614- Identifying Co-Occurring Mood Disorders in Adults with ADHD

0:03Welcome to the Attention Deficit Disorder Expert Podcast Series by Attitude Magazine.

0:13Everyone, I'm Annie Rogers, and on behalf of the Attitude team, I'm so delighted to welcome you to today's ADHD Experts presentation titled Identifying Co-Occurring Mood Disorders in adults with ADHD. Leading today's presentation is Desiree Matthews, who is leading her first webinar for Attitude, and we're so happy to have her. Desiree is a board-certified psychiatric nurse practitioner and founder of Different Mental Health Program, an integrative telepsychiatry practice focused on diagnostic clarity, evidence-based treatment, and whole-person mental health care. She specializes in ADHD, mood disorders, and complex psychiatric presentations across the lifespan.

1:04Desiree is faculty and serves on a steering committee for Psych Congress, where her educational work focuses on translating both core psychiatric principles and emerging clinical advances into practical strategies for frontline mental health providers. Her work focuses, excuse me, we're extremely lucky to learn from Desiree as she explores the connection between ADHD and common mood disorders, including anxiety, depression, bipolar disorder, and PTSD. Desiree will provide practical insights into how these conditions overlap, why they are frequently overlooked, and what evidence-based treatment and lifestyle strategies can help improve long-term outcomes.

1:52Finally, the sponsor of today's webinar is Accentrate, featuring Lysovita LPC, a premium omega-3 ingredient designed for enhanced brain delivery. Accentrate Omega Max is formulated to support mood balance, emotional wellness, and overall brain health. Designed for teens and adults seeking natural support for emotional health. Accentrate Omega Max provides a high quality formula developed to complement healthy lifestyle habits and professional care. Click the link on your screen to learn more about Accentrate Omega Max. Attitude thanks our sponsors for supporting our webinars. Sponsorship has no influence on speaker selection or webinar content.

2:41Okay, without any further ado, I'm so pleased to welcome Desiree and Matthews. Desiree, thank you for joining us and for leading this really important discussion on the mood disorders that accompany ADHD. Yes, thank you, Annie. I'm so happy to be here with my first webinar with you all. So thank you so much and thank you for that very

3:03Desiree Matthews: kind introduction and segue into our webinar today. Here are my disclosures just for a brief glance. For a number of years, I have consulted with a number of pharmaceutical companies over a diverse area of therapeutic areas in mental health and neurology. Annie went over our learning objectives very well, and I did have a chance to peek at some of the questions that were submitted during registration. So I'm really excited to help go over and really understand the nuances between ADHD, but also mood disorders, because as we'll learn, and I'm sure many of you have lived experience, this is a very common scenario where ADHD also travels along with many other mood disorders.

3:53Desiree Matthews: Up to 70 % of adults living with ADHD actually have at least one or more co-occurring condition. And although the literature really much uses that term comorbidity, I really like to think of this as more of a multi-morbidity. And the reason for that nuance is because ADHD and say generalized anxiety disorder, these can be two very prominent conditions rather than having just one primary condition. I really think about this more holistically because people can have very much prominent, say, major depressive disorder or generalized anxiety disorder, along with ADHD. And both can be just equally impairing, maybe in different ways.

4:39Desiree Matthews: So I really like to think of this as more of a multi-morbidity. In my clinical practice, I would say probably 8 out of 10 individuals that live with ADHD, I also treat or help manage a multi-morbidity, whether that be a mood anxiety disorder. Of course, substance use disorder is also highly comorbid in ADHD, but we won't really get to that. That could be a whole separate two-hour presentation. But the reason these are so commonly occurring is the fact that we may think of this as having kind of a sort of root underpinning that is the same across the whole spectrum of psychiatric disorders. And what can make diagnosis very complicated, not only getting the initial diagnosis of ADHD, but also teasing apart, is there another condition that warrants a clinical diagnosis is the fact that symptoms are really trans-diagnostic across many different conditions.

5:44So if we just go with the chief complaint of, hey, you know, I'm having trouble focusing, I can't concentrate. Maybe I'm having executive functioning issues. Well, guess what? If you look at this graph, it really shows us that things like attention or executive function is disrupted

6:02Desiree Matthews: in many different disorders, not just ADHD, but we have it in depressive disorders, of course, schizophrenia, PTSD, anxiety disorders, as well as other neurological-based disorders such as Parkinson's disease and of course advanced stages of Alzheimer's as well. So it's really important and I really come from kind of a clinical practice model where we do a very thorough screening on everybody that comes in even if they have a diagnosis already. I would say the top two reasons people come into my practice is because they're looking for diagnostic clarity and or they're looking for different treatment options because what they have on board is either not working or potentially causing side effects that are causing, you know, just issues with quality of life and being able to maintain on treatment.

6:55So going with the chief complaint can lead us astray, whether we're missing or making misdiagnosis. And thinking about psychiatric disorders, again, thinking about a composition or thinking about the root causes, we understand

7:11Desiree Matthews: now from neurobiological research, genetic research, that many of the risk factors in our genes are risk factors for more than one mental health disorder. So you can see kind of a illustrated representation of that here on the left, where ADHD may have kind of genetic underpinnings related to maybe vulnerability of developing depression, anxiety, PTSD, of course bipolar disorder as well and on the right is actually looking at some genetic risk factors and studies and you can see ADHD there in the red or pink really crosses over with shared genes that may be responsible not just for ADHD but for anxiety disorders as well as mood disorders so I really like to think that there's probably a root think about a tree right we have kind of the root and the trunk.

