Abstract
Adults with Attention-Deficit/Hyperactivity Disorder (ADHD) are at increased risk for depressive disorders but little is known about the potential cognitive and behavioral mechanisms of risk that could shape treatment. This study evaluated the degree to which cognitive-behavioral constructs associated with depression and its treatment—dysfunctional attitudes and cognitive-behavioral avoidance—accounted for variance in depressive symptoms and disorder in adults with ADHD. 77 adults clinically diagnosed with ADHD completed self-report questionnaires, diagnostic interviews, and clinician-administered symptom rating scales. Statistical mediation analysis was employed and indirect effects assessed using bootstrap analysis and bias-corrected confidence intervals. Controlling for recent negative life events, dysfunctional attitudes and cognitive-behavioral avoidance fully accounted for the variance between ADHD symptoms and depressive symptoms. Each independent variable partially mediated the other in accounting for depression symptoms suggesting overlapping and unique variance. Cognitive-behavioral avoidance, however, was more strongly related to meeting diagnostic criteria for a depressive disorder than were dysfunctional attitudes. Processes that are targeted in cognitive behavior therapy (CBT) for depression were associated with symptoms in adults with ADHD. Current CBT approaches for ADHD incorporate active coping skills and cognitive restructuring and such approaches could be further tailored to address the ADHD-depression comorbidity.
Similar content being viewed by others
References
Aalto, A. M., Elovainio, M., Kivimäki, M., Uutela, A., & Pirkola, S. (2012). The Beck Depression Inventory and General Health Questionnaire as measures of depression in the general population: A validation study using the Composite International Diagnostic Interview as the gold standard. Psychiatry Research, 197(1–2), 163–171. doi:10.1016/j.psychres.2011.09.008.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders-text revision (4th ed.). Washington, DC, USA: Author.
American Psychological Association Division 12. (2012). Website on research supported psychological treatments. Retrieved July 27, 2012, from http://www.div12.org/PsychologicalTreatments.
Anastopoulos, A. D., Benson, J., Mitchell, J. T., Knouse, L. E., Kimbrel, N. A., & Bray, A. C. (2012). Development of a measure for assessing AD/HD-related automatic thoughts. Paper presented at the annual conference of the American psychological association (APA), Orlando, FL, USA.
Barbaresi, W. J., Colligan, R. C., Weaver, A. L., Voigt, R. G., Killian, J. M., & Katusic, S. K. (2013). Mortality, ADHD, and psychosocial adversity in adults with childhood ADHD: A prospective study. Pediatrics. Advance online publication. doi: 10.1542/peds.2012-2354.
Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121, 65–94. doi:10.1037/0033-2909.121.1.65.
Barkley, R. A. (2011). Barkley adult ADHD rating scale-IV (BAARS-IV). New York: Guilford Press.
Barkley, R. A. (2012). Distinguishing sluggish cognitive tempo from attention-deficit/hyperactivity disorder in adults. Journal of Abnormal Psychology, 121(4), 978–990. doi:10.1037/a0023961.
Barkley, R. A., Knouse, L. E., & Murphy, K. R. (2011). Correspondence and disparity in the self- and other ratings of current and childhood ADHD symptoms and impairment in adults with ADHD. Psychological Assessment, 23(2), 437–446. doi:10.1037/a0022172.
Barkley, R. A., & Murphy, K. R. (2006). Attention-deficit hyperactivity disorder: A clinical workbook (3rd ed.). New York: Guilford Press.
Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in adults: What the science says. New York: Guilford Press.
Baron, R. M., & Kenny, D. A. (1986). The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51(6), 1173–1182. doi:10.1037/0022-3514.51.6.1173.
Basco, M. R., Bostic, J. Q., Davies, D., Rush, A. J., Witte, B., Hendrickse, W., et al. (2000). Methods to improve diagnostic accuracy in a community mental health setting. American Journal of Psychiatry, 157(10), 1599–1605. doi:10.1176/appi.ajp.157.10.1599.
Bauermeister, J. J., Barkley, R. A., Bauermeister, J. A., Martínez, J. V., & McBurnett, K. (2012). Validity of the sluggish cognitive tempo, inattention, and hyperactivity symptom dimensions: Neuropsychological and psychosocial correlates. Journal of Abnormal Child Psychology, 40(5), 683–697. doi:10.1007/s10802-011-9602-7.
Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press.
Beck, A. T. (2008). The evolution of the cognitive model of depression and its neurobiological correlates. American Journal of Psychiatry, 165(8), 969–977. doi:10.1176/appi.ajp.2008.08050721.
