What is the recommended treatment for a patient with a Patient Health Questionnaire-9 (PHQ9) score indicating moderate to severe depression and symptoms of Attention Deficit Hyperactivity Disorder (ADHD)?

Psychiatric Diagnoses and Treatment for PHQ-9 Score of 17 with ADHD Symptoms

Initial Assessment and Diagnostic Approach

A PHQ-9 score of 17 indicates moderately severe depression requiring referral to psychology and/or psychiatry for formal diagnosis and treatment, while simultaneously evaluating ADHD symptoms through comprehensive clinical interview covering childhood-onset symptoms that persist into adulthood. 1

Depression Severity Classification

• PHQ-9 score of 17 falls in the "moderate to severe" range (15-19), indicating the patient has majority of depressive symptoms with moderate to marked functional interference 1
• This severity level mandates referral to psychology and/or psychiatry for diagnosis and treatment 1
• First assess for risk of harm to self or others, which would require emergency evaluation 1

ADHD Diagnostic Considerations

• ADHD diagnosis in adults requires comprehensive clinical interview reviewing representative symptoms starting in childhood that continue causing impairment into adulthood 2
• Symptoms must be present in at least two different settings (work, home, social) and cause moderate to severe impairment 1
• Consider obtaining collateral information from family, friends, or review of school records to confirm childhood onset 2
• Common pitfall: Depression symptoms (poor concentration, low energy, psychomotor changes) can mimic ADHD inattentive symptoms, making differential diagnosis challenging 1, 3

Treatment Algorithm Based on Symptom Severity

Step 1: Address Depression First if Severe

For moderately severe depression (PHQ-9 = 17), the American Academy of Child and Adolescent Psychiatry recommends addressing the mood disorder as the priority before initiating ADHD treatment. 4

• Initiate SSRI as first-line antidepressant (weight-neutral, well-tolerated) 4
• SSRIs remain the treatment of choice for depression and can be safely combined with stimulants later if needed 4
• Monitor for 4-6 weeks for response before adding ADHD treatment 4

Step 2: Initiate ADHD Treatment After Mood Stabilization

Once depressive symptoms show improvement, begin stimulant medication as first-line ADHD treatment, as stimulants have 70-80% response rate and the strongest evidence base. 4, 5

Stimulant Options:

• Methylphenidate: 5-20 mg three times daily for adults 4
• Dextroamphetamine: 5 mg three times daily to 20 mg twice daily 4
• Long-acting formulations provide around-the-clock effects and reduce rebound symptoms 4
• Stimulants work rapidly (within days), allowing quick assessment of ADHD response 4

Non-Stimulant Alternative (if stimulants contraindicated):

• Atomoxetine: Initiate at 40 mg daily, increase after minimum 3 days to target of 80 mg daily 6
• Can increase to maximum 100 mg daily after 2-4 additional weeks if inadequate response 6
• Requires 2-4 weeks to achieve full effect 4
• Preferred for patients with substance abuse history (uncontrolled substance) 4

Step 3: Combination Therapy if Needed

If ADHD symptoms improve on stimulants but depressive symptoms persist, add an SSRI to the stimulant regimen, as there are no significant drug-drug interactions between stimulants and SSRIs. 4

• This sequential approach allows assessment of each medication's individual contribution 4
• Monitor for treatment response using standardized rating scales 4

Alternative Approach: Bupropion Consideration

Bupropion may be considered as an alternative antidepressant with modest ADHD benefits, but it is a second-line agent compared to stimulants for ADHD treatment. 4

When to Consider Bupropion:

• Patient has failed or cannot tolerate SSRIs 4
• Comorbid concerns like smoking cessation or weight gain from other antidepressants 4
• Patient refuses stimulant medication 4

Bupropion Dosing:

• Start bupropion SR 100-150 mg daily or XL 150 mg daily 4
• Titrate to maintenance doses of 100-150 mg twice daily (SR) or 150-300 mg daily (XL) 4
• Maximum dose 450 mg per day 4

Critical Bupropion Warnings:

• Do not assume bupropion will effectively treat both ADHD and depression—no single antidepressant is proven for this dual purpose 4
• Bupropion is inherently activating and can exacerbate anxiety, agitation, or hyperactivity 4
• Monitor closely for worsening hyperactivity, insomnia, anxiety during first 2-4 weeks 4
• Increased seizure risk, particularly at higher doses or when combined with stimulants 4

Critical Safety Considerations

Contraindications and Precautions:

• Never use MAO inhibitors concurrently with stimulants or bupropion—risk of hypertensive crisis 4
• Allow at least 14 days between discontinuation of MAOI and initiation of bupropion or stimulants 4
• Avoid stimulants in patients with uncontrolled hypertension, symptomatic cardiovascular disease, or active substance abuse 4
• Screen for bipolar disorder, mania, or hypomania before initiating stimulants 6

Monitoring Parameters:

• Monitor blood pressure and pulse at baseline and regularly during stimulant treatment 4
• Assess for suicidality, particularly when using atomoxetine with antidepressants 4
• Monitor sleep disturbances and appetite changes as common adverse effects 4
• Use structured rating scales to objectively measure treatment response 4

Comorbidity Considerations

Depression and ADHD commonly co-occur, with mood symptoms sometimes resulting from ADHD-related functional impairment rather than representing a separate disorder. 3

• Treating ADHD may indirectly improve mood symptoms by reducing ADHD-related functional impairment 4
• The presence of depression is not a contraindication to stimulant therapy—both conditions can be treated concurrently 4
• Insufficient data on interaction between ADHD and comorbidities impedes proper diagnosis and treatment 3

Follow-Up and Reassessment

• Schedule monthly follow-up visits initially to assess medication response 4
• Titrate stimulant doses to achieve maximum benefit with tolerable side effects 1
• Periodically reevaluate long-term usefulness of medications 6
• Consider referral to specialist in psychiatry if symptoms persist despite medication optimization 4