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Mood Disorders and ADHD

Major depression is present in about 5% of all adolescents, and suicide is the third leading cause of death in adolescents 15 to 19 years old. [Heron: 2013] A 2014 meta-analysis of comorbid ADHD and depression indicates a “medium” strength association between the two conditions, meaning that more youth with ADHD have depression than their counterparts without ADHD. [Meinzer: 2014] Children and adolescents with ADHD and mood disorders, including depression, dysthymic disorder, seasonal affective disorder, and bipolar disorder, are at risk of having more severe and harder to treat symptoms. [Daviss: 2008] Children with ADHD and mood disorders are also at increased risk of suicidal attempts due to their impulsivity. [American: 2013] A child or adolescent with ADHD may not have a mood disorder at the time of the ADHD diagnosis, as depressive symptoms often emerge several years after ADHD symptoms. [Daviss: 2008] Therefore, repeated screening for depressive symptoms is indicated for children with ADHD. [Meinzer: 2014]

Suspect a mood disorder or depression when the child displays:
  • Irritability
  • Depressed mood/sad (not always evident)
  • Decreased interest in usual activities
  • Appetite changes
  • Unintended weight changes
  • Sleep problems
  • Changes in energy level, fatigue
  • Feelings of worthlessness
  • Difficulty concentrating, and/or
  • Suicidal ideation or behavior
For more information, see the Ongoing Assessment page of the Portal's Depression module.

Treatment

Treatment with selective serotonin reuptake inhibitors (SSRIs) and psychological interventions such as cognitive-behavioral therapy (CBT) have been shown to be helpful in treating children/youth with depression. (Most recent Cochrane review does not show one better than the other. [Cox: 2014]) Among the multiple SSRIs, only fluoxetine has been approved by the FDA for treatment of depression in children/adolescents [National: 2015]; however, many providers prescribe alternative SSRIs to children as an off-label use. Although SSRIs carry a black box warning for suicidal ideation and behavior, studies suggest that the benefits of treatment for depression with SSRIs in children/youth may outweigh these risks. [Hetrick: 2012] Medical home providers who prescribe SSRIs for depression should ensure that the family understands the risks involved, that the patient be monitored closely, and that a plan is in place should the child/youth have increasing suicidal ideation or behavior.
Having ADHD and a comorbid mood disorder can complicate treatment of both conditions. For example, the medical home provider needs to consider whether inadequately treated ADHD symptoms are increasing the child’s depressive symptoms, or if inadequately treated mood disorders are contributing to the child’s inattentive or impulsive symptoms. Sudden worsening of ADHD symptoms when they had previously been controlled may indicate onset of a mood disorder. On a good note, there is evidence that treatment of ADHD in childhood may be protective against later depression. [Biederman: 2009] Emerging studies regarding the treatment of children/adolescents with depression and ADHD suggest that medications such as stimulants, SSRIs, bupropion and atomoxetine may be helpful in reducing ADHD and/or depressive symptoms. [Daviss: 2008] [Cubero-Millán: 2014] Psychiatric consultation may be indicated.

Role of the Medical Home Provider

  • Provide routine screening for mood disorders in all children and adolescents
  • Remain vigilant for emergence of a mood disorder among children and adolescents with a known diagnosis of ADHD, particularly if there is a family history of mood disorders
  • When a mood disorder is present, screen for thoughts of self-harm and suicidal ideation
  • Work with patient and family to establish treatment goals and priorities
  • Encourage and provide referral to a psychologist for psychotherapy
  • Prescribe and monitor medication when indicated
  • Obtain consultation from a psychiatrist when severe symptoms and/or failing interventions, or when there are concerns about medication interactions
  • Provide families and patients with information about all of their medical conditions

Resources

Information & Support

For Professionals

ADHD Resource Center (AACAP)
Includes excellent provider and parent resources; American Academy of Child & Adolescent Psychiatry.

Depression Resource Center (AACAP)
Information for clinicians and families, including FAQs, “Facts for Families,” books, videos, practice parameters, research, and getting help for depression; American Academy of Child & Adolescent Psychiatry.

Suicide and the School
Written for teachers, this online article offers information on recognizing and helping at risk students. This article offers information that will be helpful for the clinician caring for a youth who expresses suicidal thoughts; from the Northern County Psychiatric Associates, Baltimore, MD.

For Parents and Patients

ADHD (Healthy Children)
Links to more than 90 articles that discus various aspects of ADHD evaluation and management; developed by the American Academy of Pediatrics.

ADHD Resource Center (AACAP)
Includes excellent provider and parent resources; American Academy of Child & Adolescent Psychiatry.