8:06Desiree Matthews: And then off of that, we have our branches and those branches may be symptom clusters that could be consistent, say, with depression, with ADHD, but we're really kind of coming from that one root cause. Of course, there are environmental factors, adverse childhood, you know, traumatic situations that happen like neglect or abuse that can all really confound and, you know, maybe cause one condition to maybe come out. But certainly there is that inherent genetic risk that we're seeing from a lot of these conditions. Furthermore, we also have certainly sex differences when it comes to presentations.

8:48Desiree Matthews: Of course, many of you are probably familiar with ADHD and just how that looks and men versus women, young girls versus young boys. But when we think about our comorbidities or these multi-morbidities that we can see travel along with ADHD, we also see specific sex differences between men and women. Women tend to have higher rates of anxiety, bipolar disorder, as well as major depressive disorder, as we can see on this graph. And men actually tend to have higher rates of, say, substance use disorder. There are a few male-dominated conditions like substance use disorder, autism, as well as schizophrenia.

9:31Desiree Matthews: It doesn't mean that women cannot have these conditions and vice versa, but we do see that there are specific sex differences. And some of those reasons may actually be differences in the way that we express or synthesize certain neurotransmitters. For instance, women actually have 20 % more norepinephrine neurons than men, and estrogen also plays a role in norepinephrine regulation and actually allows more norepinephrine to actually stay around and hang around in the brain. Conversely, men actually have more serotonergic capacity in terms of synthesis, and this may really understand and give us a reason why maybe mood or stress-related disorders like anxiety or depression can be more prevalent in women because serotonin can kind of insulate you or kind of be a buffer between stress.

10:28Desiree Matthews: So it's really interesting that not only do we see shared risk factors and genes really across men and women, but if you get down to it, there are differences in our brain in terms of neurotransmitter synthesis, as well as other regulations such as sex hormones like estrogen. Chicagoland Wayfair's Wayday sale is on at the Wayfair store. From October 24th through 26th, you can score huge deals on everything home in person, like up to 80 % off area rugs, up to 40 % off appliances, and up to 60 % off home reno. Plus, you can take home the small stuff that day and get the big stuff shipped fast and free.

11:11Shop Wayday, October 24th through 26th at the Wayfair store at Edens Plaza in Wilmette. Wayfair, every style, every home. Serotonin is also very much an underpinning that we understand is very important now in ADHD. We never really paid too much attention to serotonin over the past few years. We've really been able to understand from brain imaging studies, but also looking again at this shared pathway in terms of dysregulation. It's not so much about, do I have too much or too little dopamine? Do I have too much serotonin or not enough serotonin? What we understand is that globally in our brain,

11:57Desiree Matthews: we can see dysregulations in serotonergic pathways and ADHD, but also in depression, anxiety, and bipolar disorder. So some of these disruptions will carry over to other disorders. Serotonin is so important, not just for mood and regulating kind of anxiety symptoms, but also in ADHD, we need serotonin regulation to make plans, to have impulse control, to be able to pay attention. It affects the reward processing. It affects motivation and arousal. So really understanding that serotonin plays an important role. And if there's dysregulation in ADHD, there's dysregulation potentially in depression.

12:43Desiree Matthews: You can see where now some of this, we can become more vulnerable when there are, say, external stressors. Maybe we're not sleeping well. maybe we have a sudden trauma you can see how this maybe make the brain vulnerable to more dysregulation and not surprisingly the most common medication prescribed alongside ADHD medication is actually an SSRI and I think really it's because we're trying to get at the root of this maybe it's the emotional dysregulation associated with ADHD maybe it's actually depression maybe it's actually potentially bipolar disorder, but we do see that SSRIs are frequently co-prescribed alongside ADHD treatment, whether that's to treat a comorbid condition or maybe it's actually trying to treat some of the emotional dysregulation symptoms that we see in ADHD.

13:39So overall, I think the key takeaway that I really want to stress is that you or a loved one,

13:45Desiree Matthews: And if you are having symptoms, you're maybe getting treatment, but things are still lurking under the surface, really make sure we're diving a little bit deeper. Just because you have a symptom doesn't mean that it's diagnostic. Of course, sleep can happen across a whole host of different medical as well as mental health conditions. And it's really important to have a good thorough workup and evaluation because an accurate diagnosis, well then at least hopefully we'll end up to more effective treatment because as we'll see in here in just a minute, depending on the diagnosis, there are specific treatment that may be more indicated or evidence-based versus another.

14:32Desiree Matthews: And I get a lot of questions in clinical practice is really, is this more than maybe what my diagnosis? A lot of times people are getting the ADHD miss. Maybe they're feeling irritable, moody. I just actually had that last week. Someone said, maybe I have bipolar disorder. And when we did some deeper screening, I said, hey, you know, I actually think you have ADHD. Because again, mood can go up and down, of course, in ADHD, we can have our ups or downs. But oftentimes that is just, you know, very short-lived and things kind of come back to baseline. If it's more up and down with discrete, say, energy patterns, they change, they switch.

