As an adult, one of the most common questions you may ask of the person you’re considering seeing for your first appointment is a straightforward one: Is it a psychiatrist or a therapist?
It’s a legitimate question – and the mental health system does not allow it to be answered easily. The language used for these professions – psychiatrist, psychologist, therapist, counselor, LCSW, LMFT – is truly confusing, and the repercussions of the wrong term will be felt.
The short answer is: If an adult thinks he or she has ADHD, needs a detailed clinical diagnosis, and might require medication, an adult should see a psychiatrist first.
The more detailed explanation is trickier. Learning it will help you to make an informed decision about what to do for your health.
The Three Providers Most Adults Confuse
A psychiatrist is a licensed medical physician who specializes in psychiatry. Psychiatrists attend medical school and undergo psychiatric training in a residency program and are therefore able to diagnose psychiatric illnesses, prescribe medications and supervise their use over time. A psychiatrist is the clinically appropriate first step for a comprehensive ADHD assessment with differential diagnosis, taking co-occurring conditions into consideration, and possible use of medication as treatment.
A psychologist has a doctoral degree (either PhD or PsyD) and focuses on psychological assessment and standardized testing, as well as psychotherapy. Psychologists are qualified to undergo formal neuropsychological testing batteries and to establish a diagnosis. In New York and New Jersey, however, psychologists are not allowed to prescribe. If you are specifically looking to have standardised cognitive testing for accommodation documentation, a psychologist is your best choice.
Therapists include licensed clinical social workers (LCSW) and licensed mental health counsellors (LMHC), marriage and family therapists (LMFT), and other master’s level clinicians. Talk therapy – such as cognitive behavioural therapy (CBT) – which has solid clinical evidence for ADHD – is offered by therapists and is helpful with the emotional and practical aspects of living with ADHD. Rather than a clinical diagnosis, therapists can only make a clinical impression that is not enough for treatment planning, and cannot prescribe.
There are not subtle differences here. They have direct implications to what each appointment will and won’t yield.
Why Adults With ADHD Usually Need to Start With a Psychiatrist
In adults, ADHD is a brain (neurological) disorder. These are all related to how the brain’s attention and dopamine systems are working: they’re inconsistent, they’re failing at exec, they’re emotionally dysregulated, they’re not doing as well as they should despite being very smart and very hardworking.
It’s also because of that neurological foundation that for most adults, treatment involves a meaningful prescription program.
Therapy has a limited effect on the primary symptoms of ADHD which are neurological. While there are emotional aspects (damaged self-esteem, relationship patterns, anxiety that developed as symptoms of these behaviors were unfocused), this can be hugely beneficial, it does not alter the underlying attentional dysfunction that medication can when taken appropriately.
Many adults in NY and NJ report years of therapy leading to better understanding of themselves, but not their underlying ability to follow through, maintain focus or manage their emotional responses during stressful situations. In many of those instances, the ADHD was never recognized – let alone treated.
A psychiatrist assesses the overall clinical situation and covers the entire case, making the determination of the presence or absence of any components and may potentially introduce medication as needed. Once that neurological foundation is set, so are all other things, including therapy.
When a Therapist Becomes the Right Addition
This is not a contraindication to therapy. It’s an argument to get things in order.
For many adults, there can be significant benefits from ADHD-specific CBT once a diagnosis is made and meds are reasonably effective. This kind of therapy is for the ones who tend to avoid getting caught up in the negative self-talk that has happened over years of being called lazy or inconsistent, the developmental relational structures that emerged when coping mechanisms weren’t managed, and the practical executive function strategies that medication doesn’t provide.
It is backed up by research. Therapy combined with medication has been repeatedly found to be more effective than medication alone alone, especially for adults since they may have established coping strategies that take years to develop, and that require active reconstruction, rather than chemical modification.
A pattern that I see a lot – someone has been in therapy for anxiety or mood issues for a long time, and there has been minimal improvement. In many of these situations it is undiagnosed ADHD that is the precipitating cause – and anxiety treatment can have no permanent effects if the attentional dysregulation that leads to anxiety isn’t first diagnosed.
