The Canadian Network for Mood and Anxiety Treatments (Canmat) Task Force Recommendations for the Management of Patients with Mood Disorders and Comorbid Attention-Deficit/Hyperactivity Disorder
Abstract
Background: Patients with bipolar disorder (BD) and major depressive disorder (MDD) experience adult attention-deficit/hyperactivity disorder (ADHD) at rates substantially greater than the general population. Nonetheless, ADHD frequently goes untreated in this population. Methods: We reviewed the literature regarding the management of adult ADHD in patients with mood disorders. Because a limited number of studies have been conducted in adults, our treatment recommendations also are partly informed by research in children and adolescents with BD+ADHD or MDD+ADHD, adults with ADHD, and our clinical experience. Results: In individuals with mood disorders, ADHD is best diagnosed when typical symptoms persist during periods of sustained euthymia. Individuals with BD+ADHD, particularly those with bipolar I disorder (BD I), are at risk for mood destabilization with many ADHD treatments, and should be prescribed mood-stabilizing medications before initiating ADHD therapies. Bupropion is a reasonable first-line treatment for BD+ADHD, while mixed amphetamine salts and methylphenidate also may be considered in patients determined to be at low risk for manic switch. Modafinil and cognitive-behavioral therapy (CBT) are second-line choices. In patients with MDD+ADHD and moderate to severe depression, MDD should be the treatment priority, whereas in mildly depressed or euthymic patients the order may be reversed. First-line treatments for MDD+ADHD include bupropion, an antidepressant plus a long-acting stimulant, or an antidepressant plus CBT. Desipramine, nortriptyline, and venlafaxine are second-line options. Conclusions: Clinicians should be vigilant in screening for comorbid ADHD in mood disorder patients. ADHD symptoms can respond to appropriately chosen treatments.
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Patients with comorbid ADHD often experience a more treatment-refractory course, more mood episodes, greater functional impairment and a heightened risk of suicide.
“Patients with comorbid ADHD often experience a more treatment‐refractory course, more mood episodes, greater functional impairment and a heightened risk of suicide.765”
For ADHD, CBT can improve both depressive and ADHD symptoms.
“For ADHD, CBT can improve both depressive and ADHD symptoms.”
From Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder (2016) · cites this paper as [22]
Studies of neurotransmitters have pointed to abnormalities in dopamine (DA) and norepinephrine (NE) signaling.
“Studies of neurotransmitters have also pointed to abnormalities in dopamine (DA) and norepinephrine (NE) signaling [16,45]”
From Adult ADHD and comorbid disorders: clinical implications of a dimensional approach (2017) · cites this paper as [16]
Neuroimaging studies have implicated differences in volume and activity in the frontal lobe, which is responsible for attention, behaviour selection, and emotion.
“Neuroimaging studies have implicated differences in volume and activity in the frontal lobe, which is responsible for attention, behaviour selection, and emotion [16].”
From Adult ADHD and comorbid disorders: clinical implications of a dimensional approach (2017) · cites this paper as [16]
There is a theoretical risk of stimulant therapy resulting in mood destabilization in individuals with bipolar disorder.
“However, there is a theoretical risk of stimulant therapy resulting in mood destabilization in individuals with bipolar disorder [16].”
From Adult ADHD and comorbid disorders: clinical implications of a dimensional approach (2017) · cites this paper as [16]
Antidepressants such as venlafaxine and bupropion have been evaluated as treatment options for ADHD, with some evidence of benefit in addressing ADHD symptoms.
“Antidepressants such as venlafaxine and bupropion have also been evaluated as treatment options for ADHD, with some evidence of benefit in addressing ADHD symptoms [16,109].”
From Adult ADHD and comorbid disorders: clinical implications of a dimensional approach (2017) · cites this paper as [16]
ADHD treatment may not be as effective in individuals with active depression.
“However, it has also been noted that ADHD treatment may not be as effective in individuals with active depression [16].”