15:15Maybe we're thinking more bipolar. If the depression is enduring, then maybe that's more major depressive disorder. So I think if there's

15:25Desiree Matthews: any change from baseline, if we're taking treatment and we're not really seeing improvement and our quality of life, that's really a good time to say, hey, is there something more that's going on? Because again, you can be living with ADHD. Things are going well. Maybe there's some increased stressors. Maybe you're not sleeping great. This can make us more vulnerable to say developing major depressive disorder episodes. So things are not always static. Just because we have one diagnosis doesn't mean that's going to be what we have for life. Things definitely can wax and wane and change over time.

16:00So certainly when we start to get to functional impairment, our quality of

16:05Desiree Matthews: life is not great. We're really struggling. I really encourage people to reach out and just make sure that we have a good thorough understanding of what's going on. So with that, we're going to move in and talk about our mood disorders first. So major depressive disorder, because it is one of the most common mental health conditions that we have in the U.S. Unfortunately, things are not slowing down in terms of the number of cases when we look at adults in the U.S. And major depressive disorder certainly has evolved over the years. You know, again, this is not I feel sad for a day or two and then I'm fine.

16:46Desiree Matthews: This is really having persistent depressed mood and or a loss of pleasure or interest in things for at least two weeks. And it's a pretty significant change in terms of functioning. We can see sleep disruption, changes in appetite, energy levels. Unfortunately, suicidality can also occur. But the point is that this is very distinct from, say, with ADHD, where we can have some emotional dysregulation, some irritability, feeling sad, sometimes kinds of motivational concerns also can play a role. But this is a very distinct, very discreet period of time. Oftentimes for folks, it can last months, if not years, if not addressed.

17:33Desiree Matthews: There are a lot of flavors of major depressive disorder. We have a lot of different specifiers now in our diagnostic manual. Really, we'll touch on just a few with the peripartum onset, otherwise known as postpartum depression. That is something that's really important to identify because there are specific treatment interventions that go along with that. And then treatment resistant depression, which unfortunately up to 30 % of people living with major depressive disorder will meet this criteria. That's trying two medications from one or more different classes for an adequate dose and duration.

18:12So not just, you know, I take some medication, it doesn't work after a week. This is a true thorough trial, but still, even with trials that are thorough, we see about 30%.

18:22Desiree Matthews: And this has a big implication on my patients if they come in with this criteria, because that really changes the treatment options that we may offer to them. So many of you probably are very familiar with antidepressants. Again, ADHD, the most common prescription alongside of that is an SSRI, such as escitalopram or fluoxetine. There's also SNRIs. There's bupropion, which increases norepinephrine and dopamine. So we do tend to see a lot of this maybe with ADHD medications. It can be a little bit synergistic in terms of if somebody has major depressive disorder, They're looking for maybe a weight neutral option or option with minimal sexual side effects.

19:11Desiree Matthews: This can be quite a common prescription that I see in my clinical practice. But the point is there's options. They tend to be more alike than different in terms of how well they work for somebody. It's really the side effect profile that we're looking at that is significantly different. But I think one of the biggest pitfalls I see in clinical practice is antidepressants is started, but there's really minimal follow-up. Really, the general rule now is if we start somebody on an antidepressant, we want to make sure that we get people having some response in two weeks. So what I look for is about a 20 % to 25 % reduction in symptoms in two weeks.

19:56And if that doesn't happen at that two-week follow-up, we're doing something.

20:00Desiree Matthews: Either we are increasing the dose or potentially we are looking at switching based on how well they're tolerating the treatment. But what we don't want is to start an antidepressant and go months without seeing your provider or having a check-in. The longer we leave folks in a depressive episode, the harder it is going to treat it, the less likely we're going to see remission. And remission should be the goal when we think about depression, because if we don't see remission and get rid of these symptoms as quick as possible, there is a higher chance that you may relapse. There's a higher chance that this will come back or be harder to treat.

20:42So certainly getting into remission, not only because that's good and we want to be back and have full restoration of our functioning, but it does change the prognosis of the disorder in terms of treatment and, you know, making sure that it doesn't come back. Is your home wish list just sitting in your cart? Well, get ready to hit checkout because Wayday at Wayfair starts October 24th with up to 80 % off everything home. That new sofa, the rug you've been eyeing, the upgrades you've been putting off, they could all be way less during Wayday. It's Wayfair's biggest sale of the year. So make your list and mark your calendar.

21:19Shop Wayday starting October 24th for up to 80 % off everything home at Wayfair.com. Wayfair, every style, every home. So treatment considerations, you know, when we think about ADHD medication, So if I have clients on ADHD medication, we identify the need to treat major depressive disorder.

21:40Desiree Matthews: Of course, psychotherapy is an option, especially if it is mild or maybe there is significant preference not to take additional medication. That's certainly understandable. But SSRIs are the most common. They are cost effective. They are widely accessible. But there are some other treatment considerations when time matters. There are some rapid acting treatments. Orally, we have dextromethorpe and bupropion combination. That is a little bit newer. It is a branded product. There's also esketamine, which can actually work within 24 hours to alleviate symptoms of depression. And we also have neuromodulation.

