ADHD with anxiety, depression and substance use

Many adults with ADHD also live with anxiety, depression, or problems with alcohol or drugs. ADHD often comes with other conditions, and each one can make the others harder to spot and treat.¹

This page explains why these conditions show up together and how a doctor sorts them out. It also covers which problem usually gets treated first, and how to use ADHD medicine safely when mood or substance use is part of the picture.

Why these conditions show up together

There is no single reason. Several things seem to work together.

• Shared roots. Genes, stress and life events can raise the risk of more than one condition at once.⁷
• The wear and tear of living with ADHD. Years of missed deadlines, lost jobs, money trouble and criticism can grind down mood and self-worth. ADHD usually starts first, and depression often develops later.³ Low self-esteem and quick mood swings are common in ADHD itself.²
• Risk-taking and impulse control. Teens and adults with ADHD are more likely to take part in risky behavior, including substance use.¹ Adults with ADHD smoke more often and have a harder time quitting.³
• Poor sleep. Up to 70% of adults with ADHD have sleep problems.⁶ Poor sleep can make focus, mood and worry worse. See sleep, mood and anxiety.

How common is the overlap?

Numbers vary from study to study. They depend on who was studied and whether they counted problems now or at any time in life.

Sources for the table: European consensus statement on adult ADHD (world surveys) and CHADD (other estimates).^2,3

ADHD is also easy to miss when another condition is in the spotlight. In a large U.S. survey published in 2006, only about 1 in 10 adults with ADHD had been treated for it. Many of them were already in care for anxiety, mood or substance problems.⁴ If you are being treated for depression or anxiety and still struggle with focus and follow-through, it may be worth asking about ADHD. See getting an adult ADHD diagnosis.

ADHD or something else? Telling them apart

Poor focus, restlessness, irritability and trouble sleeping can come from ADHD, depression, anxiety or substance use. A careful check looks at the whole picture. Doctors may need to rule out anxiety, depression, sleep problems and alcohol or drug misuse before calling it ADHD.⁵

Why bipolar disorder matters here. The ups and downs of ADHD can be mistaken for bipolar disorder, and the reverse can happen too.² Getting this right matters. Stimulant medicines can set off mania (a period of very high energy, little need for sleep and risky choices) in a person with bipolar disorder.⁹ ADHD medicine labels tell doctors to screen for bipolar disorder before starting. This includes asking about family history.^9,10 Learn more about bipolar disorder.

Bring a family member to the visit if you can. They may remember what you were like as a child, and they can describe mood changes you may not notice.

Which problem gets treated first?

There is no one rule for everyone. Experts in adult ADHD suggest this general approach.²

1. Find everything first. Before treatment starts, the doctor looks for all the conditions that are present. You and the doctor agree on the order together.²
2. Treat the most serious problem first. Psychosis, bipolar disorder, drug or alcohol misuse, severe depression and severe anxiety usually come first.²
3. Treat milder problems side by side. Mild low mood, mild anxiety and mood swings may get better once ADHD is treated. They can be treated at the same time.² Treating ADHD first can lower stress and free up attention to handle the other condition.³
4. Steady substance use, then add ADHD care. Drug and alcohol use should be brought under control first, but ADHD can be treated alongside it.²
5. Review the plan over time. Needs change. Plans should be reviewed at least once a year.³

ADHD with depression or anxiety

Talk therapy, medicine, or both can help. Cognitive behavioral therapy (CBT) teaches skills that fit ADHD, depression and anxiety. See therapy and coaching for ADHD, treatment for depression and treatment for anxiety.

Many people take an ADHD medicine and a medicine for mood or anxiety together. Some pairings need extra care:

• MAOI antidepressants. Stimulants such as amphetamines must not be taken with an MAOI (an older type of antidepressant), or within 14 days of stopping one. The mix can cause a dangerous rise in blood pressure.⁹ Atomoxetine (Strattera) must not be combined with an MAOI either.¹⁰
• Common antidepressants. Taking an amphetamine with an SSRI or SNRI antidepressant raises the risk of serotonin syndrome, a rare but serious reaction. Doctors can still use them together, with close watching.⁹
• Atomoxetine and other medicines. Some medicines raise the level of atomoxetine in the blood. The doctor may then adjust it more slowly.¹⁰
• Mood changes on treatment. Atomoxetine carries a boxed warning (the FDA's strongest warning) about suicidal thoughts in children and teens. Adult studies did not show a higher risk.¹⁰ Even so, any mood change after starting or changing a medicine is worth reporting. In stimulant studies, new manic or psychotic symptoms were rare, about 1 in 1,000 people.⁹

Your doctor starts low and goes slow. Talk with your doctor or pharmacist before changing anything. For more, see ADHD medicines.

ADHD with alcohol or drug use

Does ADHD raise the risk? Studies have found more substance problems later in life in young people with untreated ADHD. Some studies suggest the extra risk is mostly in those who also had serious behavior problems as children.⁷

Does ADHD medicine lead to addiction? The research is not final, but many studies suggest ADHD medicines do not raise the risk of a substance use disorder.⁷ In adults with no past substance problem, stimulants do not appear to trigger one.² In a large U.S. insurance study, people had fewer emergency visits tied to drugs or alcohol in months when they took ADHD medicine than in months when they did not.⁸ Moderate evidence

But stimulants can be misused. Stimulant labels carry a boxed warning. These medicines have a high potential for misuse, which can lead to addiction, overdose and death. The risk is higher at higher amounts or when the pills are crushed and snorted or injected.⁹ Your doctor should check your risk before prescribing and keep checking during treatment.⁹ Never share your pills. Keep them in a safe place, away from visitors and family.

Treatment for people with a substance use disorder. Treating ADHD in people with a substance use disorder can ease ADHD symptoms without making substance use worse. Experts say it should not be avoided.² Moderate evidence Some points doctors weigh:

• Long-acting forms. Long-acting forms with lower misuse risk are preferred. Experts advise avoiding short-acting (immediate-release) stimulants for people with a substance use disorder.²
• Non-stimulant options. Atomoxetine is not a controlled substance. In an adult study it did not produce a "high."¹⁰
• Medicine plus therapy. ADHD medicine alone has only a small effect on substance use itself.² Trials that paired ADHD medicine with CBT showed better results for both problems.²

The substance use disorder needs its own care too. The SAMHSA National Helpline at 1-800-662-4357 is free, private and open 24 hours a day, every day, in English and Spanish. It can refer you to treatment and support near you.¹¹

In later life

ADHD, depression, anxiety and alcohol use can all affect memory and focus in older adults. Drinking problems and low mood are easy to miss after retirement or a loss. Older adults also tend to take more medicines, so drug interactions matter more. Bring a full list of your medicines, supplements and alcohol use to every visit.

Read more on ADHD in later life, depression in later life, alcohol in later life and medicines that can affect mood and memory.

Questions to ask the doctor

Could it be ADHD, a mood problem, or both?

• Have you checked for depression, anxiety, bipolar disorder and sleep problems?
• Could alcohol, cannabis or another substance be causing my symptoms?
• Would it help to hear from a family member about my childhood?

What should we treat first?

• Which problem is causing me the most harm right now?
• Can we treat ADHD and my mood or anxiety at the same time?
• How often will we review the plan?

Is this medicine safe with my other medicines?

• Can my ADHD medicine be taken with my antidepressant or anxiety medicine?
• Is a long-acting or non-stimulant option better for me, given my history?
• What mood changes should I report, and to whom?

When to get help

If you are worried about a family member, see supporting someone in treatment and when a family member is in a mental health crisis.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.