What is the relationship between Adult Attention Deficit Hyperactivity Disorder (ADHD) and Depression?
Recently, I was interviewed by Qbtech – a company that designed a quick, easy-to-use online tool for quantifying symptoms of ADHD. In this interview, I share some of my clinical experiences working with patients with Adult ADHD and Depression. For more information about Qbtech, please click here.
Q. What is the link between ADHD and depression?
A: There is no clear research to say that ADHD and depression are linked. They go together all the time or some of the time. In real-world experience, the link between ADHD and depression can go two ways. Either they are comorbid problems, meaning that somebody just happens to have both of those problems. In my experience this occurs at the same rate as those without ADHD. The other type at risk of depression are those who have untreated or under-treated ADHD, especially if they are just coming to diagnosis as an adult. They have a much higher likelihood of depression related to having undiagnosed and untreated ADHD.
Q. Are people with ADHD more likely to get depression?
A: Again, I think this depends on whether ADHD was successfully treated in early childhood or not. What I see is that if somebody was diagnosed and treated as a child, and they had a good course of treatment, they are far less likely to be depressed – no more so than the non-ADHD population. A ‘good course of treatment’ means they took medicine, or they and their families made environmental changes, or they did both, as well as being supported at school.
What I do see are people who either are undiagnosed, under-treated or poorly treated. They tend to have depression in some form: it may not be major depressive disorder but it may be a chronic low level depression. Because the ADHD is not well treated, they often feel like something is wrong. That will show up in two ways.
Either their behavior is externalized; where they are very negative about the world and saying things like ‘the world is a bad place’ or ‘other people are not good people’. Or it turns inward. Which is probably what I see more commonly, where the person believes something is wrong with them. That persistent negative belief of ‘something is wrong with me’ or ‘something is wrong with the world’ – that is what can lead to depression.
Q. Is it common that patients can become (more) depressed after receiving an ADHD diagnosis?
A: Yes, it is. For patients diagnosed with adult ADHD there tends to be a “honeymoon period”, where they are really happy with treatment. They are excited and like ‘wow I feel great’ / ‘this is so much better’. But then there is often a period, 3-6 months down the road, when they realize the medicine isn’t going to fix everything in their life. And they need to do other work to get out of their depression and change some things in their life.
At this time, there is sometimes a worsening of their depression, where they realize how long they were left untreated for ADHD. And they start thinking things like “if I had known this back when I was 12 years old, my life would be totally different right now”. They essentially have a mourning period of what could have been, had they been diagnosed earlier and properly treated. It is a really fascinating pattern I have seen, especially in people who get a diagnosis in their thirties and forties.
And this is where it really helps to work with a psychiatrist who is used to seeing this pattern. If you are in primary care, and once you are stable on your ADHD medicine, you may sometimes only have to come in every six months or so. But that first 3-6 month period is really important to monitor. It is. therefore, good to work with somebody who might catch that depression early and to have that reassurance of knowing someone who has seen this before..
Q. How do you typically treat adults with both ADHD and depression?
A: For me, it depends on the severity of the depression. If I have somebody come in and they are very depressed and I think they may have ADHD, then normally I will treat the depression first – usually with medication or therapy. My aim is to get them to a place where their depression is very low level and then we can see what the ADHD looks like.
Q. Why is that?
A: Classically with depression, sufferers have cognitive dysfunction affecting their levels of concentration, which can look like ADHD. If someone is really depressed, they can’t concentrate. In these cases, it may not be ADHD but depression. If the depression is moderate to severe, I would typically treat the depression, evaluate their cognitive function and then assess and treat ADHD.
In cases where someone has ADHD and mild to moderate depression, I might choose an antidepressant that I think will help ADHD as well. However, if the person comes in to me and they have mild depression, i.e. they are still functioning really well but they have a low mood, and I think they also have ADHD, then I treat differently. I would typically focus on the ADHD first and I would try to treat that and see how much progress we make. Sometimes, in cases like these, what I see is that once you treat the ADHD, their depression starts to resolve with therapy.
This is mainly because they realize this is the ADHD and “it is not something wrong with me”. Once they realize this, they start to see things differently and their mood improves. Then, I would normally recommend psychotherapy to help them get through the rest of the depression and to re-frame their problems. We would try to re-frame the issues in their life through the context of ADHD and what is going to help them and what not.
Q. Is it more difficult to treat depression in patients with ADHD?
A: I would say this is a definite yes. Part of the challenge is that patients may forget their medication, but what I also see in some cases in those with ADHD is an increase in the emotional reactivity component.
By this I mean they tend to be more reactive emotionally to both good or bad things. So, they can be overly positive or overly negative about things compared to other people. When they get depressed, they are trapped in that moment. And it is very hard for them to remember how they felt when they were doing well and vice versa. They tend to be trapped in whatever emotional state they are in, even if they are being successfully treated for their ADHD.
Additionally, if they are low and they say things like ‘oh I am so depressed, I have never felt good, everything has always been terrible’, they can stop caring for themselves or stop doing all the good work they have been doing. They can slip into a real depressive episode, which can be like an emotional windmill of impulsivity. At these times, it is hard for them to see outside of their current emotional state, which can complicate the course of treatment.
Q. What other type of support can be helpful for those with depression and ADHD?
A: It is really important to have someone, either their care provider or a family member or friend, who can help them reflect and understand: ‘Ok, today you are having a bad day’ or ‘you are depressed but you know two weeks ago you were doing fine’. It can be very hard for them to believe others, so this person has to be a trusted source or a trusted family member to communicate this effectively. Otherwise they can remain stuck in that moment for a long time.
The challenge, however, is that I see a lot of people with ADHD who are very impulsive in their relationships. They tend to be impulsive in their speech and behavior in their close relationships, and say or do things that hurt their partners, friends and family. Which makes it hard to have the same support network that they would have otherwise.