22:20Desiree Matthews: So if people may not prefer to take more oral medication, there's neuromodulation called TMS, for instance, that is available. again some of these may have other costs associated with it there are some you know step therapies that people may have to go through such as the SSRIs but these can definitely be options and by the time you get to my practice we're probably looking at these treatment options but the point is we should really make sure that we understand kind of preferences if you've had side effects before, like weight gain or sexual side effects that really encourage everybody to explore options that may not have those side effects.

23:02Desiree Matthews: Because if we can't take a treatment option, there's no way that it's going to help. So what happens if people get a little bit better with the antidepressants? So there are FDA approved adjunctive options available. There are five of them now, these are in the class of antipsychotics. Now, I really wish we would leave that term off the table, but if you look in the prescribing information, that's what the FDA is going to have in these medications. But there are specific ones that are approved to be added on to your oral medication. Some of them do come with maybe some different side effect profiles, like movement disorders like restlessness, akathisia, even more permanent movement disorders like tardive dyskinesia.

23:51That's probably one of the bigger long-term side effects that we really need to talk to our patients about if we do choose this class of medication. But this can be really helpful even if it's just short-term rather than maybe long-term that can help when maybe we have some response from our antidepressant and we just feel more comfortable adding on. This is a very viable option. And even things like lumatepirone, this actually shows a little bit of weight loss rather than weight gain. So these medications are not all created equally, even though they may be within the same drug class. Real quick on postpartum depression, you know, therapy is first line.

24:35Postpartum depression can happen during pregnancy. The DSM states, you know,

24:40Desiree Matthews: In four weeks of delivery, I really look at it a little bit longer term. So really looking a year out. We understand postpartum depression is likely influenced by hormone changes. So zeralanone was developed as an oral neuroactive steroid that actually works on the GABA system. So it doesn't work on serotonin or norepinephrine. It actually works on the GABAergic system. It's 14 days. You can take it with or without other antidepressants on board. So it's literally a 14-day treatment. You take it once at bedtime. There is a black box warning, though, due to the potential for somnolence or sedation.

25:24That can be a problem if you're going to, say, drive. So there are some nuances with that. But OB can prescribe this primary care if they are in a psychiatric setting already.

25:36Desiree Matthews: So some of my individuals living with ADHD, if they do develop postpartum depression, this is something we certainly consider as a tool. We talked about esketamine. This is for treatment-resistant depression. The biggest thing I want to say for this is that you can use this alone or with antidepressants on board. And this is going to be an in-person treatment. So it's a nasal spray of esketamine, which helps really leverage the brain's ability to have kind of this neuroplastic effect. So it doesn't work on serotonin or norepinephrine. It works much differently. And it is for treatment-resistant depression.

26:19Desiree Matthews: Usually it's twice a week for the first month. And then people go on to once weekly after that and then touch up treatments as needed. I would say some of the advantages is that it's rapid. You don't have to take a pill every day. Some of my clients really like, you know, to not have to take oral medication every single day if possible. So definitely an option for those folks that I've tried treatment before. They qualify for that treatment-resistant depressive diagnosis. And the benefit of S-ketamine, maybe over ketamine infusions or sublingual formulations, is that this is approved by the FDA.

26:59Desiree Matthews: So there's a pathway for coverage if you do have insurance. There can be a pathway to get this covered. So just to round out, for those people that may not be interested in more medication-based options, There is Rejoin, which is a prescription digital therapy approved for a major depressive disorder alongside standard of care. This actually leverages brain training exercises. You do it for six weeks, takes about 30 minutes, three times a week. There's also layered into this app CBT or cognitive behavioral therapy lessons. This is really great option for people that really want to take treatment more into their own hands.

27:42Desiree Matthews: They want treatment on their own schedule. And we actually use and take advantage of our ability to recognize emotions as humans. And it really works in the form of exercise. We have to kind of identify the expression. So we have in the app mad faces, surprised faces, happy faces. And we have to match the emotion to the previous one that we saw. So in this example, we have a lady right now, she's smiling and it's going to ask you, does this match the previous one? The previous one would be this gentleman kind of with this like angry face. And this can get quite challenging because you may have to remember like five faces back.

28:27So, you know, I think the point is that this can be very helpful in kind of rewiring and exercising the brain so that it's better connected with each other to help alleviate symptoms of depression. So quite fascinating. You do need a prescription for this. So if you just, you know, Google this from the app store, for instance, you'll notice that you do need an access code. So this is prescription and has been approved by the FDA. Last but not least, neuromodulation. We talked about this. This is TMS, stimulates neurotransmitters using magnets.

29:04Desiree Matthews: There's also at-home neuromodulation options as well. I think one of the biggest things is that this is in person. It is generally over 36 sessions. So traditionally, people are going maybe five days a week, say for five or six weeks. There are also the SAINT protocol for TMS. I'm lucky in Charlotte, we actually have a week-long protocol for TMS that really shrinks those 36 sessions just down to one week. So definitely something to consider if medication, oral medication may not be the best answer. So the point is lots of different options. It's not a one size fit all treatment. So now moving on to bipolar disorder.

