What medications are suitable for a 17-year-old male patient with Attention Deficit Hyperactivity Disorder (ADHD), Generalized Anxiety Disorder (GAD), Major Depressive Disorder (MDD), and excessive daytime sleepiness?

Medication Management for 17-Year-Old with ADHD, Anxiety, Depression, and Excessive Daytime Sleepiness

For a 17-year-old male with ADHD, GAD, MDD, and excessive daytime sleepiness, atomoxetine (Strattera) is the most appropriate first-line medication based on his pharmacogenetic profile and comorbidities.

Medication Selection Rationale

Primary Recommendation

• Atomoxetine (Strattera):
  • Starting dose: 0.5 mg/kg/day
  • Target dose: 1.2 mg/kg/day 1
  • Addresses both ADHD and mood symptoms 2
  • Appropriate for patients with anxiety comorbidity 1
  • Avoids worsening anxiety symptoms that can occur with stimulants 1
  • Patient's CYP2D6 *1/*2 status indicates normal metabolism of atomoxetine 3

Alternative Options

1. Bupropion (extended-release):

   • Potential alternative if atomoxetine is ineffective
   • Addresses both ADHD and depression 1
   • Dosage: 150-450 mg daily 1
   • Monitor for anxiety symptoms as side effect

2. Non-stimulant alternatives:

   • Extended-release guanfacine (Intuniv): 1 mg daily
   • Extended-release clonidine (Kapvay): 0.1 mg daily 1

Pharmacogenetic Considerations

• **CYP2D6 1/2: Normal metabolizer - appropriate for atomoxetine 3
• **CYP2B6 6/6: Poor metabolizer - may affect bupropion metabolism
• COMT Val158Met A/G: Intermediate COMT activity - may influence response to stimulants
• **CYP3A4 1/1: Normal metabolism - no dose adjustments needed for medications metabolized by this pathway
• **CYP3A5 3/3: Poor metabolizer - monitor for potential drug interactions

Treatment Algorithm

1. First-line: Atomoxetine

   • Begin with 0.5 mg/kg/day for 3 days, then increase to target dose of 1.2 mg/kg/day
   • Monitor for suicidal ideation (FDA black box warning for adolescents) 3
   • Allow 4-6 weeks for full therapeutic effect

2. If inadequate response after 6-8 weeks:

   • Consider adding or switching to bupropion extended-release
   • Start at 150 mg daily and titrate based on response

3. If excessive daytime sleepiness persists:

   • Consider modafinil as adjunctive therapy for daytime sedation 4
   • Alternative: methylphenidate at low dose (2.5-5 mg) in morning only 4

4. For breakthrough anxiety:

   • Consider adding mirtazapine (especially if sleep and appetite issues persist) 4
   • Avoid benzodiazepines due to age and potential for cognitive impairment 4

Monitoring Plan

• Weekly for first month:

  • Suicidal ideation (critical with atomoxetine in adolescents) 3
  • Vital signs (blood pressure, heart rate)
  • Side effects (nausea, decreased appetite, fatigue)

• Monthly thereafter:

  • ADHD symptom response
  • Anxiety and depression symptoms
  • Sleep patterns and daytime alertness
  • Weight and growth (atomoxetine can affect growth) 3

Important Considerations

• FDA warning: Atomoxetine carries a black box warning for increased risk of suicidal ideation in children and adolescents (0.4% vs. 0% with placebo) 3

• Sleep evaluation: Consider polysomnography if sleep-disordered breathing is suspected 4

• Adjunctive treatments:

  • Cognitive-behavioral therapy for ADHD, anxiety, and depression 1, 5
  • Mindfulness-based interventions for attention and emotional regulation 1

• Caffeine use: The patient's current reliance on caffeine suggests significant daytime sleepiness that should improve with proper ADHD treatment

• Avoid: Benzodiazepines (risk of cognitive impairment) and stimulants as first-line (may worsen anxiety) 4, 1

Follow-up Plan

• Evaluate response after 4-6 weeks on target dose of atomoxetine
• If partial response, consider combination therapy or medication switch
• Regular monitoring for suicidal ideation throughout treatment
• Reassess need for continued therapy periodically

This treatment approach aligns with the American Academy of Child and Adolescent Psychiatry guidelines for treating comorbid ADHD and mood disorders, with consideration of the patient's specific pharmacogenetic profile 1.