Can a patient with anxiety and depression be evaluated for Attention Deficit Hyperactivity Disorder (ADHD)?

From the Guidelines

Yes, you can evaluate a patient for ADHD even if they present with anxiety and depression. It's essential to conduct a comprehensive assessment because these conditions frequently co-occur. Begin with standardized ADHD screening tools while gathering a thorough history of symptoms across different settings and throughout the patient's life. According to the most recent guideline 1, the evaluation of a child or adolescent for ADHD should include a process to at least screen for comorbid conditions, including emotional or behavioral conditions such as anxiety and depression. The presence of comorbid anxiety and depression does not preclude the evaluation of ADHD, and in fact, treating ADHD first with stimulants or non-stimulants can sometimes improve mood and anxiety symptoms 1. However, it's crucial to carefully differentiate between symptoms of ADHD, anxiety, and depression, as they can overlap. A combined approach using medication and psychotherapy typically yields the best outcomes for patients with these comorbid conditions. Some key points to consider during evaluation include:

• Using standardized screening tools
• Gathering a thorough history of symptoms
• Differentiating between symptoms of ADHD, anxiety, and depression
• Considering the chronological appearance of symptoms to determine primary and secondary conditions
• Addressing all conditions in treatment planning, often starting with the most impairing one.

From the FDA Drug Label

Anxiety in patients with ADHD and comorbid Anxiety Disorders - In two postmarketing, double-blind, placebo-controlled trials, it has been demonstrated that treating patients with ADHD and comorbid anxiety disorders with atomoxetine does not worsen their anxiety In a 12-week double-blind, placebo-controlled trial, 176 patients, aged 8 to 17, who met DSM-IV criteria for ADHD and at least one of the anxiety disorders of separation anxiety disorder, generalized anxiety disorder or social phobia were randomized. Atomoxetine did not worsen anxiety in these patients as determined by the Pediatric Anxiety Rating Scale (PARS). In a separate 16-week, double-blind, placebo-controlled trial, 442 patients aged 18 to 65, who met DSM-IV criteria for adult ADHD and social anxiety disorder (23% of whom also had Generalized Anxiety Disorder) were randomized. Atomoxetine did not worsen anxiety in these patients as determined by the Liebowitz Social Anxiety Scale (LSAS).

Yes, you can evaluate a patient for ADHD if they present with anxiety and depression. The FDA drug label for atomoxetine indicates that treating patients with ADHD and comorbid anxiety disorders with atomoxetine does not worsen their anxiety, as demonstrated in two postmarketing, double-blind, placebo-controlled trials 2.

From the Research

Evaluating Patients for ADHD with Anxiety and Depression

• When evaluating patients for Attention-Deficit/Hyperactivity Disorder (ADHD), it is essential to consider other mental disorders, including anxiety and depression, due to the substantial overlap of symptoms 3.
• A comprehensive clinical history and evaluation, patient symptom and function assessment, and gathering of collateral information are required for an ADHD diagnosis 3, 4.
• Clinical guidelines recommend using a subset of amphetamine and methylphenidate stimulants as first-line pharmacotherapy, which may be more effective when combined with psychotherapy 3.
• For adults with concurrent anxiety or depression, alternative options include atomoxetine, viloxazine, and bupropion 3.
• The presence of anxiety and depression can complicate the diagnosis of ADHD, but it is not a contraindication for evaluation 5, 6.
• Approximately 25% of patients with ADHD also have comorbid anxiety, and these individuals may report more childhood ADHD symptoms and higher scores on ADHD scales 5.

Assessment Measures

• Clinical interviews alone and ADHD behavior rating scales alone have adequate sensitivity but poor specificity in diagnosing ADHD 4.
• Response validity and symptom validity tests have reasonably good sensitivity and very good specificity in detecting invalid symptom presentation 4.
• Cognitive test batteries have inadequate sensitivity and specificity in identifying ADHD, but using them in conjunction with behavior rating scales can improve the specificity of an assessment battery 4.

Clinical Approach

• A pragmatic clinical approach for evaluating and managing adult ADHD in primary care settings involves considering medical and psychiatric conditions that can contribute to inattention symptoms 6.
• Healthcare providers should be aware of the potential overlap between ADHD and other mental disorders, including anxiety and depression, and use a comprehensive evaluation approach to diagnose and manage adult ADHD 3, 6.