose of ADHD. And finally, you've got Hermione, who's a de novo or adult onset ADHD. But let me explain what I mean by that. So Ron's probably the easiest one, the ones that you you've read in your textbooks, where it's uh it's the adults who grew up with the diagnosis of ADHD. So these are the kids who are diagnosed with ADHD as a child, and he grew up, um he probably got the diagnosis when he was in primary school, and by the time he comes and sees you, sees you as an adult, he's maybe asking for continuing with the medication that he's on, or he had a some break in treatment and wanting to go back on the medication that he used to be on. If you go back and ask his mum or dad about what he was like in primary school, you hear things like, oh yeah, Ron really couldn't sit still, he couldn't stop dogging, and he was always kind of playing with the Harry Kit all the time, and he was so hyperactive. So that's the kind of textbook description you get. You know that boys get picked up a lot more easily than girls, and it's probably because of the externalizing symptoms that you see in boys. So the sex ratio, the gender ratio for childhood diagnosis for ADHD is still two to four times higher in boys compared to girls. Now, there are lots of reasons why these kids or adults stopped taking medication. Um sometimes they tell you that they didn't want to keep taking medication after they turned 18, because, or sometimes they felt like they didn't need to. So some of these kids end up working in um doing things like constructions or more um labour kind of job where you don't actually need their structure, you don't actually need that medication to do well. So impairment may have gone because of the environmental changes. But probably the most common reason why here is these kids stopped taking medication because after they turned 16, 17, 18, they couldn't find a private psychiatrist to continue the medication. And sometimes these people come back 10, 20 years later when life's changed quite a bit and not so well. Now the second type of ADHD you see in adults is Harry, which is this is a retrospective diagnosis for ADHD in adulthood. So these are adults for whatever reasons whose diagnosis for ADHD was missed in childhood. So people get missed for different reasons and all sorts of different reasons. So if you ask Harry's parents about what he was like as a kid, which You can't do because Harry's parents are dead. But um, but they would say things like, well, he was a really smart kid, so he couldn't have had ADHD. Or maybe parents may thought that it kind of really, there's a lot of degenerational differences in understanding of the concept of ADHD. So they might say things like, well, I didn't think he had ADHD, or I didn't want to not, I didn't want to think about ADHD. At the same time, and this is probably, I see this quite a bit in my clinical work, is there were lots of other things going on in these kids' childhood. Um, so that getting Harry to see a pediatrician wasn't a priority. So maybe there are lots of DV happening at home, or the family environment wasn't that stable. So for whatever reasons, these kids may have had their ADHD symptoms missed in childhood. Now the thing about these kids is if you go back and have a look at objective evidence, so talking about things like school reports, talking to parents, or even things like Allied Health Reports that was done when he was younger, it is quite obvious that they had symptoms that kind of look like ADHD. So you you see things like Harry just can't focus on the tasks, or Harry can't stop distracting other kids in school reports. Finally, so this is probably you're probably gonna see a lot of cases like this. And I'm gonna call this Hermione. Uh it's a de novo case, or late onset, or adult onset case of ADHD. Now, these are adults who come and see you and say, Oh, look, I think I've got ADHD because I don't know, I read this thing on TikTok and it sounds like that's me. Um, if you go back on it in history, you just can't find any evidence of ADHD before the age of 12. And people talk about things like so often these people come in when there are significant changes in life. So things like going to university, it's a common one. Having kids is another common one, especially if the kids get diagnosed with ADHD. Or even after retirement, some people usually wives bring the husband saying, My husband's so annoying, he must have ADHD. So they're kind of different things. And people talk about things like loss of scaffolding, masking or unmasking of environment, but when you go back, there is no objective history of ADHD like symptoms in childhood. Now, according to DSM 5, this is not ADHD. I'm gonna digress a little bit. And um so I trained as a psychiatrist maybe 15 years ago now, and it's only been the last five years that I started seeing people with ADHD in adults. And I suspect that it's the same with lots of you guys. Um, and in the last five years, I'm starting to think that maybe there are