Cognitive Therapy and Research

, Volume 37, Issue 6, pp 1220–1232 | Cite as

Depression in Adults with Attention-Deficit/Hyperactivity Disorder (ADHD): The Mediating Role of Cognitive-Behavioral Factors

  • Laura E. Knouse
  • Ivori Zvorsky
  • Steven A. Safren
Original Article

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.

Keywords

Attention-Deficit/Hyperactivity Disorder (ADHD) Depression Depressive symptoms Adults Cognitive behavior therapy (CBT) 

References

  1. 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.PubMedCrossRefGoogle Scholar
  2. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders-text revision (4th ed.). Washington, DC, USA: Author.Google Scholar
  3. American Psychological Association Division 12. (2012). Website on research supported psychological treatments. Retrieved July 27, 2012, from http://www.div12.org/PsychologicalTreatments.
  4. 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.Google Scholar
  5. 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.
  6. 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.PubMedCrossRefGoogle Scholar
  7. Barkley, R. A. (2011). Barkley adult ADHD rating scale-IV (BAARS-IV). New York: Guilford Press.Google Scholar
  8. 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.PubMedCrossRefGoogle Scholar
  9. 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.PubMedCrossRefGoogle Scholar
  10. Barkley, R. A., & Murphy, K. R. (2006). Attention-deficit hyperactivity disorder: A clinical workbook (3rd ed.). New York: Guilford Press.Google Scholar
  11. Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in adults: What the science says. New York: Guilford Press.Google Scholar
  12. 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.PubMedCrossRefGoogle Scholar
  13. 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.CrossRefGoogle Scholar
  14. 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.PubMedCrossRefGoogle Scholar
  15. Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press.Google Scholar
  16. 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.PubMedCrossRefGoogle Scholar
  17. 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.CrossRefGoogle Scholar
  18. 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.CrossRefGoogle Scholar
  19. 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.PubMedCrossRefGoogle Scholar
  20. 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.PubMedCrossRefGoogle Scholar
  21. 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.PubMedCrossRefGoogle Scholar
  22. 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.PubMedCrossRefGoogle Scholar
  23. 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.PubMedCrossRefGoogle Scholar
  24. 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.PubMedCrossRefGoogle Scholar
  25. 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.Google Scholar
  26. 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.PubMedCrossRefGoogle Scholar
  27. 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.PubMedCrossRefGoogle Scholar
  28. 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.Google Scholar
  29. Ferster, C. B. (1973). A functional analysis of depression. American Psychologist, 28(10), 857–870. doi:10.1037/h0035605.PubMedCrossRefGoogle Scholar
  30. 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.Google Scholar
  31. 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.PubMedCrossRefGoogle Scholar
  32. 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.CrossRefGoogle Scholar
  33. 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.
  34. 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.PubMedCrossRefGoogle Scholar
  35. 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.PubMedCrossRefGoogle Scholar
  36. 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.Google Scholar
  37. 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.Google Scholar
  38. Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for guided action. New York: W. W. Norton.Google Scholar
  39. 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.CrossRefGoogle Scholar
  40. 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.Google Scholar
  41. 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.PubMedCrossRefGoogle Scholar
  42. 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.PubMedCrossRefGoogle Scholar
  43. 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.Google Scholar
  44. 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.
  45. 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.PubMedCrossRefGoogle Scholar
  46. 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.PubMedCrossRefGoogle Scholar
  47. 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.PubMedCrossRefGoogle Scholar
  48. 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.Google Scholar
  49. 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.CrossRefGoogle Scholar
  50. Orvaschel, H. (1985). Psychiatric interviews suitable for use in research with children and adolescents. Psychopharmacology Bulletin, 21(4), 737–745.PubMedGoogle Scholar
  51. 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.PubMedCrossRefGoogle Scholar
  52. 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.PubMedCrossRefGoogle Scholar
  53. 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.Google Scholar
  54. Questionnaire Development System. [Computer software]. Bethesda, MD, USA: NOVA Research Company.Google Scholar
  55. 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.CrossRefGoogle Scholar
  56. 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.CrossRefGoogle Scholar
  57. 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.PubMedCrossRefGoogle Scholar
  58. 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.Google Scholar
  59. 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.CrossRefGoogle Scholar
  60. 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.Google Scholar
  61. 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.PubMedCrossRefGoogle Scholar
  62. 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.Google Scholar
  63. 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.PubMedCrossRefGoogle Scholar
  64. 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.PubMedCrossRefGoogle Scholar
  65. 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.
  66. 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.Google Scholar
  67. 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.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Laura E. Knouse
    • 1
    • 2
  • Ivori Zvorsky
    • 2
    • 3
  • Steven A. Safren
    • 1
  1. 1.Behavioral Medicine Service, Department of PsychiatryMassachusetts General Hospital and Harvard Medical SchoolBostonUSA
  2. 2.Department of PsychologyUniversity of RichmondRichmondUSA
  3. 3.Behavioral Pharmacology Research UnitJohns Hopkins School of MedicineBaltimoreUSA

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