MHM Magazine

Issue 2 | 2021 | MENTALHEALTHMATTERS | 15 MHM Prevalence Anxiety Disorders 47% Panic Disorder 34.5% Mood Disorders 38% Major Depressive Disorder 16 – 18% Bipolar Mood Disorder 9.5 – 19.4% Substance Abuse Disorders 32% Alcohol 27% Other 18% Personality Disorders 10 – 20% Cluster B (Borderline Personality Disorder, Narcissism) 20% comorbid psychopathology. In fact, up to 87% have one comorbid psychiatric disorder and at least 57% have two. It’s always a good idea for GPs with adult patients presenting with ADHD to refer to a psychiatrist for the initial assessment. The most important, or common, comorbidities in private practice are: Mood Disorders, Anxiety Disorders, Sleep Disorders, Obesity, Substance Use Disorders and Borderline Personality Disorder. In a study conducted in 2014, a database of 3.3 million medical aid beneficiaries were analysed. Over 15 000 were flagged for ADHD. MOOD DISORDERS It’s crucial to distinguish between ADHD symptoms and a mood or anxiety disorder. Often, when patients with ADHD talk about their mood swings, it may seem like Bipolar Disorder. A hypomanic episode has all the symptoms present in ADHD. The crucial factor is that ADHD is present every day whereas a mood disorder is episodic. In ADHD, mood swings can happen daily – a patient may feel fine in the morning and something small may trigger their mood. One of the core symptoms of ADHD is an erratic mood – or Emotional Dysregulation - in addition to the traditional triad – hyperactivity, impulsivity, and inattention. Emotional Dysregulation, whilst it has all the hallmarks of a mood disorder, doesn’t necessarily point to a mood disorder.  DEPRESSION In adults presenting with ADHD, a mood disorder is often the cause for their cognitive difficulties. About 80% of patients with ‘ADHD’, in my practice, are sleep deprived, many mismanage screen time, and about 70% have underlying depression. A volatile, irritable mood is frequently seen in adults with ADHD, usually due to a mood disorder. Explosiveness and volatility are not usually present in a mood disorder. It’s important to remember that cognitive symptoms are the last to respond to treatment which makes evaluating the time course of the symptoms difficult. Clinical assessment must evaluate what condition was present first – the mood disorder or the ADHD – as well as whether ADHD symptoms (whether diagnosed or not) were present in childhood. Try choosing anti-depressants that have pro-cognitive effects, especially noradrenergic and dopaminergic. ADHD medication won’t trigger depression but it’s worth noting that in a patient who is already depressed or vulnerable to depression, it may trigger the onset of symptoms. BIPOLAR DISORDER Between 10 and 20% of people with ADHD also have Bipolar Disorder. In addition, 40-80% of children and 15- 20% of adults with ADHD also have Bipolar Disorder. The comorbidity is tricky to treat and should be managed on psychiatric level rather than by a General Practitioner. In addition, some ADHD medication may trigger sleep disturbance which is a big risk factor for Bipolar relapse. What may indicate whether the patient has ADHD or a mood disorder is looking at family history, age of onset of symptoms, and chronicity versus periodicity. Mood disturbances in Bipolar, for example, often begin in early adolescence, at about 13 or 14; whereas ADHD symptoms will be present from before age 7. In addition, ADHD is the most inheritable of all psychiatric conditions – up to 80%. Doing a complete family history of neurodevelopmental disorders and mood disorders in crucial. As with depression, the rule of thumb is to treat the Bipolar first. All stimulants should be stopped and, a patient should be on a mood stabiliser until it’s safe to slowly re-introduce stimulants. Patients on non-stimulant ADHD medication may not have to stop their medication, but it must be used judiciously and under psychiatric supervision. The safest anti-depressant is bupropion because of its pre-cognitive effects and because it works on similar receptors as stimulants, without the stimulant effect. ANXIETY DISORDERS There is a 30% comorbidity with ADHD and anxiety disorders, more so in inattentive type ADHD. Distinguishing between GAD and ADHD can be problematic because there is an overlap of symptoms and GAD symptoms are present daily, as are ADHD symptoms. The flag for ADHD is the impulsivity. While other symptoms can overlap or co-occur, patients with anxiety disorders are generally risk-averse and not impulsive. In addition, patients with anxiety disorders are generally poorer sleepers with more insomnia. Patients with anxiety worry about their worry – when they get distracted, they worry about being distracted and this increases their anxiety level.