two different types of ADHD. So let's think about diabetes. You've got, you know, how you've got type 1 diabetes and type 2 diabetes. Type 1 diabetes, more genetic condition that's got very different etiology compared to type 2 diabetes, which is a lot more driven by environmental factors. Late onset. And I'm starting to think that maybe there might be something similar with ADHD. So you might have something like type 1 ADHD and type 2 ADHD. So type 1 ADHD is your pediatric uh neurodevelopmental condition that you've seen. That's your runs of the world when you're a kid, and you can tell that's a waiting room diagnosis where you can see the kit who just can't sit still. But maybe there's a lot more type 2 ADHD coming up. So these are the people who are late on set, probably about my age, just can't focus and got lots of things going on at the same time. And just like increased access to high-density fast food takeaways have increased the rate of type 2 diabetes, maybe the world that we live in, the environment that we live in, the fact that we've got fast broad internet, we've got so much things destructing us, have made us more likely to have ADHD symptoms later in life. So type 2 ADHD. Okay, that's not in DSM. But interesting thing is when you look at, so this is the rate of ADHD in adults, the gender rate goes back to almost 1 to 1. And I think, in fact, last year, for the first time in Australia, the prescription rate for ADHD medication, I think there are more females getting prescribed ADHD medication than males over the age of 25 now. So the gender rate changes as people get older. Alright, so I'm gonna go through the diagnostic process of ADHD. Before I do that, I'm gonna talk about diagnosis in psychiatry. So, in psychiatry, um, diagnoses are like star signs. So, what we do are they're very subjective, they lack clear biological markers, and there's because of that, there are a lot of significant overlaps between different conditions. And whatever label I'm gonna throw at you, it's not gonna fully capture the individual's experience. So we um the way that Professor Alan Francis, who was the who was the guy who let the DSM fall, um, task force, said, I think he described psychiatric diagnosis as being seeing something that exists, so that's your stars, but with a pattern that's shaped by what we expect to see. So that's our star science. So people's distress, the symptoms are real, but how we conceptualize it are much like star science, is not real. Having said that, though, going back to what I started off with, objectivity is so important in working with ADHD. And things like DSM and ICD, this photo's about three years old, but that's actually me, and that's actually not my. I don't have a TikTok page, I just made it up, or my daughter made it for me. Um, but so it's um DSM or ICD, whatever classification you use, even though it might not be, it might only be star science, using such classification is so much more robust than an opinion from someone like me saying, talking about type 1 and type 2 ADHD that's not in DSM, or someone like that influencer you see on social media. So again, objectivity is important. What we know is comorbidity is really common in psychiatry. In fact, in ADHD, comorbidity, so comorbidity is having a different condition on top of ADHD is a rule rather than an exception. And I can say with hand in my heart that I never see a straightforward ADHD as my patients. People always come with something else, and ADHD comes with it. Some studies have said that psychiatric comorbidity among ADH people with ADHD is as high as 80%. And luck of focus, which is the most common reason why people seek the diagnosis of ADHD, is actually a really, really common symptom in DSM or any mental illness. So it's transdiagnostic, it happens in a lot of different diseases, and it's not at all specific to ADHD. In fact, difficulty concentrating as a diagnostic criteria is present in about 17 different diagnoses in DSM-5, which makes it, I think, number three in the most common symptom of a mental illness. In addition to that, response to treatment is not diagnostic. So just because you can focus better after taking dexamphetamine doesn't mean you've got ADHD. In fact, I think most of us would focus better after taking dexamphetamine. So in practice, when you are trying to assess for ADHD, what try what you're trying to do is you're trying to exclude or rule out the reversible causes of difficulty focusing. And a lot of that is actually kind of physical causes like low thyroid, iron deficiency, anemia, sleep apnea. And at the same time, thinking about medications to manage and what are the potential contraindications for psychostimulants that you may use for your patients. So, in terms of assessing, and this is probably, if any of you guys are thinking about building wealth and doing ADHD assessment, um this is the take-home message I want you to take. There is no such thing as ADHD assessment. You have to start off with a comprehensive psychiatric assessment. 