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Treating Comorbid ADHD, Major Depression, and Panic

Key Words: Attention-Deficit/Hyperactivity Disorder • Depression • Panic Disorder • Psychopharmacology

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.

Case Report

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.

REFERENCES

1. Barkley RA: Comorbid disorders, social relations, and subtyping, in Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York, Guilford, 1998, pp 139–163

This article has been cited by other articles:

				L. Calabrese and G. McEnany Stimulant Use in the Treatment of Iatrogenic Somnolence Journal of the American Psychiatric Nurses Association, August 1, 2001; 7(4): 125 - 127. [PDF]

Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via HighWire Citing Articles via Google Scholar Articles by SCHALLER, J. L. Articles by BEHAR, D. Search for Related Content PubMed Citation Articles by SCHALLER, J. L. Articles by BEHAR, D. Attention Deficit Hyperactivity Disorder

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