What is the relationship between ADHD and major depressive disorder?

Depression is a common co-occurrence in attention-deficit/hyperactivity disorder (ADHD), with roughly one-fourth of patients in treatment having both. Clinicians often see the overlap, but it may still be hard to identify, diagnose, and determine which disorder to treat first. Following his session "Managing ADHD and Comorbidities" at Psych Congress 2022, Timothy Wilens, MD, Chief of the Division of Child and Adolescent Psychiatry at Massachusetts General Hospital, discussed what tip-offs to be aware of in this relationship and how to approach treatment.

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Timothy Wilens, MD, is chief of the division of child and adolescent psychiatry and is co-director of the center for addiction medicine at Massachusetts General Hospital. He is the MGH Trustees Chair in addiction medicine and a professor of psychiatry at Harvard Medical School. Dr Wilens earned his MD at the University of Michigan Medical School in Ann Arbor and completed his residency in child, adolescent, and adult psychiatry at Mass General.

Dr Wilens’ research interests include the relationship among attention-deficit/hyperactivity disorder (ADHD), bipolar disorder, and substance use disorders; embedded health care models, and the pharmacotherapy of ADHD across the lifespan. He has published more than 300 peer-reviewed articles, concerning these and related topics. Dr Wilens is a distinguished fellow of the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry and is on the editorial boards or is a scientific reviewer for more than 35 journals.

Read the Transcript:

Dr Wilens: Hi. My name is Dr Tim Wilens and I'm Chief of the Division of Child and Adolescent Psychiatry and Co-Director for our Center for Addiction Medicine at Massachusetts General Hospital in Boston. And I'm a professor of Psychiatry, Harvard Medical School.

Question: What is the relationship between ADHD and major depressive disorder? How do medications impact symptoms?

Dr Wilens: There are a lot of questions about mood disorders in general, and depression in particular as it relates to ADHD. Depression is an unfortunate common co-occurrence in ADHD. Up to 20% of kids will develop depression through adolescence into adulthood. Data in children with depression and adults with depression show that roughly a quarter of them have ADHD. So again, that overlap exists.

It's important to realize that sometimes people interpret the irritability in ADHD as just being oppositionality, when in fact it could be a mood disorder. Seething anger often is a tip-off that an individual may be depressed, in addition to the mood symptoms of sadness, down, et cetera. It's persistent and pervasive, as opposed to the demoralization that kids may feel with ADHD as they grow up, which tends to be more short-lived and cyclical.

In terms of addressing the treatment, it's important to take a look at what's more severe. And typically, the depression is going to be the more severe condition and one is going to think about treating that initially. Data would indicate that treatment of the depression with a medicine such as an SSRI, selective serotonin reuptake inhibitor, or an SNRI, serotonin norepinephrine reuptake inhibitor, may be indicated with the consideration of other medicines for ADHD, such as stimulants. Trial, for example, a multi-site study that utilized peroxetine alone and in combination with dextroamphetamine, found that there were improvements in mood and anxiety in those individuals who were given the peroxetine, and in either alone or in combination of dextroamphetamine. And that the side effects were added in between the dextroamphetamine and the peroxetine. There was no known drug-drug interactions with the two and that's been our clinical expertise also. Other considerations would be medicines that we know work for both ADHD and for depression. Used off-label for ADHD would include bupropion or Wellbutrin, as well as the tricyclic antidepressants, such as desipramine or imipramine.

Again, in conclusion, it's important to acknowledge if there's depression in ADHD or ADHD in depression, to address the more severe condition, which is typically depression, first, and then to sequence your treatment for the ADHD with either stimulants or non-stimulant medications.