90% of people who are coming in or who will end up being diagnosed with ADHD will have some other mental health conditions. So you have to start off looking for any other psychiatric condition that might be present with that patient. So you look up your mood, both low and high. You look at the anxiety that's really common, especially in younger people. Substance use, psychosis or history of psychosis, and trauma, and I don't know how. I think trauma history, you want to feel pretty comfortable with the patient before you start asking about that. If any of these symptoms are obvious and disabling, you should start off treating those symptoms first. Don't worry about ADHD, start treating. If someone's having panic attacks every day, you should treat that before you start thinking about ADHD. So things like mania, substance use and psychosis, what I do is from the start, I tell people that because of these symptoms or the history of these conditions, I'm not going to be able to provide you with psychostimulant medication. And I think what I find is 50% of people don't come back to the second appointment if I tell that. So I think a lot of people are. But it basically gives you a structured way of interviewing people according to other DSM or ICD classification criteria. You're always looking for onset of symptoms, so they have to have a started in their childhood, pervasiveness, and how much these symptoms are impairing the function of your patients in front of you. Now it would be nice to have cultural history or cultural information from someone right now. So sometimes I get information from the partners. Um, but you need to get the childhood evidence if you are to diagnose ADHD formally. So one of the diagnostic criteria is that you've got objective symptoms of ADHD before the age of 12. So without that, you can't make a diagnosis for ADHD. Alright. How are we going's time? Good? Not far to go. Medication. So I tell registration, so psychiatry pre-psychiatry is pretty easy, and ADHD is not that hard either. So medication options. You've got two by two by two. You've got two types, two subtypes, and two agents for ADHD medications. So two types, psychostimulants or non-psychostimulants. Two subtypes. So if you go down to cyclostimulants, you've got your methylphanidate and you've got your amphetamins. Then you've got two, sorry, you've got short acting and long acting. So that's your two subtypes. Then you've got two agents. So you've got your amphetamines and you've got methylphanidates. So if you've got short acting, you can get short-acting methylphanidate. Most of them are retlining SA. Or dexamphetamine, which is a short acting form of your amphetamine cyclostimulant. For long acting, you've got methylphanidate, you've got two different types. So you've got retlining LA, which is 50-50 long-acting and short acting, it lasts for about eight hours. Or conchurata, which is 75-25, I think, long-acting and short acting. So it lasts you for about 12 hours. So it lasts you a little bit longer. Lisdexamphetamine, or bivans, is your long-acting amphetamine substance. It lasts you for about 12 hours. Then you've got your non-syc non-cycle stimulants. You've got your atomoxistine, which is selective noadrenaline reuptake inhibitor, and you've got guanosine, which is um alpha agonist, I think. Guanhosine, which you use at nighttime. Now, a lot of pediatricians tend to use clonidin. Um the evidence for adults for ADHD for clonidine is quite small. Um, and so, and it's not PBS approved. So I don't stop people on clonidine if they've been on it for a long time, but I don't start people on clonidin either. Thinking about red lights, amber lights, kindotrophic light system, I kind of touched on this before, but I wouldn't treat ADHD with psychostimulants if someone's got current symptoms of acute psychiatric disorders. So if someone's psychotic, if someone's manic or someone's acutely suicidal, all these things, we should be treating these first before we start thinking about ADHD. In IUE, if someone's got a clear history of clear psychosis, we just don't use psychostimulants. So we just feel that the risk of psychosis on psychostimulants is too high if someone's got history of psychosis. Similar with mania, and I know some private psychiatrists feel comfortable enough to treat people with bipolar one with psychostimulant medication, but I wouldn't, and I wouldn't feel comfortable. Um, and finally, substance use disorder, and this is probably the one that comes up quite a bit, especially medicinal cannabis. But where I work, we've got a protocol which says if you've been using any illicit substance and medicinal cannabis, in the last two years, we're not going to be able to provide you with psychostimulant medication. So we're worried about increased psychosis risk, but we also worried about misuse of psychostimulant medication. Now that last one is the one that people kind of get quite upset about, especially medicinal cannabis. Um