Dueling Diagnoses: The Causes and Societal Effects of Medication for ADHD and Anxiety

by Lucy Nelson

WINSTON SALEM, NC—When Wake Forest University student Rachel Esham was a freshman three years ago, she joined the reported 40 million adults in the United States to be diagnosed with an anxiety disorder. While the transition from high school to college can be anxiety-inducing for just about anyone, Esham’s newly diagnosable levels of anxiety may have had something to do with a different change in her routine: Adderall.

At just 8 years old, she was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), and her pediatrician prescribed a daily dose of 10 milligrams of Adderall, a common medication used to treat ADHD. Esham stopped taking the medications in sixth grade when she went to The Landmark Boarding School in Boston that offered specialized teaching for her ADHD and other learning disorders, replacing the need for Adderall. It was not until seven years later when she got to college that she started taking a daily prescribed dose of Adderall again.

“I started taking it again just because I was in a different setting—classes were bigger and there were harder assignments that required more focus without concentrated help for kids like me with learning disorders,” Esham said. “Unfortunately, I think that it started making me feel more anxious. I mean, I think I’ve always had anxiety, but it felt very manageable until I started taking Adderall again and that was when I no longer had control over it.”

Soon after her Generalized Anxiety Disorder (GAD) diagnosis, Esham was prescribed Zoloft, the generic brand for a type of sertraline medication commonly used to treat anxiety, depression, and other mental health disorders. Since then, she has been struggling with trying to cut down on the doses of the medication, as well as their conflicting side effects.

The commonly comorbid conditions are aggressively treated with medications

Esham’s comorbidity, or the simultaneous presence of two diagnosed conditions—in this case, anxiety and ADHD—is not uncommon; the National Comorbidity Survey Replication reported that 47 percent of adults with ADHD also have an anxiety disorder. Both are typically treated aggressively with medications, as supported by the rapidly rising sales of anti-depressant/anti-anxiety medications and ADHD-type stimulants.

Common medications for anxiety are Selective Serotonin Reuptake Inhibitors (SSRIs), which relieve anxiety symptoms by blocking the reabsorption of serotonin by certain nerve cells in the brain. The medication leaves more serotonin to improve the patient’s mood.

A majority of prescribed medications for ADHD include amphetamine or dextroamphetamine stimulants, sold under brand names such as Adderall, Vyvanse, Focalin, and Concerta. The stimulants directly activate parts of the brain by increasing dopamine levels, transmitting signals that improve attention span and focus and regulate impulsive behavior.

Transparency leads to increased reports of ADHD and GAD in the past 20 years

Just twenty years ago, these medications, let alone the disorders themselves, were rarely heard or spoken of. Since then, the number of people taking antidepressants has soared by about 65 percent, and the diagnoses of ADHD among children has almost doubled from 6 percent of children in 1998 to more than 10 percent in 2016, according to a study conducted by the Journal of the American Medical Association (JAMA). Their discussion points to a major leap in diagnoses as a result of genetic and environmental risk factors, increased public awareness, improved access to health services, and improved referral from primary care and communities to specialty mental health services.

The study also suggests that fewer stigmas about mental-health and ADHD in minority communities may lead to more people receiving an ADHD diagnosis. This decrease in stigma about mental-health has been attributed to a rise in anxiety diagnoses as well.

Dr. Terry Blumenthal, a psychology professor at Wake Forest University agrees that the reported numbers of people with ADHD, and especially those with anxiety, could be a result of more people feeling comfortable talking about their diagnosis. Blumenthal notes that the willingness to report may be driven by society’s shift in viewing mental illness and other disorders as ‘real’ and not just an excuse.

“Two decades ago, it used to be ‘Oh, well you don’t wanna talk about [anxiety or ADHD]’ because people found out that you had these problems, they would think that you are weak, you might have other problems, and they weren’t going to hire you, that’s for sure,” Blumenthal said. “There’s a lot less of that negative stigma—it’s not all gone, by any means, but there is less, and so people are more willing to come forth and say ‘I have a problem, can you come and fix it?”

