Mood, Anxiety Disorders Complicate ADHD TX

By Sherman, Carl | Clinical Psychiatry News, December 2006 | Go to article overview

Mood, Anxiety Disorders Complicate ADHD TX


Sherman, Carl, Clinical Psychiatry News


Adults with attention-deficit hyperactivity disorder frequently have other psychiatric problems as well. The National Comorbidity Survey Replication found 12-month prevalence rates of 38% for mood disorders and 47% for anxiety disorders in this population. Conversely, increased rates of ADHD were seen among depressed and anxious individuals (Am. J. Psychiatry 2006;163:716-23).

The relationship among disorders is not always clear. "We think depression is independently transmitted about half the time," said Dr. Timothy Wilens of Harvard University and Massachusetts General Hospital, Boston. "For the other half, chronic demoralization and recurrent life events associated with ADHD are contributing factors in development of the mood disorder."

Anxiety disorders are more often transmitted independently, but what appears to be a separate diagnosis may represent a set of phobic responses to ADHD-associated situations. "If an individual always has difficulty completing tasks, he'll become anxious just being assigned a task," Dr. Wilens said. "If work is a constant struggle, simply walking into work may trigger intense anxiety."

The link may be stronger. A study led by Dr. Lenard Adler, director of the adult ADHD program at New York University, New York, found substantially higher rates of ADHD in patients with posttraumatic stress disorder (PTSD) than in those with panic disorder (J. Atten. Disord. 2004;8:11-6). "Having ADHD may put an individual at risk for PTSD," he suggested.

Often, only one condition is identified. "If there is a history of being disruptive, ADHD is usually diagnosed first," said Dr. Margaret Weiss, director of the provincial ADHD program at Children's and Women's Health Centre in Vancouver, B.C.

"If ADHD is primarily attentional, it may be missed until a transition, such as starting college, causes a significant change in functioning. Then the patient comes in for depression," she said.

Attentional problems may remain unnoticed until severe mood or anxiety symptoms have been brought under control, Dr. Wilens said.

Disentangling the relationships among symptoms and manifestations "may lead to different interventions," Dr. Wilens said. "It becomes imperative to have a very solid diagnostic understanding of what you're dealing with before you start."

"Take a good longitudinal history," Dr. Adler advised. "There's a tendency to focus on the immediate issue. It would be reasonable to evaluate all patients with anxiety and mood disorders for ADHD."

Treating one condition effectively means treating the others, ideally to remission, Dr. Weiss said. When they come to her, one-fourth of her ADHD patients are on or have had past trials of antidepressants, with less-than-optimal response. "The underlying symptomatic and functional deficits of ADHD were not addressed," she noted.

ADHD can create its own issues of mood regulation and impulse control and can compound difficulties in motivation. "This is important to keep in mind when co-occurring depression isn't improving," said Dr. Adler, author of "Scattered Minds: Hope and Help for Adults With Attention Deficit Hyperactivity Disorder" (New York: Penguin Group, 2006).

Often, what is diagnosed as treatment-resistant or atypical depression represents untreated ADHD. On the other hand, a history of depression or anxiety complicates treatment of ADHD. "It's harder to get a robust response to a stimulant," Dr. Weiss said.

Treatment is usually sequential. 'As a clinical rule of thumb, treat the most impairing disorder first," Dr. …

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