Attention deficit hyperactivity disorder, or ADHD, is a disorder that begins in childhood. It usually persists for years and results in significant deficits in cognitive, academic and social development. it is found to occur in about 3-7% of children, and persists in 36-60% of them into adulthood for an overall adult prevalence of about 4.5%.
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It is found that as ADHD continues to play a major role in the individual’s life, demoralization occurs to a large extent leading to comorbidities, such as substance abuse or depressive symptoms, as an effort to cope or due to internalization of the underachievement they face on a chronic basis. Many adults with ADHD did not receive adequate interventions during childhood, resulting in chronic occupational and social impairments which seriously reduce the quality of life. This adds confusion to the diagnostic features, as they may present with symptoms suggestive of anxiety or depression, but have other signs and symptoms of complicated ADHD, which has taken its own course. Overall, the occurrence of ADHD with depression is found in about 9-50% of patients.
It is important to assess all patients reporting with ADHD for the co-occurrence of primary anxiety disorders or for secondary symptoms of anxiety arising due to the primary ADHD. It is also essential to discriminate between the two so that the primary condition is treated rather than the secondary symptoms. It is known that individuals with both conditions coexisting have a higher risk of suicide, poor job outcomes, and broken relationships, as well as putting a greater cost-burden on society. The distinction may be assisted by the knowledge that fixed depressive affect or suicidal ideation is rare with ADHD per se, which is usually associated with stable moods despite deficits in executive functioning.
Treatment of ADHD with depressive symptoms or ADHD with major depressive disorder is different. The best way to treat secondary depressive symptoms, such as lack of memory, poor concentration, loss of interest in life, and sleep problems, is by effective therapy of ADHD. However, primary depression will need to be treated by itself along with ADHD as a separate condition.
Parental ADHD is closely related to a heritable form of ADHD in the children, with the heritability being very high, at 0.8. This also has therapeutic implications, since screening and effective treatment of these affected parents typically has a beneficial effect on the treatment outcome of the child with ADHD.
Screening of a patient presenting with depressive symptoms should include questions about the history of ADHD, in the individual or the family, and any school-related problems in childhood. Such issues should be explored further to distinguish learning or behavioral difficulties, which could point to the presence of undiagnosed ADHD. ADHD itself should be diagnosed only on the basis of a history of inattention, impulsivity and hyperactivity. Further evaluation should look for functional deficits as a result of these symptoms. A standardized scale such as the Adult Symptom Rating Scale may be very helpful in this screening process. Medical illnesses should be ruled out as a cause or contributor to these symptoms.
Medication with the stimulants methyphenidate or amphetamine salts, or the non-stimulant atomoxetine, have been the mainstay of ADHD treatment outside Europe. However, if depression is the condition that is causing the more severe difficulty or impairment, it should be treated first. Once the symptoms of depression are alleviated, ADHD should be reassessed and the need for treatment decided upon. If the patient’s depression is refractory to treatment, the diagnosis should be re-evaluated and ADHD should receive greater attention as well. Psychosocial interventions should be initiated to improve symptoms as well as help the patient to function better in social and workplace or school settings.
Drug interactions are a potential hazard when medications are combined for the treatment of depression and ADHD, but this is rare. One absolute contraindication is the use of monoamine oxidase inhibitors along with stimulant drugs, or with atomoxetine. Close monitoring is essential to pick up side effects, especially behavioral. Such therapy should be commenced only if the depression does not improve with adequate treatment of the ADHD or if both are equally pressing in their clinical effects.
Reviewed by Jonas Wilson, Ing. Med. Further Reading