From Adult ADHD and comorbid disorders: clinical implications of a dimensional approach (2017) · cites this paper as [16]
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“As such, one can imagine this low hedonic tone as a key feature shared by MDD and resulting from a shared dysfunction in monoamine signaling, particularly in the ventral striatum [52].”
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The vigilance regulation model of affective disorders and ADHD
Hegerl, U., & Hensch, T. (2014) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2012.10.008 · Cited by 212 · see citing works
Bauer, M., Severus, E., Köhler, S., Whybrow, P. C., Angst, J., Möller, H.-J., & on behalf of the Wfsbp Task Force on Treatment Guidelines for Unipolar Depressive Disorders (2015) · The World Journal of Biological Psychiatry · doi:10.3109/15622975.2014.1001786 · Cited by 199 · see citing works
“…MDDs in adults (Kennedy et al. 2009a, 2009b; Lam et al. 2009; Parikh et al. 2009; Patten et al. 2009; Ravindran et al. 2009; Beaulieu et al. 2012; Bond et al. 2012; McIntyre et al. 2012a, 2012b; Ramasubbu et al. 2012a, 2012b; Rosenbluth et al. 2012; Schaffer et al. 2012), the British Association…”
BackgroundMacQueen, G. M., & Memedovich, K. A. (2017) · Psychiatry and Clinical Neurosciences · doi:10.1111/pcn.12463 · Cited by 172 · see citing works
Diminished effort on a progressive ratio task in both unipolar and bipolar depression
Hershenberg, R., Satterthwaite, T. D., Daldal, A., Katchmar, N., Moore, T. M., Kable, J. W., & Wolf, D. H. (2016) · Journal of Affective Disorders · doi:10.1016/j.jad.2016.02.003 · Cited by 157 · see citing works
“Given mixed evidence for antidepressant use in bipolar disorder, including those enhancing dopaminergic function (Bond et al., 2012; Goldberg et al., 2004; Pacchiarotti et al., 2013), objective measures of amotivation could help tailor individualized risk-benefit calculations for using”
Lorenzo, R. D., Balducci, J., Poppi, C., Arcolin, E., Cutino, A., Ferri, P., D’Amico, R., & Filippini, T. (2021) · Acta Neuropsychiatrica · doi:10.1017/neu.2021.23 · Cited by 153 · see citing works
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An overview on neurobiology and therapeutics of attention-deficit/hyperactivity disorder
da Silva, B. S., Grevet, E. H., Silva, L. C. F., Ramos, J. K. N., Rovaris, D. L., & Bau, C. H. D. (2023) · Discover Mental Health · doi:10.1007/s44192-022-00030-1 · Cited by 125 · see citing works
“The prescription of this medication might be specially considered as an option when comorbid conditions such as mood disorders or nicotine dependence are present, considering its primary antidepressant effect and its contribution to smoking cessation [200, 201].”
BackgroundOluboka, O. J., Katzman, M. A., Habert, J., McIntosh, D., MacQueen, G. M., Milev, R. V., McIntyre, R. S., & Blier, P. (2018) · International Journal of Neuropsychopharmacology · doi:10.1093/ijnp/pyx081 · Cited by 104 · see citing works
“Because patients with MDD have a 2-fold higher prevalence of ADHD relative to the general population and the presence and severity of comorbid ADHD can inform treatment selection for both conditions (Canadian Attention Deficit Hyperactivity Disorder Resource Alliance, 2011; Bond et al., 2012), the authors recommend as…”
MethodSelf-citationSandstrom, A., Perroud, N. A., Alda, M., Uher, R., & Pavlová, B. (2021) · Acta Psychiatrica Scandinavica · doi:10.1111/acps.13283 · Cited by 98 · see citing works
Katzman, M., & Sternat, T. (2016) · Neuropsychiatric Disease and Treatment · doi:10.2147/ndt.s111818 · Cited by 83 · see citing works
“148,149 As well, individuals with MDD and ADHD experience higher levels of substance use and psychosocial impairment than each disorder in isolation, 150–153 suggesting a potential variant of MDD, and therefore explaining the treatment resistance in this population when treated with traditional…”
Personality Disorders in Older Adults: Emerging Research Issues
van Alphen, S. P. J., van Dijk, S. D. M., Videler, A. C., Rossi, G. M. P., Dierckx, E., Bouckaert, F., & Voshaar, R. C. O. (2014) · Current Psychiatry Reports · doi:10.1007/s11920-014-0538-9 · Cited by 71 · see citing works
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“At present, evidence on effective treatment for ADHD with comorbidities in adults have been confined to individual comorbidities such as bipolar disorder, depression, or anxiety (Bond et al., 2012; CADDRA, 2018; Katzman et al., 2017).”
