Treatment of Comorbid Depression, Anxiety, and ADHD

Primary Treatment Approach

• The American Academy of Child and Adolescent Psychiatry recommends initiating treatment with a stimulant medication first, even in the presence of comorbid anxiety and depression, unless the depression is severe with psychosis, suicidality, or severe neurovegetative signs 1, 2, 3
• If major depressive disorder (MDD) is the primary disorder or presents with very severe symptoms, treat the MDD first, according to the American Academy of Child and Adolescent Psychiatry 1, 2
• If MDD is less severe or not primary, proceed directly to a stimulant trial for ADHD, as suggested by the American Academy of Child and Adolescent Psychiatry 1, 2
• Start with methylphenidate (5-20 mg three times daily) or dextroamphetamine (5 mg three times daily to 20 mg twice daily) as first-line treatment, recommended by the American Academy of Child and Adolescent Psychiatry 1, 2
• Stimulants offer rapid onset of action, allowing quick assessment of whether ADHD symptoms—and often comorbid anxiety and depressive symptoms—have remitted, according to the American Academy of Child and Adolescent Psychiatry 1, 2, 3
• The reduction in morbidity caused by ADHD symptoms can have substantial impact on both depressive and anxiety symptoms without additional medication, as noted by the American Academy of Child and Adolescent Psychiatry 1, 2, 3
• Comorbid anxiety is not a contraindication to stimulants, and ADHD patients with comorbid anxiety may have better treatment responses to stimulants, according to the American Academy of Child and Adolescent Psychiatry 1, 2, 3

Reassessing After Stimulant Trial

• If ADHD improves but depression remains severe, add psychotherapeutic treatment or an antidepressant, as recommended by the American Academy of Child and Adolescent Psychiatry 1, 2
• No single antidepressant treats both ADHD and MDD effectively, and treatment of residual depression is necessary, according to the American Academy of Child and Adolescent Psychiatry 1, 2
• If ADHD improves but anxiety remains problematic, first pursue psychosocial intervention for anxiety, and consider adding an SSRI to the stimulant if necessary, as suggested by the American Academy of Child and Adolescent Psychiatry 1, 2, 3

SSRI Selection and Management

• Prefer citalopram/escitalopram due to least CYP450 enzyme interactions with stimulants, as recommended by the American Academy of Child and Adolescent Psychiatry 3
• Monitor closely for suicidal ideation, clinical worsening, and unusual behavioral changes, particularly in the first months of treatment, according to the American Academy of Child and Adolescent Psychiatry 4, 3

Alternative First-Line Option: Atomoxetine

• Consider atomoxetine instead of stimulants in specific contexts, such as active substance use disorder or severe pre-existing sleep disorders, as suggested by the American Academy of Child and Adolescent Psychiatry 3
• Atomoxetine can be combined with SSRIs, but monitor for increased blood pressure and pulse, and adjust dosing as necessary, according to the American Academy of Child and Adolescent Psychiatry 3

Common Pitfalls to Avoid

• Do not assume anxiety is a contraindication to stimulants, and do not treat only one condition when multiple are present, as noted by the American Academy of Child and Adolescent Psychiatry 3
• Do not use strict mg/kg dosing, and titrate stimulants systematically to maximum benefit with minimum adverse effects, according to the American Academy of Child and Adolescent Psychiatry 3
• Do not combine bupropion with stimulants without careful consideration due to lack of safety data, as recommended by the American Academy of Child and Adolescent Psychiatry 3