Beck, A. T., Brown, G. K., Steer, R. A., & Weissman, A. N. (1991). Factor analysis of the Dysfunctional Attitude Scale in a clinical population. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3(3), 478–483. doi:10.1037/1040-3590.3.3.478.
Beck, A. T., Steer, R. A., & Carbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8(1), 77–100. doi:10.1016/0272-7358(88)90050-5.
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571. doi:10.1001/archpsyc.1961.01710120031004.
Biederman, J., Ball, S. W., Monuteaux, M. C., Mick, E., Spencer, T. J., McCreary, M., et al. (2008). New insights into the comorbidity between ADHD and major depression in adolescent and young adult females. Journal of the American Academy of Child and Adolescent Psychiatry, 47(4), 426–434. doi:10.1097/CHI.0b013e31816429d3.
Boonstra, A. M., Oosterlaan, J., Sergeant, J. A., & Buitelaar, J. K. (2005). Executive functioning in adult ADHD: A meta-analytic review. Psychological Medicine, 35, 1097–1108. doi:10.1017/S003329170500499X.
Bunevicius, A., Staniute, M., Brozaitiene, J., Pommer, A. M., Pop, V. J. M., Montgomery, S. A., et al. (2012). Evaluation of depressive symptoms in patients with coronary artery disease using the Montgomery Åsberg Depression Rating Scale. International Clinical Psychopharmacology, 27(5), 249–255. doi:10.1097/YIC.0b013e328357670d.
Chen, Y., & Dilsaver, S. C. (1996). Lifetime rates of suicide attempts among subjects with bipolar and unipolar disorders relative to subjects with other axis I disorders. Biological Psychiatry, 39(10), 896–899. doi:10.1016/0006-3223(95)00295-2.
Chronis-Tuscano, A., Molina, B. S., Pelham, W. E., Applegate, B., Dahlke, A., Overmyer, M. A., et al. (2010). Very early predictors of adolescent depression and suicide attempts in children with Attention-Deficit/Hyperactivity Disorder. Archives of General Psychiatry, 67(10), 1044–1051. doi:10.1001/archgenpsychiatry.2010.127.
Cusin, C., Yang, H., Yeung, A., & Fava, M. (2010). Rating scales for depression. In L. Bear & M. A. Blais (Eds.), Handbook of clinical rating scales and assessment in psychiatry and mental health (pp. 7–35). New York: Springer.
Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., et al. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74(4), 658–670. doi:10.1037/0022-006X.74.4.658.
Dohrenwend, B. S., Askenasy, A. R., Krasnoff, L., & Dohrenwend, B. P. (1978). Exemplification of a method for scaling life events: The PERI Life Events Scale. Journal of Health and Social Behavior, 19(2), 205–229. doi:10.2307/2136536.
Dozois, D. J. A., & Beck, A. T. (2008). Cognitive schemas, beliefs, and assumptions. In K. S. Dobson & D. J. A. Dozois (Eds.), Risk factors in depression (pp. 121–143). San Diego, CA, USA: Academic Press.
Ferster, C. B. (1973). A functional analysis of depression. American Psychologist, 28(10), 857–870. doi:10.1037/h0035605.
First, M., Spitzer, R. L., Gibbon, M., & Williams, J. (1995). Structured clinical interview for DSM-IV Axis I disorders, Patient edition: Biometrics Research Department. New York, NY, USA: New York State Psychiatric Institute.
Garcia, C. R., Bau, C. H., Silva, K. L., Callegari-Jacques, S. M., Salgado, C. A., Fischer, A. G., et al. (2012). The burdened life of adults with ADHD: Impairment beyond comorbidity. European Psychiatry, 27(5), 309–313. doi:10.1016/j.eurpsy.2010.08.002.
Hayes, A. F. (2009). Beyond Baron and Kenny: Statistical mediation analysis in the new millennium. Communication Monographs, 76(4), 408–420. doi:10.1080/03637750903310360.
Hayes, A. F. (2012). PROCESS: A versatile computational tool for observed variable mediation, moderation, and conditional process modeling. Retrieved July 30, 2012, from http://www.afhayes.com/public/process2012.pdf.
Judd, L. L., Akiskal, H. S., Zeller, P. J., Paulus, M., Leon, A. C., Maser, J. D., et al. (2000). Psychosocial disability during the long-term course of unipolar major depressive disorder. Archives of General Psychiatry, 57(4), 375–380. doi:10.1001/archpsyc.57.4.375.
