A patient who could be several things at once
During her talk on treating ADHD and depression, Dr Ramya Srinivasan opened with a case. A teenager, diagnosed with ADHD at nine and started on medication at eleven, had stopped handing in schoolwork and was attending school less regularly. At home, his parents had noticed that he seemed increasingly irritable and was not sleeping well. He said he felt useless, no longer wanted to see his friends, and was failing everything. His teachers wondered whether his mood, not only his ADHD, needed attention.
The question, then, was not simply whether he was struggling, but what was driving that change. Was this part of his ADHD, a sign of depression, or some combination of the two?
When ADHD and depression can look alike
Answering that question is not always straightforward. ADHD and depression share several features that can make it difficult to tell what has changed, including difficulties with concentration, restlessness and disrupted sleep, some of which can also be affected by treatment.
Rather than trying to assign each symptom neatly to one diagnosis or the other, Srinivasan emphasised looking at the wider pattern. When did the change begin, and is it different from the young person’s usual presentation? Does it appear across settings or only in particular situations? And, importantly, how much is it affecting school, relationships, daily routines or activities they previously enjoyed? Timing, context, and impact can help build a clearer picture when individual symptoms are difficult to interpret on their own.
So are some symptoms more informative than others? One study discussed in the talk suggested that they may be. Difficulties with concentration and psychomotor agitation did relatively little to distinguish depression from ADHD, whereas social withdrawal, anhedonia and suicidal thoughts were more informative. For clinicians faced with several overlapping symptoms, this suggests that changes in a young person’s interests, relationships and sense of hope may warrant particular attention.
The evidence behind sequencing treatment decisions
Recognising that both conditions may be contributing is only part of the problem. The next question is what to do when ADHD and depression both appear to need treatment.
Srinivasan noted that the evidence base for treating co-occurring ADHD and depression remains limited, although several studies offer useful guidance. One large treatment study involving children with ADHD found that medication was associated with improvements extending beyond core ADHD symptoms, while combined approaches offered additional benefits on some broader outcomes. Other research in adolescents with depression has suggested that treating depression may also improve attentional symptoms. Together, these findings suggest that improvements in one condition may sometimes have benefits for the other.
Where there is a genuine choice about sequencing, the evidence discussed in the talk suggested that addressing ADHD first can be a reasonable starting point. Where depression is severe, particularly when there are immediate safety concerns, addressing the depression may need to take priority. Importantly, the relationship between the two conditions means that treating one may sometimes bring improvements in symptoms associated with the other.
Access decides the order as much as evidence does
What stayed with me was how quickly the talk moved from what guidance recommends to the practical limitations of putting it into practice. The decision, Srinivasan said, depends on what is actually available: which service a young person can reach, how long the wait is for a depression intervention against an ADHD medication review, what a family can realistically attend. A default sequence is easier to state than to follow when access ends up shaping the next available appointment.
Guidance can describe a reasonable sequence when ADHD and depression occur together. It cannot determine the sequence that will be right — or even immediately available — for every young person. For the teenager in Srinivasan’s opening case, the task was therefore not to find a single symptom or rule that provided the answer. It was to understand what had changed, decide what required the most immediate attention, and work from the options actually available to him and his family.
Perhaps that is the most useful way to think about treatment sequencing here: not as a fixed answer, but as an evidence-informed starting point that has to be adapted to the young person in front of us.
Closing thoughts
A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. (1999). Archives of general psychiatry, 56(12), 1073–1086. https://doi.org/10.1001/archpsyc.56.12.1073
Where next
Depression in Autism and ADHD: What do we know? In this ‘In Conversation’ podcast, Dr. Lucy Livingston provides insight into the comorbidity of Depression in Attention-deficit / hyperactivity disorder (ADHD) and Autism