Diagnosing ADHD in Adult Patients With Major Depression

Question:

"I am uncertain of how to diagnose ADHD in my adult patients with major depression. Is this diagnosis even warranted in a patient with depression?"

Rakesh Jain, MD, MPH:

I completely understand your uncertainty. From a diagnostic perspective this is a challenging issue we often face. Matters are further complicated by the fact that from a DSM-IV perspective, concentration difficulties are a shared symptom by both attention-deficit/hyperactivity disorder (ADHD) and major depressive disorder (MDD). Both of these disorders are high frequency disorders both in society and in our clinics; hence, the question you have asked is one that confronts us on a daily basis.

Let’s first examine the literature. Epidemiological studies do tell us that yes indeed these two disorders are frequent fellow travelers. ^1-6 We also know that while each of these disorders individually cause a great deal of disability, their co-occurrence is quite disabling to our patients ^7-11 The data also point to this extremely important fact: while there are overlapping symptoms between MDD and ADHD, they are "stand alone" diagnoses that happen to love each other’s company. ^12,13 In other words, they often exist together and that idealized outcomes depend heavily on us, the clinicians, being able to make an appropriate differential diagnosis. ¹⁴

How is one to appropriately diagnose and treat ADHD in a patient with comorbid MDD? ^15-18 I offer a three-step recommendation for you:

1. Be suspicious, Be very suspicious!

Be aware that ADHD is a common comorbidity of MDD. Men and women, young and old—the risk exists in all populations.

2. Screen. Verify. Confirm.

a. Always ask patients with MDD if they have a long-standing history of difficulties with attention, concentration, impulsivity, hyperactivity, etc.

b. Ask if these difficulties exist only during a mood episode, or even outside of a mood episode (if it only occurs during mood episodes, this is not ADHD). Now, mood episodes can worsen the above difficulties, but the ADHD symptoms must have started before the age of 7 (and can’t be entirely explained by the major depression).

c. Consider the use of screening tools, such as the Adult ADHD Self-Report Scale (ASRS) ^19-21 and ADHD Rating Scale (ADHD-RS). ^22-24 I am a big fan of both of these instruments. The former is a WHO screening tool, while the later is based on DSM-IV symptoms, and I have found it useful for both screening and treatment response assessment.

d. Verify your positive or negative findings by obtaining collateral information (from spouses, significant others, friends, past educational or medical records, etc.).

e. Confirm your diagnosis using DSM-IV criteria. Some of the key elements of this are: onset of symptoms before age 7; presence of at least six out of nine symptoms in either/both of the inattentive items or the hyperactivity/impulsivity items; and impairment in at least two domains of functioning (school, home, social life), and that the symptoms are not entirely due to another psychiatric or medical or substance misuse cause.

3. Treat. Watch. Recalibrate.

   Finally, in most instances it is appropriate to treat the major depression first as optimally as possible and then reassess for the progression of the patient’s ADHD symptoms and impairment. If they are indeed present and impairing, biopsychosocial treatment of the ADHD is highly appropriate. This will often include behavioral and psychological help, and if needed, appropriate pharmacotherapy of ADHD.

As most likely have astutely noted, there is no proscription in DSM-IV from making a comorbid diagnosis. In fact, we are encouraged by the extant literature to make such multiple diagnoses if the evidence for it exists.

