ADD and Depression: A dangerous mix

Number 2 FDA, SSRI and Suicide Series: ADD/ADHD present very frequently with all the variety of depressions. Sometime ADD is comorbid, exists together as a second shadow problem with depression, -and less frequently arises as secondary to [caused by the} the depression.

In the latter presentation, when it is caused by the depression, antidepressants correct the late onset focus and attention problem brought on by cognitive anxiety, low self esteem or the context of personal turmoil, or depression mixed with sleep issues. We can treat this “ADD” presentation with only an SSRI – with one med for a relatively short time. Counseling the person will often help them regroup, and in 6mo-1yr we can carefully remove the SSRI, watching for Discontinuation Syndrome. No problem. But less common.

More commonly presented in our offices are years of depression with congnitive anxiety [think worries] and avoidance, neither of which fit the criteria for ADD in the DSM 4 diagnostic manual, the reference for all psych care. See more below:

Even if the counselor thinks the patient may have ADD, our current most omnipresent back up team who actually reviews these matters with some attempt at finding evidence for treatment… the psychologists, stays with the limited criteria of the DSM4. Professional will report:

• “I am not sure,
• they meet some criteria,
• with some ‘attentional issues,' and
• ADD is not yet determined at this time, due to the murky presentation'
• They do have depression.

Without careful questions about cognition, school learning patterns, history of cognition, family history of thinking/cognitive/mental function, ability to focus, ability to complete tasks and the ever present avoidance, they miss the boat. They may call it anxiety alone, or OCD, and both of those cognitive and somatic types will often first be treated by, guess what: An SSRI.

So whats the problem, how does all this fit with the FDA inquiry:

SSRIs in this situation can, either soon [within one week] or over time [3-4 weeks] and likely will, aggravate the already existing monster ADD worry problem. Will aggravate the ADD. The mind works less well. The brain feels like it is out of control.

What do I do now, I am more depressed and my brain is running faster than it every was… I really want to die [passive thought: please take me], or am thinking of all the crazy things… [active wish:] how to I kill myself?

Never felt this way before, never thought these things, but can't turn it off.

Beyond the handicap of frozen brain, now I have to feel some pain to turn this off, [often the woman says:] “Perhaps cutting myself?”  The male: There's my arch enemy: “Punch me, go ahead hit, hit me.”

With some kind of pain they can get out of the rut: Suicide can be the outcome of SSRIs given without an appreciation of these matters.

Yes this presentation may be bipolar, but ADD must to be ruled out. Stimulants are first line for ADD, mood stabilizers for Bipolar. Neither one works for the other condition, each can aggravate the other condition.

Missed diagnosis can cause years of pain, failure from academic pursuits, loss of job… many more painful outcomes.

Let's put the black box on the DSM4 and make it more useful. Let's put a black box ,a tag, on every script, every chart that has not ruled out these other diagnostic issues.

SSRIs are only the tip of an operational iceberg that drifts pervasively through our society.

Next missive on #3 in the SSRI Depression issue: Temporal Lobe Dysregulation: Brain Injury