What non-stimulant medication is suitable for a 36-year-old female patient with Attention Deficit Hyperactivity Disorder (ADHD), Major Depressive Disorder (MDD), and Generalized Anxiety Disorder (GAD), who has a history of benzodiazepine dependence and is currently taking Flexeril (cyclobenzaprine), gabapentin, and Seroquel (quetiapine)?

Non-Stimulant Medication for ADHD in a Patient with History of Benzodiazepine Dependence

Atomoxetine (Strattera) is the most appropriate non-stimulant medication for this 36-year-old female patient with ADHD, MDD, GAD, and history of benzodiazepine dependence who is currently taking cyclobenzaprine, gabapentin, and quetiapine. 1, 2

Medication Selection Algorithm

1. First choice: Atomoxetine

   • Starting dose: 0.5 mg/kg/day
   • Target dose: 1.2 mg/kg/day (maximum 1.4 mg/kg/day or 100 mg/day, whichever is lower)
   • Dose adjustment: Every 7-14 days 1

2. Second choice: Bupropion

   • Consider if atomoxetine is ineffective or poorly tolerated
   • Beneficial for patients with comorbid depression and substance use disorders 1

3. Third choice: Alpha-2 agonists (guanfacine ER, clonidine ER)

   • Consider if both atomoxetine and bupropion are ineffective or contraindicated

Rationale for Atomoxetine Selection

Benefits for This Patient

• Substance Use History: Atomoxetine has no abuse potential, making it appropriate for patients with history of substance dependence 3, 1
• Anxiety Comorbidity: Atomoxetine may be beneficial for patients with anxiety disorders 1
• Once-daily dosing: Improves medication adherence compared to multiple daily doses 3
• Mechanism: Selective presynaptic norepinephrine transporter inhibitor that doesn't worsen substance use disorders 4

Considerations for Current Medications

• No significant interactions with patient's current regimen:
  • Flexeril (cyclobenzaprine) 150 mg
  • Gabapentin 400 mg
  • Seroquel (quetiapine) 50 mg at bedtime

Monitoring Plan

• Schedule follow-up within 2-4 weeks after initiation
• Monitor vital signs, particularly blood pressure and heart rate
• Assess for side effects including:
  • Drowsiness
  • GI upset
  • Tremor
  • Hyperreflexia
  • Tachycardia
  • Hypertension 4

Important Precautions

• Black box warning: Increased risk of suicidal ideation in children and adolescents (though this patient is an adult) 2
• Monitor for clinical worsening or unusual changes in behavior
• Atomoxetine may take 2-4 weeks to reach full effectiveness, unlike stimulants which work immediately

Alternative Options

Bupropion

• May be particularly beneficial given the patient's comorbid MDD 1, 5
• Lower abuse potential compared to stimulants
• Effective for both ADHD and depression symptoms
• Caution: May increase anxiety in some patients with GAD

Alpha-2 Agonists (Guanfacine ER, Clonidine ER)

• Less effective for core ADHD symptoms than atomoxetine 6
• May cause hypotension, sedation
• Not ideal first choice for this patient given her psychiatric comorbidities

Avoid in This Patient

• Stimulant medications (methylphenidate, amphetamines) due to history of substance dependence 3
• Benzodiazepines are absolutely contraindicated given patient's history of dependence 7, 8

By following this approach, the patient can receive effective treatment for ADHD while minimizing risks related to her history of benzodiazepine dependence and addressing her comorbid conditions.