SIR: Attention-deficit/hyperactivity disorder (ADHD) increases one's risk for both major depression (MD) and an anxiety disorder by approximately 25%.
+1 Some individuals have all three. Therefore, we are proposing patients with such comorbidities should have their MD treated first, their anxiety disorder next, and finally be offered a noncombination, low-potency stimulant for ADHD.
A 38-year-old man was initially diagnosed with MD by use of the Inventory to Diagnose Depression (IDD), scoring a 38 (0—10 is normal). A trial of sertraline 125 mg produced a remission (IDD<10).
His generalized anxiety partially decreased on the sertraline, as measured by Beck Anxiety Inventory's (BAI) decreasing from 28 to 20. His panic attacks, occurring at a frequency of twice per week, continued on the sertraline, although with reduced distress. Having failed a competent trial of extensive exposure and cognitive reconstructing panic therapy prior to our treatment, he was tried on clonazepam 0.25 mg three times a day, producing a stable BAI of 4 (normal), with no panic attacks for 2 months.
Despite his improvement, the patient still met criteria for adult ADHD, with a childhood onset at age 5. Two first-degree relatives had ADHD. Common standard diagnostic scales such as the Brown Adult ADHD Scale, the Wender Utah Retrospective Scale, and the Semi-Structured Adult Interview for ADHD all confirmed his mental status exam and reported history.
The patient asked for a trial off clonazepam to "keep his medication simple." He was weaned off clonazepam, and his BAI rose to a "tolerable" 15, with no clear panic attacks. A trial of 5 mg Adderall, at breakfast and at 2:00 p.m., caused clear, repeated anxiety spikes 4 hours after each dose. Since Adderall represents two stimulants or four different amphetamine compounds, one or more may have been exerting marked stimulation at the 4-hour mark.
Back on his clonazepam, the patient tried methylphenidate 7.5 mg tid (he had "failed" dextroamphetamine as a teenager). He had an 85% reduction of his ADHD symptoms, with no increase in anxiety.
This case suggests that one should treat ADHD with comorbid anxiety with a low-potency noncombination stimulant, to prevent sensitivity to stimulants.