ADHD and Depression: Diagnosing, Treating, and Managing a Dual Diagnosis

Are you depressed because you have untreated ADHD, or are you dealing with something more serious? Here's how to tell the difference between reactive depression and major depression — and get the help you need.

Cartoon man suffering from ADHD and depression sitting under rain cloud

"Once a person’s response to antidepressants starts, it takes eight to 10 weeks to see full benefit."


BMD and ADHD: Not-So-Strange Bedfellows

Major Depressive Disorder (MDD) and Bipolar Mood Disorder (BMD) are affective disorders that are characterized by the intensity of moods. Think of your brain as having a thermostat that regulates the intensity of your moods. When the thermostat works normally, you have some days that are better than others for no apparent reason, but the intensity of your moods remains in a very narrow range.

Imagine that the thermostat fails and your energy for life slowly drains away until there is no joy or reason to get out of bed. This is MDD. If both ends of the thermostat fail, you can go both low and high. In the highs, called mania or hypomania, a person has tremendous energy, creativity, and feels on top of the world. She can also be grandiose, impulsive, irritable, hypersexual, have insomnia, and get into a lot of trouble. This is Bipolar Mood Disorder, which used to be known as Manic Depression. Most of the time a person who is Bipolar has only depressive episodes. It requires only one manic episode to get a diagnosis of BMD.

Although we use the term "depression" to mean both conditions, they are different and respond to different treatments. The rule of thumb in clinical practice is that a depressed person who has not had a robust and sustained response to a trial of three antidepressant medications should be screened for ADHD or Bipolar or, usually, both.

Like simple depression, ADHD and BMD occur together more frequently than would be expected by chance. Two studies of BMD found that as many as 40 percent of people with BMD have ADHD as well. The earlier the mood disturbance starts, the more likely a person is to have both.

At first the treatment of co-existing BMD and ADHD was cautious, due to the fear that the use of stimulant medications might trigger manic episodes. There is considerable research on children who have both ADHD and BMD, but there isn't a single published study of these disorders co-existing in adults. Nonetheless, clinicians have cautiously moved ahead with the treatment of simultaneous ADHD and BMD, using the research done with children and adolescents as a guide.

Treatment should be reserved for someone with extensive experience with both conditions. Clinical experience has shown that it is safe to treat both conditions if the mood disorder can be well stabilized with the standard mood stabilizing medications (lithium, atypical neuroleptics, valproic acid). The most common pattern is for the symptoms of BMD to get better and more stable with the addition of a stimulant medication. If a Bipolar patient stops his Bipolar medications, the ADHD medication should be stopped, too.


To most people, depression means feeling blue or down in the dumps. This is an almost universal experience for people with ADHD. At some point in their lives, they feel down due to the frustration and demoralization of trying to fit into a neurotypical world that makes little effort to understand or accept them. Often this is called secondary, or reactive, depression.

It must be emphasized, however, that "reactive depression" is a normal experience and not something that has gone wrong. It is an accurate perception of how hard and frustrating it is to have ADHD, especially if it is not being treated.

This is not how a doctor thinks of depression when he diagnoses a patient. A clinician is trained to see depression as a gradually worsening state in which a person loses energy and the ability to experience pleasure from the things she enjoyed. There is no predictable cause-and-effect relationship between what is going on in a person's life and her emotional response to those events. A diagnosis of depression means that a person's moods "have taken on a life of their own, separate from the events of her life and outside her conscious will and control."

A depressive person usually has family members with depression, who, for no apparent reason, have lost the ability to have fun, laugh, and enjoy anything (food, sex, hobbies), become irritable or sad, cry easily or for no reason, and who withdraw from life and social interaction.

A study at the National Cancer Institute asked people which was worse: being diagnosed with depression or terminal cancer? Ninety-eight percent said that their depression was worse on every level than the cancer that was killing them. Depression is a lot more than just being unhappy because things aren't going well right now.

Differences Between ADHD and Depression

Many people are confused about the overlapping symptoms of depression and ADHD. The two disorders have much in common. Both involve decreased memory and concentration, irritability, sleep disturbances, sadness, hopelessness, and pessimism. It is common to attribute such symptoms to ADHD and the proclivity for a lifetime of defeats and losses the condition engenders.

So the question is: Are depressive symptoms due to ADHD, Major Depressive Disorder (MDD), or both. A significant number of people are unlucky enough to have both conditions. The National Comorbidity Replication Study (NCRS) found that having either condition makes having the other about three times more likely. The two disorders can be distinguished from each other based on six factors:

1. Age of onset. ADHD symptoms are present for a lifetime. The DSM-V requires that the symptoms of ADHD be present (although not necessarily impairing) by 12 years of age. The average onset of MDD is 18 years of age. Symptoms that began before puberty are almost always due to ADHD. A person with both conditions is usually able to see the presence of ADHD in early childhood, with the symptoms of MDD appearing later in life, usually in high school.

2. Consistency of impairment and symptoms. ADHD and its frustrations are always present. MDD comes in episodes that ultimately stabilize to more or less normal mood levels in about 12 months.

3. Triggered mood instability. People with ADHD are passionate people who have strong emotional reactions to the events of their lives. However, it is this distinct triggering of mood shifts that distinguishes ADHD from MDD mood shifts, which come and go without any connection to life events. In addition, the moods that come with ADHD are appropriate to the nature of the perceived trigger. Happy events in the lives of ADHD individuals bring a happy and excited mood. Unhappy events, especially the experience of being rejected, criticized, shamed, or teased, lead to painful emotional states.

4. Rapidity of mood shift. Because ADHD mood shifts are almost always triggered, they are often instantaneous complete turns from one state to another. Typically, they are described as "crashes" or "snaps," which emphasize the sudden quality of their passage. By contrast, the untriggered mood shifts of MDD take weeks to move from one state to another.

5. Duration of mood shifts. People with ADHD report that their moods change rapidly according to what is going on in their lives. Their responses to severe losses and rejections are usually measured in hours or a few days. The mood shifts of MDD must be present without a break for at least two weeks.

6. Family history. Both disorders run in families, but people with MDD usually have a family history of MDD, while individuals with ADHD have a family tree with multiple cases of ADHD.

During an evaluation with a doctor, a person who has both ADHD and MDD should be able to give a clear history of ADHD impairments continuously present in all of his activities as far back as his memory goes. He should be able to remember that the insidious slide into an ever-worsening state of sadness that sucks the joy and meaning out of life began in late adolescence.

NEXT: Treating Reactive Depression and ADHD

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TAGS: Depression, Comorbid Conditions with ADD, Adult ADD: Late Diagnosis

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