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. Author manuscript; available in PMC: 2020 Dec 4.
Published in final edited form as: Curr Dev Disord Rep. 2017 Feb 27;4(1):1–4. doi: 10.1007/s40474-017-0106-1

ADHD and the Development of Depression: Commentary on the Prevalence, Proposed Mechanisms, and Promising Interventions

Michael C Meinzer 1, Andrea Chronis-Tuscano 1
PMCID: PMC7717502  NIHMSID: NIHMS855919  PMID: 33282629

Abstract

Attention-deficit/hyperactivity disorder (ADHD) has been identified as a significant risk factor for the development of later depression. Furthermore, their comorbid presentation results in greater levels of impairment than either disorder in isolation. Research has pointed to several causal mechanisms by which ADHD co-occurs with depression including the persistence of ADHD symptoms, reward responsivity, and emotion dysregulation as well as parenting/family factors and maternal depression. Stemming from this mechanistic research, interventions have been developed in recent years that aim to prevent depression in youth with ADHD. The Behaviorally Enhancing Adolescents Mood (BEAM) Program and The Integrated Parenting Intervention for ADHD (IPI-A) have both demonstrated promising results. Directions for future research are discussed with an emphasis on neurobiological mechanisms and the dissemination/implementation of interventions to reduce risk for depression among youth with ADHD in community care settings.

Keywords: ADHD, attention-deficit/hyperactivity disorder, depression, community care, research, commentary

Invited Commentary

With the recognition that attention-deficit/hyperactivity disorder (ADHD) typically persists into adolescence and adulthood,1 increased focus has been given to serious outcomes that can arise-- including the development of depression. It has been estimated that 44% of individuals with ADHD experience a depressive episode before age 30 compared to 25% of individuals without ADHD.2 Numerous longitudinal studies conducted in both male and female samples have concluded that youth with ADHD are significantly more likely to experience a depressive disorder than youth without ADHD even after accounting for other psychological comorbidities.2–4 Furthermore, this relationship has been demonstrated continuously in that young adults with a childhood history of ADHD were at significantly higher levels of depressive symptoms through age 18 to compared to adults without a childhood history of ADHD.5 Summarizing this research in a meta-analysis, we concluded that ADHD and depression were significantly and positively related utilizing a sample of 29 cross-sectional or longitudinal studies.6 Furthermore, empirical evidence indicates that individuals who suffer from comorbid ADHD and depression experience greater levels of impairment and risk for completing suicide than either disorder in isolation.7,8 Adolescents with a childhood diagnosis of ADHD also have significantly greater levels of suicide attempts compared to adolescents without a history of ADHD (12.0% vs. 1.6%).4 Despite these findings, adolescents with more overt, externalizing psychopathology (e.g., delinquent behavior, substance abuse) tend to draw referrals from teachers and parental help-seeking compared to those with internalizing psychopathology.9,10 It is essential that we begin to devote attention to the understanding and intervention of comorbid ADHD and depression, particularly given the increased risk for suicide.

Recent efforts have attempted to identify mechanisms or mediators which can explain risk for depression among youth with ADHD. As previously noted, ADHD symptoms and impairment persist into adolescence and adulthood, and persistence of ADHD has recently been identified as a key factor that predicts adverse outcomes (e.g., lower income, lower post-secondary education, greater levels of receiving public assistance, risky sexual behavior, poor emotional outcomes, substance use)1 Research has also reported that in one sample the association between childhood ADHD and young adult depressive symptoms was no longer significant when accounting for the persistence of ADHD symptoms.5 Coupled, these results suggest that chronic treatment of persistent ADHD symptoms could have a preventative effect on the development of depressive symptoms. This possibility remains a question to be empirically tested.

A demoralization model has also been suggested in which depression is merely a result of academic and social impairment secondary to ADHD. In other words, youth with ADHD may become depressed after years of academic and social failure and consequent negative feedback from their social environments. However, research support for the demoralization model is equivocal. In one study peer problems, but not academic impairment, mediated the relationship between ADHD and depression.11 Other studies have not found an association between school and family difficulties and the course of depression in children with ADHD.3 Another study reported that adolescents with ADHD remained at significantly greater risk for depression even after controlling for social and academic impairment.2 These latter findings suggest that other explanatory variables are likely at play.

