For people with ADHD, and their family and friends, understanding the related mental health conditions and emotional challenges can be both important and helpful. This article hopes to shed light on the complex relationship between ADHD and two of the most common mental health conditions: anxiety and depression. We will explore both depression and anxiety within the context of ADHD, drawing on key insights from public health information and research evidence.
What are Anxiety & Depression?
Depression and anxiety are common internalised mental health conditions that can affect anyone, regardless of age, gender, race or background.
“Internalised” refers to the fact that the main symptoms and experiences associated with anxiety and depression occur within the internal mental and emotional state of the person. Although these experiences can influence an individual’s external behaviours and interactions, the core struggles, thoughts and emotions are mostly experienced from within.
Anxiety and depression share commonalities in terms of their impact on mood, cognition (mental processes), and behaviour, often involving disruptions to sleep patterns, concentration, and negative perceptions about oneself and the future.
It is also important to note that signs of raised anxiety or depressed mood can occur even if they are not considered to be severe enough to meet the threshold for a formal mental health diagnosis – these experiences can still have a detrimental impact on someone’s wellbeing.
Anxiety
Anxiety is described as a feeling of unease, such as worry, nervousness or fear, which can be mild or severe. A clinical condition, like an anxiety disorder, is considered when the when anxious thoughts, feelings, and behaviours become more persistent, rather than temporary, and cause significant distress and interference in daily life[i].
Some common signs that you, or someone you know, might be experiencing anxiety include:
- Restlessness and feelings of worry
- A fast, thumping or irregular heartbeat
- Faster breathing, sweating or hot flushes
- Nausea (feeling sick) or a churning feeling in the stomach
- Panic attacks – intense episodes of overwhelming fear/discomfort, accompanied by physical symptoms such as rapid heartbeat & shortness of breath
Depression
When a sad, or low, mood lasts for a long time, and interferes with everyday life, this might be a sign that someone is depressed or experiencing a depressive episode.
A depressive episode can be categorised as mild, moderate, or severe depending on the number and severity of symptoms that someone is experiencing, as well as the impact on the individual’s functioning i.e. how much their life is impacted by their low mood.
Some common signs that you, or someone you know, might be experiencing depression include:
- Continual sadness over an extended period of time
- Loss of motivation & interest in activities that were once enjoyed
- Changes in sleep (such as insomnia or excessive sleep) and in appetite
- Moving or speaking more slowly than usual
- Feeling hopeless and helpless, and/or tearful
- Having thoughts of harming yourself or of suicide
The connection between ADHD, Anxiety & Depression
Research widely suggests that people with ADHD have a heightened susceptibility to experiencing symptoms of depression and anxiety[ii]. This connection is likely due to a combination of factors, including:
Executive Function Challenges – ADHD is characterised by difficulties in executive functions like impulse control, organisation, and planning. These challenges can lead to heightened stress levels and difficulties in managing daily life, potentially contributing to the development of depressive and anxious symptoms.
Social, Professional and Academic Struggles – The challenges commonly associated with ADHD, such as difficulties in school, work or strained interpersonal relationships, can create additional stressors. These stressors may act as triggers for the onset or exacerbation of depression and anxiety symptoms in individuals with ADHD. Individuals with ADHD may also experience chronic frustration due to difficulties in meeting societal expectations.
Criticism & self-esteem issues – Persistent struggles and societal misconceptions about ADHD may negatively impact an individual’s self-esteem. People can often be criticised because of their ADHD symptoms – a survey of 162 people with ADHD[iii] showed that they were most frequently criticised for behaviours related to focus, forgetfulness, organisation, and time management — symptoms largely outside their control. These and other similar criticisms can then in turn damage self-esteem, and result feelings of inadequacy or frustration, which can contribute to the development of depressive symptoms and heightened anxiety.
Rejection Sensitivity – Individuals with ADHD may exhibit heightened sensitivity to social cues as signs of rejection. Some people with ADHD also experience rejection sensitive dysphoria (RSD)[iv], where even mildly negative comments or thoughts of disappointing others can provoke strong reactions of panic, guilt and/or and self-loathing. These emotional challenges can contribute significantly to the development of depressive and anxious symptoms.