Although society has become more accepting of anxiety disorders, the new shift in its definition of happiness and success often ignites or emphasizes such disorders or even symptoms of those disorders in individuals. This has led to an increase of comorbidity of ADHD and GAD, perhaps due to the shift in America’s society from a focus on intrinsic desires to extrinsic ones. The joy of family and friends now seems to be replaced with the need to be financially successful in order to buy a big house or a fancy car. There is an elevated pressure to be focused, get good grades, and obtain a high-paying job, leading to elevated levels of anxiety.

Intense, college-focused shifts in school structures set students up for failure and lead to medication as a quick-fix

Additionally, the increased rigorous school structure, with 7-hour days starting in elementary school, is anxiety-inducing and is especially hard for individuals with ADHD.

“I think my ADHD always has affected me positively, I just think that academic settings aren’t designed to teach kids with ADHD because I had that in high school with the structure of my school and the curriculum which was individualized towards me,” said Esham. “They gave us designated free time and then we had study halls all together. Now, with a typical American schooling structure, it’s really hard to stay focused and organized, especially with ADHD, and it causes a lot of anxiety.”

A study by the University of Michigan found that time spent in school increased 18 percent and time spent doing homework increased 145 percent between 1981 and 1997. The same study found that time spent in any kind of play (recess, socializing, etc.) decreased 16 percent and much of it had shifted to indoor activities, often involving a computer and no other children. In The Coddling of the American Mind, Greg Lukianoff and Jonathan Haidt attribute part of this rigorous shift in school structures to the “fear that haunts American parents and children—particularly those in the middle class and above—far more than it did in the late twentieth century: the college admissions process.”

Haidt and Lukianoff found that with college acceptance rates rapidly lowering and competition to get into elite universities rising, opportunities for self-direction, social exploration, and scientific discovery have increasingly diminished. Attention is focused on preparing students to meet state testing requirements and, with external pressure from parents, more pressure to participate in an excessive amount of community service, extracurriculars, and anything else that will help to boost a college resumé.

The process “warps the values of students drawn into a competitive frenzy” and “jeopardizes their mental health” Frank Bruni, New York Times columnist wrote in a 2016 column. Parents seem to be willing to do anything to help their kids keep up with today’s stressful and competitive environment, even if it’s a quick-fix of expensive medication to help their kids focus and to help them handle the anxiety that has come along with this aggressive pressure.

Contradictory side effects of medications cause dangerous increase in dosages

A pressing issue in relation to the medication-related treatment of the comorbidity of ADHD and Generalized Anxiety Disorder is that the side effects of the medications prescribed for each of the conditions almost directly contradict one another.  

“The medication for Generalized Anxiety Disorder can increase lack of focus because it’s sort of a tranquilizer, while the medication for ADHD can increase anxiety because it’s a stimulant,” Blumenthal said. “So if you’re taking both of these, they are counteracting each other to a certain extent.”

In talking to multiple Wake Forest University students, the result of this counteraction seems to be a tendency to constantly increase both medications to extremely high doses for the comorbid patients, regardless of the individual’s level of severity of the conditions. Esham, for example, started at 10mg of Adderall and 50mg of Zoloft and now is taking daily doses of 30mg of Adderall and 75mg of Zoloft. Kaitlyn Stilson, another Wake Forest University student who struggles with both disorders, started by taking 10 mg of Adderall for her ADHD and 20 mg of Fluoxetine for her GAD at age 15, and now takes 60mg of Vyvanse and 60mg of Fluoxetine.  

While medications for both disorders can be crucial in helping patients lead more comfortable lives, taking high doses for long periods of time can be dangerous. For instance, the cardiovascular effects related to ADHD stimulant medications, including hypertension and tachycardia, were prominent enough that in 2005 Canada withdrew the brand medication Adderall XR from the market.