—Rakesh Jain, MD, MPH

References

1. McIntyre RS, Kennedy SH, Soczynska JK, et al. Attention-deficit/hyperactivity disorder in adults with bipolar disorder or major depressive disorder: results from the international mood disorders collaborative project. Prim Care Companion J Clin Psychiatry. 2010;12(3).
2. Waite R, Tran M. ADHD among a cohort of ethnic minority women. Women Health. 2010;50(1):71-87.
3. Goodman D. Adult ADHD and comorbid depressive disorders: diagnostic challenges and treatment options. CNS Spectr. 2009;14(7 Suppl 6):5-7; discussion 13-4.
4. Biederman J, Monuteaux MC, Mick E, et al. Psychopathology in females with attention-deficit/hyperactivity disorder: a controlled, five-year prospective study. Biol Psychiatry. 2006;60(10):1098-1105.
5. McGough JJ, Smalley SL, McCracken JT, et al. Psychiatric comorbidity in adult attention deficit hyperactivity disorder: findings from multiplex families. Am J Psychiatry. 2005;162(9):1621-1627.
6. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):716-723.
7. Park S, Cho MJ, Chang SM, et al. Prevalence, correlates, and comorbidities of adult ADHD symptoms in Korea: Results of the Korean epidemiologic catchment area study. Psychiatry Res. 2010;[Epub ahead of print].
8. Friedrichs B, Igl W, Larsson H, Larsson JO. Coexisting psychiatric problems and stressful life events in adults with symptoms of ADHD--A large Swedish population-based study of twins. J Atten Disord. 2010;[Epub ahead of print].
9. Biederman J, Ball SW, Monuteaux MC, et al. New insights into the comorbidity between ADHD and major depression in adolescent and young adult females. J Am Acad Child Adolesc Psychiatry. 2008;47(4):426-434.
10. de Graaf R, Kessler RC, Fayyad J, et al. The prevalence and effects of adult attention-deficit/hyperactivity disorder (ADHD) on the performance of workers: results from the WHO World Mental Health Survey Initiative. Occup Environ Med. 2008;65(12):835-842.
11. Birnbaum HG, Kessler RC, Lowe SW, et al. Costs of attention deficit-hyperactivity disorder (ADHD) in the US: excess costs of persons with ADHD and their family members in 2000. Curr Med Res Opin. 2005;21(2):195-206.
12. Quinn PO. Attention-deficit/hyperactivity disorder and its comorbidities in women and girls: an evolving picture. Curr Psychiatry Rep. 2008;10(5):419-423.
13. Fischer AG, Bau CH, Grevet EH, et al. The role of comorbid major depressive disorder in the clinical presentation of adult ADHD. J Psychiatr Res. 2007;41(12):991-996.
14. Babcock T, Ornstein CS. Comorbidity and its impact in adult patients with attention-deficit/hyperactivity disorder: a primary care perspective. Postgrad Med. 2009;121(3):73-82.
15. McIntosh D, Kutcher S, Binder C, et al. Adult ADHD and comorbid depression: A consensus-derived diagnostic algorithm for ADHD. Neuropsychiatr Dis Treat. 2009;5:137-150.
16. Antai-Otong D. The art of prescribing pharmacological management of adult ADHD: implications for psychiatric care. Perspect Psychiatr Care. 2008;44(3):196-201.
17. Newcorn JH, Weiss M, Stein MA. The complexity of ADHD: diagnosis and treatment of the adult patient with comorbidities. CNS Spectr. 2007;12(8 Suppl 12):1-14.
18. Diler RS, Daviss WB, Lopez A, et al. Differentiating major depressive disorder in youths with attention deficit hyperactivity disorder. J Affect Disord. 2007;102(1-3):125-130.
19. Kessler RC, Adler LA, Gruber MJ, et al. Validity of the World Health Organization Adult ADHD Self-Report Scale (ASRS) Screener in a representative sample of health plan members. Int J Methods Psychiatr Res. 2007;16(2):52-65.
20. Adler LA, Spencer T, Faraone SV, et al. Validity of pilot Adult ADHD Self- Report Scale (ASRS) to rate adult ADHD symptoms. Ann Clin Psychiatry. 2006;18(3):145-148.
21. Kessler RC, Adler L, Ames M, et al. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2005;35(2):245-256.
22. Szomlaiski N, Dyrborg J, Rasmussen H, et al. Validity and clinical feasibility of the ADHD rating scale (ADHD-RS) A Danish Nationwide Multicenter Study. Acta Paediatr. 2009;98(2):397-402.
23. Ohnishi M, Okada R, Tani I, et al. Japanese version of school form of the ADHD-RS: an evaluation of its reliability and validity. Res Dev Disabil. 2010;31(6):1305-1312.
24. Tani I, Okada R, Ohnishi M, et al. Japanese version of home form of the ADHD-RS: an evaluation of its reliability and validity. Res Dev Disabil. 2010;31(6):1426-1433.