This is an everyday issue in real world clinical practice.
The old adage of “Treat mood and anxiety first” before treating ADHD has long been considered the recommended standard of care when confronted with patients with ADHD comorbid with significant mood or anxiety symptoms.
Recent findings by Chen et al from a nationwide longitudinal study of ADHD and comorbid major depression (MDD/ADHD) may cause clinicians to rethink this strategy. Their study identified 1,891 patients with MDD/ADHD and compared them with 1,891 age and sex matched patients with major depression only in a 1-year longitudinal study. Patients with MDD/ADHD had 232% the risk of treatment resistance to multiple antidepressants compared with patients with major depression without ADHD. Their study went on to find that individuals receiving regular treatment for ADHD had a significantly lower risk for antidepressant treatment resistance. In conclusion, “Patients who had dual diagnoses of major depression and attention deficit hyperactivity disorder were more likely to have treatment resistance to antidepressants… prompt and regular treatment for attention deficit hyperactivity disorder would reduce this risk”.
This study highlights the fact that when ADHD symptomatology are driving functional impairments and exacerbating underlying mood disorders, anxiety disorders or substance abuse, that concomitant treatment of ADHD and these associated conditions often yields the best overall therapeutic response.
How will these findings influence your clinical practice?
How do these results change the way we teach our colleagues to manage patients with depression and co-ocurring ADHD?
Greg Mattingly MD
Chen et al. Eur Neuropsychopharmacol. 2016 Sep 22. pii: S0924-977X(16)30562-4. doi: 10.1016/j.euroneuro.2016.09.369. [Epub ahead of print] Attention - deficit hyperactivity disorder comorbidity and antidepressant resistance among patients with major depression: A nationwide longitudinal study.
The comorbidity between attention deficit hyperactivity disorder ( ADHD ) and major depression is common. However, the influence of ADHD comorbidity in the response or resistance to antidepressants remains unknown among patients with major depression. 1891 patients with major depression and ADHD and 1891 age-/sex-matched patients with major depression only were enrolled and followed for 1 year in our study. Use of antidepressants and ADHD medications during 1-year follow-up period were assessed. Antidepressant resistance was defined as treatment failure in two or more than two different antidepressants for adequate treatment dose and duration. Patients with major depression and ADHD had an increased risk of treatment resistance to antidepressants (odds ratio [OR]: 2.32, 95% confidence interval [CI]: 1.63-3.32) compared with patients with major depression only after adjusting for demographic characteristics and other psychiatric comorbidities. Regular treatment for ADHD would reduce this risk (OR: 1.76, 95% CI: 0.72-4.27).
Anxiety (OR: 3.15, 95% CI: 2.24-4.44) and substance use (OR: 2.45, 95% CI: 1.16-5.17) disorders were also associated with an elevated likelihood of resistance to antidepressants during the follow-up. Patients who had dual diagnoses of major depression and ADHD were more likely to have treatment resistance to antidepressants compared with patients with major depression only. Prompt and regular treatment for ADHD would reduce this risk.