Treating Comorbid ADHD, Major Depression and Panic

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 such patients should have their MD treated first, their anxiety disorder next, and finally offered a non-combination, low potency stimulant for ADHD.

A 38 year old man was initially diagnosed with MD using the Inventory to Diagnose Depression (IDD), scoring a 38 (0-10 is normal). A trial of 125 mg. trial of sertraline 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, though 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 .25 mg three times a day, producing a stable BAI of 4 (normal), with no panic attacks for two months.

Despite his improvement, the patient still met criteria for Adult ADHD with a childhood onset at five. 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 it, and his BAI rose to a "tolerable" 15, with no clear panic attacks. A trial of 5 mg. Adderall, at breakfast and 2 p.m., caused clear, repeated anxiety spikes four hours after each dose. Since Adderall represents two stimulants or four different compounds, one or more may have been exerting marked stimulation at the four-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, without any increase in anxiety.

Finally, based on this case, one should treat ADHD with comorbid anxiety with a low potency non-combination stimulant, to prevent sensitivity to stimulants.

Sincerely,

James L. Schaller M.D., M.A.R.
Chestr County Research Center

David Behar M.D.
Eastern Pennsylvania Psychiatric Institute
Philadelphia, PA.

Reference

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.