2 adult ADHD patients spent their lives in a revolving door of antidepressants
Could your depression/anxiety actually be undiagnosed ADHD? The New York Times recently published an important article on attention-deficit/hyperactivity disorder (ADHD): Doctors Are Still Figuring Out Adult A.D.H.D. The NYT article says “A.D.H.D. is one of the most common psychiatric disorders in adults. Yet many health care providers have uneven training on how to evaluate it, and there are no U.S. clinical practice guidelines for diagnosing and treating patients beyond childhood.”
The tragedy is they’ve spent most of their lives in a revolving door of antidepressants, when their main condition was ADHD . . .
At Advanced Brain + Body Clinic Ketamine TMS, we often see patients who are diagnosed with depression and anxiety and started on antidepressants, but who actually have undiagnosed ADHD; a medical condition that results in insufficient dopamine and norepinephrine levels in the brain. Untreated, this deficiency can contribute to the development of depression and anxiety. However, treating the underlying deficit with a stimulant medication can be much more effective than using traditional antidepressants, since most antidepressants impact serotonin, an entirely different neurotransmitter.
The tragedy is that many people have spent their entire lives in a revolving door of antidepressants, when their condition was easily treatable. Mandatory childhood screenings should be implemented nationwide in wellness child exams to help identify kids who have ADHD. Overtime, this would result in fewer cases of undiagnosed ADHD in adults.
One complicating factor is that ADHD has three types – hyperactive, inattentive and combined. The hyperactive and combined types are easily identified through externalized behaviors, but the inattentive type can go unnoticed for years, with patients receiving feedback that they are underperforming, not paying attention, or simply not trying hard enough.
ADHD is particularly underdiagnosed in women. According to Lisa MacLean, M.D., a psychiatrist at Henry Ford Health, “Girls (and women) are more likely to have inattentive behaviors,” says Dr. MacLean. “But that doesn’t mean that’s their only symptom. The hyperactivity side of ADHD is often also present in girls—it may just look different . . . girls with ADHD may just seem energetic, talkative and social. Since girls often display fewer behavioral problems and less noticeable symptoms, their difficulties are often overlooked.”
ADHD is a heritable condition. It is not uncommon for us to treat three generations of a single family.
Many adults who have untreated and undiagnosed ADHD can’t understand why some things seem so difficult and they often struggle at school, in relationships, and at work. Untreated ADHD has a lasting negative impact on self esteem, as people grow up feeling like they aren’t good enough to accomplish things that others seemingly do with ease. They may end up divorced multiple times, having to change jobs repeatedly and frequently don’t make it through college. Many people with ADHD develop addiction issues to food, sex, caffeine, alcohol or other drugs as a way to increase dopamine in the brain.
ADHD is a heritable condition and any time one family member is diagnosed, there are inevitably other close relatives who share the same condition. It is not uncommon for us to treat three generations of a single family.
Fortunately, treatment for ADHD can take effect immediately with stimulants, such as methylphenidate or amphetamines. Genetic testing can help identify which medication may work best, as some people respond more to amphetamine based medications, such as Adderall, Dexedrine, and Vyvanse rather than methylphenidate based options, such as Ritalin, Concerta, and Focalin.
Patients who receive treatment for ADHD often remark how life changing it is, and they can suddenly function at work, home, and school in an entirely different capacity than ever before. This also comes with a grieving process after recognizing how different their lives could have been if their invisible disability had been appropriately identified and treated.
Many patients with depression and anxiety who have comorbid ADHD are able to stop or decrease all other mental health medications after their ADHD is addressed.
The NYT article focuses primarily on what some experts deem as incomplete guidelines for adult ADHD and a new effort to provide practitioners with something better. And while universal screening guidelines should be implemented, primary care practitioners and mental health generalists should partner with a psychiatrist experienced in treatment-resistant depression to ensure that patients with ADHD aren’t misdiagnosed.
Some clues that a patient may have undiagnosed ADHD include:
- Multiple failed antidepressant trials.
- Fails to give close attention to details or makes careless mistakes.
- Trouble holding attention.
- Does not seem to listen when spoken to directly.
- Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
- Has trouble organizing tasks and activities.
- Avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
- Loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile phones).
- Is easily distracted.
- Is forgetful in daily activities.
Adult ADHD Case Studies
Steve’s Story: After decades of treatment for depression and anxiety, Steve’s symptoms resolved simply by treating their primary cause; his undiagnosed ADHD.
Steve is a married man in his 60s with autism spectrum disorder who runs his own firm. He has declared bankruptcy three times and has a lifelong long history of depression and anxiety, for which he has tried transcranial magnetic stimulation (TMS), ketamine infusions, and a number of antidepressants for 30 years, including Prozac, Wellbutrin, Auvelity, Paxil, plus many others, as well as Buspar and Ativan for anxiety.
Steve received a total of 49 ketamine infusions, finding these helpful for mood. Over time, he developed sedating side effects to ketamine and stopped taking it. Shortly thereafter, one of our psychiatrists diagnosed him with ADHD, inattentive type.
He started Adderall and felt that it was more effective for his mood than any other medication he had taken historically. He was able to function much better at work and decided to sell his now successful business so that he could retire.
After increasing Adderall to the maximum recommended FDA dose of 60mg a day, Steve was able to stop all medications for depression and anxiety, as his symptoms resolved simply by treating their primary cause; his ADHD.
Jean’s Story: Abused for decades and married multiple times, Jean wonders how different her life could have been.
Jean is a retired executive in her 70s. She suffered lifelong depression, anxiety and PTSD after being physically abused by her father plus two subsequent husbands, as well as experiencing childhood sexual abuse. She had taken clonazepam twice a day as needed for 20 years in addition to bupropion for 10 years, with six-month trials of duloxetine and fluoxetine.
Jean had been under the care of psychiatrists and psychologists for decades in different states, as well as primary care providers. She came to our clinic after several of her children and grandchildren had been diagnosed with ADHD, stating, “I can never relax. Never. Why can’t I have a good time? I can’t enjoy anything.”
After being diagnosed with ADHD, Jean started Adderall and found it incredibly effective to improve her ability to function with no side effects. “For the first time in years, I was able to read the newspaper and get things done around the house. I could even socialize at a party without worrying…my daughter and her children visited and said it was the most relaxing time we have ever spent together.” Sleep improved with Adderall, and she was able to stop bupropion entirely as ineffective for mood.
Married multiple times, Jean has subsequently wondered how different her life and career could have been if her invisible disability of ADHD had been identified and treated at a young age.
If you think you could have undiagnosed ADHD, give us a call to schedule an appointment with one of our specialists.
Resources:
1. National Institute of Health Attention-deficit/hyperactivity disorder (ADHD) – Prevalence of ADHD in Adults, https://www.nimh.nih.gov/health/statistics/attention-deficit-hyperactivity-disorder-adhd#part_255
2 Henry Ford Health, Why ADHD Is Often Underdiagnosed In Women September 7, 2023.
Brian Johns, MD is a Minneapolis psychiatrist and a mental health leader who helped shape ketamine treatment for depression in Minnesota and the nation. He co-authored a Minnesota VA Hospital medical trial to open the door for ketamine treatment to change–from a revolving-door hospital intervention, to an ongoing regimen at an outpatient clinic–while setting the benchmark for ketamine infusions nationwide. He then developed the region’s first ketamine infusion clinic. Over the past several years, he has administered or overseen thousands of ketamine treatments. Dr. Johns is a graduate of the University of Minnesota Medical School and completed his residency in Psychiatry. He is certified by the American Board of Psychiatry and Neurology.