A Critical Mistake: Misdiagnosing ADHD as Depression or Anxiety

 

Misdiagnosing ADHD as depression or anxiety is a significant public health issue. This is especially true when patients with undiagnosed ADHD are prescribed SSRIs such as Luvox, Celexa, and others. In this post, we’ll explore why this happens, what can be done about it, and delve into related research.

Bonus:  When you live with ADHD, in yourself of a loved one, I highly recommend an active, not passive, approach. If we remain poorly educated on these topics, how can we possibly even assess expertise?

You’ll find below a free excerpt from my online training: Solving Your Adult ADHD Puzzle “Considering Misdiagnoses—And Missed Diagnoses” .  

ADHD Or Depression Confusion: A Widespread Problem

Maybe you’re like me. Every time I hear “ADHD is over-diagnosed!”, I want to counter: “ADHD is massively misdiagnosed as depression, anxiety, bipolar disorder, trauma, etc.—and has been for decades. Where’s that headline?”

Does depression or anxiety sometimes co-exist with ADHD? Yes, but that’s a different topic.

Why Is ADHD Misdiagnosed as Depression?

Why do we often see depression and anxiety but miss ADHD? Here are the most prominent reasons that I see:

  • Symptom Overlap: To the untrained eye, ADHD can mimic symptoms of depression or anxiety due to both ADHD symptoms and the consequences of living undiagnosed.
  • Knowledge Gap: Mental health professionals are generally more familiar with depression and anxiety than with adult ADHD. They often think of ADHD as fidgety kids or hyperactive “happy go lucky” adults. Yet, while unrecognized ADHD is serious in childhood, it can be even more impairing in adulthood.
  • Popular Culture Influence: Adults with ADHD (diagnosed or not) and their partners misinterpret symptoms and request antidepressants from their physicians.

In short, clinicians and consumers alike judge by behavior—what it “looks like” superficially—rather than the cause. Everybody thinks they know what depression or anxiety looks like, but they simply don’t recognize the many faces of ADHD.

Why ADHD Misdiagnosed As Depression Matters

Why ADHD Misdiagnosed As Depression Matters

Accurate diagnosis is crucial. That’s because it determines the appropriate medications and strategies. For ADHD, the first-line medications are stimulants like Ritalin, Concerta, and Vyvanse. Conversely, the most commonly prescribed medications for depression and anxiety are SSRIs (Selective Serotonin Reuptake Inhibitors), which are not recommended for treating ADHD.

Yes, SSRIs can sometimes lessen feelings of anxiety. Yes, ADHD patients might feel relief. Trouble is, they  still might struggle with focus, distractibility, hyperactivity, and executive function issues—all indicating the presence of ADHD. Even trickier, SSRIs can suppress dopamine in parts of the brain, intensifying ADHD symptoms and even preventing stimulants from being effective.

Here’s a simple explanation: Think of antidepressants as a shovel beating back ADHD-fueled anxiety, whereas stimulants support from the ground up, enabling better self-regulation of thoughts and emotions.

Insights from Research on ADHD and Treatment-Resistant Depression (TRD)

As Tia Sernat, MS, MPsy, co-author with Martin A. Katzman, MS, FCRP, of the paper summarized below, states:

“Depressed patients with ADHD don’t typically respond to SSRIs because of the psychopathology involved—you have to activate the catecholaminergic system to treat ADHD. They come in saying, ‘I feel better, but I’m not happy; I’m tired, I’m anxious, I’m having trouble with attention,’ and what you are seeing are the adult signs of ADHD coming through. Physicians need to screen for premorbid conditions, including ADHD, before diagnosing treatment-resistant depression.”

ADHD not Depression

Study Highlights: ADHD or “Treatment-Resistant Depression”?

You can read the full paper here:

“Low Hedonic Tone and Attention-Deficit Hyperactivity Disorder: Risk Factors for Treatment Resistance in Depressed Adults”

Quick Definitions

  • Low Hedonic Tone: A trait that reduces a person’s ability to experience pleasure.
  • Anhedonia: The inability to feel pleasure, a key feature of several mood and attention disorders, including Major Depressive Disorder (MDD) and ADHD.
  • Treatment-Resistant Depression (TRD): A depressive disorder that doesn’t respond well to treatment.

Background On ADHD and Treatment-Resistant Depression

Depression and ADHD frequently co-exist and share a complex relationship. That’s why researchers hypothesized that ADHD might predict TRD. This exploratory study aimed to determine the percentage of undetected ADHD in those with TRD and evaluate factors associated with treatment resistance and undetected ADHD in depressed patients.

