Expert: Dr Billy Levin - 8/18/2010

Question
Dear expert,

I've just recently been diagnosed by a psychologist with co-
morbid major depression and inattentive ADD. Due to being
academically gifted, the ADD went completely undetected
until my recent degeneration failed to respond to typical
anti-depressant therapy (I'm presently 25).

A major part of my condition (for the past year or so) has
involved some unfortunate cognitive deficits - namely,
trouble thinking in the abstract, severe concentration
difficulties, mental fatigue, sluggish processing, etc. etc.
The symptoms seem to be an intense exaggeration of my
previous, untreated ADD symptoms, and there are no other
complicating issues like psychosis etc.. Strangely, I have
found these deficits to be highly respondent to nicotine
(I've been self-medicating with the lozenges out of
desperation); caffeine also helps to a marginal extent.

I've just recently changed countries and where I now live,
there are only a handful of psychiatrists permitted to treat
adult ADHD. At present, I have been referred to a general
psychiatrist to deal with the depression and anxiety - with
the option of seeing an ADHD specialist in the future were I
wanting to pursue stimulant therapy.

I guess my main question is: how thoroughly trained are most
psychiatrists in recognizing and understanding particular
cognitive deficits, if that makes sense? For example, if I
complain that "I'm having trouble concentrating and thinking
in the abstract (and have found said difficulty to be
unresponsive to anti-depressant treatment)" is that a
symptom whose etiology a general psychiatrist should
recognize? Are most psychiatrists in tune with, say, the
properties of nicotine that might be benefiting me? Or do
you feel that psychiatrists specializing in ADHD have a
better grasp on the neuropsychiatric dimension of suffering?
In the past, prior to my ADD diagnosis, I have been met with
responses that varied from frustratingly vague ('sometimes
your neurotransmitters just burn out') to being directly
challenged that what I was suffering from was simply a
confidence issue.

Sorry if my question seems a little vague; it's just
intensely frustrating trying to transmit what I'm going
through, and I'm wondering if I might be wasting my time
dealing with general psychiatrists. I have been assured that
the person I am slated to see is very good, but still,
between the depression, anxiety and intense fatigue my
condition brings there's only so much patience I can have.

Thanks
Daniel

Answer
Your question was not vague by any means, only long winded. Part of ADD. You canot have "inattentive ADD"! ADD is inattentive. You must mean you are not  ADHD(hyperactive). Having ADD and  a high IQ is often missed. Neglected ADD will very often result in depression in the adult that will not respond to anti-depressants until the ADD is also treated with stimulant like Ritalin. The treatment of ADD/ADHD in the child and the adult is virtually the same. Titrating a dose to an optimal level and lasting the whole day, not part of the day. Thereafter adding in an antidepressant only if required because Ritalin is also a mild antidepressant. It is essential to see a medical expert who has knowledge and experience in this field. With no disrespect intended the average good  doctor has no or little  experienced in theis field.