What is the best approach to treat Attention Deficit Hyperactivity Disorder (ADHD) with co-existing anxiety?

From the Guidelines

The most effective approach to treating ADHD with co-existing anxiety is a multimodal treatment plan that combines medication, psychotherapy, and lifestyle modifications, with a focus on first addressing ADHD symptoms with stimulants like methylphenidate or amphetamine-based medications, as supported by the most recent study 1. When considering medication, it's essential to weigh the potential benefits and risks. Stimulants, such as methylphenidate (Ritalin, Concerta) at 18-36mg daily or amphetamine-based medications (Adderall, Vyvanse) at 20-70mg daily, are often recommended as the first line of treatment for ADHD, as they can rapidly improve ADHD symptoms and may also reduce anxiety symptoms 1. Some key points to consider when treating ADHD with co-existing anxiety include:

• The potential for stimulants to exacerbate anxiety in some cases, although this is not universally supported by evidence 1
• The use of non-stimulant options like atomoxetine (Strattera, 40-100mg daily) as an alternative, which may treat both conditions with less risk of exacerbating anxiety 1
• The importance of cognitive-behavioral therapy (CBT) in addressing both ADHD and anxiety symptoms, teaching skills to manage attention difficulties and providing strategies for anxiety reduction
• The value of lifestyle modifications, such as regular exercise (30 minutes daily), adequate sleep (7-9 hours), stress management techniques like mindfulness meditation, and maintaining a structured routine, in complementing medication and psychotherapy It's also crucial to regularly assess medication adherence and openly discuss potential issues, as lack of adherence can lead to reduced effectiveness and increased adverse events 1. Ultimately, a personalized treatment plan that takes into account the individual's specific needs, preferences, and circumstances is essential for achieving the best outcomes in treating ADHD with co-existing anxiety, as emphasized by the most recent and highest quality study 1.

From the FDA Drug Label

Anxiety in patients with ADHD and comorbid Anxiety Disorders - In two postmarketing, double-blind, placebo-controlled trials, it has been demonstrated that treating patients with ADHD and comorbid anxiety disorders with atomoxetine does not worsen their anxiety In a 12-week double-blind, placebo-controlled trial, 176 patients, aged 8 to 17, who met DSM-IV criteria for ADHD and at least one of the anxiety disorders of separation anxiety disorder, generalized anxiety disorder or social phobia were randomized. Atomoxetine did not worsen anxiety in these patients as determined by the Pediatric Anxiety Rating Scale (PARS). In a separate 16-week, double-blind, placebo-controlled trial, 442 patients aged 18 to 65, who met DSM-IV criteria for adult ADHD and social anxiety disorder (23% of whom also had Generalized Anxiety Disorder) were randomized. Atomoxetine did not worsen anxiety in these patients as determined by the Liebowitz Social Anxiety Scale (LSAS).

The best approach to treat Attention Deficit Hyperactivity Disorder (ADHD) with co-existing anxiety is to use atomoxetine, as it has been demonstrated in clinical trials that it does not worsen anxiety in patients with ADHD and comorbid anxiety disorders 2.

• Key points:
  • Atomoxetine does not worsen anxiety in patients with ADHD and comorbid anxiety disorders.
  • Clinical trials have shown that atomoxetine is effective in treating ADHD without exacerbating anxiety.
  • Atomoxetine can be used to treat ADHD in patients with co-existing anxiety disorders, including separation anxiety disorder, generalized anxiety disorder, and social phobia.

From the Research

Treatment Approaches for ADHD with Co-existing Anxiety

• The treatment of Attention Deficit Hyperactivity Disorder (ADHD) with co-existing anxiety can be challenging due to the complexity of symptoms and the need for a comprehensive treatment plan 3.
• Studies have shown that atomoxetine, a non-stimulant medication, can be effective in reducing symptoms of ADHD and anxiety in both children and adults 4, 5, 6, 7.

Efficacy of Atomoxetine in Treating ADHD with Anxiety

• Atomoxetine has been shown to be effective in reducing symptoms of anxiety in patients with ADHD, with significant improvements in anxiety symptoms and quality of life 4, 6, 7.
• A systematic review of clinical trials found that atomoxetine demonstrated good efficacy in improving anxiety symptoms in children and adolescents with ADHD, without exacerbating anxiety symptoms 7.
• Another study found that atomoxetine monotherapy was effective in treating ADHD and reducing depressive and anxiety symptoms in children and adolescents with comorbid symptoms 6.

Considerations for Treatment

• The treatment of ADHD with co-existing anxiety requires a comprehensive approach, taking into account the individual's specific needs and symptoms 3.
• The use of atomoxetine, either as monotherapy or in combination with other medications, may be a useful treatment option for patients with ADHD and anxiety 4, 5, 6, 7.
• Further studies are needed to fully understand the efficacy and safety of atomoxetine in treating anxiety disorders in patients with ADHD, particularly in terms of anxiety subtypes 7.