these are your ambolites, or things that I probably think about talking to someone else or seeking second opinions. So epilepsy, so seizure and psychostimulant medication, I think evidence is a little bit mixed, but I feel much better if a neurologist's okay with psychostimulant medication. Um, cardiac issues, I've got a whole slide on the next slide, so I'll come back to that. Eating disorder. So that's only restrictive eating disorders like anorexia that we're worried about. So binge eating disorder, five ants is actually a treatment TGR approved for binge eating disorder. So it's mainly because psychostimulants reduces appetites. So if someone's you if you worry about someone's weight, that's when you're gonna start worrying about using psychostimulant medication. Now, bipolar type 2, if someone's got a diagnosis of bipolar type 2, I probably would get a psychiatrist to do an assessment on that. And the main reason for that is I think bipolar type 2 and ADHD can present quite frequently, and you can really treat ADHD and bipolar type 2 quite well if you've got the bipolar part disorder. So that's probably one type of people that you might want to get psychiatric review. Anyone over the age of 55, only because there's no safety data for 55N plus for psychostimide medications, and obviously, if you're worried you're not sure about anything, refer to psychiatrist, I guess. Any cardiologist in the room? No. So I don't even know how to read ECG, so I've got a pretty low threshold to refine to cardiologists. But this this is a binational um um ADHD treatment guidelines. Um and basically, if you've got any congenital heart disease or any risk of, I guess, uh structural cardiac disease, you should get um cardiologists to have a look before starting on psychostimulant medication. And even after you start people on psychostimulant medication, so we get we actually ECG, get ECG on everyone. Uh you're looking at QTC prolongation, um, and you also check blood pressure and heart rate regularly after starting medication. Most people's blood pressure will go up, but it's just a matter of just kind of monitoring to make sure that it's not shooting up. So let's go back to the Harry Potter kits and uh let's see what medications we can prescribe. So under PBS, your psychostimulant medication options actually depends on the timing of diagnosis. So if you're like Ron and if you had a diagnosis as a kid, you can take all the medications that I talked about. But if you're like Harry and have that retrospective diagnosis, then you've only got five ants or retalin LA, not conscious. And non-cyclestimulants, so atomoxine and gramphosine, are not on PBS if your diagnosis was retrospective. And finally, if you're like Hamani, late onset ADHD, that's not a DSM condition. So you're not uh you're not eligible for any ADHD medication on the PBS. So if Ron was in my room, let's say he's now 35, um, I usually start with long actin. So either vivans or one of mesophenolate long actin, so either Ritalin LA or conscious. If that doesn't work, you move move on to the next one. So if you tried vivans, you might want to try Ritalin. And if that doesn't work, you could technically go for the second mesylphanidate, but most people probably decide to go short acting. Um after long actin, so some people do tend to do better in short acting, but in IUE where I work, we decided that we should get psychiatry review before switching over to short acting medication. And that's mainly because due to we're thinking about kind of, I guess, misuse of medication. After that, you can try non-stimulants. Artomoxetin in particular has got quite a robust evidence for adults with ADHD. It takes a lot longer to work, it probably takes four to eight weeks before you start seeing the benefit of atomoxetin. But in the long-term, actual effect size, the magnitude of effect size for atomoxetin is quite similar to methylphanidate. So it's quite an effective medication if people can stick with it. Guan sense's got probably a smaller body of evidence, but it kind of acts in a slightly different way. It can help with your sleep, it can be more sedating, and some people like that benefit. And the last step is if all these steps are not working, you have to start thinking about why medication's not working. So I'll come back to that. Now, if you've got Harry, so this is a retrospective diagnosis of ADHD, it's actually quite similar to run, except you don't have the option of conchurda, and when you're using non-psychostimulant medication, that's not under PBS. So I think Atomok stands about $30 to $40 a month now. Glanf stands a lot more expensive. I think it's for $80 and onwards. Um, again, if these medications are not working, you start thinking about why it's not working. Finally, Hamani, she doesn't have ADHD, so you kind of limit that in terms of which medication you can use. What we do is we try non-stimulant off label, and some people do well on our tamoxetin. Um, not many people can actually afford to