Kessler, R. C., Adler, L., Barkley, R. A., Biederman, J., Conners, C. K., Demler, O., et al. (2006). The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. American Journal of Psychiatry, 163(4), 716–723. doi:10.1176/appi.ajp.163.4.716.
Knouse, L. E., & Safren, S. A. (2011). Psychosocial treatment of adults with Attention-Deficit/Hyperactivity Disorder. In S. W. Evans & B. Hoza (Eds.), Treating attention deficit hyperactivity disorder. Kingston, NJ, USA: Civic Research Institute.
Lewinsohn, P. M. (1974). A behavioral approach to depression. In R. J. Friedman & M. M. Katz (Eds.), The psychology of depression: Contemporary theory and research (Vol. 318, p. 17). Oxford, England: Wiley.
Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for guided action. New York: W. W. Norton.
Mazure, C. M. (1998). Life stressors as risk factors in depression. Clinical Psychology: Science and Practice, 5(3), 291–313. doi:10.1111/j.1468-2850.1998.tb00151.x.
McDermott, S. P. (2000). Cognitive therapy for adults with attention-deficit/hyperactivity disorder. In T. E. Brown (Ed.), Attention-deficit disorders and comorbidities in children, adolescents, and adults (pp. 569–607). Washington, DC, USA: American Psychiatric Press.
McQuade, J. D., Hoza, B., Waschbush, D. A., Murray-Close, D., & Owens, J. S. (2011). Changes in self-perceptions in children with ADHD: A longitudinal study of depressive symptoms and attributional style. Behavior Therapy, 42(2), 170–182. doi:10.1016/j.beth.2010.05.003.
Miller, T. W., Nigg, J. T., & Faraone, S. V. (2007). Axis I and II comorbidity in adults with ADHD. Journal of Abnormal Psychology, 116(3), 519–528. doi:10.1037/0021-843X.116.3.519.
Mitchell, J. T., Anastopoulos, A. D., Knouse, L. E., Kimbrel, N. A., & Benson, J. (2008). Evaluating potential mechanisms of change in the treatment of AD/HD in adulthood: an exploratory analysis of maladaptive thoughts. Paper presented at the annual conference of the association for behavioral and cognitive therapies, Orlando, FL, USA.
Mitchell, J. T., Benson, J., Knouse, L. E., Kimbrel, N. A., & Anastopoulos, A. D. (2013). Are negative automatic thoughts associated with ADHD in adulthood? Cognitive Therapy and Research. Advance online publication. doi: 10.1007/s10608-013-9525-4.
Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382–389. doi:10.1192/bjp.134.4.382.
Müller, D. J., Chiesa, A., Mandelli, L., De Luca, V., De Ronchi, D., Jain, U., et al. (2010). Correlation of a set of gene variants, life events, and personality features on adult ADHD severity. Journal of Psychiatric Research, 44, 598–604. doi:10.1016/j.jpsychires.2009.11.011.
Müller, M. J., Himmerich, H., Kienzle, B., & Szegedi, A. (2003). Differentiating moderate and severe depression using the Montgomery–Åsberg depression rating scale (MADRS). Journal of Affective Disorders, 77(3), 255–260. doi:10.1016/S0165-0327(02)00120-9.
Murphy, K. R. (2006). Psychological counseling of adults with ADHD. In R. A. Barkley (Ed.), Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (pp. 692–703). New York: Guilford.
Nelson, L. D., Stern, S. L., & Cicchetti, D. V. (1992). The Dysfunctional Attitude Scale: How well can it measure depressive thinking? Journal of Psychopathology and Behavioral Assessment, 14(3), 217–223. doi:10.1007/bf00962629.
Orvaschel, H. (1985). Psychiatric interviews suitable for use in research with children and adolescents. Psychopharmacology Bulletin, 21(4), 737–745.
Ostrander, R., & Herman, K. C. (2006). Potential cognitive, parenting, and developmental mediators of the relationship between ADHD and depression. Journal of Consulting and Clinical Psychology, 74(1), 89–98. doi:10.1037/0022-006X.74.1.89.
Ottenbreit, N. D., & Dobson, K. S. (2004). Avoidance and depression: The construction of the Cognitive-Behavioral Avoidance Scale. Behaviour Research and Therapy, 42(3), 293–313. doi:10.1016/S0005-7967(03)00140-2.
Posner, K., Brent, D., Lucas, C., Gould, M., Stanley, B., Brown, G., et al. (2008). Columbia suicide severity rating scale. New York: New York State Psychiatric Institute.
