Psychiatric diagnoses often hard to pin down

Dear Dr. Roach: I am a 47-year-old woman, and I’ve dealt with inherited major depressive disorder since my teens. Drug treatment has always given me moderate relief. Two years ago, I described to my new doctor my lifelong tendency to have shifting moods (best in the mornings, worst in the evenings) and my difficulty staying focused. He added a daily dose of Lamictal to my already-prescribed Pristiq.

Since then, I’ve felt, simply put, “normal” for the first time in my life. My moods are far more stable, and I can concentrate on whatever I want without extreme effort. Absentmindedness is no longer a problem. I couldn’t believe my relief, and I asked him where this drug had been all this time.

He smiled and quietly asked me whether anyone in my family had ever been diagnosed with ADHD. I was shocked. I come from a stable and intelligent family of high achievers. I am not supposed to have what many consider a “learning disability,” but now I believe that had I been medicated, I’d have had a much easier, happier life to date. I’m sure my ancestors would have as well.

In short, I am asking you to convey to your readers that they should never stigmatize ADHD as I did, because its symptoms are easily masked within mood disorders, and one problem can worsen the other. Just ask to be screened. It might really help. Thanks for spreading the word.

J.M.W. Making diagnoses in psychiatry can be difficult. There isn’t a lab test or imaging study to confirm the diagnosis, and the symptoms people notice can overlap among several different conditions, treatment for which can vary widely.

For instance, people with symptoms of depression (such as depressed mood and little interest in pleasurable activities) might have an obvious diagnosis: major depression.

However, they might instead have bipolar disease type 2. To make this diagnosis, there must have been at least one episode where a person had “hypomania”: a period of symptoms including increased energy, elevated mood and little need for sleep, lasting at least four days. This might not be recalled by the patient, and the diagnosis can go unmade. This is important because the treatments are different.

I mention bipolar 2 because lamotrigine (Lamictal) is a treatment for bipolar disease. It acts as a mood stabilizer. It also sometimes is used in people with ADHD, as it helps with the sideeffects of stimulants.

I honestly don’t have enough information to say whether you have ADHD, bipolar disease, both, or neither. There are diagnostic criteria and a screening test that can be done for ADHD (see add.org/adhd-test/).

I should add that many people, both those with ADHD and those with bipolar disease, perform at extremely high levels. I have had people write to me that they feel successful partly because of, rather than in spite of, their ADHD.

In the future, we might have better success prescribing medications based on someone’s genes in addition to their symptoms — there already is promising research in this area.

What is clear is that it sometimes takes more than one expert to find the right treatment, including medication (or combination) in people with a serious psychiatric illness.