ADHD, Depression, and Adolescent Girls

Depression and ADHD in Teenage Girls

Several studies in recent years have looked into the impact of ADHD on the lives of teenage girls. MRI studies report that teenager’s brains are rapidly maturing, but that they are not fully mature until the early 20’s in females, and perhaps the early 30’s in males. Long-term studies on behavior and emotional health report that girls with ADHD may struggle through the teen years. And other studies report that depression is common among teens with ADHD, and is so common among adolescents that the use of medications for ADHD, antidepressants, anti-psychotics, and even sleep medications, is up sharply with adolescent girls.

It has been reported that while many children and teens with ADHD also suffer from some degree of sadness or discouragement, as many as 25% are clinically depressed. Children and teens with ADHD are as much as 300% more likely to also suffer from depression than are children or teens without ADHD.

The co-morbid depression seems little associated with the ADHD symptoms such as inattention, impulsivity, hyperactivity, or academic problems. These problems might result in discouragement, sadness, or frustration, but not clinical depression.

Rather, the depression seems to be most correlated to social awkwardness or interpersonal difficulties that are often a part of having ADHD. The lack of friendships, the sense of loneliness, or the sense of being a “social outcast” seemed to be behind the depression. And these feelings are, of course, much stronger in the teenage years.

In girls who were diagnosed with ADHD, and were followed by long-term studies through the years, it was observed that as they moved from childhood to adolescence their “outward” symptoms of ADHD, such as hyperactivity and impulsivity, tended to decrease.

We do want to note that most girls with ADHD do not have the symptoms of hyperactivity or impulsivity. Most girls with ADHD are inattentive, distracted, disorganized, or “space cadets,” which is why girls are so under-diagnosed for ADHD. Girls tend to just sit in the classroom, get distracted, and do poorly on the tests. But they don’t cause trouble in the classroom so they don’t get the attention that might lead to a diagnosis and treatment.

But for those girls were did have the symptoms of hyperactivity or impulsivity, and had been diagnosed as children, their “outward” symptoms tended to decrease as they reached the teenage years.

However, as these girls reached the teenage years, it was noted that their academic performance continued to be a problem, and that the academic gap between them and their non-ADHD peers continued to widen with each passing year.

These researchers also noted that, while some girls with ADHD actually “out-grew it” as they reached adolescence, for the most part the girls not only continued to suffer from it but many began to get into serious trouble. Both behavioral and emotional problems began to emerge in many of these girls, and the need for specialized treatment greatly increased.

There were increased problems with friends, which led to increased levels of depression. There were increased levels of substance abuse (both alcohol and drug abuse). School delinquency increased as the academic problems got worse. And, surprisingly, eating disorders became a serious problem among many of these girls.

All of these problems were at higher levels among these ADHD girls than among their non-ADHD peers.

SPECIFIC TREATMENT STRATEGIES FOR ADHD AND DEPRESSION

As we have noted elsewhere, twice as many teens with ADHD will run away from home than teens without ADHD. About 16% of teens run away from home at some point, versus 32% of teens untreated for Attention Deficit Hyperactivity Disorder - ADD ADHD. And as many as 50% of all teenagers in juvenile facilities have Attention Deficit Hyperactivity Disorder but were untreated for ADHD.

Teenagers untreated for ADHD are ten times more likely to get pregnant, or cause a pregnancy, than those without ADHD, and teenagers untreated for Attention Deficit Hyperactivity Disorder are 400% more likely to contract a sexually transmitted disease than teens without ADHD: 16% to 4%.

ADHD, and Depression

With as many as 25% of teenagers with ADHD being clinically depressed, it is important to understand what depression looks like, why it is important to treat it and manage it, and the treatment options available.

When we think of someone who is depressed, we usually picture a sad, tearful, lonesome person. But teenagers with depression don't look like adults with depression.

Current studies show that there are about as many teenagers who are depressed as there are adults that are depressed, about 10% of the general population. And as we have noted, as many as 25% of teens with ADHD are depressed.

However, depression in teenagers doesn’t always look like depression in adults. Teenagers do not commonly display gloom, self-depreciation, or talk about feeling hopeless like adults do.

Teenagers with Major Depression are described as often becoming negative and antisocial. Feelings of wanting to leave home or wanting to run away will increase. There may be a strong sense of not being understood and approved of by parents, siblings, or peers.

The teen often changes, and becomes more restless, grouchy, or aggressive. A reluctance to cooperate in family ventures, and withdrawing from the family by retreating into their room is pretty common.

School difficulties are likely even in those few ADHD teens who were doing pretty well in school, as concentration is even more affected than from the ADHD alone.

SPECIFIC TREATMENT STRATEGIES FOR ADHD AND DEPRESSION

Sometimes the teen will stop paying attention to personal appearance, and sometimes they will adopt the “uniform” of social groups that profess depression or despondency as a way of life. They often become much more emotional “at every little thing.” Often there is an increased sensitivity to rejection in love relationships as well.