This Paper’s Findings:

  • Previously undetected ADHD was found in 34% of patients with TRD.
  • Factors associated with undetected ADHD in TRD patients included the number of failed medications at intake, past SSRI failure, and the number of failed SSRIs. This suggests that ADHD may indicate resistance to antidepressants, specifically SSRIs.
  • TRD patients are more likely to have psychiatric comorbidities than non-TRD patients.
  • Screening depressed patients for ADHD and chronic anhedonia/low hedonic tone may help identify those with TRD and undetected ADHD, improving treatment outcomes.

First-Person Account

Here is a first-person account of what happens when ADHD goes misdiagnosed as depression. For decades.  Only the correct diagnosis of ADHD and the correct treatment gave this woman hope: ADHD Misdiagnosed as Depression Until 39: Best Week Of My Life

She had sought help from a string of mental-health professionals—for decades. Yet, again and again, they misdiagnosed her ADHD symptoms as depression and anxiety.  For decades. She took medications for depression and anxiety. Life only got harder and harder.

I’ve met many women and men with this experience. If you love someone diagnosed and treated for “depression” or “anxiety” who does not seem to get better with treatment, you owe it to that person: Suggest the possibility of ADHD.

Through a mutual friend, I recently met a woman whose ADHD went misdiagnosed and medically mistreated until age 39. With predictable negative side effects. Fortunately,  her friend is one of my book’s biggest fans—and most energetic ADHD evangelists. She shined a light on a brighter path for her friend.

Using the pen name Khanji, this woman agreed to share with ADHD Roller Coaster readers a short report of her life until ADHD was finally diagnosed and treated. Thank you, Khanji.

Summary

  • Mistaking ADHD for depression or anxiety can lead to ineffective treatments and ongoing struggles for patients.
  • Accurate diagnosis is essential for effective treatment, as ADHD requires medications that address its specific neurobiological associations.
  • Understanding the relationship between ADHD and mood disorders can improve patient outcomes and avoid the pitfalls of misdiagnosis.


 

Learn More About Diagnosing ADHD and Co-Existing Conditions:

ADHD confuses the public and the mental health profession on many fronts.  To be a strong advocate for yourself or a loved one, it behooves you to learn serious sources.  Otherwise, you risk bouncing around from one “guesstimate” opinion after another, being treated with medications that might make things worse.  It’s your life, and no one will care more about it than you do.

Above is a free excerpt from my online training: “Considering Misdiagnoses—And Missed Diagnoses” .  You’ll find more details on this comprehensive training at Solving Your Adult ADHD Puzzle: Foundations

—Gina Pera

If you have first-hand experiences on this topic, please share them in a comment!

MORE FROM GINA

10 thoughts on “A Critical Mistake: Misdiagnosing ADHD as Depression or Anxiety”

  1. Thanks for this informative article, perhaps most importantly, the poor efficacy of SSRI’s with or without ADHD meds.
    I am (reluctantly as this point) in a 40 yr marriage with a man only diagnosed with ADHD about 3 years ago. The whole process to get to the Evaluation was painstaking and his primary care doctor has not been supportive of any medication, thus, no meds. He also has MCI (Cognitive Impairment) and, (my assessment) learning & sensory disabilities which compound the many issues. I have not been able to find any articles addressing this particular co-morbidity scenario. Perhaps we should the ‘pilot’ couple for observation (haha).

    Karen

    1. Hi Karen,

      I’m glad you found my blog. If you want to make a go of this relationship — or beyond a relationship, help this person get on tract with understanding/managing ADHD — I strongly encourage you not to go it alone.

      Truly, the biggest make folks make is assuming they can figure it all out. It’s taken me 25 years of serious study and close interaction with thousands of adults with ADHD and their partners to appreciate the complexity involved.

      As you’ve already found, primary care doctors don’t always understand even ADHD basics. Sorry to say, neither do medical specialists, including sleep docs and PSYCHIATRISTS. All that is triply so for therapists.

      For example, what you perceive as “learning and sensory disabilities” are most likely ADHD-related side effects. And they respond to medication.

      MCI, unless it’s from a head injury, can also be ADHD. Also, responds to medication. Typically. There are always outliers. And much depends on being self-educated and pro-active with medications.

      I encourage you to get strong on the basics. ADHD simply does not get the respect it deserves. Also, change is hard and old dogs and tricks.