Depression Resource Center (AACAP)
Information for clinicians and families, including FAQs, “Facts for Families,” books, videos, practice parameters, research, and getting help for depression; American Academy of Child & Adolescent Psychiatry.

Patient Education

Depression Resource Center (AACAP)
Information for clinicians and families, including FAQs, “Facts for Families,” books, videos, practice parameters, research, and getting help for depression; American Academy of Child & Adolescent Psychiatry.

Services

Psychiatrist, Child-18

See all Psychiatrist, Child-18 services providers (28) in our database.

Psychologist, Child-18

See all Psychologist, Child-18 services providers (151) in our database.

For other services related to this condition, browse our Services categories or search our database.

Helpful Articles

PubMed search for ADHD and mood disorder in children, last 5 years.

Daviss WB.
A review of co-morbid depression in pediatric ADHD: etiology, phenomenology, and treatment.
J Child Adolesc Psychopharmacol. 2008;18(6):565-71. PubMed abstract / Full Text
An article discussing comorbid conditions of ADHD, pediatric bipolar disorder, and overlapping or distinguishing characteristics.

Quintana H, Butterbaugh GJ, Purnell W, Layman AK.
Fluoxetine monotherapy in attention-deficit/hyperactivity disorder and comorbid non-bipolar mood disorders in children and adolescents.
Child Psychiatry Hum Dev. 2007;37(3):241-53. PubMed abstract
A small study demonstrating positive but short-term associations with use fluoxetine to decrease depression and ADHD in youth with comorbid ADHD and depression.

Biederman J, Monuteaux MC, Spencer T, Wilens TE, Faraone SV.
Do stimulants protect against psychiatric disorders in youth with ADHD? A 10-year follow-up study.
Pediatrics. 2009;124(1):71-8. PubMed abstract
An encouraging 10-year case-control study of how stimulant use for treatment of ADHD decreases risk of developing comorbid mood disorders as well as improves academic success.

Wintersteen MB.
Standardized screening for suicidal adolescents in primary care.
Pediatrics. 2010;125(5):938-44. PubMed abstract
A study supporting the use of standardized screening tools for suicidality in pediatric primary care.

Authors

Reviewing Author: Robyn Nolan, MD - 4/2015
Compiled and edited by: Lynne M Kerr, MD, PhD - 7/2009
Content Last Updated: 4/2015

Page Bibliography

American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders, DSM-5.
Fifth ed. Arlington, VA: American Psychiatric Association; 2013.

Biederman J, Monuteaux MC, Spencer T, Wilens TE, Faraone SV.
Do stimulants protect against psychiatric disorders in youth with ADHD? A 10-year follow-up study.
Pediatrics. 2009;124(1):71-8. PubMed abstract
An encouraging 10-year case-control study of how stimulant use for treatment of ADHD decreases risk of developing comorbid mood disorders as well as improves academic success.

Cox GR, Callahan P, Churchill R, Hunot V, Merry SN, Parker AG, Hetrick SE.
Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents.
Cochrane Database Syst Rev. 2014;11:CD008324. PubMed abstract

Cubero-Millán I, Molina-Carballo A, Machado-Casas I, Fernández-López L, Martínez-Serrano S, Tortosa-Pinto P, Ruiz-López A, Luna-del-Castillo JD, Uberos J, Muñoz-Hoyos A.
Methylphenidate ameliorates depressive comorbidity in ADHD children without any modification on differences in serum melatonin concentration between ADHD subtypes.
Int J Mol Sci. 2014;15(9):17115-29. PubMed abstract / Full Text

Daviss WB.
A review of co-morbid depression in pediatric ADHD: etiology, phenomenology, and treatment.
J Child Adolesc Psychopharmacol. 2008;18(6):565-71. PubMed abstract / Full Text
An article discussing comorbid conditions of ADHD, pediatric bipolar disorder, and overlapping or distinguishing characteristics.

Heron M.
Deaths: Leading Causes for 2010.
U.S. Department of Health and Human Services. Volume 62, Number 6; December 20, 2013. / http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_06.pdf

Hetrick SE, McKenzie JE, Cox GR, Simmons MB, Merry SN.
Newer generation antidepressants for depressive disorders in children and adolescents.
Cochrane Database Syst Rev. 2012;11:CD004851. PubMed abstract

Meinzer MC, Pettit JW, Viswesvaran C.
The co-occurrence of attention-deficit/hyperactivity disorder and unipolar depression in children and adolescents: A meta-analytic review.
Clin Psychol Rev. 2014;34(8):595-607. PubMed abstract

National Institute of Mental Health.
Antidepressant Medications for Children and Adolescents: Information for Parents and Caregivers.
U.S. Department of Health and Human Services; (2015) Accessed on 3/2015.