Which reminds me of a Cornell University study that reported that the leading cause of teenage depression was breaking up with a boyfriend or girlfriend. And that the younger the teen was in this relationship, the more likely the breakup would lead to depression.

Teenage boys will often become aggressive with their parents or peers, seem more agitated around the house, and get into more trouble at home, at school, or with the law.

Teenage girls will sometimes become preoccupied with themes of death or dying, and become decreasing concerned about how they look. Think black – black hair, nails, clothes, lips.

Suicidal thoughts are common in depressed teens. Some studies suggest that 500,000 teens attempt suicide each year, and 5,000 are successful. That would be 10% of depressed teens. Other studies suggest that the number is 15% of depressed teens ending their life via suicide.

By the way, another study notes that of all the teenagers that commit suicide each year, only seven percent were receiving mental health treatment at the time of their death.

Poor self-esteem is common with teenagers, but especially with those who are depressed, and there is often an increase in “self-destructive behaviors” such as alcohol abuse, drug abuse, and sexual promiscuity.

Parents are often confused and frustrated when their teens begin to act like this. Sometimes parents become stern disciplinarians, or even put the teen down, which only serves to increase feelings of guilt and depression. Other times, parents feel helpless, and stand by waiting for adulthood to arrive. Of course neither course is the right one to take.

From 2001 to 2006, the use of ADHD medicines prescribed to girls was up by nearly 75%, and the use of antidepressant medications was up by nearly 10% in girls.

Black Box Warning Label

No doubt you have seen recent news headlines about a federal panel that recommended to the FDA that anti-depressant medications carry the strongest possible warning label for use in children and teenagers. This recommendation to the FDA shook the medical community, especially those who work with depressed young people, and now the FDA does mandate that antidepressants used to treat adolescent depression carry the “black box” warning label.

The warning label reads:

Suicidality in Children and Adolescents

Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. [Drug Name] is not approved for use in pediatric patients except for patients with [Any approved pediatric claims here]. (See Warnings and Precautions: Pediatric Use)

Pooled analyses of short-term (4 to 16 weeks) placebo-controlled trials of nine antidepressant drugs (SSRIs and others) in children and adolescents with MDD, obsessive compulsive disorder (OCD), or other psychiatric disorders (a total of 24 trials involving over 4400 patients) have revealed a greater risk of adverse events representing suicidal thinking or behavior (suicidality) during the first few months of treatment in those receiving antidepressants. The average risk of such events on drug was 4%, twice the placebo risk of 2%. No suicides occurred in these trials.

The biggest problem from the treatment community's point of view was not the recommendation for the warning label, but the way that the media portrayed the panel's recommendation. The panel reported that 2% to 4% of children and teens that were given anti-depressants for the treatment of depression had suicidal thoughts, or made suicidal attempts of one kind or another. None of the 4,000 children and teens studied committed suicide.

What the media did not report well is the fact that 10% to 15% of children and teens with depression that receive no treatment will commit suicide. These 10% to 15% will not just think about it, but will actually kill themselves.

So what are we to do? If the media had their way it seems that no teens with depression would receive anti-depressants. As a result the suicide rate for those who could be using the medication would rise from nearly zero percent to about fifteen percent, which is the suicide rate for depressed teens who are untreated.

While there actually are young people, and adults, who have become suicidal only after beginning treatment with an anti-depressant, and some have in fact gone on to take their own lives, which is absolutely tragic and heart-breaking, so is the fact that untreated depression is potentially a fatal disease. As many as fifteen out of one hundred young people with depression take their own lives unless they receive treatment. These young people should be allowed to receive a treatment that will lower the suicide rate dramatically, and without any stigma attached to it by the media.

With proper diagnosis and treatment a depressed teen, or adult, can be greatly helped. If someone close to you is suffering from depression, first please understand that depression is a very emotionally painful condition. Please take the situation seriously.

If you know of a teen whose behaviors have changed to look like what has been described above, let the parents know that there is help available, and encourage the family to seek help from a professional.

Women with ADHD: More Severe Symptoms than Men?

Let’s begin by pointing out that we have recently written about ADHD and Depression in Teenage Girls, and have even produced a brief internet video on the topic. As reported in that article, females with ADHD tend to have the “inattentive” type of ADHD (what we refer to as Winnie the Pooh type), where males tend to have the “impulsive-hyperactive” type or a “combined type” of ADHD (what we refer to as Tigger type ADHD).

As a result, males tend to have more behavioral problems that go along with their ADHD, which leads to referrals from the classroom teacher to a physician where he can receive a diagnosis and treatment. Their female counterparts, however, tend to be inattentive in the classroom, without the behavioral problems, and as less likely to get a referral which might lead to a diagnosis and treatment.

