Independently, Major Depressive Disorder (MDD) and Attention-Deficit Hyperactivity Disorder (ADHD) are two of the most commonly diagnosed psychiatric conditions. Additionally, many people who have concerns about depression and/or ADHD present first in the primary care setting. It is not uncommon for these disorders to present together, which can have implications for assessment, treatment and outcomes. Individuals with ADHD are almost six times more likely to develop depression than the general population.
The first thing to be aware of is that there can be overlap in terms of the symptom presentation of these two disorders. Symptoms that can occur in and are diagnostic criteria for either disorder include: difficulty with poor concentration and distractibility, hyperactivity/psychomotor agitation, sleep disturbance, low self-esteem, and irritability. Of course, one would use other symptoms that are different between the two disorders and a timeline of symptoms to help distinguish between the two diagnoses. The key to diagnosing ADHD in a person presenting with depression is to ask about childhood symptoms of hyperactivity, impulsivity and inattention that pre-date other depressive symptoms.
When the disorders occur co-morbidly, there is a higher risk of suicidal ideation and a higher risk of the depression converting to a bipolar disorder. When a patient has co-morbid bipolar disorder and ADHD, the treatment for ADHD can exacerbate the symptom of the bipolar disorder. Patients with unrecognized or undertreated ADHD are at higher risk of developing depression. While family members of patients with ADHD are at a higher risk for ADHD or depression, environmental factors (trauma, parenting, family stressors) rather than genetic factors are stronger predictors of which patients with ADHD become depressed. Patients with co-morbid ADHD and MDD are at higher risk of co-morbid substance abuse issues as well.
There are steps that can be taken to reduce the risk of co-morbid psychiatric concerns in a patient who is presenting with ADHD. Early effective treatment (medication and therapy) for ADHD symptoms can help reduce the risk of developing depression later.
In terms of treatment, the stimulant medications are the first-line medication treatment for uncomplicated ADHD, and the SSRIs and SNRIs are the first-line medication treatment for MDD. There are no medications that are FDA approved for co-morbid ADHD and MDD. There is one study that shows that atomoxetine (Strattera), which is approved for ADHD, might be helpful for co-morbid MDD. The alpha agonists (guanfacine and clonidine) are approved for ADHD but have not been studied with co-morbid MDD. There is some evidence that bupropion is somewhat helpful for ADHD symptoms as well as MDD. For an adult presenting with ADHD symptoms that are impairing, consider atomoxetine or bupropion if a long acting stimulant is contraindicated, based on mood disorder or substance abuse concerns.
The Texas Children’s Medication Algorithm Project (CMAP) offers treatment algorithms for comorbid pediatric MDD and ADHD. In a situation when one disorder seems to be having more impact than the other, it is reasonable to start with a medication intervention for that disorder and then assess if there is a need to treat the second disorder separately with medication. For example if a 13yo presents with depression symptoms and ADHD concerns and the depressive symptoms are currently more impairing, it would be reasonable to start with a trial of fluoxetine and then consider if a stimulant medication needs to be added over time. For patients with co-morbid ADHD and MDD, therapy plays an important component of treatment.
It is our hope that this primer on the assessment and treatment of co-morbid ADHD and MDD is helpful for providers in the primary care setting.