Why So Sad? Depression in ADD Adults

Depression is surprisingly common among ADD adults. Fortunately, there’s no need to suffer in silence.

by Carl Sherman, Ph.D.

Feeling down? You’re not alone. At any given time, more than 17 million American adults are battling the dark moods and general listlessness of depression. A disproportionate number of these individuals also have ADHD.

In fact, major depression is estimated to be 2.7 times more prevalent among adults with ADHD than among the general adult population. (That’s not surprising, since the same neurobiological systems that control attention also control mood.) A mild form of depression, known as dysthymia, is a whopping 7.5 times more common.

That’s the bad news. The good news is that effective remedies for depression are readily available, and that they work just as well for ADDers as they do for others. Of course, it can take a while to find the right types of medication, psychotherapy, and lifestyle strategies.

Primary vs. secondary depression

Some ADDers become depressed for no obvious reason—the condition strikes even in the absence of unpleasant life circumstances or events (difficulties at work or in school, job loss, relationship problems, chronic illness, and so on). Risk for this form of depression, known as primary depression, seems to be largely inherited.

“Major depression tends to run in families that have ADHD,” says Lenard Adler, M.D., director of the adult ADHD program at New York University Medical Center in New York City.

In other cases, depression arises as a direct consequence of the chronic frustration and disappointment of living with untreated or poorly controlled ADHD. Such cases of depression are said to be secondary to ADHD.

“I frequently see depression in adults whose ADHD wasn’t recognized and treated in their younger years,” says Yvonne Pennington, Ph.D., an Atlanta-based psychologist who specializes in adult ADHD. “Having endured so many blows to their self-esteem, they’ve accepted the idea that they’re lazy and stupid.”

Kathy, a fifth-grade teacher in St. Paul, Minnesota, would probably agree. “It was the stress of trying to cope with ADHD that got to me—always trying to compensate for shortcomings and falling short of expectations. I never could be the person I wanted to be.”

In other words, ADHD impairs what psychologists call the “core sense of identity”—the way an individual sees herself and her social interactions. ADDers—especially that 25 percent of adults with the disorder who have never gotten appropriate treatment—come to feel that they’ll never be “good enough” to succeed socially or professionally.

As Denver-based psychiatrist William Dodson, M.D., puts it, “People come in and say, ‘I’ve been depressed every moment of my life. I try so hard, and nothing works out. I feel like giving up.’ What they’re describing is frustration and demoralization stemming from real experiences.”

Telling ADHD and depression apart

To complicate matters, doctors sometimes mistake ADHD for depression. Liz, a 22-year-old teacher living in Dallas, was diagnosed with depression during her freshman year at college. Her doctor prescribed antidepressants, sleeping pills, and pills for anxiety—but she still didn’t feel right. “My mood improved,” she recalls, “but not enough to make me feel good.” She was restless and unable to focus on her course work.

The breakthrough didn’t come until the following year: “My doctor figured out I had ADHD. I started taking a stimulant, and, after 19 years, I finally felt I could live up to my potential.”

Liz still has days when she feels down and unable to accomplish much. “But,” she says, “it’s a complete 180 from what it used to be. I get out of bed and enjoy life.”

Differentiating ADHD from depression can be difficult because both disorders bring mood problems, forgetfulness, an inability to focus, and a lack of motivation. There are, however, subtle distinctions between ADHD-induced symptoms and those caused by depression.

One distinction involves emotions. ADHD can cause dark moods, but these are usually linked to a specific setback. The bad feelings tend to be transient. An ADDer may descend to the depths for an hour or two, but then moves on. In contrast, mood problems associated with depression are generally pervasive and chronic, often lasting weeks or months. And, unlike the bad feelings caused by ADHD (which often began showing up in childhood), depression typically doesn’t develop until adolescence or later.

With ADHD, it seems impossible to accomplish anything, because you’re “in a dither and can’t decide what to do first,” says Roberta Tsukahara, Ph.D., a psychologist in Austin, Texas. “With depression, it’s more that you’re lethargic and can’t initiate activity.”

Sleeplessness is another symptom common to both depression and ADHD. Yet the pattern of insomnia differs between the two disorders. With ADHD, the problem usually occurs while falling asleep; the mind refuses to “turn off,” and keeps adding things to the next day’s to-do list. In contrast, people who are depressed tend to fall asleep readily, but wake up repeatedly during the night (and early in the morning). At each awakening, the mind is filled with negative or anxious thoughts.

This article comes from the October/November 2006 issue of ADDitude.

To read this issue of ADDitude in full, purchase the back issue and SUBSCRIBE NOW to ensure you don't miss a single issue.

Fighting Depression, Part 2

Antidepressants and ADHD meds

If you or someone you love has been feeling out of sorts for two weeks or longer, it’s important to find out what’s wrong. “I would not go after both ADHD and primary depression at the same time,” says Dr. Adler. “I’d first work on the condition that causes greater impairment. Although the problems raised by ADHD are very real, severe depression can be life-threatening.”

