Attention deficit and hyperactivity disorder (ADHD) affects between 5% and 7% of schoolchildren, but because doctors can only prescribe treatment for a month at a time, many South African children, especially those who can’t afford monthly doctors’ visits, don’t access medication regularly.
It’s time we changed the script, writes psychiatrist Renata Schoeman for Bhekisisa.
Methylphenidate, the gold standard of treatment, is classified as a schedule six drug in South Africa, meaning patients must visit their doctor each month for a new prescription.
In the private sector they’d need to pay for a doctor’s visit each month, aside from paying for the medication, and in the public sector, patients need to take a day each month to queue up at their local clinic.
Studies have shown that when the methylphenidate is used correctly, children’s school marks improve and they become better equipped to develop social skills.
So effective ADHD treatment doesn’t just help schoolgoers with ADHD to sit still and focus in class, but it also supports them to learn and socialise – outcomes which form the foundation of a healthy and productive adulthood.
However, methylphenidate is classified as a schedule six drug in South Africa – in the same regulatory category as medicines with a high potential for abuse – so pharmacies are therefore only allowed to dispense it to people with prescriptions, and by law, physicians can only prescribe 30 days’ worth of methylphenidate treatment at a time.
The current scheduling thus creates huge administrative and financial difficulties for patients and caregivers when they try to get treated, especially for those navigating ADHD’s very symptoms: executive dysfunction, forgetfulness and inattention.
As a psychiatrist, working in both the public and private healthcare sector, I’ve seen first hand the toll that untreated ADHD takes on children, adults and families, from fractured educational journeys to unemployment, depression, addiction and even suicide.
These are not theoretical risks but daily realities for many South Africans. And yet one of the biggest obstacles that locks people out of treatment – our own healthcare policies – remains unchanged.
A 2024 qualitative study with 23 South African stakeholders, which included healthcare professionals, pharmacists, regulators, patients and caregivers, revealed they did not see the current scheduling as an effective way to prevent misuse and illegal use.
Instead, participants said, classifying methylphenidate a schedule six drug has a negative impact on treatment adherence.
The South African Health Products Regulatory Authority (SAHPRA) must urgently review the scheduling of methylphenidate to consider rescheduling it to a schedule five drug, allowing doctors to prescribe six-monthly scripts. Schedule 5 medicines have a low to moderate potential for abuse or dependence.
Here are four reasons why methylphenidate should be a schedule five medication.
1. More people with ADHD will get treated
ADHD is not rare. A review of 53 research studies shows it affects 7.6% of children between three and 12 years and 5.6% of teens between 12 and 18.
In 65% of cases, children’s ADHD persists, at least partially, into adulthood.
While we rightly invest in treating chronic conditions like diabetes and hypertension, we continue to overlook the profound, lifelong impact of untreated ADHD. Studies have confirmed that people with ADHD have a higher chance to also develop other psychiatric disorders such as anxiety or depression; they’re far more likely to suffer from substance use disorders; to have accidental injuries; underachieve in school; be unemployed; become gamblers; fall pregnant as teenagers; commit suicide and to die early.
These factors contribute to the burden of disease and consequent stress on the health system, but most importantly, they reduce the quality of life of people with ADHD and their families.
Medication can change this, yet access is limited. In many poorer communities virtually no children who need treatment are receiving it.
Although stigma and the cost of methylphenidate (on average, between R700 and R1 000 for a month’s treatment in the private sector) play a role in making treatment harder to get, having it classified as a schedule six drug plays a big part in making the medication inaccessible – and it affects people in rural areas, the unemployed, and those without medical aid the most, further widening the treatment gap between public and private healthcare sectors.
2. Current scheduling does not prevent abuse
Opponents of rescheduling often cite concerns about misuse, especially among tertiary students using methylphenidate for academic enhancement. Although these concerns are valid, evidence suggests that the schedule six classification does little to prevent non-medical use.
In fact, studies show that 28.1% of medical students have used methylphenidate without a prescription. This raises an uncomfortable truth: those determined to misuse the drug will find ways to do so, regardless of scheduling.