Biological Factors – Genetic predisposition and family history play a role in both ADHD and mood disorders. Individuals with a family history of depression or anxiety may be more vulnerable to experiencing these symptoms, and an interplay of genetic and environmental factors can heighten the risk of developing comorbid mental health conditions.
Understanding Anxiety in ADHD
Although it is not part of the ADHD diagnostic criteria, many individuals with ADHD do experience elevated levels of anxiety. Relatedly, both ADHD and anxiety disorders frequently occur together.
Reports estimating the extent of this overlap vary, as they are dependant on the specific group being investigated. Some studies report rates of co‐occurrence between anxiety and ADHD as being higher than 25%[v] [vi], whilst other research estimates that almost half of adults with ADHD are living with an anxiety disorder[vii].
These conditions can simply exist simultaneously, or ADHD symptoms may contribute to the development of anxiety. It can be difficult to differentiate between anxiety disorders and ADHD as the two conditions can appear similar. For example, some signs that are common to both conditions include difficulty socialising, fidgeting, inattentiveness, and working slowly.
Research also shows that females living with ADHD are more likely to experience a mood disorder, such as anxiety, than males[viii]. In fact, because females often present fewer overt symptoms of ADHD than males, professionals can sometimes diagnose a female with anxiety and miss the presentations of ADHD.
Contributors to Anxiety within an ADHD context
Everyday situations which might seem manageable to others, may trigger feelings of stress and anxiety in individuals with ADHD, which may be contributed to by:
- Difficulties in regulating emotions – The emotional roller coaster that individuals with ADHD may navigate can intensify the experience of anxiety. Challenges in managing emotions can make it harder to cope with stressors, both big and small.
- Sensory Sensitivities – Heightened sensitivity to sensory stimuli. Individuals with ADHD may find themselves more susceptible to environmental factors such as noise, light, or crowds. These heightened sensitivities, and therefore often overwhelming stimuli, can amplify stress levels and contribute to the experience of anxiety.
- Task initiation difficulties – Procrastination is a common challenge for individuals with ADHD, and the stress associated with impending deadlines can be a significant additional source of anxiety. The perpetual cycle of delay and urgency can have negatively impacts, including being detrimental to mental wellbeing.
- Time management – Individuals with ADHD can struggle with estimating and managing time effectively. This can result in chronic lateness or the perception that time is slipping away, contributing to worry about being unable to fulfil responsibilities or meet expectations within certain timeframes. Negative thoughts about this might be further exacerbated by heightened fears of rejection, which are more prominent for those with ADHD.
Masking within the context of ADHD
Masking is a concept which is highly relevant to the overlaps we see between anxiety and ADHD. For those who grow up with ADHD, whether diagnosed or not, it is common to develop ways of “masking” their natural behaviours to try to better fit in with family, friends, and societal expectations.
Masking can result in hyper-monitoring of their own behaviour when they are around others and ignoring or hiding their needs/feelings – which can in turn contribute to persistent stress and feelings of anxiety.
Difficulties in staying focused during conversations or impulsively interrupting others can also lead to feelings of social inadequacy, unease and nervousness in social settings. Social situations, including small talk and maintaining conversations, can therefore be anxiety-provoking for individuals with ADHD.
How Anxiety might show up
Anxiety symptoms can be particularly taxing for many individuals with ADHD and their loved ones. Experiencing high levels of anxiety can lead to exhaustion, fatigue and burnout which can significantly affect someone’s quality of life, including their physical and mental health, work/school and social life.
The symptoms of anxiety in ADHD can be similar to those shown in the general population, but they may also present in unique ways.
Experiencing anxiety alongside ADHD, may worsen some ADHD symptoms, such as feeling more restless or greater difficulty concentrating than usual. For example, research has shown that anxiety can worsen difficulties in inhibitory control and emotion regulation (i.e., ability to control emotional responses and express emotions) in both children[ix] and adults[x] with ADHD.
Certain ADHD symptoms can also result in the amplification of worries and fears for some individuals. For example, challenges in organising thoughts and planning can worsen anxiety and make it more difficult to effectively regulate anxious thoughts.
