What is the best course of action for a 30-year-old male (YOM) with anxiety, currently on Vyvanse (lisdexamfetamine) for Attention Deficit Hyperactivity Disorder (ADHD), who experienced adverse side effects from escitalopram (Lexapro) and continues to struggle with low motivation, depression, and anxiety?

From the Guidelines

The best course of action for this 30-year-old male with anxiety, ADHD, and depression who experienced adverse effects from Lexapro while on Vyvanse would be to consult with a psychiatrist about trying a different class of antidepressant, such as bupropion (Wellbutrin). Bupropion may be particularly beneficial as it works on dopamine and norepinephrine pathways, potentially addressing both the depression and low motivation without worsening anxiety or interfering with Vyvanse, as suggested by low-quality evidence from a trial 1. Starting at 150 mg once daily for one week, then increasing to 150 mg twice daily if tolerated, would be a typical approach. Additionally, incorporating cognitive behavioral therapy (CBT) alongside medication would provide skills to manage anxiety symptoms, with moderate-quality evidence from 4 trials showing no difference in overall discontinuation rates between SGAs and CBT at 8 to 14 weeks of follow-up 1. The patient should also discuss with his doctor whether his current Vyvanse dosage needs adjustment, as ADHD symptoms can overlap with anxiety and depression. Non-pharmacological approaches like regular exercise, adequate sleep, and stress management techniques should complement medical treatment. This combined approach addresses the neurochemical imbalances while providing coping strategies for symptom management, with low-quality evidence showing no difference in overall discontinuation rates for treatment with escitalopram versus a combination of escitalopram and telephone-based CBT 1. Regular follow-up appointments every 2-4 weeks initially would allow for medication adjustments and side effect monitoring, considering the evidence on comparative harms of pharmacologic versus nonpharmacologic treatment options 1.

From the Research

Treatment Options for Anxiety and Depression

The user is experiencing anxiety, depression, and low motivation while on Vyvanse for ADHD and has had adverse side effects from escitalopram. Considering the evidence, here are some potential treatment options:

• Escitalopram is an effective treatment for major depressive disorder and anxiety disorders, with a relatively fast onset of action and minimal interactions with other drugs 2, 3, 4.
• However, the user has already experienced adverse side effects from escitalopram, so alternative treatments may be necessary.
• Other SSRIs, such as citalopram, paroxetine, fluoxetine, and sertraline, may be considered, but their efficacy and tolerability compared to escitalopram are variable 2, 3.
• Serotonin-noradrenaline reuptake inhibitors (SNRIs), such as duloxetine and venlafaxine, may also be effective for depression and anxiety, but their use in combination with Vyvanse for ADHD is not well-studied 2, 5.
• Bupropion, a norepinephrine-dopamine reuptake inhibitor, has been shown to be effective in treating ADHD and depression, but its use in combination with Vyvanse is not well-studied 5.
• Switching to a different antidepressant or combining antidepressants may be helpful in patients who have not responded to initial treatment, but the choice of strategy should be individualized and based on the patient's specific needs and circumstances 6.

Considerations for ADHD Treatment

The user is currently on Vyvanse for ADHD, which is a psychostimulant. Here are some considerations:

• Psychostimulants, such as Vyvanse, are the most effective treatment for ADHD, but they may not address comorbid depression and anxiety 5.
• Antidepressants, such as SSRIs and SNRIs, may be used to treat comorbid depression and anxiety in patients with ADHD, but their efficacy and tolerability in combination with psychostimulants are variable 2, 5.
• The use of multiple medications, such as a psychostimulant and an antidepressant, requires careful monitoring for potential interactions and side effects 5, 6.

Next Steps

Based on the evidence, the next steps for the user could be:

• Consult with a healthcare provider to discuss alternative treatment options for depression and anxiety, such as switching to a different antidepressant or combining antidepressants 6.
• Consider cognitive-behavioral therapy (CBT) or other psychotherapies to address depression, anxiety, and low motivation.
• Continue to monitor the user's response to treatment and adjust the treatment plan as needed to optimize efficacy and minimize side effects.