Treating Comorbid ADHD, Major Depression, and Panic

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Back to table of contents Previous article Next article LetterFull AccessTreating Comorbid ADHD, Major Depression, and PanicJames L. Schaller, M.D., M.A.R., , and David Behar, M.D., James L. SchallerSearch for more papers by this author, M.D., M.A.R., West Chester Child and Adult Psychiatry Center, Downingtown, PA, and David BeharSearch for more papers by this author, M.D., Eastern Pennsylvania Psychiatric Institute, Philadelphia, PAPublished Online:1 Nov 1999https://doi.org/10.1176/jnp.11.4.516AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail SIR: Attention-deficit/hyperactivity disorder (ADHD) increases one's risk for both major depression (MD) and an anxiety disorder by approximately 25%.1 Some individuals have all three. Therefore, we are proposing patients with such comorbidities should have their MD treated first, their anxiety disorder next, and finally be offered a noncombination, low-potency stimulant for ADHD.Case ReportA 38-year-old man was initially diagnosed with MD by use of the Inventory to Diagnose Depression (IDD), scoring a 38 (0–10 is normal). A trial of sertraline 125 mg produced a remission (IDD<10).His generalized anxiety partially decreased on the sertraline, as measured by Beck Anxiety Inventory's (BAI) decreasing from 28 to 20. His panic attacks, occurring at a frequency of twice per week, continued on the sertraline, although with reduced distress. Having failed a competent trial of extensive exposure and cognitive reconstructing panic therapy prior to our treatment, he was tried on clonazepam 0.25 mg three times a day, producing a stable BAI of 4 (normal), with no panic attacks for 2 months.Despite his improvement, the patient still met criteria for adult ADHD, with a childhood onset at age 5. Two first-degree relatives had ADHD. Common standard diagnostic scales such as the Brown Adult ADHD Scale, the Wender Utah Retrospective Scale, and the Semi-Structured Adult Interview for ADHD all confirmed his mental status exam and reported history.The patient asked for a trial off clonazepam to “keep his medication simple.” He was weaned off clonazepam, and his BAI rose to a “tolerable” 15, with no clear panic attacks. A trial of 5 mg Adderall, at breakfast and at 2:00 p.m., caused clear, repeated anxiety spikes 4 hours after each dose. Since Adderall represents two stimulants or four different amphetamine compounds, one or more may have been exerting marked stimulation at the 4-hour mark.Back on his clonazepam, the patient tried methylphenidate 7.5 mg tid (he had “failed” dextroamphetamine as a teenager). He had an 85% reduction of his ADHD symptoms, with no increase in anxiety.This case suggests that one should treat ADHD with comorbid anxiety with a low-potency noncombination stimulant, to prevent sensitivity to stimulants.References1 Barkley RA: Comorbid disorders, social relations, and subtyping, in Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York, Guilford, 1998, pp 139–163Google Scholar FiguresReferencesCited byDetailsCited byStimulant Use in the Treatment of Iatrogenic Somnolence2 September 2016 | Journal of the American Psychiatric Nurses Association, Vol. 7, No. 4 Volume 11Issue 4 November 1999Pages 516-516 Metrics History Published online 1 November 1999 Published in print 1 November 1999