It is also widely reported amongst individuals with ADHD that even the thought of starting a project or daily chore can evoke anxiety. Executive function difficulties (characteristic of ADHD) may make it difficult to break down tasks into manageable steps and initiate action without feeling overwhelmed. Analysis paralysis is a related term used to describe the inability to make decisions or take action due to overthinking and excessive consideration of potential choices and outcomes. This struggle with anxiety around initiating tasks can contribute to a cycle of procrastination and avoidance – a phenomenon commonly reported by individuals with ADHD.
Types of Anxiety Common in ADHD
Some common anxiety conditions to be aware of, which most often co-occur alongside ADHD, are:
-
- Social Anxiety Disorder – Involves difficulty navigating social norms and cues can lead to heightened social anxiety.
- Generalised Anxiety Disorder (GAD) – involves persistent worry and fear about various aspects of life can common
- Obsessive Compulsive Disorder (OCD) – where repetitive behaviours and obsessive thoughts can be prevalent, and require specialised understanding.
Understanding Depression in ADHD
A disproportionate number of individuals with ADHD experience depression. Research has estimated that up to 40% of adults with ADHD experience either mild, chronic depression (known as Dysthymia), Major Depressive Disorder or Bipolar Disorder, compared to just 11% for individuals without ADHD[xi].
Those with ADHD are therefore at an increased risk of having depression, and this is especially true within the first year of being diagnosed[xii].
For some people, depression and ADHD just happen to coexist, but for others, depression is a result of ADHD challenges.
There are some common symptoms of ADHD which overlap with those presented in a depressive episode, such as changes in appetite and disrupted sleep patterns. Social withdrawal, often associated with depression, may also be displayed by individuals with ADHD, who might retreat not only due to emotional distress but also as a coping mechanism for sensory overwhelm.
The relationship between ADHD and depression can also be cyclical, with each condition feeding into the symptoms of the other.
For example, when ADHD symptoms disrupt daily life or work responsibilities, this can leave a person feeling sad, hopeless, irritable and frustrated, all of which are symptoms of depression. These difficulties can also contribute to the person dealing with low self-esteem and poor self-image, which can contribute to the development of low mood.
In the other direction, the cognitive and emotional symptoms of depression can impede on tasks requiring extensive focus and attention, which can exacerbate existing ADHD challenges.
To further complicate things, some possible side effects of ADHD medications can imitate symptoms of depression, such as sleep problems, loss of appetite, and fatigue. This is why it’s important to talk to a medical professional who can help you understand the particular situation and how to best help.
How Depression might show up
The symptoms of depression in people with ADHD can be similar to those in the general population, as described earlier. The interplay of these conditions may also, however, present unique challenges which extend beyond conventional symptoms.
- Intensified Reactions – Individuals with ADHD may experience heightened emotional responses, leading to more intensified feelings of sadness, despair, or hopelessness during depressive episodes. Impulsivity, a hallmark of certain ADHD subtypes, can also contribute to the impulsive expressions of emotions. These elements may also contribute to increased conflict in relationships during depressive episodes.
- Physical Health Neglect – Depression can result in a lack of motivation to engage in self-care activities, ranging from showering and feeding oneself, to doing basic household chores or brushing one’s teeth. Individuals with ADHD, who may already struggle with organisation and routine, often find it even more challenging to attend to their physical wellbeing during depressive episodes. Neglect of self-care activities (whether obvious or more discrete) can therefore be a sign of depression for individuals with ADHD, and should be acknowledged.
- Negative thoughts & self-talk – Depression can exacerbate negative self-perception and feelings of failure. Individuals with ADHD may be more prone to harsh self-criticism due to the challenges they face in daily life. The impulsivity inherent in some individuals with ADHD can also exacerbate feelings of guilt and worthlessness, as individuals may act on their impulses without thinking, leading to more feelings of regret and self-blame. Hyperfocus, a trait associated with ADHD, may also develop into obsessive rumination (repetitive thinking or dwelling) during depressive episodes, trapping individuals in cycles of intense focus on negative thoughts
- Cognitive fatigue – Cognitive fatigue, a common symptom of depression, refers to a unique sort of tiredness that affects the mind and how it works. Depression may bring about both this, and related symptoms, such as difficulty concentrating, making mistakes more frequently and making decisions. In individuals with ADHD, who may already grapple with these difficulties, this may be more accentuated during depressive episodes. Difficulties amplified during depression, such as organisation, time management, and task initiation, can also lead to chronic procrastination, which in turn can contribute to other difficulties, such as a sense of failure and of not being good enough.
