Is It ADHD, Depression, or Both?
Depression is nearly three times more prevalent among adults with attention deficit hyperactivity disorder. Here, Dr. Sherman explains what links ADHD and depression, and how to differentiate symptoms for better treatment.
ADHD and Depression: What’s the Connection?
ADHD and depression are comorbid conditions. Depression is estimated to be 2.7 times more prevalent among adults with attention deficit hyperactivity disorder (ADHD or ADD) than among the general adult population. Children and adults with depression have ADHD at rates of about 30–40%. As many as 70% of people with ADHD will be treated for depression at some point in their lives.
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.
ADHD and Primary 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.
ADHD and 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 ADHD 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.
Is It ADHD or Depression? Differentiating Symptoms
To complicate matters, doctors may mistake ADHD for depression — and vice versa. 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 emerge in pre-adolescence), depression typically doesn’t develop until adolescence or later.
MOTIVATION. With ADHD, motivation feels wholly dependent on what is stimulating to the person. It is extremely difficult for someone with ADHD to be activated throughout a task they find boring, but they can often engage and complete tasks that provide them a sense of reward even if the task takes time and energy. In other words, what is present externally totally impacts how someone with ADHD can internally engage. With depression, the internal lethargy and feeling of hopelessness makes every activity laborious, even ones that they may love to do and can easily do when they are not in a depressive state.
SLEEP DIFFICULTIES. With ADHD, the main issues with sleep revolve around the transitions — getting to sleep at night and waking up in the morning. Resistance to bedtime, engaging in over-stimulating activities before bed, and the “peace and quiet” of having fewer distractions from others at nighttime all make getting to bed at an appropriate time very challenging.
When in bed, people with ADHD have a hard time surrendering to slumber as their minds connect to a range of things they are anxious or excited about and they review the current day or what the next day will bring. Many times, people with ADHD report not feeling tired in the night time and getting their “second wind” around the time others are getting to sleep.
In contrast, people who are depressed tend to feel tired all the time. They may either get too much sleep (sometimes sleeping up to 14 hours every night) or too little sleep despite trying. Insomnia is a common issue and serves as a risk factor for suicide amongst those who struggle with depression. They feel exhausted and agitated at the same time making It difficult to fall asleep. Other times they might get to sleep quickly but wake up repeatedly during the night (and early in the morning). At each awakening, the mind is filled with negative or anxious thoughts.
How to Treat ADHD and Depression
“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.
Treatment for Secondary Depression with ADHD
Even if the depression is secondary to the ADHD, the depression can independently snowball into its own issue, even when ADHD symptoms are effectively managed. That said, minor medication or lifestyle adjustments may make a tremendous difference. 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 for Depression and ADHD
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.
Updated on October 4, 2019