Adult ADHD and Depression in Women: Why They So Often Occur Together

By Leigh Anne Hulva, BSN, RN— Women’s Health Educator

This elegant case study about Lydia will provide you with an understanding a common clinical scenario which is often missed for years, with significant suffering.

Many women are treated for depression for years before anyone asks whether adult ADHD may be part of the picture. ADHD and depression can overlap in symptoms such as low motivation, poor concentration, sleep problems, and low self-esteem. This article explains why adult ADHD may hide depression in women and when to seek a more complete evaluation

Meet Lydia: Depression, Motivation, and Missed Diagnosis of Adult ADHD

Lydia, at 42, has been a social worker in Nashville for 20 years.  She has that kind of compassionate calm that patients and colleagues alike are drawn to, especially in times of crisis. She is the person you go to when you need help with a problem at home or advice on a work assignment.

She is also a person who has— quietly and doggedly— trudged through almost two decades of depression. She has, over the past 15 years, tried two different therapists and three different antidepressants. The first antidepressant seemed to work for a while, then just wore off. The second helped her reach the questionable peak of feeling “slightly better than terrible,” and the third caused her dizziness and nausea that just weren’t worth the slight improvement in mood. Her second therapist diagnosed her with “treatment-resistant depression,” which felt both accurate and somehow like they had given up on her.

The years she has spent in therapy have not been wasted. She has taken deep dives into processing some childhood trauma, recognizing her patterns in relationships, even learning Cognitive Behavioral Therapy techniques that help her manage stress in real-life situations. Still, she felt there was more to her depression that just wasn’t being named. She was often deeply frustrated with her apparent lack of motivation, her inability to get things done when she truly wanted to.

Then one day, her regular therapist was out sick, and a substitute was offered to her. He asked Lydia a question she had never been asked, and had never thought to ask herself.

“When you say you can’t get motivated,” he asked, “do you mean you don’t want to do the things? Or do you want to, but you just can’t seem to get started?”

Lydia sat with the question. There was something to it that really struck her. She had always assumed the two issues were the same problem. “The second one,” she finally said.

“I think,” the therapist replied, “we need to talk about ADHD.”

H2: How Often Do  Adult ADHD and Depression Co-Occur?

The overlap between ADHD and depression is significant. Adults with ADHD are likely to also have depression.

Depression, especially in women, is usually the disorder that gets recognized (and treated) first. Women with ADHD tend to have the “inattentive type” as opposed to the “hyperactive type” and therefore are much less likely to get diagnosed in childhood (and beyond). The symptoms they display early in life are more likely to be described as “forgetful” or “daydreamy” or “careless” and not receive the attention that, say, a child who is disruptive in class might receive.

Because of this underdiagnosis in childhood, the low mood and poor concentration of ADHD might be misdiagnosed as depression. A woman’s first trip to a therapist is therefore more likely to result in a diagnosis of depression than ADHD because many healthcare providers are more familiar with those symptoms as being depression related. This isn’t exactly inaccurate; it’s just not treating the whole problem.

A Diagnostic Tangle: Why ADHD Often Hides Behind Depression

Overlapping Symptoms

ADHD and depression share a surprising number of symptoms. These include difficulty concentrating, low motivation, poor sleep, difficulty completing tasks, feelings of inadequacy, and low self-esteem. A healthcare provider working with a person displaying this group of symptoms can understandably conclude that depression is the culprit. For many patients, that will be at least partly correct. But for women with undiagnosed ADHD, it’s not the whole story.

Which Came First: Adult ADHD or Depression

In something of a “chicken or the egg” situation, it’s hard to parse out which came first: the ADHD or the depression. The relationship between ADHD and depression usually follows one of two patterns.

In the first, depression develops after years (or decades) of dealing with undiagnosed ADHD and the fatigue and shame— as discussed in our article on ADHD and Self-Esteem— of managing without help or treatment. The weight of that accumulated frustration, of interpreting your own inability to start and complete tasks with ease as a personal failing, can understandably lead to depression that sits on top of the underlying ADHD. Treating depression in these cases will lead to partial relief at best.

In the second pattern, ADHD and depression are two separate conditions, each with its own biological causes, that happen to occur together in the same person. The two conditions interact and amplify each other. Treating one without treating the other will also lead to incomplete relief.

Lydia’s therapist thought that perhaps Lydia had both undiagnosed ADHD and genuine biological depression that had been exacerbated by decades of frustration and shame. He decided to treat both issues simultaneously.

The Trap of a “Treatment-Resistant” Diagnosis in a Woman with Co-Morbid Adult ADHD

A diagnosis of treatment-resistant depression shouldn’t be a stopping point. You need to find a provider who asks the next reasonable questions: What is it resistant to, and why? Going through life feeling “just better than terrible” isn’t an acceptable finish line for a provider to reach.

If you have been told that your depression is treatment-resistant and something about that just doesn’t feel right to you, it is reasonable for you to request further testing.

