Content Warning: This post mentions effects of Depression that include self-directed harm. If you or someone you know has experienced anything similar, you may want to proceed with caution.
We’re continuing today with the Comorbidity Series, a monthly series of posts about ADHD and comorbidity with other common psychiatric conditions. You can see all of the posts here.
Comorbidity is the occurrence of two or more psychiatric and/or neuropsychological conditions in a person. If a person has ADHD and OCD, the conditions are considered comorbid.
Comorbidity can be tough! It makes diagnosis difficult, especially when those two or more conditions present with similar manifestations. Then it can be difficult to say “what’s the ADHD” and “what’s the other condition”.
Today we’re talking ADHD and Depression, which is one of the most common psychiatric conditions and affects millions of children and adults around the world.
Defining Each Condition
Attention Deficit Hyperactivity Disorder (ADHD) is a neuropsychological disorder characterized by difficulty with paying attention, hyperactivity, impulsivity, and/or difficulty controlling or regulating emotions. ADHD is broken into three categories (or presentations): Primarily Inattentive, Primarily Hyperactive-Impulsive, and Combined.
Depression is a mood disorder that causes persistent sadness and loss of interest in daily activities. There are many kinds of depression, including Persistent Depressive Disorder, Major Depressive Disorder, and Postpartum Depression. Depression typically causes a person to experience feelings of hopelessness, worthlessness and numbness.
What Are the Different Types of Depression?
Depression isn’t a singular diagnosis. There are many different types, and a person can experience more than one throughout their life or even within the same year.
It’s more than just sadness. Depression typically comes with feelings of emptiness, loneliness and may cause social withdrawal. Left untreated for too long, it can lead to drug or alcohol abuse, problems at work or in relationships, self-harm, or suicide. Nearly 800,000 people worldwide take their lives each year. If you or someone you know is having suicidal thoughts, please visit SAVE’s resource page here to get help.
Persistent Depressive Disorder (PDD)
Persistent Depressive Disorder, or dysthymia, is a chronic form of depression that is typically considered mild or moderate. PDD is diagnosed when a person has experienced persistent low mood, loss of interest and limited energy on most days for at least two years.
Many people with PDD will experience a major depressive episode at some point in their life.
Major Depressive Disorder (MDD)
Major Depressive Disorder is sometimes referred to as Clinical Depression. MDD consists of recurring depressive episodes in which a person may experience changes in habit and behavior.
To be diagnosed with MDD, these episodes need to have occurred for at least two weeks and you need to have experienced depressed mood or loss of interest in pleasurable activities. A diagnosing doctor will also ask if you have experienced fatigue, difficulty sleeping, changes in appetite, irritability, sudden weight gain or loss, or thoughts of self-harm or suicide.
Postpartum Depression (PPD)
Postpartum Depression occurs after a person has given birth and affects up to 15% of new parents. PPD can happen after a first child is born, or with any subsequent birth.
PPD is marked by mood swings, exhaustion, and a persistent feeling of hopelessness or worthlessness that last for several weeks or months. Many people experiencing it may withdraw from their friends and family, feel disconnected from their baby, or have intrusive thoughts about harming themselves or their baby.
PPD can cause a new parent to feel guilty because they are struggling to take care of themselves and their baby. This shame often leads parents to attempt to hide or mask their symptoms from others. Many experts believe that PPD is twice as common as currently reported and many people go untreated for it, which is dangerous for both parent and baby.
Seasonal Affective Disorder (SAD)
Seasonal Affective Disorder is a depression that lasts during certain months of the year because of the seasons. Most people with SAD will experience it between Fall and Winter.
SAD might start mild and become more moderate or severe as the months go on. Symptoms include fatigue, changes in appetite, loss of interest in favored activities, difficulty sleeping, sluggishness, irritability and feelings of hopelessness or worthlessness.
How Do You Tell ADHD and Depression Apart?
ADHD and depression are two distinct conditions, but some similarities in manifestations can make them difficult to tell apart at times.
Both ADHD and depression can cause difficulty falling and staying asleep, daytime fatigue, restlessness, boredom, difficulty paying attention, and loss of interest in things you typically enjoy.
There are also distinct differences between the catalyst of the two conditions, and a diagnosing doctor will attempt to understand the root causes of commonly experienced manifestations in order to tell them apart.
With ADHD, a person may lose interest in things because they are bored by it – it’s no longer novel or unique or interesting, and thus they will move onto the next interest. ADHDers can easily jump from hyperfixation to hyperfixation because they need newness.
With depression, a person may lose interest in things because of an overall feeling of numbness or emptiness. They may have trouble feeling any emotions (except perhaps irritability) and therefore interest wanes because they simply can’t get excited about anything.
ADHD can cause a person to experience low moods, sadness or irritability. Typically, these feelings will be caused by a particular event or interaction.
When a person is depressed, they can also experience low moods, sadness or irritability. However, there may not be a specific root cause. Depressed people can have these feelings even if everything around them is going exceedingly well.
Is Depression a Comorbidity or a Secondary Condition?
To complicate a dual-diagnosis of ADHD and depression even more, it’s very common for depression to develop as a secondary condition due to years of difficulty with ADHD – especially undiagnosed ADHD.
ADHDers are more likely to develop unstable self-image and low self-esteem because of executive dysfunction difficulties and persistent negative self-talk.
Imagine that you struggle every day to do the basic things you need to do in order to feel successful. This may include housework, schoolwork, work projects and tasks, getting to appointments on time, basic hygiene or exercise.
