What is the best approach to treat Attention Deficit Hyperactivity Disorder (ADHD) with co-occurring Post-Traumatic Stress Disorder (PTSD)?

From the Guidelines

The best approach to treat Attention Deficit Hyperactivity Disorder (ADHD) with co-occurring Post-Traumatic Stress Disorder (PTSD) typically involves a combination of medication and psychotherapy, with careful sequencing of interventions, starting with addressing PTSD symptoms first. This approach is crucial as trauma symptoms can exacerbate ADHD symptoms and interfere with ADHD treatment effectiveness 1.

Key Considerations

• Treatment should generally begin by addressing the PTSD symptoms first, using trauma-focused psychotherapies like Cognitive Processing Therapy (CPT) or Eye Movement Desensitization and Reprocessing (EMDR), typically delivered in 12-16 weekly sessions.
• Medication options for PTSD include SSRIs such as sertraline (50-200 mg daily) or fluoxetine (20-80 mg daily).
• Once PTSD symptoms have stabilized, ADHD treatment can be initiated with stimulants like methylphenidate (starting at 5-10 mg twice daily, titrating up as needed) or amphetamine salts (starting at 5-10 mg daily), with careful monitoring for side effects like increased anxiety or sleep disturbances.
• Non-stimulant options like atomoxetine (40-100 mg daily) may be preferable for patients with substance use concerns or significant anxiety.

Medication Selection

• The selection of medication for ADHD should consider the patient's specific needs, including the severity of symptoms, presence of comorbidities, and the need for symptom relief throughout the day 1.
• Stimulants, such as methylphenidate and lisdexamfetamine, are generally recommended as first-line therapy for ADHD, due to their large effect sizes for reducing ADHD core symptoms and rapid onset of treatment effects.
• Non-stimulants, such as atomoxetine and guanfacine, may be considered as second-line therapy or for patients with specific comorbidities, such as substance use disorders or sleep disorders.

Monitoring and Adjustment

• Regular assessment of both ADHD and PTSD symptoms is essential, as improvement in one condition often positively impacts the other.
• Medication adherence should be regularly assessed, and potential issues in adherence openly discussed, to increase medication adherence and improve treatment outcomes 1.
• The dosing regimen can also affect medication adherence, with once-daily dosing generally preferred over twice-daily dosing.

From the Research

Treatment Approaches for ADHD with Co-occurring PTSD

• The treatment of Attention Deficit Hyperactivity Disorder (ADHD) with co-occurring Post-Traumatic Stress Disorder (PTSD) requires a comprehensive approach, considering the complexity of both conditions 2.
• Studies suggest that pharmacotherapy, such as atomoxetine and Vyvanse, may be effective in managing comorbid symptoms of ADHD and PTSD 2.
• Mindfulness training has also shown potential benefits in reducing symptoms of ADHD and PTSD 2.

Pharmacological Interventions

• Selective serotonin reuptake inhibitors (SSRIs) have been found to be effective in reducing PTSD symptoms, with a response rate of 58% compared to 35% for placebo 3.
• The noradrenergic and specific serotonergic antidepressant (NaSSA) mirtazapine and the tricyclic antidepressant (TCA) amitriptyline may also improve PTSD symptoms, although the evidence is based on low-certainty studies 3.
• The combination of methylphenidate and SSRIs has been found to be safe and effective in adults with ADHD and comorbid depression, with a lower risk of headache compared to methylphenidate alone 4.

Predictors of Treatment Response

• Predictors of treatment response to SSRIs in patients with PTSD include gender, childhood sexual trauma, and sexual assault as index trauma 5.
• Latent class analysis has identified three classes of treatment response: fast responders, responders with low pretreatment symptom severity, and responders with high pretreatment symptom severity 5.
• Class membership is predicted by factors such as time since index trauma, severity of depression, and severity of anxiety 5.

Considerations for Treatment

• Early diagnosis and effective treatment of ADHD may reduce the risk of developing PTSD 2.
• A comprehensive treatment plan should consider the individual's specific needs and circumstances, taking into account the complexity of both ADHD and PTSD 6.
• Further research is needed to explore the underlying mechanisms and optimal treatment strategies for individuals with ADHD and PTSD comorbidity 2.