29:51Most of us are going to recognize bipolar disorder probably as bipolar depression. That is what is most commonly presented in the clinical setting. Certainly, we do need that index episode of mania. And that's where talking about ADHD and bipolar disorder and having that conversation and really a nuanced conversation is so important. It's not just mood up and down, although mood is a component, of course, of bipolar disorder.

30:25Desiree Matthews: What we see as more of kind of a diagnostic kind of differentiator is really this discrete period for an increase in energy with this kind of increase in goal-directed activity. For bipolar one, this is one week or more or any duration if somebody has to go to the hospital or if there's psychosis involved with the mania. There's also, you know, certainly other behaviors such as impulsivity, excessive, you know, engagement and high risk activities. But I think the big thing is really looking for that discrete period of decreased need for sleep and increased goal directed activity. because we don't see that sustained in ADHD.

31:14Bipolar II, again, the differences there is the impairment of the mania.

31:21Desiree Matthews: We really call that hypomania. So maybe lasting a little bit shorter and it's not necessarily impairing to the degree that bipolar I mania episodes are. I will say and caution that bipolar 2 depression, this is not necessarily like one is any more severe than the other. In fact, bipolar 1 and 2 depression really can be equally as severe and disabling. It's not kind of just a lighter version because in reality, most people spend most of their time living with bipolar more in the depressive episodes. And that can make it really difficult sometimes to distinguish it from other disorders such as ADHD or major depressive disorder.

32:09But there certainly are some things that can help in clinical practice or if you or your loved one have concerns that this could possibly maybe be more than major depressive disorder.

32:19Desiree Matthews: We have the mood disorders questionnaire and the rapid mood screener. And this is really looking at predictive and diagnostic features of mania. I really like the rapid mood screener because it also adds some other risk factors. For instance, if you've had a lot of depressive episodes prior to the age of 18, that does increase the risk or probability that this could actually be bipolar depression and we should look a little bit deeper. It's not diagnostic, but certainly a screener can be helpful to kind of get the conversation started with a healthcare provider or a loved one. As far as treatments are concerned, you'll notice for bipolar 1 and 2, although, yes, we're talking a lot of times about treating the depression, but guess what?

33:10Desiree Matthews: Antidepressants, we really don't see efficacy for that class of medications. So the mainstay of treatments are either going to be antipsychotics that modulate serotonin and dopamine amongst other receptors, as well as mood stabilizers. The biggest thing with this class of medications, again, we want to make sure that we understand there are differences in tolerability or safety, but also differences in what these are going to treat. There are only a few medications that are FDA approved to treat bipolar depression. And in this graph, you can see even less that are approved for bipolar 2 depression.

33:53Desiree Matthews: Lumetepirone, my apologies, there's a typo there. Lumetepirone and quetiapine are the only two medications that are indicated or FDA approved for bipolar 2 depression. In clinical practice, however, we tend to use other medications that have approval for bipolar 1 depression as well. So really understanding kind of where you are in terms of the bipolarity really will make a difference in terms of what treatment options may be considered first. There are also mood stabilizers. I tend to work with a lot of young individuals that may be childbearing age or maybe they are looking to start a family.

34:34So we really have to take into consideration medications that may have reproductive concerns in terms of harm. And you can see the call outs there for belfrate as well as carvazepine. So those are considerations.

34:49Desiree Matthews: Lithium, I would say, still tends to be underutilized. This is great. medication, especially if you're trying to stay away maybe from the antipsychotic category just because of certain side effects. But lithium does tend to work better if we use it earlier in the course of the illness. So it's really important to try to ensure that diagnosis is made as soon as possible. Last but not least, there are longer acting treatments. So for folks that may not love to take medications every day. Maybe they want to be able to have a little bit more discretion. This can be really popular with my college students.

35:28They don't necessarily feel comfortable

35:30Desiree Matthews: of having that stigma that is still unfortunately associated with bipolar disorder. Sometimes they feel that having a long-acting treatment is a little bit more private. And we have medications such as aripiprazole and risperidone that are available to be given via an injection by a healthcare provider, such as a nurse, a doctor, pharmacist. And it's actually given in the arm for aeropiprazole as an injection. It lasts one or two months. And there's also risperidone as a subcutaneous injection. So it's a smaller needle and it goes under your skin in a little bit of a fat fold. So either the back of the upper arm or around the abdomen.

36:12And that lasts once a month. So these can be really helpful. And if you look at the literature, we really see a lot of benefit from these longer acting treatments in terms of producing better outcomes, such as a lower chance of a relapse. So these are available. Sometimes it can be a little hard sometimes to get access to this.

36:36Desiree Matthews: Not all providers may utilize this, but even in private practices like myself, we utilize our pharmacy programs to help make sure that patients have access to these treatments when they are needed or preferred. And then last thing I'll say about bipolar disorder, and this can be tricky in clinical practice. Oftentimes folks need treatment for both. This is a common comorbidity. I think the big thing is really making sure that patients are aware, clinicians are aware to monitor for signs of mania or hypomania because unfortunately ADHD is increasing some neurotransmitters that certainly may lend itself to having mania or hypomania because we're increasing dopamine and really in bipolar disorder and mania, we already have kind of excess dopamine release during these episodes.