Eventually, the struggle starts to wear you down. You begin to think of yourself as a failure and a loser. On top of this, you see your peers advancing much more quickly than you in all arenas.
Depression sets in when the perception that you are unable to succeed at anything takes hold and your negative self-image goes untreated.
Not all depression is a secondary condition. Children and teenagers who are diagnosed at a young age with ADHD, and who have the opportunity to access treatment and medication early, are still at higher risk to also be depressed than their neurotypical peers.
Researchers suspect that the dual diagnosis of ADHD and depression is so common because both conditions are related to a deficient amount of dopamine in the brain, and the inability for that dopamine to be transmitted properly.
Treating ADHD and Depression Together
Most doctors go with the school of thought that you should treat the more severe condition first. In most cases, they will especially want to treat depression before ADHD as depression can put you in more life-threatening situations.
However, there is also some research to suggest that treating the ADHD first can actually help lessen symptoms of the comorbid condition. This is especially true if there’s suspicion that the comorbid condition arose as a secondary response to untreated ADHD.
What is most important to keep in mind is that you, as the patient, absolutely have a say in your treatment plan.
Options for Medication
ADHD medications and anti-depressants are an option and can be taken together. The most common ADHD medications are stimulants, including Adderall, Ritalin, Vyvanse and Concerta. Some people also respond well to nonstimulant ADHD medications, like Straterra or Clonidine.
Wellbutrin can be prescribed for both ADHD and depression and may be an excellent option for many.
Otherwise, depression can be treated with any of the following types of medication:
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- Serotonin and Noradrenaline Reuptake inhibitors (SNRIs)
- Monoamine Oxidase Inhibitors (MAOIs)
- Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs)
- Tricyclic Antidepressants (TCAs)
For many years, doctors have been resistant to the idea of prescribing both stimulants and MAOIs to patients because of concerns over severe or possibly fatal reactions when the two drug types are taken together.
A recent literature review from 2015 concluded that a stimulant could be prescribed in concert with a selegiline transdermal patch (a type of MAOI introduced in the US in 2008), with lessened dietary restrictions and few side effects.
Other similar reviews have stated that additional study should be done to uncover if the combination of stimulants and MAOIs might now be considered safe and effective.
Options for Therapy
There are many types of therapy suitable for management and treatment of both ADHD and depression.
Cognitive Behavioral Therapy (CBT) is typically the most popular option. It’s a type of talk therapy where a therapist who will attempt to help you challenge thought and behavioral patterns, and work on emotional regulation.
CBT can be difficult for people who also have ADHD because it involves learning and then remembering to use new strategies. It’s important to make your therapist aware of your working memory deficits so they can help you work on no more than 1-2 strategies at a time.
Interpersonal Therapy (IPT) is a short-lived treatment that will have you focus on improving interpersonal and social relationships in the hope of reducing depressive symptoms.
Electroconvulsive Therapy (ECT) is a reasonably stigmatized procedure in which very small electrical currents are passed through the brain to trigger a brief seizure that will cause wanted changes in brain chemistry for relief from depression (and other related mental illness).
It’s typically only used in more extreme treatment-resistant depression cases, or when medication isn’t possible (like during pregnancy or because of intolerability).
ECT is still viewed with suspicion today because it used to be commonly performed on patients without consent, without anesthesia, and without humane regard for their well-being. Minus these three crucial elements, ECT can cause brain damage, excessive loss of memory and fractured skull bones.
It’s important to note that no treatment, whether it’s ECT, medication or therapeutic, should be performed on a person who has not willingly consented to receive said treatment.
Do you have ADHD? Are you depressed? Same. Come talk to me about it!
References, in no particular order or citation style:
- “Major Depressive Disorder (Clinical Depression)”, Michael Kerr, medically reviewed by Alex Klein, PsyD, https://www.healthline.com/health/clinical-depression
- “Persistent Depressive Disorder (PDD)”, https://my.clevelandclinic.org/health/diseases/9292-persistent-depressive-disorder-pdd
- “Postpartum Depression Statistics”, Medically Reviewed and Fact-Checked by Kimberly Langdon M.D., https://www.postpartumdepression.org/resources/statistics/
- “Suicide Facts”, https://save.org/about-suicide/suicide-facts/
- “Everything You Need to Know About Postpartum Depression”, Ann Pietrangelo, medically reviewed by Julie Lay, https://www.healthline.com/health/depression/postpartum-depression
- “Seasonal affective disorder (SAD)”, https://www.mayoclinic.org/diseases-conditions/seasonal-affective-disorder/symptoms-causes/syc-20364651
- “Depression (major depressive disorder)”, https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007
- “Persistent depressive disorder (dysthymia)”, https://www.mayoclinic.org/diseases-conditions/persistent-depressive-disorder/symptoms-causes/syc-20350929
- “Depression Medicines”, https://my.clevelandclinic.org/health/treatments/9301-depression-medicines
- “Combining Stimulants and Monoamine Oxidase Inhibitors: A Reexamination of the Literature and a Report of a New Treatment Combination”, Joshua A. Israel, MD, originally published in The Journal of Clinical Psychiatry, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4805402/
- “Treatment & Management”, https://adaa.org/understanding-anxiety/depression/treatment-management
- “Electroconvulsive therapy (ECT)”, https://www.mayoclinic.org/tests-procedures/electroconvulsive-therapy/about/pac-20393894