What is the recommended treatment approach for a patient with Attention Deficit Hyperactivity Disorder (ADHD) and depression?

Treatment of ADHD and Depression

Begin with a stimulant medication trial for ADHD as first-line treatment, then add an SSRI if depressive symptoms persist after ADHD symptoms improve. 1

Treatment Algorithm Based on Symptom Severity

For patients with primary ADHD and milder mood symptoms:

• Initiate stimulant therapy first (methylphenidate or amphetamines), as these medications have 70-80% response rates and work rapidly within days, allowing quick assessment of ADHD symptom response 1
• Stimulants may indirectly improve mood symptoms by reducing ADHD-related functional impairment 1
• If ADHD symptoms improve but depressive symptoms persist, add an SSRI to the stimulant regimen—there are no significant drug-drug interactions between stimulants and SSRIs 1

For patients with severe major depressive disorder:

• Address the mood disorder first before treating ADHD 1
• The Treatment of Adolescent Depression Study demonstrated efficacy for combination therapy and medication management, but not for cognitive-behavioral therapy alone at 12 weeks, suggesting that beginning with psychotherapy only in moderate to severe depression may not be optimal 2

Specific Medication Dosing

Stimulant options:

• Methylphenidate: 5-20 mg three times daily for adults, with long-acting formulations preferred for better adherence and consistent symptom control 1
• Dextroamphetamine: 5 mg three times daily to 20 mg twice daily for adults 1
• Long-acting formulations (such as Concerta) provide around-the-clock effects and reduce rebound symptoms 1

SSRI addition:

• SSRIs remain the treatment of choice for depression, are weight-neutral with long-term use, and can be safely combined with stimulants 1

Alternative Approaches and Augmentation

If stimulants are contraindicated or ineffective:

• Atomoxetine (60-100 mg daily) is the only FDA-approved non-stimulant for adult ADHD, though it requires 2-4 weeks to achieve full effect 1
• Alpha-2 agonists (guanfacine 1-4 mg daily or clonidine) are additional options, particularly if sleep disturbances or tics are present 1

Bupropion considerations:

• Bupropion can be added to stimulant medication to enhance ADHD symptom control, particularly when comorbid depressive symptoms are present 1
• Starting dose: 100-150 mg daily (SR) or 150 mg daily (XL), titrated to maintenance doses of 100-150 mg twice daily (SR) or 150-300 mg daily (XL), with maximum dose of 450 mg per day 1
• Critical caveat: Do not assume bupropion alone will effectively treat both ADHD and depression—no single antidepressant is proven for this dual purpose, and bupropion is a second-line agent for ADHD treatment compared to stimulants 1

Psychosocial Interventions

Cognitive-behavioral therapy (CBT) as adjunctive treatment:

• CBT combined with medication produces greater improvements than medication alone in ADHD symptoms, organizational skills, and self-esteem 3
• For adults with ADHD on stable medications but with residual symptoms, adding CBT results in significantly more treatment responders (56%) compared to medication alone (13%) 4
• CBT addresses cognitive-behavioral factors (dysfunctional attitudes and avoidance) that fully account for variance between ADHD symptoms and depressive symptoms 5

Critical Safety Considerations

Absolute contraindications:

• Never use MAO inhibitors concurrently with stimulants or bupropion due to risk of hypertensive crisis—at least 14 days must elapse between discontinuation of an MAOI and initiation of these medications 1

Monitoring requirements:

• Monitor blood pressure and pulse at baseline and regularly during treatment 1
• Monitor for worsening hyperactivity, insomnia, anxiety, and agitation during the first 2-4 weeks when using bupropion 1
• Atomoxetine carries a black box warning for suicidality and requires monitoring for clinical worsening, particularly important in patients with depression 1

Common Pitfalls to Avoid

• Do not delay ADHD treatment due to comorbid depression—the presence of depression is not a contraindication to stimulant therapy, and both conditions should be treated concurrently 1
• Do not discontinue effective stimulant therapy for mild, transient side effects without proper evaluation 6
• Do not use immediate-release formulations when long-acting options are available, as long-acting formulations provide better adherence and lower rebound effects 1, 6
• Be cautious with stimulants in patients with substance abuse disorders—consider long-acting formulations with lower abuse potential (such as Concerta) or atomoxetine as first-line 1