- Physical Restlessness and Agitation – Restlessness is a core symptom of ADHD, and during depression, this restlessness can manifest as physical agitation. Hyperactivity can display both in the mind and in the body – individuals may find it difficult to sit still or experience racing thoughts, contributing to a sense of internal distress. This can also make it challenging to relax and unwind, particularly as bedtime approaches. Individuals with ADHD may already face challenges in establishing consistent sleep routines and feelings of restlessness, and depression can exacerbate these difficulties, leading to more serious sleep problems such as insomnia.
Getting mental health support
Identifying signs of depression and anxiety early on can help with getting timely mental health support or treatment. An understanding the nuanced interplay of ADHD, anxiety and depression is crucial for accurate identification and for targeted intervention such as personalised mental health support.
If you think you, or a loved one, are depressed or anxious to an extent which is detrimentally affecting their life, please talk with a doctor or a mental health professional as soon as possible.
There are numerous forms of treatment available for both depression and anxiety, including psychological and medicinal options, which should be overseen by a health professional.
- Samaritans – 116 123
- Phone 0800 107 0160 – free confidential support 24/7
- SaneLine: 0845 767 8000 – 6.00pm to 11.00pm (Offers multilingual support)
- Shout Crisis Text Line – text SHOUT to 85258 anytime
- NHS GP on call – 111
- Talk to someone you trust
Self-help guidance
Being open to understanding what experiences or actions might trigger difficult feelings for someone is also important when it comes to getting appropriate wellbeing and mental health support – and what this looks like will be different between individuals.
Identifying and monitoring when feelings of anxiety or depression occur can be useful in coming up with solutions to minimise distress. For example, being aware of increased stress or depleted energy levels following social interactions might remind someone to recharge or take some alone time to engage in activities they enjoy.
There are also other self-help and practical strategies that might support someone facing mental health difficulties within the context of ADHD, such as:
- Experiment with relaxation activities & self-soothing
Practicing relaxation techniques, such as meditation, progressive muscle relaxation, visualisation, and deep-breathing exercises can help reduce stress and anxiety by slowing the heart rate, reducing muscle tension, and boosting concentration and mood[xiii]. Engaging in activities that you enjoy, whether it is something creative like painting, or gentle movement like yoga, might help to self-soothe and buffer negative emotions. Learn more about relaxation techniques in our blog post: The Benefits of Breathing techniques for People with Neurodiverse Conditions
- Increasing physical activity
Research has consistently found that exercise can lower symptoms of anxiety[xiv]. Activities such as playing sports or running can also serve as a valuable outlet for excess energy for individuals with ADHD, which might aid in improved focus and attention, and may improve mood by promoting the release of endorphins.
- Breaking down tasks
Splitting bigger tasks into smaller, more manageable steps may help to alleviate feelings of overwhelm that can contribute to anxiety. Taking this sort of action can also support productivity and promote a sense of accomplishment, which may in turn lift mood and even self-esteem and confidence. This method is relatively universal as it can be for any task, whether it is a large domestic chore at home, or a project at work or school.
- Daily structure and routine
Using a visual schedule or an organisation mobile app may help buffer against issues of disorganisation that may contribute to mental stress. Introducing methods of time-tracking, or other tools to help individuals with ADHD effectively manage their time, can support time awareness and act as reminders to stay on task.
- Fostering a sense of acceptance
If you can help people to feel relaxed and comfortable being themselves, they are less likely to be consciously concerned about ‘masking’ their neurodivergent traits, which may reduce their stress. Facilitating training sessions or workshops to educate the public or employees about ADHD can also increase awareness around ADHD-related challenges, to foster empathy and understanding within both home and work environments. It can also reduce any stigma around the condition that may be contributing to their mental burden.
- Making adaptations to the environment
This could relate to facilitating the use of flexible work schedules or work-from-home options, which can help to accommodate for fluctuations in mood and energy levels and help individuals manage their workload during times of stress or low mood. Trying to have access to designated quiet spaces for retreat during times of overwhelm or anxiety, could also be useful, as could the use of comfortable seating, minimal noise and soft, natural lighting, to create a more soothing environment.
