COMMENTARY

ADHD With Anxiety and Depression: What Drives What?

David Feifel, MD, PhD

Disclosures

February 07, 2011

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Hi. I'm Dr. David Feifel, Professor of Psychiatry at University of California San Diego (UCSD), and I'm the founder and director of the UCSD Adult ADHD program. Adult attention-deficit/hyperactivity disorder (ADHD) is what I want to talk with you about today.

Specifically, I want to talk about ADHD in the adult who also exhibits signs of depression and anxiety. In my years of working with patients with ADHD, one thing that I've been very impressed with is the number of patients with adult ADHD who also have comorbid depression and anxiety. What is very important to realize (and something that I've realized with many years of experience) is that the depression and the anxiety, rather than being totally independent phenomena, are often secondary to the underlying adult ADHD. This is a rather unrecognized feature of ADHD and of patients with depression and anxiety, because most psychiatrists who see patients with clinical depression or clinical anxiety automatically assume that those are the primary disorders that require our priority in terms of treatment. However, it can be very frustrating if you have a patient with ADHD and depression, or ADHD and anxiety, if the depression or anxiety is driven by their ADHD, because trying to treat the depression or anxiety will be very difficult. The ADHD will continue to generate the depression and anxiety.

Let me give you a couple of clues about how to recognize when depression or anxiety might be secondary to ADHD. First let's focus on depression. People who have depression along with ADHD, specifically when it emanates from ADHD, will often tell you if you ask them carefully that the things about which they are really depressed are not just general existential things. They are frustrated with their inability to accomplish things that they feel they should be able to accomplish. Adults with ADHD are quite bright and ambitious and they put in a lot of effort, yet they don't achieve the same degree of results that you would expect from someone with these abilities. Over time, this tends to wear them down and predisposes them to clinical depression. Patients with anxiety have similar problems. The way you can differentiate them from patients who have anxiety secondary to ADHD is by asking them what they tend to be anxious about. Whereas a person with generalized anxiety disorder might be anxious about a litany of things and just about everything under the sun, a person with anxiety secondary to ADHD is usually anxious about features related to their productivity -- whether it's work or school -- because at some level they know they have a limited capacity. Sometimes it gets, worse even when they've gotten a promotion or something good has happened, and they've been given more responsibilities because they realize now that their limited capacities really may be challenged.

So please do keep an eye open for the possibility that your patients' depression or anxiety could be secondary to ADHD, because treating the underlying ADHD sometimes is the key to really undoing a lot of the depression and anxiety.

Thank you for watching. I'm Dr. David Feifel.

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