“I think I might benefit from ADHD meds, but I don’t know how any of this works. What do I do now?”
Getting an ADHD diagnosis is sufficiently complicated that there’s a joke, "You know which people don't have ADHD, because no one with ADHD could make it through the process to get diagnosed."
Hopefully this quick overview of my diagnosis process can make finding a doctor and getting diagnosed more approachable.
Note, my diagnosis process was in the UK. The process is similar in the US, but I understand that system less well.
How to find a psychiatrist
Step one is finding a doctor to diagnose you.
If you need to go through a provider covered by your insurance or (if you’re in the UK) the NHS, you probably want to start by asking your primary care physician for a referral or contacting your insurance provider for a list of covered psychiatrists. It will probably be a huge hassle. I asked my GP for a referral – only to be informed that there is a four-year waitlist to get an appointment.
In the US, you can also try asking your primary care provider if they can diagnose you and prescribe meds. I think it’s common for them to say no, but it might be the simplest option if they do agree.
If you can afford to drop one to two thousand quid, you can go the private route and get diagnosed in a few weeks to a few months.
UK
I used The ADHD Centre, an online private clinic. The process took three weeks from scheduling to an initial diagnosis call, then about a month to get medical tests and a follow up appointment to prescribe medication. So altogether about two months, and cost about £1,500 (£795 for the initial appointment and £225 for a few monthly follow-up appointments until I was stable on meds that worked for me.) As a second data point, a friend also had a good experience with them.
Another friend had a good experience with Psychiatry-UK. They signed up for an account, looked over a list of doctors with availability in the next few days, and scheduled an appointment in a couple days for £360 per session. You might be able to have the NHS cover this or other ADHD diagnosis services through Right to Choose.
Canada
One person recommended the online service Frida.
USA
I’ve tried to list some US options, but they’re not great. Sorry! The services available vary state-to-state in the US, so you’re going to have to check if any of these are available where you are. In addition, telehealth availability will probably change in the next few weeks as the extended telehealth permissions from Covid are rolled back. If you send me updated information or additional services, I’ll try to update this list.
I asked a few people for their recommendations, and got:
Bay Area Adult ADHD worked pretty well for one person. I think they’re an assessment clinic that can assess you and recommend a treatment plan to your doctor, but not able to directly prescribe medication.
One person worked with Boston Neurobehavioral Associates exclusively through Telehealth.
Online services like Done are relatively accessible, but are under scrutiny as the telehealth rules change.
One recommendation on the EA Mental Health Navigator was for Talkiatry, an online “group psychiatry practice that operates in multiple states, accepts most major insurances, and offers primarily medication management.”
The EA Mental Health Navigator provider database has more recommendations for providers who can prescribe medication (you can filter by specialty for ADHD).
If none of these work for you, you can try asking for recommendations from friends and family members who have received treatment for ADHD. Based on the examples I found so far, I’m guessing that you probably want to look for online practices that advertise ADHD diagnoses, so you’re less likely to run into a doctor who will refuse to prescribe medication.
Do your own research
This step is optional, but I’d recommend you at least read Scott’s post on ADHD medication (linked below), since the doctor may or may not give you enough information to make sensible choices for yourself. (My doctor basically told me “Here are four medications. Two are short acting, two are long acting. Which do you want?”)
Psychiatrist Scott Alexander has an excellent overview here with the medication he recommends. He also covers most of the other questions I hear -- possible side effects, tolerance, addiction, etc.
If you want more sources, UpToDate.com (a medical overview website for doctors) covers the treatment of ADHD in adults, including citing relevant studies. For a different approach, StuffThatWorks aggregates thousands of patient reviews to see which treatments work best.
tl;dr: The other two sources mostly seem to support Scott’s claim that Adderall is slightly preferable to Ritalin, and that both usually work well for people diagnosed with ADHD.
