Guidance for Uncertain Times: Am I Depressed?
Podcast date: August 6, 2020
- Recognize the symptoms of depression in children and adults
- Learn how depression can impact someone with ADHD
- Find out the treatment options for depression and ADHD
- Learn about medications for depression and ADHD and potential barriers
- Find out which professionals can treat ADHD with coexisting
Announcer: You're listening to a special podcast of All Things ADHD in response to the coronavirus pandemic.
Susan Buningh: Hi, I'm your host Susan Buningh, and I'm here today with Dr. Eugene Arnold, CHADD's resident advisor. Good afternoon, Dr. Arnold.
Dr. Eugene Arnold: Good afternoon.
Susan Buningh: So, our topic today is depression, and especially relevant I think, in the context of what we're all facing with this coronavirus pandemic. So, Dr. Arnold, how common is depression in people with ADHD and what are the prevalence rates in children and in adults with ADHD?
Dr. Eugene Arnold: That's an interesting question because the reports in the literature are all over the landscape. The MTA, for example, the Multimodal Treatment study of children with ADHD, the landmark study that started in the 1990s, found a depression rate of 5% or less in that sample of children with combined type ADHD. They were between seven and nine years old. However, other studies, particularly those with older patients in the sample, report higher rates, even up to 80%. And I think that's because, as people age, they may become more aware of the problems they have. Young children with ADHD are often oblivious to their problems, and as they get older, they start to realize the situation, so that, in some sense, depression may actually be a good sign. There's increased insight reflected in depression. And as long as that results in taking steps to improve the situation, that may be good.
However, in general, depression is not desirable to have because it can decrease motivation and energy level and become impairing in its own right. One of the things about depression that is different from ADHD, ADHD being a more chronic, stable kind of problem, is that depression tends to come and go. It may only last a few weeks. It's often driven by some situation that occurred. And then as a person resolves that situation, they get over their depression, or just biologically, it tends to come and go. Particularly with women, it could be associated with menstrual cycle or other things like that. And of course, the phase of the moon still hasn't been ruled out as having some effects. You know, the old term lunatic, that people's mood can change with the phase of the moon has not really been ruled out scientifically. When it occurs, it needs to be dealt with in some way.
Susan Buningh: What are the symptoms of depression in children and the symptoms in adults, and how are they different?
Dr. Eugene Arnold: The symptoms are basically the same, with just a few adaptations for children. I'm looking now at the DSM, the Diagnostic and Statistical Manual, and I'm just going to read down through these. There are nine cardinal symptoms of depression. In order to make the diagnosis, you should have five or more. One of them needs to be a mood problem, either depression or irritability. If it's irritability, you have to have five other symptoms. If it's depression, you only need four other symptoms. However, for children, irritability counts as much as sadness. So that would be one difference between adults and children, that in children, rather than looking sad or appearing sad or expressing sad feelings, they may show irritability as their dysphoric mood, as it's called.
Next symptom is a diminished interest or pleasure in almost all of the activities that they previously enjoyed, including possibly eating, but also, you know, video game playing or sports or whatever they previously liked to do. And one of the things I'll often ask a child is, "What do you do for fun?" And then the next question, "When's the last time you did it?" And if they said three weeks ago, or if the only fun they ever had is going to Disneyland and no other fun in life, that's a red flag. This loss of interest or pleasure could substitute for the dysphoric mood, the sadness or irritability.
Another thing is weight loss or gain. Here's another difference between adults and children, because for children, the weight loss could just be a lack of expected weight gain that occurs with normal growth and development, and that's usually associated with a change in appetite. Now, we have an additional complication. If someone is taking a stimulant medicine for their ADHD, they may lose weight and appetite as a side effect of the drug. So that has to be taken into consideration. You have insomnia or hypersomnia, that's a sleep disturbance, either not being able to sleep at night or being tired and sleepy during the day.
