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Early studies noted a connection between ADHD and depression. Several studies have now shown this connection. R. C. Kessler (2005) presented this data from the National Comorbidity Survey-Replication, which shows that a lifetime prevalence for major depression disorder (MDD) is more than 16 percent greater in women than men; the same survey found clinically significant ADHD in adults in 4.4 percent of the same population, with a higher prevalence in men than in women. Dysthymia, a mild form of depression, related 22 percent in those who met the criteria for ADHD. These data suggest that if individuals have ADHD, they are likely to have MDD, and those with dysthymia were more likely to have ADHD. ADHD and major depressive disorder (MDD) are the most common psychiatric disorders occurring in adulthood.

Also, a two-way connection between ADHD and depressive disorders in many generations has shown a possible genetic link. Several studies have suggest that the incidence of ADHD in offspring of adults with recurrent depression is higher than in the general population and that first-degree relatives of juveniles with ADHD show higher rates of MDD. Scientists also know mood disorders are highly heritable In a 2004 twin study, M. J. Rietveld and colleagues found that ADHD is one of the most heritable psychiatric disorders, estimated at 80 percent. Thus the connection between ADHD and mood disorders indicates a genetic component.

The problem of which comes first--ADHD or depressive disorder--is difficult to determine. J. D. Burke (2004) assessed adolescent boys for a period of years up to age 18 and found that ADHD predicted a later diagnosis of oppositional defiant disorder (ODD), which later predicted anxiety and depression. This study suggests that children with ADHD begin school with difficulty in conforming to social and scholastic norms, which causes them to use undesirable behaviors. The cycle of further social isolation and school difficulties then leads to anxiety, anger, and depression. These findings shed light on many of the comorbidity of ADHD and MDD occurring in adults.

Diagnosis of ADHD and MDD is difficult because no reliable objective tests are available to evaluate them. The symptoms are similar and may overlap: inattention, memory difficulties, poor motivation, irritability, restlessness, and procrastination. Even an experienced clinician may have difficulty in making the assessment. However, the major factor in establishing the presence of chronic adult ADHD symptoms is the presence of these symptoms in childhood and looking for absence of a major depressive episode. Several rating forms are available.

Treatment of both MDD and ADHD is accepted as effective. The treatments fall in four categories: antidepressants and ADHD, psychostiumlants and depression, psychostimulants+antidepressants, and psychotherapy:

- Antidepressants and ADHD. More than a dozen FDA approved medications are available for depression, and several have moderate effect for treating ADHD. Bupropion, a norepinephrine reuptake inhibitor (NRI) has treated both conditions. The class of serotonin-norepinephrine reuptake inhibitors (SNRI) includes venlafaxine and duloxetine. A new norepinephrine reuptake inhibitor, atomoxitine entered the market as a treatment for ADHD. No studies have shown that purely serotonergic drugs affect the core symptoms of ADHD.

- Psychostimulants and depression. The most common treatment for ADHD has long been the stimulants, which are used in children. For adults studies are just now appearing that include several formulations of methylphenidate (MPH), including the most recently approved transdermal patch and dextroamphetamine. In adults use of mixed amphetamine salts extended release (MAS-XR) and dexmethylphenidate XR has been approved.

- Psychostimulants+antidepressants. Combining psychostimulants and selective seretonin reuptake inhibitor (SSRI) antidepressants can be safe and effective, with little potential for drug-drug interaction. Combining psychostimulants with SNRIs or NRIs can be successful, monitoring for possible side effects.

- Psychotherapy. The use of cognitive-behavior therapy (CBT) and interpersonal therapy has been effective in treating MDD and is comparable to use of drugs. S. A. Safren et al. in a 2005 study found that combining CBT and medication showed promising results in adults with ADHD. Psychotherapeutic interventions for ADHD have been successful in children. One study, the Multimodal Treatment of ADHD (Jensen 2001), found excellent responses using a combination of treatments.

Education is the heart of any therapeutic intervention. For the adult who has long attempted to overcome the personal shortcoming of ADHD, understanding that there is a neurological basis can be valuable. Personal coaching can provide strategies and encouragement and help the person set goals. According to Kessler (2005), MDD costs the economy nearly $40 billion annually in lost economic productivity and is estimated to be responsible for loss of thousands of lives a year through suicide. Adults who have the problems of executive function as seen in ADHD have a lower socioeconomic status than adults without these deficits. The outlook for treatment is good and comes at a relatively low cost; helping people to see the value of treatment is invaluable.

Bibliography:

1) Amen, Daniel. 2001. Healing ADD: The breakthrough program that allows you to see and heal the 6 types of ADD. New York: Berkley Books.

2) Burke, J. D. et al. 2005. Developmental transitions among affective and behavioral disorders in adolescent boys. Journal of Child Psychology and Psychiatry 45:577-88.

3) Jensen, P. S. et al. 2001. Findings from the NIMH multimodal treatment study of ADHD (MTA): Implications and applications for primary care providers. Journal of Behavior Pediatrics 22:60-72.

4) Kessler, R. C. et al. 2005. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archive General Psychiatry 62:793-802.

5) Rietveld, M. J. et al. 2004. Heritability of attention problems in children: Longitudinal results from a study of twins, age 3 to 12. Journal of Child Psychology and Psychiatry 45:577-88.

6) Safren, S. A. et al. 2005. Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms. Behavior Research Therapy 43:831-42.

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