ADHD and Depression and Addiction

The kids are not back in school until next week and we are up in the mountains enjoying a 15 foot natural rock water slide.  We have it all to ourselves as most kids in our neck of the woods are back at school.  The private school that my kids go to always starts much later than our area schools so we have a few more days of stress free living.

I recently read a study that I wanted to tell you about so I thought I would write about it while the kids are busily sliding. The study I read speaks to a concern that I have had regarding the combination treatment of ADHD and depression.

I have posted previously about the link between ADHD and depression. Russell Barkley has reported that 20% to 30% of individuals with a diagnosis of ADHD will also be diagnosed with Depression. Other researchers have reported an association between depression and ADHD that is as high as 75%.

People with ADHD are also more prone to have problems with addiction including addiction to stimulants.  Russell Barkley reports that, paradoxically, treatment with stimulants may protect people with ADHD from developing substance abuse problems.  Other ADHD researchers, however, have argued that the exposure to stimulants make all ADHD patients more prone to stimulant addiciton and to substance abuse problems so I believe that the jury is not yet out on this question.

The most common combination treatment for depression with ADHD is Methylphenidate (Ritalin) and SSRI (Paxil, Zoloft, etc). A new study published in the August edition of the European Journal of Neuroscience has found that the combination of Methylphenidate and the SSRIs makes adolescent mice more prone to Methylphenidate addiction.

The combination of SSRIs and Ritalin seems to somehow alter the expression of the gene known to cause Ritalin addiction in such a way that these adolescent mice were more likely to develop an addiction to the stimulant. This is horrible news for the treatment of ADHD with co-morbid depression, as countless numbers of patients are on this combination of medications.

The study did not report on whether the combination of amphetamines (Adderall, Vyvanse) with SSRIs would cause a similar alteration in gene expression but I am sure that subsequent studies will address this concern. It is also unknown if the findings in this animal study apply to humans but the researchers have good reason to believe that they would.

The use of a combination of psychiatric medication in children and teens is a relatively new medical phenomenon. No one would argue that ADHD and depression should be treated with medication if all other measures have been tried and failed but these findings are concerning. Children with ADHD and depression are known to end up doing extremely poorly if they are untreated. Longitudinal studies have shown that these kids will likely carry these diseases into adulthood and do better in life if they are treated early.

The risk/benefit of using a combination regimen such as Ritalin and Paxil vs just one or the other, given the findings of the European Journal of Neuroscience, are as yet unknown. It, unfortunately, will take years for Psychiatrist to sort out whether it is better to treat with stimulants and SSRIs or to chose a different approach and it is likely that our generation of children will be the test cases on which these decisions are made. 

For those of us already concerned with the use of pediatric psychiatric medication, these findings are, at best, troublesome and at worse, terrifying.