37:33So really making sure to have a clear understanding of if this happens, what do I do? Unfortunately, that is generally stopping the ADHD medication or any medication that could be worsening the mania for a period

37:47Desiree Matthews: of time. So there certainly needs to be adequate stabilization of the bipolar disorder. This is probably the one time where I would not treat these together. If someone came in with, say, depression, major depressive disorder or anxiety, I would feel very comfortable treating both of those at the same time if they were new to treatment. But if this is certainly a bipolar disorder and ADHD, the bipolar disorder is going to have to take precedence. And once we have stability there and we have a good game plan, then we can carefully start to treat ADHD, whether that be with a stimulant or a non-stimulant.

38:26We see a lot of safety data, of course, with methylphenidate, but that doesn't mean that we can't use other stimulants or non-stimulants alongside. So PTSD, this is really the criteria. You guys have this for your reference. I think

38:43Desiree Matthews: of what is clinical interest right now is really the evolving definition of complex or CPTSD. We really have kind of a lot of the same core symptoms. However, we oftentimes see additional symptoms, including a lot of difficulty with regulating emotions, a lot of shame and guilt, trouble with interpersonal relationships. And a lot of times this is caused by trauma that is really seen as inescapable. So childhood trauma, domestic violence, that's difficult, prolonged, and we can't get away from. Not necessarily, you know, just something that happened maybe once, but really repeated and prolonged trauma that's inescapable in many cases.

39:34Desiree Matthews: And with ADHD, unfortunately, we do see in this population that they are more likely to also develop PTSD. Now, not everybody will develop PTSD after a trauma or repeated trauma. However, we do understand that there is some inherent concerns in terms of untreated ADHD, more likely to get into a car accident. And car accidents or motor vehicle accidents can certainly be a significant source of development of PTSD. We may see higher childhood adversity or interpersonal conflict. and unfortunately even in childhood we see that there may be greater risks of bullying that that's a very unfortunate and and can persist for quite a number of years if it's not if it's not dealt with so we do see that there are just at the end of the day in ADHD increased exposure to trauma but again thinking about the underpinnings we have this kind of some dysregulation of dopamine, norepinephrine, and serotonin in ADHD.

40:49Desiree Matthews: And this can overlap and can make maybe us more vulnerable, perhaps, to develop PTSD. So it's a very complex interplay. But nonetheless, we should be aware that this can happen. And if you have experienced trauma or your patients have experienced trauma, I really encourage screening for PTSD for everybody. Sometimes the traumas are not so easy to bring up in clinical practice. Maybe you have a new client, you're a new patient to a provider. But sometimes I find these clinical screening tools to be a really good way to segue into a deeper conversation. In terms of treatment options in ADHD, there's not necessarily any big precautions that come to mind.

41:42Desiree Matthews: Psychotherapy is still the mainstay of PTSD treatment. We do use SSRIs, SNRIs. There is not a lot of FDA approved options, unfortunately, for this category. And that's why many of us in the field are really looking for alternatives because we know that medications really don't always do the best job. And that's why psychedelic therapy, for instance, is very welcome in the field right now, could that potentially help people recover from trauma? There are also some FDA-approved digital therapies that are really cool. PRISM is actually a biofeedback system, and it helps people expose themselves to non-traumatic simulations on a computer while helping them understand to relax and reduce their stress through a biofeedback system.

42:35Desiree Matthews: So you can see they have that cap. Generally, it takes about two to three hours and is over a course of about eight sessions. But this is a really cool option. And if you have a facility near you, that is wonderful. I think that's kind of the biggest issue right now is there may not be the best access to this. There's also Nightwear. It uses an Apple Lodge. This is great for people that have issues with nightmares related to their PTSD.

43:11So now going to anxiety disorders. There's a number of anxiety disorders. I think the key takeaway here is that when we think about anxiety, is this a symptom of the ADHD or is it an actual standalone diagnostic separate criteria that they've met? Oftentimes, I like to ask patients, okay, you're feeling anxious. Like, what are you anxious about? Oftentimes in ADHD, we hear a lot of anxiety in terms of thinking about their to-do list and things are kind of

43:45Desiree Matthews: just running through their head about what I have to get done. What did I forget to do today? whereas generalized anxiety disorder is generally really it's all over the place it's about any little thing there's a lot of catastrophizing there's a lot of kind of ruminating about how to maybe prevent something bad from happening there's a lot of planning and just like mental energy that goes into generalized anxiety disorder when we think about treating any sort of anxiety disorder alongside ADHD, really understanding that there may be concerns that stimulants, for instance, could mimic some symptoms of anxiety, like feeling restless, maybe heart racing.

44:30So it's important to sometimes tease apart, is this maybe a medication side effect? Is this anxiety? So we really do have to kind of look at that from more of a holistic standpoint. And then thinking about OCD, for instance, that can be well treated with medication and therapy. But a lot of times what I see is people try SSRIs, but they only, you know, they're maybe trying, you know, just like halfway through the dosing range. A lot of times we need much higher doses to successfully treat OCD rather than, say, anxiety or social phobia. So really important note there.

