Is It ADHD, Depression, or Both?
Depression is nearly three times more prevalent among adults with ADHD. Here, Dr. Sherman explains what links the two conditions, and how to differentiate symptoms.
First the bad news: ADHD and depression often go hand in hand. Depression is estimated to be 2.7 times more prevalent among adults with attention deficit hyperactivity disorder than among the general adult population.
Now the good news: Effective remedies for depression are readily available, and they work just as well for adults with ADHD as they do for others. If you think you have the condition, there is no need to suffer.
Primary vs. Secondary Depression
Some adults with ADHD 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 and may be tied to hypersensitivity.
Take Charge of Secondary Depression
In other cases, depression arises as a direct consequence of the chronic frustration and disappointment of living with untreated or poorly managed ADHD. By some estimates, 25 percent of adults with the disorder haven’t gotten appropriate treatment. 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-or not good enough to succeed socially or professionally.”
Telling ADHD and Depression Apart
To complicate matters, doctors may mistake ADHD for depression. Differentiating the conditions can be difficult because both disorders bring mood problems, forgetfulness, an inability to focus, and lack of motivation. There are, however, subtle distinctions between ADHD-induced symptoms and those caused by depression.
EMOTIONS. ADHD can cause dark moods, but these are usually linked to specific setbacks. The bad feelings tend to be transient. 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 begin showing up in childhood), depression typically doesn’t develop until adolescence or later.
MOTIVATION. 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. “With depression, it’s more that you’re lethargic and can’t initiate any activity.”
SLEEP DIFFICULTIES. 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.
What You Should Treat First
“I would not go after ADHD and primary depression at the same time,” says Lenard Adler, M.D., director of the adult ADHD program at the NYU Langone Medical Center in New York City. “Work first on the condition that causes the greater impairment. Problems raised by ADHD are real, but 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. Wellbutrin (bupropion) is an antidepressant that can also be useful for ADHD.
Most of the time, depression improves substantially with the first antidepressant tried. If it doesn’t work, a second one probably will. About half of those who take antidepressants achieve complete relief of depressive symptoms.
When depression is secondary to ADHD, minor medication or lifestyle adjustments may be all it takes to get out of a funk. What if depression persists despite adherence to an ADHD drug regimen? Doctors recognize that lifestyle changes are likely to help. Aerobic exercise “has a profound effect on the mood level of people with ADHD,” says William Dodson, M.D., a Denver-based psychiatrist. “If you can’t motivate yourself, exercise can normalize your mood.”
Many individuals with ADHD find that their mood darkens when they have nothing to do. “The ADHD nervous system feeds on interest and challenge,” says Dodson. To guard against idleness, he recommends setting up an “interest closet”: Whenever you come across something interesting – a good book, for instance, or a craft project – 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
Meditation also has its place in treating depression. 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 so, or try it for 10 to 20 seconds whenever you have trouble moving 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. The first goal of CBT is to enable the patient to identify and reduce frequent, intense negative thoughts — “This is too hard to do,” for example.
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.
The goal is to reduce the frequency and intensity of symptoms. Don’t expect to eliminate them. But you can manage symptoms that once got in the way of living a happy life.