Do You Have Depression, ADD, or Both?

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Alex, an 18-year-old college student, was referred to me by his parents who were Russian immigrants and engineers. Alex was pursuing a degree in engineering but obviously depressed, they said. He couldn't get up in the morning. He was flunking his classes. They described to me their long history of being frustrated by Alex, whom they believed to be very smart but had never "applied himself" in school. "He doesn't concentrate. He is easily distracted. We don't know how he will ever make a living," his mother complained to me.

Boredom vs. Depression

When I met Alex in our initial consultation, he was dressed in jeans and a T-shirt. There was nothing terribly unkempt about his appearance that suggested he wasn't caring for himself. He seemed a bit glum and unhappy to be speaking to a psychiatrist but he didn't have that overwhelmingly hopeless demeanor that characterizes someone who is severely depressed.

"Your parents are worried about you, Alex," I said. "Can you tell me what's going on?"

Alex stared at me with a dark look in his eyes and responded with anger, "They are not worried about how I feel. They are just upset because I have no interest in engineering."

Alex went on to tell me that he was bored to tears in engineering classes. He'd never liked school and always found himself daydreaming about his real love, music. I asked what kind of music he enjoyed. He told me he played piano but disliked playing the classical music that his parents, accomplished musicians, wanted him to play. He explained that part of the problem was that he could easily memorize a classical piece of music and play it in his head. He then found it too painfully boring to sit down and play it on the piano.

"What I really want to play is jazz," he said, with his eyes lighting up. It turned out that the improvisational nature of jazz was what turned Alex on. He began citing some of the jazz greats he admired—Art Tatum, Duke Ellington, Bill Evans, Thelonius Monk... Alex was off and running.

Classic Signs of ADD

The more Alex talked, the more I could see that he fit the profile of someone with attention deficit disorder (ADD). He couldn't concentrate on something in which he was not interested. Even though he was highly intelligent, his school years had been challenging because he was bored and irritable in class. Yet, when talking about jazz, he wasn't just enthusiastic, he was hyper-focused. This performance differential is a classic sign of ADD when it is undiagnosed and untreated.

Children as well as adults who suffer from ADD are often held back in life—at school and in the workplace. Unable to focus, they are accused of being lazy and not trying. They have to struggle desperately hard to concentrate on things that they consider boring—and they hate nothing more than boredom. Their minds wander and they lose a sense of time, often angering others with their chronic lateness. They feel trapped in a world that does not understand how they think and operate. It is depressing.

Determining a Diagnosis

There is no single medical, physical, or genetic test for ADD or ADHD (attention deficit disorder with a hyperactivity component). But part of the job of a psychiatrist is being attuned to small details that speak volumes. Even though Alex was introduced to me as someone suffering from depression, I could sense that there was something additional going on. I screened him for ADD, asking questions about daily matters that typically become major stumbling blocks for people with the condition. When Alex reported having a lifetime of problems with paying attention, following directions, being organized, being on time, losing things, and being careless, it clearly pointed to a diagnosis of ADD. (If I had observed him being fidgety, impulsive, noisy, talking excessively, interrupting, and/or being impatient, the diagnosis would have been ADHD.)

When co-morbid disorders are diagnosed—in Alex's case, depression and ADD—we need to treat both. I prescribed an antidepressant to calm his mood. Alex felt alienated from his parents, whom he felt did not understand or respect his musical interests and only cared about his being able to get a high-paying job after college. I knew I needed to decrease the intensity of his anger to begin working with him on a rapprochement with his parents. I also prescribed a psychostimulant to increase his ability to concentrate.

The Treatment Outcome

Over the next few weeks and months, we went through a trial of medication to establish what dose was right for Alex and at what time of day. His medication worked well enough to allow him to focus on his engineering classes. He even took some classical piano lessons to make his parents happy. But what really took off was his jazz playing. He secretly joined a small jazz group and played, unbeknown to his parents, at several clubs downtown. Eventually, his parents found out and snuck into the bar to watch Alex and his band perform. They called me and were enraged. The band was brilliant, they said. Alex's playing was superb. He had a way of mixing classical piano with jazz in one of the most mellifluous performances they'd ever heard. The audience loved it.

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With a rave review like this, I couldn't imagine what the problem could be.

"Alex is never going to be an engineer," his mom said. "I saw his passion. He was totally swept up in the music. I'd never seen him that involved with anything."

"It sounds amazing," I said.

"What my wife means is that there is no career in jazz," Alex's father interjected. "Alex may be a musical genius. We know many geniuses in the arts who are working in dead-end jobs. We only want what is best for him."

It's hard to know what to say when parents are devastated to discover that their child is remarkably talented but has a talent that may never bring him financial success. In their minds, playing jazz was just a slightly higher form of work as waiting on tables.

I told them, and I meant it, that they needn't be so fearful.

It's true that, by increasing focus and concentration, psychostimulants help someone improve in areas of their least interest while they may take off like a rocket in an area to which they are naturally drawn. But I caution against drawing a straight line from now into the future. In my experience, having the ability to meet one's potential in one area of strength and interest builds up the psyche. Down the line, it may feed into a maturational process that allows one to buckle down and take on projects which are less engaging but important in practical ways of life. In other words, I explained that I don't think they need to think of Alex's interests as music or engineering. Those two pursuits may not work against each other at all. His musical accomplishments may help him focus later on in another area of his professional life.

For patients like Alex, the diagnosis and treatment of ADD go a long way to helping to treat depression. Some patients with ADD have a family history of depression and they need to continue to be treated for it, even once ADD is addressed. For others, identifying and treating ADD, along with helping to create a supportive family environment, allows for the eventual termination of antidepressant treatment. The key, though, is to ensure that we have a complete picture of the issues facing a patient during the consultation. Without that, we can't have an accurate assessment, diagnosis, and treatment plan.

An Epilogue

It turned out that Alex went on to earn his degree in engineering. He eventually discovered that it wasn't so boring after all. He continued playing with his band, making money in clubs throughout college. Today he works as an engineer and plays jazz piano on the side at small clubs on occasional weekends. He is on an effective, stable medication regimen and is in therapy to help him navigate his intimate relationship and continue to maintain a work/life balance that includes time for both his musical passion and the practicalities of earning a living. He is living a full and satisfying life.