take glance off label for long term. Uh, I probably wouldn't use psychostimulants off label for people like Hermione. So, what do we do if it's not working? So, going back to their star side. idea. Psychiatric diagnosis are not black and white. So if ADHD medications are not working, the first thing you have to think about is does he or does she have ADHD? So think about diagnosis again. And if you think that there's ADHD, make sure that you've tried a maximum doses of psychostimulant medications available. I wouldn't go any higher than that, but try the maximum doses that you can use. If that's not working, think about so ADHD medications are great for ADHD symptoms, but things like executive dysfunction, emotional dysregulation, they may not work as well. So make sure that you're treating and addressing non-ADHD core symptoms in different ways. As with any mental illness you always have to think about psychosocial issues that may be impacting someone's life and if up to 80% of people have comorbid illness you have to make sure that that's been treated properly. So that brings us to the title of my talk I think the thing about ADHD is when you start seeing someone with ADHD it looks like everyone's got ADHD. And you start treating people with ADHD medication and people get better and you kind of feel like everyone's got ADHD, including yourself, and you start treating everyone with ADHD medication. And the risk with that is when you have a hammer, everything looks like an L. And I think this is what's happening. And if everything looks like an L, you probably have a hammer. So I don't know if any of you guys are starting to assess and diagnose ADHD. I went through three about two or three years where 90% of people I saw I ended up diagnosing ADHD and you kind of have to think, step back and think am I really doing this properly? We are worried about that. So the college of psychiatrist has so Vivance is now the fastest growing medication on PBS. The College of Psychiatrist has, so that's the president has made a public statement saying that we are worried about these increases in ADHD medication prescription and the rate's only going to go up now that we've had changes in legislations. Alright finally just quickly non-pharmacotherapy so I guess the take-home message here is ADHD medication is really good at treating ADHD symptoms but not so good at treating things like functioning and well-being of people. Non-pharmacological therapy and it's actually the same with any mental illness I think they actually help with improving functioning and well-being of people. So for ADHD in particular I think there's a bit of evidence for CBT but it's not actually that great. But I think it's kind of common sense that anyone with mental illness will benefit from lifestyle intervention like exercise, diet, sleep hygiene and I think ADHD is not an exception. And you always you I think you almost always need to be thinking about that when you see anyone with mental illness including people with ADHD. Often what I find is that it kind of comes back to the cost benefit both money and time in terms of what kind of help that people choose to get in terms of non-pharmacological treatment. So I'm going to finish up my last take-home message is for us do no harm I think ADHD is a life changing diagnosis. A lot of my patients come back and thank me for ADHD and treatment and you know as a psychiatrist I don't get thanked a lot so it's a really nice experience. But it's not a life-threatening condition. I'm actually really excited about these changes that's happening in ADHD and that's the reason why some of you have seen me more than once and going around talking to GPs about ADHD because I'm so sick and tired of ADHD. But also I think it's a common condition it needs to be assessed, diagnosed managed in primary health sector it's like saying diabetes needs to be treated by endocrinologists. It just makes no sense. So ADHD needs to be managed mainly by GPs and we should only get the complex ones that people get difficulty with. But at the same time I'm really worried about what's happening in the ADHD space and I feel like there's a lot of shifting goalposts in terms of what ADHD is, what the diagnosis might be and what people say when people are talking about ADHD. And it's not just the medical issue there's a lot of societal and political drive that's shaping this space. And again I think if it's good too good to be true it probably is and we've seen this in things like opioids, benzos and medicinal cannabis people get better and five years later we might have lots of problems and I worry about that with HD medication and psychostimulants. So I'm going to leave you with something that my couple my supervisors said to me during my training and that is sometimes and that's more often than you think oops in psychiatry and I suspect that it's the same in most fields of medicine we do more harm by trying to help someone than not doing anything at all. All right thank you