Depression: When It’s More Than a Symptom Of ADHD
Depressed but unsure if it’s the result of your ADHD or something more? Learn what sets reactive and major depression apart, including family history and how quickly your mood shifts, as well as which treatment is best for you.
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.
Depression and ADHD
Many people are confused about the overlapping symptoms of depression and ADHD. The two disorders have much in common:
- Decreased memory and concentration
- Sleep disturbances
It is common to attribute such symptoms to ADHD and the proclivity for a lifetime of defeats and losses the condition engenders.
Distinguishing Between Depression and ADHD
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 and 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 individuals with ADHD 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 symptoms 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.
Almost everyone with ADHD will contend with what has been called secondary, or reactive, depression. Life is harder for people with ADHD. They have to learn how to manage their ADHD nervous system, which is unreliable in its ability to get engaged and get things done. Sometimes they are in hyperfocus and can accomplish wonderful things, and sometimes they can’t get started on a task, no matter how hard they try. Two things help:
1. Developing competency. Ask a person with an ADHD nervous system the question: “When you have been able to get engaged and stay engaged with a particular task, have you ever found anything that you couldn’t do?” Most people will answer, “No. If I can engage with something, I can do anything.” This is the main source of frustration: ADHDers know they can do remarkable things, but they can’t do them on demand. They never know whether their abilities are going to show up when they are needed.
To cope with ADHD is to learn from what goes right in their lives, not what goes wrong. How do you get in the zone to do practically anything? When you have understood and mastered your ADHD nervous system, you can be successful in a neurotypical world. Competence brings confidence and a lasting sense of well-being.
2. Having a cheerleader. We know that a lot of people with ADHD have been very successful without taking medication. How did they conquer discouragement to persevere? Probably the most important factor is that they had someone in their life who sustained them through the inevitable rough patches. Whether you are a child or an adult, it is important to have someone who sees you, not your problems.
Treating Major Depression and ADHD
What should people with both ADHD and MDD do? Which should be addressed first? The decision is usually made by the patient based on what he thinks is the most urgent or impairing condition. Given the choice, I treat ADHD first with a stimulant. This is based on my experience that a high percentage of patients (about 50 percent) report that their mood lifts when they have achieved optimal doses of stimulant-class medication.
If the depressive symptoms persist, an antidepressant is usually added to the ADHD medication. Many clinicians opt for fluoxetine (Prozac), since it has no effect on ADHD and its long duration in the body makes it an ideal drug for patients who forget to take it.
Some clinicians may use a second-line medication alone for cases of mild to moderate depression plus ADHD. It should be noted that, while antidepressant medications have published studies to show that they help with ADHD symptoms, none have shown robust effects. They have demonstrated detectable benefits but only as second-line medications when the use of stimulants or an alpha agonist is not appropriate.
What can a person expect from treating depression with medication? All of the available antidepressant medications have a response rate of about 70 percent. Consequently, the choice of which medication to start with is made on the basis of tolerability and cost. Bupropion (Wellbutrin) is lowest in side effects, followed by the third-generation SSRI medications, such as citalopram (Celexa) and escitalopram (Lexapro).
Antidepressants work slowly. Most people see no benefit for the first 10 to 14 days. After two weeks, irritability and daily crying spells usually go away. Once a person’s response to medication starts, it takes eight to 10 weeks to see the full benefit of an antidepressant. During this time, the standard medications for ADHD can be fine-tuned. These two classes of medications “play well with each other” and are commonly used together without interactions.
It must be emphasized that getting better with an antidepressant is not the same as full remission. You won’t return to your jolly old self. Most people will need an augmenting agent to boost the initial response into full remission. The stimulant medications themselves are often used as augmenters, whether or not the patient has ADHD.
It is important for a clinician to think clearly about the common overlap of ADHD and true major depression. Mistaking “reactive depression” for the real thing often leads to years of failed trials on antidepressants and postpones the treatment of ADHD.
Conversely, even when ADHD is being treated, the failure to recognize and treat major depression leaves the patient without the energy and hope to pursue learning how to manage their ADHD nervous system. A careful initial assessment is vital. More often than not, clinicians will recognize what they have been trained to see. They will usually misinterpret ADHD as a mood disorder unless you help them make this distinction.
Successful treatment requires that each condition be identified and managed in order to get all the relief that is possible.
William Dodson, M.D., is a member of ADDitude’s ADHD Medical Review Panel.