- Eating a healthy balanced diet where possible
A balanced diet, which is rich in nutrients, supports optimal brain function and provide the essential building blocks for neurotransmitters important for mood regulation. Moreover, maintaining stable blood sugar levels through nutritious meals can help mitigate against rapid dips in energy, as well as buffer against mood swings or drops in attention and focus.
If you require further information on how diet can affect mood, view our blog articles:
Or for additional help with your diet, book an appointment with one of our experienced nutritionists:
Discover more about support options for mood, anxiety, and depression related issues on our Mental Wellbeing Support page. Additonally, you may wish to view our supplements page:
Important – This article is for insight and educational purposes. Identifying with any symptoms or experiences mentioned should not be taken as a substitute for a formal or clinical diagnosis of these complex conditions, nor the specific support required to support a particular individual. Please talk to a qualified health professional or GP if you are seeking mental health or specific ASD, ADHD, dyslexia or dyspraxia support. Every individual is unique, and a diagnosis alone is also not an adequate basis on which to determine all of an individual’s potential, abilities or needs.
Written by Hazel De Maeijer
MSc | GMBPsS | BSc (Hons)
REFERENCES
[i] https://www.nhs.uk/mental-health/conditions/generalised-anxiety-disorder/
[ii] Katzman, M.A., Bilkey, T.S., Chokka, P.R., Fallu, A. and Klassen, L.J., 2017. Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC psychiatry, 17, pp.1-15.
[iii] Beaton, D.M., Sirois, F. and Milne, E., 2022. Experiences of criticism in adults with ADHD: A qualitative study. Plos one, 17(2), p.e0263366.
[iv] https://www.psychologytoday.com/gb/blog/friendship-20/201907/what-is-rejection-sensitive-dysphoria
[v] Biederman, J. , Newcorn, J. , & Sprich, S. (1991). Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. American Journal of Psychiatry, 148, 564–577.
[vi] Bowen, R. , Chavira, D.A. , Bailey, K. , Stein, M.T. , & Stein, M.B. (2008). Nature of anxiety comorbid with attention deficit hyperactivity disorder in children from a pediatric primary care setting. Psychiatry Research, 157 (1–3), 201–209.
[vii] Quenneville, A.F., Kalogeropoulou, E., Nicastro, R., Weibel, S., Chanut, F. and Perroud, N., 2022. Anxiety disorders in adult ADHD: A frequent comorbidity and a risk factor for externalizing problems. Psychiatry research, 310, p.114423.
[viii] Solberg, B.S., Halmøy, A., Engeland, A., Igland, J., Haavik, J. and Klungsøyr, K., 2018. Gender differences in psychiatric comorbidity: a population‐based study of 40 000 adults with attention deficit hyperactivity disorder. Acta Psychiatrica Scandinavica, 137(3), pp.176-186.
[ix] Sørensen L., Plessen K. J., Nicholas J., Lundervold A. J. (2011). Is behavioral regulation in children with ADHD aggravated by comorbid anxiety disorder? Journal of Attention Disorders, 15(1), 56–66. 10.1177/1087054709356931
[x] Jarrett M. A. (2016). Attention-deficit/hyperactivity disorder (ADHD) symptoms, anxiety symptoms, and executive functioning in emerging adults. Psychological Assessment, 28(2), 245–250. 10.1037/pas0000190
[xi] Kessler et al. (April 2006). The Prevalence and Correlates of Adult ADHD in the United States: Results From the National Comorbidity Survey Replication, American Journal of Psychiatry 163(5):71.
[xii] Gundel, L.K., Pedersen, C.B., Munk-Olsen, T. and Dalsgaard, S., 2018. Longitudinal association between mental disorders in childhood and subsequent depression–A nationwide prospective cohort study. Journal of Affective Disorders, 227, pp.56-64.
[xiv] Aylett, E., Small, N. and Bower, P., 2018. Exercise in the treatment of clinical anxiety in general practice–a systematic review and meta-analysis. BMC health services research, 18, pp.1-18.
Disclaimer: The views and opinions expressed in this blog post are those of the author and do not necessarily reflect the official policy or position of any professional organization or guidelines. The information provided is for educational and informational purposes only and is not intended as a substitute for professional advice, diagnosis, or treatment. Always seek the advice of your therapist or other qualified health provider with any questions you may have regarding a medical or mental health condition.