Then we have what's called psychomotor agitation or retardation. That just means speeding up or slowing down from their usual pace. The picture of agitation would be the hand ringing, pacing around. That's somebody who's in great distress. The loss of energy and fatigue is another issue, and feelings of worthlessness or excessive guilt. Feeling guilty over things they didn't really do is not appropriate guilt. In other words, if somebody has done something bad and they feel guilty for it, that's good. They should feel guilty, and that's not a sign of depression. But feeling guilty for things they have no control over or that they didn't do, blaming themself for all the woes of the world, and things like that. And then inability to concentrate, diminished ability to concentrate.
Now, you've noticed these symptoms of depression are the same as symptoms of ADHD, which makes another important issue in diagnosing depression in people with ADHD, which could account for some of the differences in reported rates of depression. It depends on how people handle these overlapping symptoms. But the issue here is a change from previous ability. Someone may have trouble concentrating because of ADHD, but if that gets momentarily worse at a time when they're feeling sad or irritable and not enjoying things and so forth, then that could count for depression. Also, thoughts of death, suicide, dying, either with or without a plan, or a suicide attempt, anything along that line.
Susan Buningh: You've touched a little bit on children and adults with ADHD. What are the available treatments for depression in children and adults with ADHD, whether they're taking medications for ADHD or are not medicated?
Dr. Eugene Arnold: Many of the treatments that are good for depression are also good for ADHD. For example, there are antidepressant drugs that are proven to help both depression and ADHD. One of them is bupropion, tradename Wellbutrin, and then the old-fashioned tricyclic antidepressants, so things like imipramine, desipramine, nortriptyline, amitriptyline. Those all have good scientific evidence of efficacy for ADHD, as well as for depression, which they were originally designed for. They do have some risks and are generally not as safe as the stimulants, and not quite as effective, but they do work.
The monoamine oxidase inhibitor is another class of antidepressants that has scientific proof of efficacy for ADHD symptoms also, and has been used, to some extent, for adults with ADHD. They do require certain food restrictions that make it kind of a nuisance and may make it difficult for children.
Susan Buningh: So, if someone has coexisting ADHD and depression, which one should be treated first?
Dr. Eugene Arnold: I don't think you really have to make a choice. You can treat both of them at the same time, as I said, with these drugs that have overlapping efficacy between the two disorders. But if you are going to focus on which one you're treating, and you may wish to, for example, treat the depression with a serotonin reuptake inhibitor, like fluoxetine or paroxetine or sertraline or escitalopram, something like that, which does not help ADHD, and perhaps you want to treat the ADHD with a stimulant, which does not help the anxiety, it would partly depend on which one is the biggest problem at the moment. In other words, you go for the main problem and then reevaluate, after you treat that, what's left.
For example, if you treat the ADHD first and they're depressed because of the problems they're having in school or at work or in their marriage, and by treating the ADHD symptoms those other problems clear up, the depression may clear up also by itself. On the other hand, depression can make ADHD symptoms worse. So, if they're really depressed, you might want to treat the depression. And in that case then, the ADHD symptoms may abate enough so that they're only mild and don't require medication.
Susan Buningh: As we go forward in a time when kids can't participate in school and in the things they're normally participating in, and adults are all working from home, and people are not socializing physically, would you expect to see an uptick in symptoms of depression?
Dr. Eugene Arnold: Let me say a couple of things about that. One of them is that this is not really such an unprecedented situation. Prior to the vaccines, every summer, there was a polio scare. And people would socially distance, they'd close down the community swimming pool. And there were buildings, large children's hospitals had special buildings dedicated to treating the aftermath of polio, rehabilitating people. And there would be measles or mumps or chicken pox or rubella epidemic. The public health officer would just come out and tack up a quarantine sign on your house and you stayed in. And people would bring food and leave it on your doorstep.
This situation has occurred before. We got spoiled because we have all the vaccines and we have treatments for a lot of infectious diseases we didn't have before. So, we have come to forget what life was really like. We can get through this again. We've done it before, and we can do it again. Social distancing is very difficult for humans because we're herd animals, and therefore, we are going to feel some stress with that. I think it's probably more anxiety than depression, although both would enter into it. I think the fear of the infection is more an anxiety-inducing thing, and the loss of social contact is more of a depression-inducing problem.
