Will Strattera (atomoxetine) help with anxiety?

Atomoxetine (Strattera) for Anxiety: Efficacy and Recommendations

Atomoxetine (Strattera) can help with anxiety, particularly in patients who have comorbid ADHD and anxiety disorders, but it is not a first-line treatment for anxiety disorders alone.

Mechanism and Evidence for Anxiety Treatment

Atomoxetine is a selective norepinephrine reuptake inhibitor that works by inhibiting the presynaptic norepinephrine transporter in the prefrontal cortex 1. While primarily indicated for ADHD, there is evidence supporting its use in anxiety:

• FDA labeling information indicates that atomoxetine does not worsen anxiety in patients with ADHD and comorbid anxiety disorders 2
• Clinical trials have demonstrated that atomoxetine did not worsen anxiety in patients with ADHD and comorbid anxiety disorders as measured by the Pediatric Anxiety Rating Scale (PARS) and Liebowitz Social Anxiety Scale (LSAS) 2
• In a 16-week double-blind placebo-controlled trial with 442 adult patients who had both ADHD and social anxiety disorder, atomoxetine was effective without worsening anxiety symptoms 2

Efficacy for Anxiety

The evidence for atomoxetine's efficacy specifically for anxiety varies by patient population:

• For patients with ADHD and comorbid anxiety:

  • Atomoxetine has shown efficacy for both ADHD symptoms and anxiety symptoms 3
  • In some cases, atomoxetine demonstrates "impressive efficacy" for both ADHD and anxiety disorder symptoms 3

• For patients with primary anxiety disorders:

  • First-line pharmacologic therapies for anxiety disorders are SSRIs and SNRIs according to clinical guidelines 4
  • Atomoxetine is not mentioned as a first-line treatment for primary anxiety disorders in major guidelines 4

• For patients with partially responsive anxiety:

  • One open-label study showed that atomoxetine as adjunctive therapy to SSRIs or SNRIs in adults with ADHD and partially responsive anxiety symptoms led to significant improvement in anxiety symptoms as measured by the Hamilton Anxiety Scale 5

Treatment Recommendations

For patients with anxiety:

1. If anxiety is the primary condition without ADHD:

   • First-line pharmacological treatments are SSRIs and SNRIs 4
   • Psychological therapy, predominantly CBT, is the initial treatment approach for most patients 4
   • Atomoxetine is not recommended as first-line treatment for primary anxiety disorders

2. If anxiety coexists with ADHD:

   • For patients with ADHD as the primary condition and comorbid anxiety:
     • Stimulants are typically first-line treatment, which often improves both ADHD and anxiety symptoms 3
     • If stimulants don't adequately address anxiety symptoms, atomoxetine can be considered as an alternative 3
     • Atomoxetine at a target dose of 1.2 mg/kg/day may be effective for both conditions 6, 7

3. For patients with partially responsive anxiety already on SSRIs/SNRIs:

   • Atomoxetine may be considered as adjunctive therapy if ADHD is also present 5

Monitoring and Side Effects

When using atomoxetine, monitor for:

• Common side effects: appetite loss, abdominal pain, headaches, somnolence, nausea, and mild increases in heart rate and blood pressure 6
• Serious but rare concerns: black box warning for suicidal ideation in children and adolescents 1
• Cardiovascular effects: slight increases in heart rate and blood pressure 1

Conclusion

While atomoxetine is not a first-line treatment for primary anxiety disorders, it may be beneficial for patients who have both ADHD and anxiety disorders. For patients with primary anxiety disorders, SSRIs and SNRIs remain the first-line pharmacological treatments, along with CBT as the initial treatment approach.