Treating Comorbid ADHD, Major Depression, and Panic

Case Report

A 38-year-old man was initially diagnosed with MD by use of the Inventory to Diagnose Depression (IDD), scoring a 38 (0–10 is normal). A trial of sertraline 125 mg produced a remission (IDD<10).

His generalized anxiety partially decreased on the sertraline, as measured by Beck Anxiety Inventory's (BAI) decreasing from 28 to 20. His panic attacks, occurring at a frequency of twice per week, continued on the sertraline, although with reduced distress. Having failed a competent trial of extensive exposure and cognitive reconstructing panic therapy prior to our treatment, he was tried on clonazepam 0.25 mg three times a day, producing a stable BAI of 4 (normal), with no panic attacks for 2 months.

Despite his improvement, the patient still met criteria for adult ADHD, with a childhood onset at age 5. Two first-degree relatives had ADHD. Common standard diagnostic scales such as the Brown Adult ADHD Scale, the Wender Utah Retrospective Scale, and the Semi-Structured Adult Interview for ADHD all confirmed his mental status exam and reported history.

The patient asked for a trial off clonazepam to “keep his medication simple.” He was weaned off clonazepam, and his BAI rose to a “tolerable” 15, with no clear panic attacks. A trial of 5 mg Adderall, at breakfast and at 2:00 p.m., caused clear, repeated anxiety spikes 4 hours after each dose. Since Adderall represents two stimulants or four different amphetamine compounds, one or more may have been exerting marked stimulation at the 4-hour mark.

Back on his clonazepam, the patient tried methylphenidate 7.5 mg tid (he had “failed” dextroamphetamine as a teenager). He had an 85% reduction of his ADHD symptoms, with no increase in anxiety.