Treatment of comorbid attention deficit hyperactivity disorder and depression in pediatric patient

Tratamento do transtorno de déficit de atenção com hiperatividade e depressão coexistentes em paciente pediátrico

CARTA AOS EDITORES

Treatment of comorbid attention deficit hyperactivity disorder and depression in pediatric patient

Tratamento do transtorno de déficit de atenção com hiperatividade e depressão coexistentes em paciente pediátrico

Dear Editor,

The comorbidity between attention deficit hyperactivity disorder (ADHD) and mood disorders has been a controversial issue.¹ There are evidence that mood disorders and ADHD may be comorbid disorders, that ADHD and bipolar disorder may be related, and that depression may be an outcome of ADHD.¹ In the case presented below, comorbid ADHD and depression were successfully treated with a combination of bupropion and cognitive behavioral therapy.

P., 7 years old, male, had been diagnosed with ADHD when he was 2 years old. There was no family history of psychopathology. Different health professionals had treated him with several medications without improvement. P. was referred by a neurologist because he was having severe behavioral problems. He was violent, defiant, and irritable, had low self-esteem and struggled to express himself in an appropriate manner. He had not learned to read and write, and his drawings were bizarre. His parents reported that P. experienced anxiety, sadness, fear, frequent crying, tantrums, self-mutilation and ideas of death. At the interview, P. was restless, avoided eye contact, presented blunted affect, and dysphoric mood. His speech was disorganized and incoherent. His walking was spastic and lethargic. P. was medicated with regular methylphenidate, methylphenidate SR, chlordiazepoxide and imipramine. At the end of evaluation, the diagnostic hypotheses were ADHD and depression.

At the beginning of treatment, all the medications were gradually tapered off. Without medication, P. became more aggressive, agitated, manipulative, and presented out-of-control behavior. P. had to leave the school due to violent behavior towards his peers. Next, bupropion was prescribed, 37.5 mg twice a day and, after 15 days, the dosage was gradually increased to 75 mg twice a day. Bupropion was the drug of choice for several reasons: 1) P. had already been treated with many different medications, including stimulants and SSRIs which are the first and second choice, respectively, to treat comorbid ADHD and depression,² without improvement; 2) P. had both severe ADHD and depressive symptoms; 3) bupropion has been helpful in the treatment of children who have both ADHD and depression.³ Pharmacotherapy was associated with cognitive behavioral psychotherapy, including individual work with the child and the parents. After three months of treatment, P.'s agitation and aggressive behavior had reduced. His speech, walking, and affect had improved significantly. He was able to express his interests and his frustrations in a more appropriate way. Eighteen months after the beginning of the treatment, P. is still on monotherapy with bupropion. He is polite, compassioned and is well adapted to school. He doesn't experience any fears, sadness or thoughts of death. Some restlessness is still observed and he presents occasional tantrums.

ADHD may be mistaken by depression because both disorders share some of the same symptoms.⁴ In addition, some depressive symptoms may be caused by the patients' problems in several areas of their lives.⁴ When treating ADHD children, it is important to consider that depression may coexist. Bupropion may be useful when treating children who have both ADHD and depression.³ Bupropion has few side effects,³ and since psychostimulants have been associated with physical and psychological dependence,⁵ it may be a good alternative.

Marcela Alves de Moura

Centro Médico Integrado do Hospital dos Fornecedores de Cana de Piracicaba,

Piracicaba (SP), Brazil

References

1. Wilens TE, Biederman J, Spencer TJ. Attention deficit/hyperactivity disorder across the lifespan. Annu Rev Med. 2002;53:113-31.

2. Pliszka SR, Crismon ML, Hughes CW, Corners CK, Emslie GJ, Jensen PS, McCracken JT, Swanson JM, Lopez M. The Texas Children's Medication Algorithm Project: revision of the algorithm for pharmachotherapy of attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2006;45(6):642-57.

3. Wilens TE. Straight talk about psychiatric medications for kids. New York: Guilford Press; 1999.

4. Miller JA. O livro de referência para a depressão infantil. São Paulo: M Books do Brasil; 2003.

5. Kaplan HI, Sadock BJ. Concise textbook of clinical psychiatry. Baltimore: Williams & Wilkins; 1996.

Financing: None

Conflict of interests: None

Publication Dates

• Publication in this collection
  06 July 2007
• Date of issue
  June 2007