Several other endophenotypes, or constructs that underlie psychopathological symptoms, have been examined as potential mediators of the relationship between ADHD. Reward responsivity, or how individuals respond to pleasurable stimuli,12 has been identified as one variable that is genetically and neurologically related to both ADHD13,14 and depression.15,16 Reward responsivity has been shown to mediate ADHD and depression in a cross-sectional study.17

Emotion regulation—defined as the awareness of emotions and ability to control impulsive emotional responses has been linked to both ADHD18,19 and depression.20,21 Both cross-sectional and longitudinal research has identified emotion regulation as a mediator that (at least in part) explains the relationship between ADHD and depression.22–24

Another construct that has helped explain the relationship between ADHD and depression is the quality of parenting and the family environment. Parenting constructs have been defined and evaluated in numerous manners across longitudinal and cross-sectional studies. Parent management (effective and consistent management of disruptive behavior),25 parent-child dysfunction,11 and parental support (i.e., a composite of autonomy granting, parental warmth, and parental involvement)26 all mediated the relationship between ADHD and depressive symptoms.

In addition to reward responsivity, emotion regulation, and parenting/family support, maternal depression has been linked to an array of adverse outcomes in children with ADHD, including depression.4,27 Over 50% of mothers of children with ADHD and disruptive behavior disorders experience maternal depression.28 Furthermore, maternal depression predicts the course of conduct problems over a period of 8 years27 as well as depression and suicidal ideation and attempts 5 to 13 years later4 among youth with ADHD.

Despite the progress in developing tailored intervention programming designed to reduce negative externalizing outcomes in youth with ADHD (e.g., reckless driving, substance use),28,29 until recently, relatively few efforts have been made to reduce risk for depression in this population. Grounded in empirical evidence that reward responsivity, emotion regulation, and family support mediate the association between ADHD and depression, we developed The Behaviorally Enhancing Adolescents’ Mood (BEAM) depression prevention program for adolescents with ADHD.30 BEAM was delivered in 4, 3-hour sessions on Saturday mornings. Parents and adolescents met separately for majority of the session but participated in joint activities at the end of each session to practice skills learned. BEAM was also designed to meet the developmental needs of adolescents by taking a more active, behavioral approach and avoiding complex cognitive strategies. Results of an open trial indicated that parents and adolescents were highly satisfied with the intervention, it was easy to implement and that following the intervention adolescents experienced improvement in emotion dysregulation and reward responsivity and decreases in depressive symptoms.31 Future research should examine this intervention in a randomized control trial. Moreover, dissemination and implementation of BEAM in the middle or high school setting and/or pediatric primary care would increase access to services at a developmental time point when services for this population tend to decline.32 Given the enormous gap between need and delivery of child mental health services33 and the unparalleled opportunities to engage youth in the school system,34 school mental health represents an optimal method for reaching youth with mental health needs, especially those with ADHD and comorbid depression.

Another program that holds potential to reduce risk for depression in youth with ADHD by reducing maternal depression symptoms is the Integrated Parenting Intervention for ADHD (IPI-A).35 The group-based program for parents integrates behavioral parent training strategies as well as cognitive behavioral treatment for adult depression (i.e., The Coping with Depression Course).36 Following the intervention, there were significant reductions in maternal depressive symptoms, observed negative parenting, child deviance, and overall child impairment and further, these results were maintained at follow-up.37

Unfortunately, effects on child depressive symptoms were not examined. Future research should measure the extent to which IPI-A reduces current depressive symptoms and the risk for future depressive episodes among youth with ADHD. Additionally, IPI-A has yet to be disseminated into community mental health settings which could decrease depression in mothers of children with ADHD, decrease their child’s behavior problems, and potentially reduce the risk for adverse outcomes for their child with ADHD.

Conclusions

In sum, the literature provides clear evidence that children with ADHD are at risk for the development of depression. Recent efforts to identify mechanisms placing children with ADHD at risk for depression have pointed to reward responsivity, family support, and emotion regulation. Identification of such mechanisms paves the way for targeted interventions to prevent adverse outcomes. Though several (i.e., reward responsivity, emotion regulation, and family support) have been identified and empirically tested, there are undoubtedly more to uncover as to the mechanisms by which ADHD predicts subsequent depression. For example, ADHD also is predictive of externalizing disorders such as substance use and delinquency.38,39 Research has yet to determine what characteristics place youth with ADHD at risk for one (or both) of these outcomes and how comorbidities such as substance use and depression are interrelated among individuals with ADHD. Continued research is necessary into other endophenotypes of comorbid ADHD and depression. Further, other methodologies such as neuroimaging or neurocognitive tasks need to be incorporated into the investigation of mechanisms linking ADHD and later depression.40 Although the foundation has been laid for research on comorbid ADHD and depression, there exists an abundance of unanswered empirical questions and clinical opportunities to be addressed.

Acknowledgments

Michael C. Meinzer a reports loan payment grant from NIMH.

Andrea Chronis-Tuscano reports grants from NIMH (R03 MH070666–1, R34 MH073567–01A1, R34 MH 099208–01) from NIAAA (R34 AA−−22133-A1), and McNeil Pediatrics; and study drug donation from Shire Pharmaceuticals.

Footnotes

Compliance with Ethics Guidelines

Conflict of Interest

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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