Questionnaire Development System. [Computer software]. Bethesda, MD, USA: NOVA Research Company.
Ramsay, J. R., & Rostain, A. L. (2003). A cognitive therapy approach for adult Attention Deficit/Hyperactivity Disorder. Journal of Cognitive Psychotherapy, 17(4), 319–334. doi:10.1891/jcop.17.4.319.52537.
Rush, A. J., Kilner, J., Fava, M., Wisniewski, S. R., Warden, D., Nierenberg, A. A., et al. (2008). Clinically relevant findings from STAR*D. Psychiatric Annals, 38(3), 188–193. doi:10.3928/00485713-20080301-08.
Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Nierenberg, A. A., Stewart, J. W., Warden, D., et al. (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: A STAR*D report. American Journal of Psychiatry, 163(11), 1905–1917. doi:10.1176/appi.ajp.163.11.1905.
Safren, S. A., Perlman, C. A., Sprich, S., & Otto, M. W. (2005). Mastering your adult ADHD: A cognitive-behavioral therapy approach. New York: Oxford University Press.
Safren, S. A., Sprich, S., Mimiaga, M. J., Surman, C., Knouse, L. E., Groves, M., et al. (2010). Cognitive behavioral therapy vs. relaxation with educational support for medication-treated adults with ADHD and persistent symptoms. The Journal of the American Medical Association, 304(8), 857–880. doi:10.1001/jama.2010.1192.
Shaffer, D., Fisher, M., & Lucas, C. (1997). National institute of mental health diagnostic interview schedule for children (Version 4.0). New York: Division of Child Psychiatry, Columbia University.
Solanto, M. V., Marks, D. J., Wasserstein, J., Mitchell, K., Abikoff, H., Alvir, J., et al. (2010). Efficacy of metacognitive therapy for adult ADHD. American Journal of Psychiatry, 167, 958–968. doi:10.1176/appi.ajp.2009.09081123.
Spencer, T. J., & Adler, L. (2004). Diagnostic approaches to adult attention-deficit/hyperactivity disorder. Primary Psychiatry, 11(7), 49–53. Retrieved from http://www.primarypsychiatry.com/aspx/articledetail.aspx?articleid=772.
Spencer, T. J., Adler, L. A., Qiao, M., Saylor, K. E., Brown, T. E., Holdnack, J. A., et al. (2010). Validation of the Adult ADHD Investigator Symptom Rating Scale (AISRS). Journal of Attention Disorders, 14(1), 57–68. doi:10.1177/1087054709347435.
Spencer, T. J., Wilens, T., Biederman, J., Faraone, S. V., Ablon, J. S., & Lapley, K. A. (1995). A double-blind cross-over comparison of methylphenidate and placebo in adults with childhood-onset attention deficit hyperactivity. Archives of General Psychiatry, 52, 434–443. doi:10.1001/archpsyc.1995.03950180020004.
Weissman, A. N., & Beck, A. T. (1978). Development and validation of the dysfunctional attitude scale: A preliminary investigation. Paper presented at the association for the American educational research association, Toronto, Canada. Retrieved from http://www.eric.ed.gov/PDFS/ED167619.pdf.
Wilens, T., Nierenberg, A. A., Rostain, A., & Spencer, T. J. (2008). Adult attention-deficit hyperactivity disorder and the role of depression. CNS Spectrums, 13(5), 2–17. Retrieved from http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=1575.
Zanarini, M. C., & Frankenburg, F. R. (2001). Attainment and maintenance of reliability of axis I and II disorders over the course of a longitudinal study. Comprehensive Psychiatry, 42(5), 369–374. doi:10.1053/comp.2001.24556.
Acknowledgments
This research was supported by the Kaplen Fellowship on Depression and the Livingston Award from the Psychiatry Department at Harvard Medical School awarded to the first author. Data analysis and writing of the manuscript was supported by a Faculty Summer Research Fellowship at the University of Richmond awarded to Dr. Knouse. Dr. Steven Safren is supported by grant 5K24MH094214. Sincere thanks to Meghan Groves, B.A. for her assistance with data collection on this project.
Conflict of interest
The authors have no potential conflicts of interest pertaining to this manuscript to declare.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Knouse, L.E., Zvorsky, I. & Safren, S.A. Depression in Adults with Attention-Deficit/Hyperactivity Disorder (ADHD): The Mediating Role of Cognitive-Behavioral Factors. Cogn Ther Res 37, 1220–1232 (2013). https://doi.org/10.1007/s10608-013-9569-5
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10608-013-9569-5