45:14Desiree Matthews: And if medication is not always a great answer for folks, there are digital therapies like Free Spira. This actually helps use biofeedback through a sensor device. It's super cool. helps people go through guided breathing to help reduce stress. This can be used for panic and PTSD. And then last but not least, you know, we can't have a webinar without talking about sleep. And what I will leave you with is in terms of insomnia, we really want to do our best to not only use good sleep hygiene, but introduce the concept of cognitive behavioral therapy. And this is something that can be delivered simply through a workbook,$14 online for a workbook for CBTI that people can do.

46:05Desiree Matthews: They can see a therapist, a psychiatrist, and there's also a digitally delivered therapy called Sleepio that walks individuals through CBTI. Certainly, there are medication considerations and other sleep disorders that may mimic insomnia. but really the importance is to understand that this is really a core feature and a pillar of not only medical wellness but also of course wellness in mental health whether that be ADHD, depression, anxiety when we don't get a good night's sleep our day is going to be much harder and can certainly exacerbate or increase symptoms that we see from other mental health disorders.

46:50Desiree Matthews: So with that I I would love to invite Annie back to go over any questions that have come up during this webinar. Desiree, thank you so much for that incredibly thorough presentation. You covered so much ground. We so appreciate your expertise in all of the above. And before we launch into Q &A, I will quickly thank Accentrate for sponsoring today's webinar. Okay, lots of great questions today. I wanted to start with you touched on a little bit the impact of estrogen and how hormonal changes may trigger changes in ADHD and mood disorders. I wonder if you could just give us a bit of an overview, the science that we understand today regarding the impact of hormonal changes, specifically in perimenopause, what an individual might experience and a better understanding of estrogen in particular?

47:57Yeah, absolutely. So such a great question. So unfortunately, you know, estrogen and progesterone can be protective in terms of mood disorders when our estrogen and progesterone levels are elevated.

48:17Desiree Matthews: So people without perimetopause or metapausal symptoms, we understand that just fluctuations during a woman's cycle, we can tend to see increases in ADHD symptoms during the cycle. So right before our menses, we can see kind of in that luteal phase, progesterone and estrogen start to come down. And unfortunately, what a lot of our women will see is that kind of a week or two before their menstrual cycle starts, they can have increase in difficulties in terms of inattention symptoms. They can feel like maybe their medication is not working. And, Annie, there was actually a small study. It was nine women.

49:00Desiree Matthews: And they were given flexibility to increase their dose of their stimulant anywhere from 30 to 50 percent from their doctor. And what we found in nine out of nine women, this flexibility during that period where the hormone levels are decreasing can actually help maintain improvement across the woman's cycle during the month. We also see, you know, pre-ovulatory in women. We actually can see more inattentive symptoms and actually more alcohol consumption right before women ovulate, believe it or not. So it's a really interesting interplay. And certainly I encourage women, if you are experiencing symptoms and they seem to change based on your cycle and time of the month, to really talk to your doctor or healthcare provider because there may be potential options.

49:55Desiree Matthews: Now, for those folks in perimetopause, we understand that not only can this bring changes in sexual functioning, our hair, our skin, we can also see big impacts in terms of new onset anxiety symptoms, sleep disruptions. And as I talked about at the end, if our sleep starts to get disrupted, oftentimes times women will wake up in the middle of the night. They just seem like they're having restless sleep, sweating. Unfortunately, that will lead to vulnerabilities and increased stress on our body and brain that can even lead to major depressive disorder. But we also see a lot of women saying that their ADHD symptoms are also getting worse during this time and things just seem very unsettled.

50:44Mood is up and down, tearful, hot, sweaty, cranky. This really can throw people into a loop in terms of things were so steady for a while. Now, all of a sudden, why are things changing? And really looking at hormone changes, I think is important. We do suggest oftentimes women do get their hormones checked because sometimes small doses of estradiol and progesterone

51:10Desiree Matthews: can actually help improve symptoms of mood-related symptoms with perimenopause, but also low doses, say, of progesterone can really help maintain and get people better sleep without maybe adding on more antidepressants, adding on more add-on treatments. And I think that's sometimes where we get where we go wrong. We end up looking at, oh, hey, this is new diagnosis. This is worsening of your depression when maybe really it's a hormonal cause. And then we end up with more and more medication on board when maybe the answer is hormone replacement therapy, which quite frankly can be sometimes more tolerable than increasing, say, our antidepressants.

51:51We're really trying to get at that root cause, Annie, and oftentimes hormone replacement can be the answer for many patients. And we're learning so much even now in real time, you know, research on, I don't need to tell you this research on women has been lagging and in this area in particular. And so I do feel like we're learning more every day. And there are so many women here today who, you know, it wasn't so long ago that it was thought ADHD, first of all, just resolved in adulthood and be that it impacted only boys. So a number of women are wondering, they've been diagnosed with bipolar disorder maybe for decades and they don't feel that diagnosis is correct.

