Coordinating Treatment for ADHD and Psychiatric Comorbidities

How should clinicians approach treatment for attention-deficit/hyperactivity disorder (ADHD) in patients who also present with cooccurring substance use or mood dysregulation? In this video, Psych Congress NP Institute Co-Chair Julie Carbray, PhD, PMHNP-BC, PMHCNS-BC, FAAN, walks clinicians through key treatment considerations for patients with ADHD and these highly prevalent psychiatric comorbidities. Carbray outlines treatment priorities for this patient population and underscores a holistic model for ensuring that both ADHD symptoms and any concurrent disorders are effectively addressed in clinical practice.

• Substance use disorders (SUDs) occur in approximately 20% of patients with ADHD, while concurrent mood dysregulation affects about 50% of children and adolescents and somewhat fewer adults.
• In patients with active SUDs, clinicians should prioritize treatment of the substance use disorder, establish commitment to treatment, and consider ongoing drug screening and motivational interviewing before initiating or renewing stimulant therapy.
• Clinicians should first clarify and stabilize coexisting mood disorders, incorporate psychotherapy such as cognitive behavioral therapy (CBT) and motivational interviewing, and consider nonstimulant ADHD medications when concerns exist about worsening substance use or mood instability.

Julie Carbray, PhD, PMHNP-BC, PMHCNS-BC, FAAN: Hi, I'm Julie Carbray. I am a clinical professor of nursing and psychiatry at the University of Illinois Chicago's Institute for Juvenile Research Department of Psychiatry, and I'm also a psychiatric mental health nurse practitioner.

Psych Congress NP Institute: What is the prevalence of substance use disorders and mood instability in patients with ADHD?

Carbray: We all know that the prevalence of SUDs in ADHD is robust, maybe around 20%. Some studies say less, some studies say more. We know when we're thinking about children and adolescents that adequate treatment of ADHD actually results in less SUDs. 

But comorbidity in adult populations and even in adolescent populations is at about that 20% range, highly relevant. 

For concurrent mood disorders, the rate is even higher. In children and adolescents, it's about 50% concurrent mood dysregulation along with ADHD. A little less than that in adult populations, but it is frequently present.

The symptoms typically do not manifest in a DSM-5 mood disorder-fitting criteria, but instead mood dysregulation accompanies classic symptoms of ADHD—the distractibility, the inattention, what we typically think about—and quite commonly can come hand in hand with ADHD.

PCNPI: What are some key challenges in prescribing treatment for ADHD in high-risk populations, like individuals with comorbid SUDs or mood disorders?

Carbray: Some common challenges with treating patients who may have concurrent disorders of substance use disorders, mood disorders, are we really want to back up and treat either the substance use disorder or the mood dysregulation disorder first. That's a rule of thumb. 

If a patient comes to me and they have an ongoing active substance use disorder and ADHD, I know I want to treat both. I want to get a commitment from the patient around their substance use treatment before I'm going to write that or renew that prescription for the stimulant they were taking. 

I may likely want to do ongoing drug screens and have some sort of a conversation using motivational interviewing around how we will continue to manage both the substance use disorder along with their ADHD. 

But affirming for them first, we have to make sure we have a handle on the substance use disorder. 

I would say it's very similar with mood dysregulation disorders. We want to start first understanding, what is the mood dysregulation disorder? Are we looking at a bipolar 2 disorder? Are we looking at major depressive disorder (MDD)? I'm going to really want to treat mood dysregulation first. 

If I have a good sense of that mood disorder is on the way to more stability or we're getting closer to baseline, then I'm going to be incorporating more psychopharmacologic treatments for ADHD. 

Now underlying both of these comorbid disorders, I'm going to have onboard treatment that is likely psychotherapy-based, CBT, motivational interviewing, patients going to support groups for substance use. I just really want to have a holistic approach to treatment in treating that substance use disorder and mood dysregulation disorder so that it is fairly well controlled before I jump into stimulant treatment. And it may be less likely that it's in control if I jump into a non-stimulant medication because the risk of aggravating substance use disorder or mood disorders would be less likely with one of our non-stimulant options.

Julie Carbray, PhD, PMHNP-BC, PMHCNS-BC, FAAN, holds her PhD (93) and Master of Science (88) degrees from Rush University, Chicago and her Bachelor of Science (87) degree from Purdue University in West Lafayette, Indiana. A Clinical Professor of Psychiatry and Nursing at the University of Illinois Chicago, she has been practicing as a Psychiatric Nurse Practitioner over 35 years. As UIC faculty, Carbray teaches course content in psychopharmacology, mood disorders, and development and therapeutic interventions with children and adolescents for students across various multidisciplinary programs. As the Director of the Pediatric Mood Disorder Clinic, she leads the clinical program and multidisciplinary training and is a nationally recognized clinical expert in children and adolescents with mood disorders.

Carbray holds a national reputation of excellence in serving families of children with mood disorders, and was recognized with the UIC Preceptor of the year award, the Karen Gousman Excellence in Nursing Award, the American Psychiatric Nurses Association Best Practices in an Outpatient Program for Bipolar Disorder Award, the UIC Inspire Award, the APNA Distinguished Service Award, and the Susan McCabe psychopharmacology lectureship from the International Society of Psychiatric Nurses. 

© 2026 HMP Global. All Rights Reserved.
 
Any views and opinions expressed above are those of the author(s) and do not necessarily reflect the views, policy, or position of the Psych Congress Network or HMP Global, their employees, and affiliates.