BackgroundPhilipsen, A. (2012) · Expert Review of Neurotherapeutics · doi:10.1586/ern.12.91 · Cited by 57 · see citing works
Liu, C., Hua, M.-H., Lu, M., & Goh, K. K. (2023) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12455 · Cited by 60 · see citing works
Adult ADHD and comorbid anxiety and depressive disorders: a review of etiology and treatment
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Use of Stimulants in Bipolar Disorder
Perugi, G., Vannucchi, G., Bedani, F., & Favaretto, E. (2017) · Current Psychiatry Reports · doi:10.1007/s11920-017-0758-x · Cited by 51 · see citing works
Modafinil for the treatment of attention-deficit/hyperactivity disorder: A meta-analysis
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“Despite multiple pharmacological agents available, a large proportion of children and adolescents with ADHD do not gain adequate response (Bond et al., 2012).”
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“Regarding other clinical features, several previous studies (15, 17–19) had described an earlier age of onset of BD in the comorbid group, although this was not found in all the studies (16, 20, 22).”
BackgroundResultKatzman, M. A., & Sternat, T. (2014) · CNS Drugs · doi:10.1007/s40263-014-0175-1 · Cited by 40 · see citing works
“[6 7 ] R an d o m iz ed , d o u b le -b li n d ,”
BackgroundPrescription Stimulant Use and Hospitalization for Psychosis or Mania: A Population-Based Study
Cressman, A. M., Macdonald, E. M., Huang, A., Gomes, T., Paterson, M. J., Kurdyak, P. A., Mamdani, M. M., & Juurlink, D. N. (2015) · Journal of Clinical Psychopharmacology · doi:10.1097/jcp.0000000000000406 · Cited by 37 · see citing works
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Integrating Bipolar Disorder Management in Primary Care
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“Due to a substantial overlap between mood and ADHD symptoms, it could be difficult to differentiate between the two conditions and some authors speculate that this large comorbidity is often an artifact [45].”
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“The greater burden associated with the ADHD phenotype in mood disorder populations hints at the need for adequately designed clinical trials aiming to establish safe and effective pharmacological and psychosocial approaches in individuals meeting criteria for both conditions [10].”
BackgroundMcIntyre, R. S., Alsuwaidan, M. T., Soczynska, J. K., Szpindel, I., Bilkey, T. S., Almagor, D., Woldeyohannes, H. O., Powell, A. M., Cha, D. S., Gallaugher, L. A., et al. (2013) · Human Psychopharmacology Clinical and Experimental · doi:10.1002/hup.2325 · Cited by 31 · see citing works
Self-citationComorbidity of Adult Attention Deficit and Hyperactivity Disorder in Bipolar and Unipolar Patients
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“In adults with major depressive disorder (MDD), the prevalence of co-occurring ADHD was 5%–12% (6,7,8).”
BackgroundSchoretsanitis, G., de León, J., Eap, C. B., Kane, J. M., & Paulzen, M. (2019) · CNS Drugs · doi:10.1007/s40263-019-00683-7 · Cited by 28 · see citing works
Comorbidities in Youth with Bipolar Disorder: Clinical Features and Pharmacological Management
Sesso, G., Brancati, G. E., & Masi, G. (2022) · Current Neuropharmacology · doi:10.2174/1570159x20666220706104117 · Cited by 30 · see citing works
“…that psychostimulants and other ADHD medications may be particularly effective in treating ADHD in people with mood disorders, while future research should be aimed to explore different treatment options, as well as acceptability, safety and efficacy of treating ADHD along with mood symptoms [59].”