      My foundational course could really help you find your feet and start understanding what’s what.

      https://ginapera.adhdsuccesstraining.com/solvingyouradultadhdpuzzle

      good luck!
      Gina

  2. I quickly scanned this article and my ADHD was misdiagnosed as depression in 2002. I was put on antidepressants and feel that I lost 7 years of a productive life. I was diagnosed at UPenn with ADHD in 2009.
    There is so much I want to say. The only two ADHD drugs I’ve takes are vyvanse of varying doses and 20mg Adderall. For me, adderall was life changing in a very positive way. The key here for me was that in adderall, not only do I think more clearly and and transition from task to task more fluidly; but I have motivation. I connect future long term goals with the need for daily action.
    Even when I took vyvanse, every morning I climbed an emotional hill just to execute on the basics. It took me until at least 10am to talk myself out of my flat emotional state. I couldn’t even talk to people because thoughts were so jammed up in my head. I was frozen in thought and could not communicate effectively at all.
    Vyvanse was terrible for me but never realized it until I took adderall. Again, just my experience. When for over a month vyvanse wasn’t available, I spoke to my doctor and was put on adderall. With 20 years of sobriety I was very wary of adderall. However, for me it was perfect.
    Again, there is so much more to say and I’d be more than willing to share more. Thanks

    1. Thank you, Tim. I’m sorry to read of your experiences.

      When stimulants are introduced, there should be a trial of both classes (methylphenidate and amphetamine) and even a couple of each class.

      Because the delivery systems are different. Moreover, Adderall is in a class by itself. It’s “stronger” than all the other stimulants in that it targets more moledules and has an extra mechanism of action (pushing neurotransmitters from the neuron).

      For some people, this is too much. For others, it’s finally enough.

      The topic of ADHD is so full of nuance and variability…..it’s nothing like the simplistic stereotypes we tend to hear about.

      Good for you!

      Gina

  3. Maria A Pugliese MD

    As a psychiatrist, I have certainly seen what is described here. Depression can certainly be secondary to a lifetime of struggles with ADHD. To the untrained eye, anxiety and hyperactivity can look exactly the same. One caveat, if the person is suicidal, the depression must be treated immediately. If there is a positive response, then an ADHD med can be added. Interestingly enough in Europe Strattera was used first as an antidepressant. Most of my adult ADHD patients needed in the end needed both a stimulant and antidepressant for maximal functioning. ADHD in adults is clearly often missed. Encouraging the patient as you do to bring to their doctor’s attention all their symptoms is critical. Admittedly it is difficult if your insurance gives you only a 15 minute consultation. Be persistent. I am especially encouraged that the AAAP and ASAM are encouraging usage of ADHD meds in recovering addicts with ADHD to improve their chances of recovery.

    1. Thanks for sharing your long experience, Dr. Pugliese!

      ADHD treatment is so nuanced. It’s not, as one psychiatrist said to me: “ADHD is easy. You just throw a stimulant at it.” 🙂

      That’s great news about recognizing ADHD’s role in addiction — and treating it as such.

      One major problem is that most patients are not familiar with the ADHD diagnostic criteria — much less how they might relate to it, specifically. They don’t know what are medication-sensitive targets versus what will require therapy or skill-training. There are no treatment goals and little tracking.

      That’s a major reason I wrote my first book, in 2008! And it’s also why I created my online training, to help people take charge of their education and their treatment. The situation is worse now than in 2008, as far as I can see. So many more people chasing evaluations/treatment and even fewer experienced ADHD specialists.

      take care
      Gina

    2. Barbara Taber

      What type of antidepressants are you referring to? I ask because SSRIs are well documented to downregulate dopamine receptors and cause a myriad of dopamine related adverse events, including Parkinson’s and extrapyramidal symptoms /movement disorders, apathy, executive dysfunction, and, most importantly, akathisia which is the primary impetus for suicide, violence, and homicide on SSRIs.
      Ref: Joseph Glenmullen, MD; Peter Breggin, MD; David Healy MD; Ann Blake Tracy PhD; Grace Jackson, MD; Eugene Makela, PharmD (to name just a few).

      (Wendy) Dolin v GSK/Paxil is a very interesting lawsuit. If you look into it, please read what the 7th Circuit Court of Appeals did.

      I used to sell psych drugs and the amount of inflammation withheld by pharma is absolutely astounding. It requires FOIA to access it, though I’m certain it doesn’t uncover all.

      Thank you for your comment. We need more docs speaking up.

    3. Not much is “known among physicians” when it comes to ADHD neurobiology.

      That’s an interesting angle, Barbara, and illustrates my point about SSRI intensifying ADHD symptoms. Because underlying much SUD is poorly managed ADHD.

      thanks,
      g

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