You can also check your own symptoms against the questionnaire the doctor will use. My doctor used the Adult ASRS Scale, which I think it’s the most common one. Scoring “often” or “very often” on 6 or more of the questions is suggestive of ADHD. (Specifically, I think my doctor was checking that I scored “often” or “very often” on 6 or more in childhood and 5 or more in adulthood.) The doctor will look at more factors, especially whether the symptoms are negatively impacting your life, but this gives you a good baseline.
The diagnosis process with the psychiatrist
Before the diagnostic appointment, the doctor sent me three questionnaires. I filled in one, and the others were filled in by who knows me now and someone who knew me as a kid. I think these were all versions of the Adult ASRS Scale. These checked whether I’d had symptoms spanning from childhood into adulthood that impacted my life now.
During the diagnostic appointment, my doctor used the following criteria based on the DSM-V:
1) Having 6 or more than 6/9 symptoms of attention deficit and/or hyperactivity/impulsivity in childhood and 5 or 5/9 in adulthood.
The doctor administered the Adult ASRS Scale separately for me as an adult and me in childhood. The scale has 18 questions addressing different aspects of inattentive and hyperactive presentations. Essentially, scoring “often” or “very often” for more than 6 of these is the threshold for an ADHD diagnosis, though that’s not sufficient. It’s possible other doctors would more heavily weigh the six questions in part A.
2) Having a lifelong pattern of symptoms.
The doctor checked that I’d had symptoms starting in childhood and continuing to adulthood, even if they were more minor and/or never diagnosed as a child.
3) Symptoms / impairment are expressed in at least two domains of functioning in childhood (before the age of 12)
Basically, did ADHD symptoms negatively impact at least two life areas such as schoolwork, social relationships, etc.? Examples from childhood included things like making spelling mistakes, getting distracted from homework, failing to finish tasks, or talking at inappropriate times.
4) Symptoms / impairment are expressed in at least two domains of functioning in adulthood
ADHD symptoms need to negatively impact at least two “domains of functioning” (like work, romantic relationships, friendships, money management, or well-being) to be diagnosed. Examples from adulthood include things like spending money impulsively, having difficulties in your relationships because you forget things, getting fired or losing a job because of poor performance.
5) The symptoms cannot be better explained by the presence of any other psychiatric disorder.
The doctor screened for autism and asked some questions about mental health to see if e.g. depression better explains the symptoms.
6) Clear interference / reduction in level of functioning and well-being in more than one domain
Is the negative impact from ADHD symptoms in at least one area severe enough that it’s making life worse? I think this last area is pretty important. If ADHD symptoms aren’t negatively impacting you, the doctor understandably is less likely to give you medication.
Examples might be if: you’re anxious about work because you can’t reliably meet deadlines, your work performance is worse than it should be, you’ve gotten bad feedback about being late, you’ve lost a job, you have a hard time managing money because you spend impulsively, you have problems in a romantic relationship because you zone out or forget things.
Medical screening
The doctor also asked some questions about my health (smoking, drinking, drugs, heart problems, family medical history, meds I take) that screen for any potential risks for stimulant medication. I’ve heard elsewhere that taking illegal drugs can be a dealbreaker.
Medical checkup
My doctor had me take a few medical tests before starting medication (ECG, a few blood tests, a doctor listening to my heart with a stethoscope). I think this is standard if you have a heart condition or other medical issue that might interact with stimulants.
It took me a few weeks of trying to get my GP to schedule an appointment before I gave up and just scheduled one myself at a private clinic. (I used SameDayDoctor in London, which was extremely convenient.)
Titration
Finally, the doctor prescribed medication.
I had to meet with the doctor monthly until we figured out which medication and dose was best for me. I tracked a bunch of metrics over the titration period (especially the first month) to measure how the meds worked. You can see those experiments here.
After that, you just get the medication regularly refilled by your doctor.
In the UK, after you’re stable on a medication, you can have the ADHD doctor hand over prescribing responsibility to your GP by sending them a shared care agreement. My GP refused (which I’m told is unusual), so I switched to Babylon GP at Hand, an online GP that accepts shared care agreements in London.