One of the advantages we have now is that much of our social life has occurred already with social distancing, by phones and tablets and other cyber connections, Facebook and Twitter, and all these other things, so that people are used to texting each other rather than talking to them face to face. So, a lot of the social contract can be maintained. With a little thought, we can get through that. One other issue though is the fact that in families who have ADHD, being closed in together, the cabin fever aspect of this, may be a bit worse than for other people. They may get on each other's nerves more. The lack of organization, for example, could be more stressful for them. So, a little bit of attention to organizing what it's going to be like inside the cabin for the duration could be helpful in those cases.
I'd like to return to the issue of treatments for depression and ADHD because I didn't get a chance to mention other treatments besides medication are also important. CBT, cognitive behavioral therapy, is a proven treatment for depression, and there's increasing evidence coming out that it can also be used for ADHD, particularly in adults and older teens. Other things under the rubric of complementary and alternative treatments also have some evidence for both depression and ADHD. One of these is Omega-3 fatty acids, which generally doesn't show an effect until you've taken it for about three months. And the effect is small, but in many cases, it takes the edge off. Even though it's small, it's significant. That would be an important thing to remember to consider, as should be wild ocean fish, wild caught ocean fish that's oily, things like cod and salmon and anchovies, sardines, things like that.
Another nutritional issue is vitamins and minerals. Julia Rucklidge in New Zealand has published evidence that a comprehensive formulation of vitamins and minerals, over 30 ingredients having all of the known vitamins and minerals, had a significant effect on ADHD, on inattention, and on emotional dysregulation, which has many symptoms of depression included in it. It had a significant benefit for those in both adults and children.
Susan Buningh: How does medication work to relieve depression?
Dr. Eugene Arnold: Well, there are several ways. One of them is that serotonin we know is important. It's made by one type of neuron that is a communication to another type of neuron. It's a neurotransmitter. In other words, it transmits a signal from one neuron to another in the brain. As it's used, it is then taken back up by the first neuron and broken down, metabolized. What the serotonin reuptake inhibitors do, like Luvox and Prozac and Paxil, Lexapro, all of those things, what they do is to prevent that reuptake so that you get more bang for the buck out of each molecule of serotonin and each molecule lasts longer in the synaptic cleft, and therefore continues transmitting the signal for a longer time.
The same sort of thing happens with norepinephrine, which is also important in depression, and there are medications that will increase the norepinephrine neurotransmission, such as bupropion and the old-fashioned tricyclic antidepressants that I mentioned earlier. And also, there are newer ones now that have an effect on both serotonin and norepinephrine, things like, well, Effexor is not so new, but it's what was one of the first, and there are others now like vortioxetine and duloxetine. Those, again, would probably be useful for treating depression, maybe not so much for ADHD.
Susan Buningh: Do individuals who are treated with medications need to use them for a long time?
Dr. Eugene Arnold: This is what you might call a personalized medicine issue. If someone has experienced some large loss and it goes beyond normal grief issues and becomes depression, they may need the treatment for only a short time. If someone has a chronic depression problem that lasts and lasts over years, they may need to take the antidepressant for a much longer time. In either case, it's a good idea after some months or years, to try decreasing, tapering down and see if they still need it.
The same sort of principle applies to ADHD treatment, except over a longer period of time. We know that about half of people with ADHD in childhood tend to lose the symptoms and impairment over time, to an extent that they no longer need medication in adulthood. In this case, we're talking about years rather than months, but the same principle applies.
Susan Buningh: What type of healthcare provider can best treat someone who has coexisting ADHD and depression?
Dr. Eugene Arnold: Well, a psychiatrist could treat both. A psychologist can treat both to the extent of providing things like CBT, coaching and other supportive measures. They could also make recommendations about nutrition, which could help both disorders. For the medications I talked about, stimulants and bupropion, antidepressants and so forth, you would need a physician. A primary care physician could prescribe those, pediatricians prescribe them, family practitioners. Internists will sometimes do it. Of course, a psychiatrist would be able to provide both treatments for both disorders.
Susan Buningh: Dr. Arnold, thank you so much for your time today.
Dr. Eugene Arnold: It was a pleasure.
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