Why Adult  ADHD and Depression in the Same Woman are so Often Missed

As discussed throughout this blog, ADHD in women is significantly underdiagnosed, especially when it is the “inattentive” type (which is more often seen in girls). Depression in women, on the other hand, is widely familiar to the medical community. A woman who comes into her doctor’s office describing low mood, poor sleep, difficulty concentrating, poor motivation, and a sense of underachievement is more likely to be screened for depression than for ADHD.

Ask Yourself the Right Questions

Questions that might reveal ADHD hiding under a diagnosis of depression include:

• When you’re struggling to get motivated, is the problem that you don’t want to start, or that you want to get started but just can’t?
• Is this consistently a problem, even when you go through periods of feeling positive and content?
• Are you able to hyperfocus on some things and not engage at all with others?
• Has your response to antidepressants been poor or mediocre?
• Do you remember experiencing forgetfulness, disorganization, or chronic lateness before you remember experiencing depression?

Treatment: Why the Order and Combination Matter

When ADHD and depression occur together, the most effective treatment will usually address both conditions. If depression is severe, it usually makes sense to begin treating the depression before adding a stimulant medication. If depression is relatively mild, initiating ADHD treatment early often makes sense. This was the case with Lydia, as her ADHD symptoms seemed to be actively feeding her depression. Her provider added a low-dose stimulant to the antidepressant she was already taking. So far, she has noticed a real improvement. Her mood is a bit better, and her ability to get tasks started and completed has improved significantly.

This will be a complex challenge for you and your healthcare provider to take on together. Be sure to choose a provider who takes the time to determine what your specific needs and expectations are when it comes to treatment. What is most important to you? What are you willing to do to include counseling or Cognitive Behavioral Therapy in your treatment plan? Are you able to implement lifestyle changes like regular exercise?

Conclusion: How the Right Diagnosis Can Change Everything

You can be diagnosed with ADHD and seek treatment for it at any point; it’s never too late. If ADHD or depression (or both!) are holding you back, now is the time to find a healthcare provider with experience treating adults with ADHD. Lydia is deeply grateful for the seemingly serendipitous timing of the substitute therapist. Sometimes, being asked the right question at the right time is all it takes to change the course of life. If this article resonates with you, consider talking to your doctor about potential treatments. Find a provider who helps you figure out how to move forward into your best life!

Frequently Asked Questions (FAQs):

How common is it to have both  Adult ADHD and depression?

Very common, and more common in women than in men. The relationship between ADHD and depression works in both directions, so to speak: Depression can develop as a consequence of living with undiagnosed ADHD, and ADHD symptoms can be exacerbated by existing depression.

Can  Adult ADHD be mistaken for depression?

Yes, there is significant overlap in symptoms. ADHD and depression both often include symptoms of low mood, poor concentration, disrupted sleep, low motivation, and low self-esteem. These symptoms are often looked at through the lens of treating depression, especially in women, whose ADHD more commonly looks like depression than the more classically male “hyperactive” type of ADHD.

Should  Adult ADHD or depression be treated first?

This is a complex issue that you and your provider will need to discuss. Your treatment plan will consider how severe your depression currently is, and whether or not the depression and the ADHD should be treated simultaneously from the outset. But remember that, in any case, you deserve to be heard and to be treated fully. If your current provider is just getting you to the point of feeling “not terrible,” know that you deserve better. Keep trying until you get to the bottom of this!

Adult ADHD care in Nashville

For many adults, especially women diagnosed later in life, ADHD care works best when the clinician takes the time to understand the whole person. At Nashville Concierge Medicines, Dr. William Conway provides private, physician-directed adult ADHD care for women,

Who is Leigh Anne Hulva in her own words

I’m Leigh Anne Hulva, BSN, RN- a registered nurse, women’s health educator, mother of teenage daughters, and passionate advocate for women navigating perimenopause and menopause. I recently completed the Harvard Medical School course on Women’s Health, and in these pages, I relish sharing what I learned there alongside what I know from lived experience. I bring to this work not only my training, but also the personal experience of navigating the very transition I write about. It is my privilege to share both, because this work is personal to me. I hope it feels that way to you, too.

I have been on the other side of this conversation, and I understand how much it matters to feel truly heard. At Nashville Concierge Medicines, my work is supervised by Dr. William Conway, MD, and I work directly under his licensure as a nurse educator.

Who is Leigh Anne Hulva by William Conway MD.

Leigh Anne is currently unrecognized as a writer. This will soon change. Leigh Anne is a gifted writer who has insights and understanding rarely understood or communicated. Leigh Anne communicates from the soul, illuminating deep truths.

Leigh Ann should be read for the enriching insights that bring clarity to human life. Leigh Anne writes in the best tradition of American humanism.

Read Leigh Ann to understand your life. Do not read Leigh Ann to nitpick over the DSM differential diagnosis.