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Characterizing, Assessing, and Treating Cognitive Dysfunction in Major Depressive Disorder
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“Similarly, increased rates of comorbid ADHD in childhood in patients developing BD are reported (Bond et al., 2012).”
BackgroundLow Risk for Switch to Mania during Treatment with Sleep Promoting Antidepressants
Wichniak, A., Jarkiewicz, M., Okruszek, Ł., Wierzbicka, A., Holka-Pokorska, J., & RYBAKOWSKI, J. K. (2015) · Pharmacopsychiatry · doi:10.1055/s-0034-1396802 · Cited by 25 · see citing works
Attention-deficit/hyperactivity disorder in adults: update on clinical presentation and care
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Risk of Excessive Daytime Sleepiness Associated to Major Depression in Adolescents
Boz, S., Lanquart, J., Mungo, A., Delhaye, M., Loas, G., & Hein, M. (2021) · Psychiatric Quarterly · doi:10.1007/s11126-021-09922-x · Cited by 19 · see citing works
Liu, Y. S., Cao, B., & Chokka, P. R. (2022) · Journal of Attention Disorders · doi:10.1177/10870547221136228 · Cited by 19 · see citing works
“For ADHD patients with a comorbid MDD, treatment options may include medications that may benefit both MDD and ADHD symptoms such as Bupropion (Bond et al., 2012).”
BackgroundHigh Resolution Mapping of Modafinil Induced Changes in Glutamate Level in Rat Brain
Haris, M., Singh, A. K., Cai, K., Nath, K., Verma, G., Nanga, R. P. R., Hariharan, H., Detre, J. A., Epperson, N., & Reddy, R. D. (2014) · PLoS ONE · doi:10.1371/journal.pone.0103154 · Cited by 19 · see citing works
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The Characteristics of Mood Polarity, Temperament, and Suicide Risk in Adult ADHD
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Getting depression clinical practice guidelines right: time for change?
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Management of inter-episodic periods in patients with bipolar disorder
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Women with Special Educational Needs. Policies & ICT for Integration & Equality
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Obesity and Mental Illness: Implications for Cognitive Functioning
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“Immediate actions may be warranted given the fact that combined medications of psychostimulant drugs with mood stabilizers are suggested for treatments of bipolar disorders that comorbid with attention-deficit/hyperactivity disorder (Bond et al. 2012).”
BackgroundAuditory evoked potentials and suicidal behaviors in patients with major depressive disorders
Kim, J. S., Kim, S., Lee, H.-S., Kwon, Y., Lee, H.-Y., & Shim, S.-H. (2021) · Scientific Reports · doi:10.1038/s41598-021-86602-7 · Cited by 14 · see citing works
Lifetime evolution of ADHD treatment
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“Indeed, some recommendations have been proposed for the management of patients with mood disorders and comorbid ADHD in national clinical guidelines (Bond et al., 2012).”
BackgroundKim, J. S., Kim, D.-W., Kwon, Y., Lee, H.-Y., Kim, S., & Shim, S. H. (2019) · International Journal of Psychophysiology · doi:10.1016/j.ijpsycho.2019.06.008 · Cited by 12 · see citing works
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“The Canadian Network for Mood and Anxiety Treatments task force [17] recommends combining an SSRI”
BackgroundAmeringen, M. V., Fineberg, N. A., Ravindran, A. V., Arnold, P. D., Beaulieu, S., Brakoulias, V., Brietzke, E. M., Dowlati, Y., Drummond, L. M., Ferretti, C. J., et al. (2026) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2025.12.039 · Cited by 10 · see citing works
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A transdiagnostic view on MDD and ADHD: shared cognitive characteristics?
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“19 Given the potential efficacy of these agents in BD and high rates of comorbidity with psychiatric disorders such as ADHD, evaluation of their safety in precipitating mood episodes in BD is critical.”