Antidepressants that aim to boost levels of the neurotransmitters serotonin and/or norepinephrine are the primary treatment for severe depression. Your doctor may also prescribe an antidepressant if mild to moderate depression persists despite lifestyle changes and effective treatment for your ADHD.

Most antidepressants work well alongside ADHD stimulant meds, as well as with the nonstimulant Strattera (atomoxetine), though minor adjustments may need to be made.

If you’re taking Paxil (paroxetine) or Prozac (fluoxetine) and starting Strattera, for example, your doctor may prescribe a lower dosage of both the antidepressant and the ADHD medication because the two will interact. Other antidepressants, like Effexor (venlafaxine) and Cymbalta (duloxetine), can magnify the effect of stimulants on blood pressure and pulse.

Wellbutrin (bupropion) is an antidepressant that can be useful for ADD, as well. “The effect of bupropion on ADD is modest, but it might be enough,” says Dr. Adler.

No matter what antidepressant you take, remember that it’s likely to take longer to “kick in” than ADHD medication—as long as 12 weeks for the full effect, although you should notice positive changes within two weeks.

Most of the time, depression improves substantially with the first antidepressant tried. If the first antidepressant doesn’t work, a second one probably will. About half of those who take antidepressants achieve full remission—that is, complete relief of depressive symptoms.

Do-it-yourself relief

When depression is secondary to ADHD, minor medication or lifesyle adjustments may be all it takes to get out of a funk. “Three-quarters of the time, when people come in and tell me they’re depressed, they’re not treating their ADD adequately,” says Dr. Dodson. “Half of those who get an ADD prescription don’t fill it the third time. Within nine months, 85 percent aren’t even taking it anymore.”

What if depression persists despite adherence to an ADHD drug regimen? Doctors recognize that a variety of lifestyle changes are likely help. Aerobic exercise, for example, “has a profound effect on the mood level of people with ADHD,” says Dr. Dodson. “If you’re finding it hard to motivate yourself, aerobic exercise can return your mood to normal.”

Working out can also calm a revved-up mind. “Exercise has made such a difference to me,” says Annie, a 40-something commercial artist living in Scituate, Massachusetts. “When I’m getting ‘dithery brain’ and I can’t decide what to do, I get out of the house and do something physical. After a bike ride, I can think straight.”

There’s another good reason to get outside. “Sunlight is a wonderful antidepressant,” says Dr. Pennington. “Humans need two hours of natural light every day. If you have attention problems, you need even more.” She recommends spending as much of your day outdoors as possible. “Take meals outside, do paperwork outside, bring your laptop,” she recommends.

Many ADDers, including Liz, find that their mood darkens when they have nothing to do. “My depression gets a lot worse when school’s in recess,” she says.

“The ADD nervous system feeds on interest and challenge,” says Dr. Dodson. To guard against idleness, he recommends setting up what he calls an “interest closet”: Whenever you come across something interesting—a good book, for instance, or a craft projec—stash it in a closet. The next time you find yourself looking for something to do, there will be something waiting for you.

Meditation and psychotherapy

Focused inactivity also has its place in treating depression, as Liz has found. “Meditation really works for me when I’m depressed,” she says. “I push everything out of my head and concentrate on breathing in and out. After five minutes, I feel better.”

Dr. Tsukahara is a fan of the “relaxation response.” To do this simple form of meditation, sit quietly, with your eyes closed, and focus on your breathing. Each time you exhale, silently repeat a one-syllable word—“one” or “peace” or “om.”

“Do this for a minute or two,” says Dr. Tsukahara, “or just try it for 10 or 20 seconds whenever your mind is in ‘dither mode’ or when you’re having trouble transitioning from one activity to another.”

Along with, or instead of, meditation and medication, a form of psychotherapy known as cognitive behavioral therapy (CBT) has proven to be highly effective against depression. In fact, this short-term therapy has been shown to work as well as antidepressants for mild to moderate depression.

The first goal of CBT is to enable the patient to identify and reduce frequent, intense negative thoughts that lead to depression. Says Dr. Tsukahara, “Certain themes keep coming up: ‘I’m a failure,’ ‘This is too much for me,’ ‘I’m just not good enough.’ The next step is to replace these self-destructive thoughts and beliefs with more realistic and constructive thoughts—“Yes, this is hard. How can I make it more manageable?” You’re acknowledging the difficulty, but not wallowing in it. You’re pointing yourself toward positive action.

According to Dr. Tsukahara, the goal is to reduce the frequency and intensity of symptoms. “Don’t expect to eliminate them,” she says.

No matter what the cause of your depression, there’s always a solution. There’s no need to suffer!

This article comes from the October/November 2006 issue of ADDitude.

To read this issue of ADDitude in full, purchase the back issue and SUBSCRIBE NOW to ensure you don't miss a single issue.