Navigating Psychiatric Comorbidities in ADHD

Patients with attention-deficit/hyperactivity disorder (ADHD) often present with at least 1 co-occurring psychiatric condition. In this insightful discussion filmed at Psych Congress 2024, faculty member Timothy Wilens, MD, dissects the challenges clinicians may face when diagnosing and treating common psychiatric comorbidities in individuals with ADHD. With a focus on depression and anxiety, Dr Wilens highlights effective treatment approaches for addressing these co-occurring disorders and the resulting range of symptoms that may be impacting patients. 

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Key Takeaways for Clinical Practice

• Approximately 75% of individuals with ADHD have at least 1 psychiatric comorbidity, with anxiety occurring in up to 40% and depression in about 20% of cases.
• When depression or anxiety is moderate to severe, clinicians should begin treatment for these conditions first—using psychotherapy, SSRIs, SNRIs, or atypical antidepressants—before adding ADHD-specific therapy such as stimulants or non-stimulants.
• Certain medications, including atomoxetine and viloxazine XR, may effectively treat both ADHD and co-occurring depression or anxiety, while bupropion and tricyclic antidepressants can serve as off-label options when mood symptoms are also present.

Read the Transcript

Timothy Wilens, MD: Hi, I'm Dr Timothy Wilens and I'm chief of the Division of Child and Adolescent Psychiatry and co-director for the Center for Addiction Medicine at Massachusetts General Hospital, and a professor of psychiatry at Harvard Medical School. 

Psych Congress Network: What are some of the primary challenges clinicians face when treating individuals with ADHD who also have comorbid mental health conditions?

Wilens: Approximately three-quarters of individuals who have ADHD across the lifespan also have another psychiatric co-occurring problem, which we refer to as comorbidity. Establishing what else is wrong with ADHD is the first big burden on clinicians. In fact, most of the evaluation time that I spend has less to do with the ADHD course symptoms and often more about the co-occurring problems, anxiety, depression, substance use, etc. 

Then. the challenge for individuals who are going to treat people with ADHD and comorbidity is: How do you address it? Do you start with ADHD treatment first? Do you treat the other psychiatric disorder first or do you treat both the comorbid psychiatric disorder and the ADHD at the same time? It really is going to depend on how severe the co-occurring problem is, what is the co-occurring problem, and what relationship do you think that co-occurring problem has with the ADHD?

PCN: When treating patients with ADHD who also may be experiencing depression and/or anxiety, should clinicians prioritize treating one condition over the others? How might they start to formulate a treatment plan for their patients?

Wilens: Probably one of the most co-occurring comorbidities we see is either anxiety disorders or depression. Anxiety disorders occur in up to 40% of individuals with ADHD across the lifespan, depression in a lesser amount, maybe 20%. Then, as you know, anxiety and depression are often interdigitated. We often will see both of them with ADHD. I call it the trifecta: ADHD, depression, and anxiety. 

In terms of how to approach these individuals, we found it helpful and the data seems to suggest that you have to first be clear on the diagnosis. Once you've established that there are 2 different disorders, that this isn't just low-level anxiety related to cognitive avoidance because of the ADHD or it's not some low-level demoralization because of hopelessness because ADHD has been untreated, but if these are truly autonomous comorbid disorders, as they are frequently, then you have to grade, how severe are they?

If you see moderate to more severe co-occurring problems, we typically sequence our treatments to start by treating them. For depression, we may use psychotherapies, SSRI, SNRI class or atypicals. For anxiety, again, SSRI, SNRIs or other anxiolytics that are specific to that. 

Then once those are treated, we may then start to think about treating the ADHD. Again, you would use stimulants or non-stimulants adjunct. Careful with potential drug interactions between them. Typically, stimulants are not a concern, but with the non-stimulants with some of the antidepressants, there may be. 

Now, there are some exceptions to that. We have certain classes of medicines, for example with anxiety and ADHD, there's good evidence that a non-stimulant atomoxetine can be helpful for both co-occurring problems. You may want to start with that first and see does that help the anxiety? Does that help the ADHD? Similarly for mood disorders like depression, sometimes some off-label medicines like bupropion or the tricyclic antidepressants may be helpful. 

Then there's some newer FDA-approved agents for ADHD, such as viloxazine XR that used to be an antidepressant in Europe, that might be helpful for ADHD and depression. So, there's some tip-offs that you can use to try to treat both disorders, but in general, you're going to have to think about addressing the co-occurring problem if it's at least moderate or severe in its severity or impairment. 

Timothy Wilens, MD, is the Chief of Child and Adolescent Psychiatry, and (Co) Director of the Center for Addiction Medicine at the Massachusetts General Hospital. He is a Professor of Psychiatry at Harvard Medical School. Dr. Wilens specializes in the diagnosis and treatment of ADHD, substance use disorders, and bipolar disorder. Widely published, Dr. Wilens has more than 350 original articles, reviews, chapters, books and editorials to his credit. Dr. Wilens is a consultant to the National Football League, Major/Minor League Baseball, Bay Cove Human Services and Gavin House and is consistently named one of the Best Doctors in Boston and in America for psychiatry.

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