Kashihara, J., Takebayashi, Y., Kunisato, Y., & Ito, M. (2021) · PLoS ONE · doi:10.1371/journal.pone.0256902 · Cited by 8 · see citing works
Repurposed Drugs for the Treatment of Schizophrenia and Bipolar Disorders
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Early optimized pharmacological treatment in patients with depression and chronic pain
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Self-citationThe influence of paroxetine on the pharmacokinetics of atomoxetine and its main metabolite
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“The treatment recommendations for managing adult ADHD and depression are similar to those for children [21] and acknowledge as a third-line treatment option the association of atomoxetine and antidepressants [22].”
BackgroundOrsolini, L., Longo, G., Volgare, R., Piergentili, S., Servasi, M., Perugi, G., & Volpe, U. (2024) · Journal of Affective Disorders · doi:10.1016/j.jad.2024.08.083 · Cited by 8 · see citing works
Management of Attention-Deficit/Hyperactivity Disorder in Primary Care
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Differentiating Pediatric Bipolar Spectrum Disorders from Attention-Deficit/Hyperactivity Disorder
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The Treatment of Adult ADHD: Complexity at Hand
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Adult ADHD in Bipolar and Related Disorders
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Managing major depressive disorder through the use of adjunct therapies
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“, 2012a), attention deficit hyperactivity disorder (ADHD) (Bond et al., 2012), chronic fatigue syndrome (Dansie et al.”
BackgroundTo Prescribe or Not? Pharmacological Options in Adult Attention-Deficit/Hyperactivity Disorder
Aoshima-Kilroy, A., Banu, S., Udoetuk, S., Shah, A. A., & Moukaddam, N. (2017) · Psychiatric Annals · doi:10.3928/00485713-20170510-01 · Cited by 1 · see citing works
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Assessment and treatment of depressive disorders in adults with ADHD
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Symptomwandel und Komorbiditäten
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- Authors
- Bond, D. J., Hadjipavlou, G., Lam, R. W., McIntyre, R. S., Beaulieu, S., Schaffer, A., & Weiss, M.
- Affiliations
- University of British Columbia (CA)
- University Health Network (CA)
- Douglas Mental Health University Institute (CA)
- Sunnybrook Health Science Centre (CA)
- Children's & Women's Health Centre of British Columbia (CA)
- Corresponding author
- Bond, David J.
- ORCID
- Venue
- Annals of Clinical Psychiatry
- Publisher
- SAGE Publications
- Published
- 2012-02
- Volume
- 24
- Issue
- 1
- Pages
- 23-37
- ISSN
- 1040-1237 (ISSN-L)
- 1547-3325
- OpenAlex
- W48669398
- Cited by
- 133
- References
- 172
- Citations by year
- 2026: 4 · 2025: 6 · 2024: 8 · 2023: 7 · 2022: 5 · 2021: 9 · 2020: 8 · 2019: 13 · 2018: 7 · 2017: 10 · 2016: 16 · 2015: 8 · 2014: 13 · 2013: 12 · 2012: 7
- FWCI
- 9.11
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Annals of Clinical Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- PubMed
- Funders
- Canadian Institutes of Health Research
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Attention Deficit Hyperactivity Disorder
- Health Sciences › Medicine › Psychiatry and Mental health › Bipolar Disorder and Treatment
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Keywords
- attention deficit hyperactivity disorder, comorbidities, bipolar disorder, major depressive disorder, mood disorders, ADHD treatment, bupropion, mixed amphetamine salts, methylphenidate, modafinil, cognitive behavioral therapy, mood stabilizers, manic switch, ADHD screening, treatment guidelines
- MeSH terms
- Adult, Central Nervous System Stimulants, Antidepressive Agents, Attention Deficit Disorder with Hyperactivity, Bipolar Disorder, Canada, Major Depressive Disorder, Humans, Comorbidity, Cognitive Behavioral Therapy, Lithium Compounds, Mood Disorders, Advisory Committees
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