Long term effects of the stimulants in large doses also include the reduction of the natural production of dopamine in the brain, impacting the brain’s reward center and altering the individual’s ability to experience pleasure without the chemical support of continued amphetamine use. The same goes for anxiety medications; they increase levels of serotonin in the brain which causes feelings of emotional numbness, because normal feelings of healthy anxiety are eliminated. This results in a lack of motivation to perform tasks or engage in social activities.  

Not just a quick fix; Low doses alongside therapy and other tools provide promising advantages

The solution to a safer and better approach to treating the comorbidity may exist in finding the lowest appropriate dose of each medication for the individual. Some studies have even found that lower dosages are often as effective, if not more, than higher doses in many cases.

“The process of discovering which dose of medication is the lowest that will provide the optimal level of symptom relief is critical,” Medical Doctor and ADHD specialist, William Dodson said.

The Anxiety and Depression Association of America (ADAA) suggests that health professionals should focus on the disorder associated with the highest degree of impairment first, and then move on to medicating the other comorbid condition. As a result, the lowest proper dose of medication for one of the disorders can be found first without catalyzing side effects of medication for the other condition.

Additionally, Dr. Dodson explains that the medications simply act as “quick fixes” if they are not paired with active behavioral or psychological therapy that provide mental practices and life skills to help control the disorders. Taking increased levels of medication simply allows for the dependence on a pill that has side effects and dangerous long-term complications. While medications can help correct ADHD individuals’ impulsive behavior and the biochemical problems associated with GAD patients, Cognitive Behavioral Therapy (CBT) helps to correct and improve lack of focus (in ADHD) and distorted ways of thinking (in GAD) in the long run.

“I feel like we have a toolbox full of resources that we use to cope and I feel like medication just makes that toolbox bigger and more accessible, but it still doesn’t fix it, and you still have to deal with what’s inside of it,” Stilson said.

Haidt and Lukianoff even outline CBT and mindfulness in their book as techniques that should be implemented in helping raise wiser children to be “present” and to not fall prey to the craze of a society focused on grades, money, and medications. Dr. Rinky Bhatia, Assistant Professor of Medicine at Johns Hopkins University reiterates that this concept of using life skills and tools could be critical in helping anyone, but particularly patients with ADHD and GAD live more successfully without the severe reliance on medications. She also explains that America’s perfectionist society deems normal personality traits as abnormal diseases that must be fixed with medication.

“There is a rise in use of drugs in the treatment of personality traits, normal reactions, adjustment disorder, symptoms (not disorders) and unapproved indications,” Bhatia said in her editorial. “This is due to the increasing tendency to find out pharmacological solution of every psychological or environmental problem. The classical example is the lesser use of physical, psychological and behavioral therapies.”  

Dr. Dodson agrees, saying, “The combination [of therapy and medication] leads to much better outcomes than does either one of them alone.”

The new emphasis on ending the stigma against disorders such as ADHD and anxiety has been increasingly positive and has encouraged those who need help to actively seek it. However, with the current tendency to over-medicate patients, and a lack of therapy and information, has eliminated the much-needed emphasis on providing skills to help individuals suffering from anxiety and ADHD succeed in the long run without impending reliance on medication and the related side effects. With today’s society and school structures requiring heightened levels of focus and fostering severe anxiety and other mental disorders, it is incredibly important that we look at the larger picture, starting by emphasizing the importance of mental tools for the millions of individuals with ADHD and GAD to live less miserably and dangerously over-medicated lives.

“Even though it’s hard, I’m actively trying to lower my dose of both medications,” said Esham, “I’m working towards not needing medication, or nearly as much medication to focus or to lead a life not filled with constant worry.”

Lucy Nelson is a Junior at Wake Forest University, where she studies Communications, Spanish, and Journalism. She is originally from Minneapolis, Minnesota. 

The views expressed in this article are those of the writer. The Contemporary takes no position on matters of policy or opinion.

The cover photo was made by the author.

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