One South African study showed that of the 11.3% of students who reported having used methylphenidate in the past year, only 27.3% had been diagnosed with ADHD; despite this, two-thirds obtained their medication through doctors’ prescriptions, just under a third got it from friends, and 6.1% bought it illegally.
Meanwhile, genuine patients, particularly children and teenagers, are penalised by overly restrictive policies that reduce access to the very tools designed to help them succeed.
We must ask ourselves: is the current scheduling preventing abuse, or is it merely restricting access for those who need it most? If the answer is the latter, then we have an ethical obligation to change course.
Rescheduling does not mean deregulation. It means creating a more nuanced, risk-based framework, one that acknowledges both the need for control and the realities of living with a chronic disorder.
3. More people will take their medicine correctly
How well someone adheres to their medication determines, to a large extent, how well the medicine works for them.
But studies show between 13% to 64% of people with ADHD and who often use methylphenidate, don’t use their medication as prescribed.
For people with ADHD – with symptoms that impair their ability to organise, plan and follow through – the monthly schedule six script requirement can become a self-defeating cycle. The very condition we are trying to treat creates challenges in adhering to its treatment.
Unsurprisingly, participants in the 2024 stakeholder study mentioned earlier in this article, viewed the current scheduling as counterproductive, and “expressed their support for the convenience of six-monthly scripts for obtaining treatment”.
Stakeholders argued that overall adherence would improve by reducing administrative challenges such as the need to take time off work and arrange monthly doctors’ visits.
Moreover, research shows, people with ADHD who use their medication correctly, are also more likely to adhere to medication for other conditions, for instance diabetes or HIV infection, that they may have. Improving adherence to ADHD medication therefore does not only improve the quality of patients’ lives, but also lessens the burden on our health system overall.
4. The state is doing the same thing for antidepressants and anti-anxiety meds
ADHD medication is not the only psychiatric medicine that needs rescheduling. South Africa’s current HIV plan for 2023–2028 recommends that certain antidepressants and anti-anxiety medications are descheduled from schedule five drugs – which only doctors can prescribe – to schedule four drugs, so that specially trained nurses are able to prescribe them.
Research has shown that there’s a high chance for someone with HIV to develop depression or anxiety: these conditions are associated with people with HIV taking their medicine less regularly.
But the state health system doesn’t have nearly enough doctors to staff clinics full-time. Instead, nurses run such clinics, with doctors doing shifts only once or twice a week.
Getting nurses to diagnose mental health conditions and to prescribe treatment will mean patients won’t have to return for doctors’ appointments to get treated.
Policy is never value neutral. It reflects what we, as a society, choose to prioritise. In the case of ADHD, we must choose inclusion over exclusion, access over fear, and healing over harm. Rescheduling methylphenidate is not about giving up control; it’s about restoring agency to patients, families and clinicians alike.
SAHPRA response from CEO Boitumelo Semete-Makokotlela:
SAHPRA is open to the rescheduling of scheduled substances. For this to happen, either the manufacturer of a medicine or anyone in the scientific community who has data for us to consider has to submit a request for rescheduling, along with the required scientific and clinical data.
We’ll have our names and scheduling committee, as well as our clinical committee, review the submissions. We would also consider additional data, outside what would have been provided, and then make a decision. This process takes about 120 days.
Professor Renata Schoeman is a Cape Town-based psychiatrist and the co-author of South Africa’s ADHD management guidelines, and chairs the SA Society of Psychiatrists special interest group for ADHD. She serves on the ministerial advisory committee for mental health and heads up the healthcare leadership MBA specialisation stream at Stellenbosch University.
See more from MedicalBrief archives:
SA Society of Psychiatrists: Pandemic’s online learning and working sees increase in ADHD symptoms
Pharma Dynamics: An app to assist parents and caregivers of ADHD children
ADHD drug benefits outweigh health risks – global study
Psychiatrist using ‘outdated’ checklist faces HPCSA complaint