Situations That Point Clearly to a Psychiatrist First
From clinical experience in treating adult patients throughout New York and New Jersey, here are the presentations in which it is obvious to begin with a psychiatrist and not a therapist:
You have never had a formal ADHD evaluation. This is the first time that you’ve had a formal ADHD evaluation. For diagnosis, a full psychiatric evaluation should be performed that includes developmental history, functional deficit and differential diagnosis. It’s a clinical process, not therapeutic.
You’ve been receiving care for anxiety or depression but haven’t gotten better. This behavior is often a sign of an unrecognized problem – such as ADHD.
You have diagnosed ADHD and you are not getting the desired results. A psychiatrist is needed for medication review, re-evaluation, and to assess for co-occurring conditions.
Your symptoms are interfering a lot with your work, relationship or everyday life. A clinical sign of meaningful functional impairment is an indication for medical evaluation.
Medications are under consideration. It’s important to note that, here in New York or New Jersey, only a psychiatrist can prescribe and monitor ADHD drugs, not a therapist or psychologist.
What a Psychiatric ADHD Evaluation Actually Involves
A thorough ADHD evaluation is not a short appointment or a checklist. Provides a complete psychiatric and developmental history. It gauges how and where symptoms are impacting your life currently including in the workplace, with others, in day-to-day functioning etc. This includes differential diagnosis strategies for distinguishing ADHD from other conditions with similar presentations like anxiety, depression, sleep disorders, and more.
It concludes with a straightforward, plain English description of what it has discovered, and what your realistic choices are.
It’s not something that can be done in a therapy session. It is a physical exam. Requires a medical doctor.
The Bottom Line
If you think you may have ADHD (or if you have been treated for years and you feel there is something missing from treatment), he should be examined by a psychiatrist.
Therapy has proven helpful in the care of ADHD. It is best used in addition to an established diagnosis and successful medical treatment and management – not in place of these.
Dr. John C. Shershow, M.D. is a Board-Certified Psychiatrist in Manhattan with over 25 years experience assessing and treating Adult ADHD throughout New York and New Jersey. He is currently seeing new patients.
United Healthcare out-of-network benefits accepted. No referral required.
Frequently Asked Questions
Q: Can a therapist diagnose ADHD?
A therapist can note the symptoms and suggest a possibility but a proper clinical diagnosis would only be made by a licensed psychiatric doctor or a doctoral level psychologist. When a therapist suspects ADHD, a psychiatric evaluation is the next step.
Q: Can a therapist prescribe ADHD medication?
No. ADHD medications can only be prescribed by a licensed medical doctor, which includes psychiatrists, in both New York and New Jersey. At any level of experience and/or licensure, Therapists cannot prescribe.
Q: What is the difference between a psychologist and a psychiatrist for ADHD?
Both are able to assess ADHD. The main difference is the ability to prescribe and manage medications – psychiatrists can, psychologists cannot. If cognitive testing is required for formal accommodation documentation, a psychologist can be used. A psychiatrist is the first doctor one should seek out if diagnosis and possible drug management for any disease is required.
Q: I have been in therapy for two years for anxiety and I am not improving. Could it be ADHD?
Yes – one of the most common patterns in adults who ultimately seek a psychiatric assessment for ADHD. Symptoms of anxiety are similar to those of ADHD, and many people suffer for years without a solution for their anxiety when the restlessness and avoidance caused by underlying ADHD is left unaddressed. An extensive psychiatric evaluation and differential diagnosis is a key step to take next.
Q: Can I see both a psychiatrist and a therapist at the same time?
Yes – for many adults, and this is ideal. Diagnosis and medication is handled by a psychiatrist, while behavioural patterns, emotional impact and executive functioning strategies are handled by a therapist. Both positions intersect. Having the providers both know each other is nice so that care remains coordinated.
Q: Do I need a referral to see Dr. Shershow?
Referrals are not necessary. Direct calls or e-mail to the office office for the very first appointment. Previous records are useful, but are not required.