52:38You touched on this a little bit. Are there just a few red flags that they could bring to their providers and say, I don't check this box, this box, this box. I know I'm 60 and I've never been diagnosed with ADHD, but I really feel I need to be considered. Could you just go over those few things that might signal it's maybe it's not bipolar. Yeah, absolutely. Again, as I mentioned, but bipolar disorder, if you ask somebody if they have mood up and down or mood swings, that is not helpful.

53:09Desiree Matthews: Everybody could say yes to that question at some point. It's really looking at that key piece. Have you ever had a period where you had a decreased need for sleep, but also significantly increased level of activity. So I'm thinking about, you know, those folks that can work, you know, 40 hours, but they're also double majoring in college and somehow they're kind of keeping things maybe all together, so to speak, from the surface. But it's really that energy and activity component that is most diagnostic. And most of the time you will have, you know, likely family history of bipolar disorder. you know and again it's not something that you may have recognized in childhood usually bipolar you're going to see this as an adult you're going to have many episodes of depression and quite frankly you know if we give people bipolar medication that have ADHD I mean they're not going to respond right it's just the wrong treatment so I think it's really important to advocate and say, hey, we've tried this.

54:14Desiree Matthews: My life is not getting any better. My functioning is not great. We really need to look under the hood. And sometimes finding an ADHD specialist, certainly primary care is a great source of mental health treatment in this country, but sometimes it's also just trying to find an ADHD specialist, no matter what age. I've treated individuals that are in their 60s. I know my colleagues, you know, have individuals in their 80s that take ADHD treatment. It doesn't matter how old you are necessarily and when you make the diagnosis. So really, I think advocating for yourself as much as possible and even showing somebody the RMS, the rapid mood screener.

54:56If you're checking no to these things or the mood disorder questionnaire, you know, that really warrants, you know, a second look at an evaluation for a potential ADHD because there's a lot of crossover. Thank you. I think all that's worth repeating. Okay. Number of people wondering if the science suggests they should be concerned about stimulant medication use exacerbating their symptoms of anxiety. um so again the the issue is sometimes we can certainly you know see of course anxiety listed as a side effect kind of in clinical trials um we also can understand people can feel restless

55:39Desiree Matthews: there can be um sometimes with these immediate release stimulants um that kind of increase in heart rate we kind of can see more um can feel it in our body so to speak um so sometimes um the release mechanism with these stimulants may lend itself to more bodily symptoms like restlessness. Your heart is racing. You're getting the dry mouth, which sometimes people get prior to having like a panic attack, so to speak. So it can be very unsettling sometimes. So yes, is there a concern? I also think there's a concern in terms of thinking about ADHD and associated anxiety symptoms. You can have anxiety symptoms that may not be generalized anxiety disorder, but we know maybe it's not the core feature of ADHD in our diagnostic checklist, but that can be something that we see quite frequently.

56:33And sometimes our stimulants always don't do a great job. Sometimes this emotional dysregulation, executive functioning problems with them can lead to a lot of anxiety

56:43Desiree Matthews: symptoms, a lot of times their stimulants don't do a great job at treating those. And I think that's why we're so hopeful in the field, thinking about, you know, biloxazine, for instance, which does touch on serotonin that could potentially help. Centenafedine is currently with the FDA in just a few weeks for a review to see if this could be FDA approved. And that potentially could be an option for folks that maybe their stimulants are exacerbating, maybe it's not doing a great job. We might have other treatment options, but at the end of the day, comorbid anxiety is very common. And sometimes we just do have to use a little bit of an SSRI or other targeted psychotherapy to help assist.

57:28Desiree Matthews: But yes, I think there should be, you know, obviously observation, but I think, you know, overly fearful is also not the way to go. I use plenty of stimulants in individuals living with comorbid anxiety disorders. We just monitor and set healthy expectation and say, hey, if this doesn't feel great, guess what? We can try different options. So I still, you know, it's appropriate to use a stimulant. You know, we can still use it in anxiety disorders. Absolutely. Great. And you just mentioned my final question. So I'll just reiterate, you mentioned centenafedine, and that is the triple reuptake inhibitor that boosts norepinephrine, dopamine, and serotonin.

58:15As you mentioned, it's going before the FDA later this month, and we're keeping an eye on it here at Attitude. It's exactly sort of designed for that patient. So rest assured, We will report as soon as we hear about approval. But unfortunately, we have run out of time. That absolutely flew by. Desiree, thank you so much. We are so appreciative of your expertise and your clarity in describing these really complex conditions and their overlaps. Thank you so much, Annie. Thank you all. I really appreciate being here today. Yes, thank you, everyone who joined us. If your question wasn't answered during the webinar, please know that the Attitude team reads each and every one of them, and we do use them for future issues of the magazine.

59:08Again, we have the QR code here for our Rising Stars survey. We would love to hear from you, and we would also urge you to share this webinar when it is in replay. You can visit AttitudeMag.com and search for Podcast 614. You'll see the slides and the recording just a few hours after we wrap up here. And if you're listening in replay mode, click on the episode description. Thank you, everyone, for joining us. Thank you so much for leading this presentation, Desiree. And we hope to see everyone again soon. For more Attitude podcast and information on living well with attention deficit, visit AttitudeMag.com.

59:53That's A-D-D-I-T-U-D-E-M-A-G dot com

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