As children mature into adolescence, the human brain matures. But the interesting thing about the brain is that the brain tends to mature from the back of the brain to the front of the brain, and the frontal lobes and pre-frontal cortex mature last. These brain areas are most associated with the “executive functions” of the brain, and their delays in maturity are associated with “inattentive ADHD.”

Since the female brain tends to achieve its full growth and maturity in the early 20’s, we see many females who had been diagnosed with inattentive ADHD seemingly “outgrow” it in young adulthood.

But what about those who don’t “outgrow” their ADHD? And what about those females who started off with “impulsive-hyperactive type” ADHD, or “combined type” ADHD? What is observed in adult years with these women?

What we know is that during the teenage years these girls with ADHD are at a much higher risk of developing depression, anxiety disorders, and eating disorders, than their peers without ADHD. And during the adults years, these problems remain.

Fred Reimherr, MD, is a professor of psychiatry at the University of Utah in Salt Lake City, where he heads up their Mood Disorders Clinic, and is active in research. He is also quite an outdoorsman and conservationist. He led a study on the effectiveness of Strattera on adult subjects, which was funded by Eli Lilly and Company, and some of his results were startling. At least until the research on adolescent girls with ADHD recently became available.

One of the “side note” findings of Reimherr’s team was that there seemed to be a lot of women with ADHD combined type out there who did not “outgrow” their symptoms, and were still greatly bothered by their ADHD.

Through the assessment process it was found that these women’s scores on various inventories were much higher, and much more severe, than were the scores found with men. These adult women with ADHD had more severe emotional symptoms, including much higher levels of anxiety and depression. The study did not report on eating disorders, but other studies on female adolescents have noted higher levels of eating disorders in young women with ADHD.

Dr. Reimherr noted that when physicians (and mental health professionals) are working with women who are being treated for either anxiety or depression (or we would add eating disorders), if they show symptoms that are not entirely consistent with anxiety or depression, such as displaying more irritability or mood instability than might be expected, the physician should at least consider the possibility of ADHD being at the root of the problem.

ADHD with Depression

ADHD with Depression

This is our old page on ADHD and Depression. Please see our new page for the latest information on ADHD and depression.

Depression in adults often appears as great sadness, difficulty sleeping or eating, not caring for how one looks, and not caring at all. But in children, and in teenagers, depression may look very different. There may be much more anger and social withdrawal. Depression with ADHD is another story altogether too.

It is estimated that 25% of children and teens with ADHD are also mildly or moderately depressed.

Teen Suicide Rates Increase as Prescriptions Decrease

A lot of teenagers, and even children, are prescribed antidepressants, somewhere from 1% to 1.5% of the population. At one point studies estimated that as many as 1.66% of children or adolescents were prescribed antidepressant medication, but after the FDA required a "black box" warning label for the medications in 2005, the prescription rate has dropped. The warning label states that the use of antidepressants among children and teenagers is associate with an increased risk of suicial thoughts, and suicial behaviors. So physicians have backed off of prescribing the medications.

However, the estimated suicide rate among American adolescents is about 16%.

So, as a result of fewer depressed teenagers receiving antidepressant treatment, the suicide rate among teenagers has gone up. See Hamilton B, et.al., Annual Summary of Vital Statistics: 2005. Pediatrics. Also see Greenhouse, J., et.al., Generalizing from Clinical Trial Data: A Case Study. The Risk of Suicidality Among Pediatric Antidepressant Users. Carnegie Mellon University.

Follow along with me here:

1. Antidepressants can increase suicidal thoughts and behaviors in children and adolescents who were not having any, or many, suicidal thoughts or behaviors, according to a study of 4,600 children and teens (and, by the way, no one in this group of 4,600 committed suicide). This was the basis of the FDA's black box warning label.

2. But in children and teens who ARE having suicidal thoughts or behaviors prior to treatment with medications, antidpressants LOWER the risk of suicide. Simon and his group studied 65,000 medical records and found that the highest risk of suicide among the depressed was the month PRIOR to beginning treatment, and that the risks greatly diminished after beginning treatment with antidepressants (Simon GE, et.al., Suicide risk during antidepressant treatment. Am J Psychiatry. January, 2006)

3. Other studies have found that the more often antidepressants are prescribed to children and adolescents who could benefit from them, the lower the suicide rates (Gibbons RD, et.al., The relationship between antidepressant medication use and rate of suicide. Archives of General Psychiatry. 2005)

So the bottom line is, black box warning label or not, if your child or teenager is not depressed and is not having suicial thoughts or behaviors, they are probably better off not taking an antidepressant medication.

However, if your child or teen is depressed, and is having suicial thoughts, or has made suicide attempts in the past, he or she is probably better off taking antidepressant medication.