Is Strattera (atomoxetine) effective for treating anxiety?

Strattera (Atomoxetine) for Anxiety: Not Recommended as First-Line Treatment

Strattera (atomoxetine) is not recommended as a first-line treatment for anxiety disorders, as there is insufficient evidence supporting its efficacy for anxiety as a primary condition. While it may have some effects on anxiety symptoms, particularly in patients with comorbid ADHD, current clinical guidelines do not include atomoxetine among recommended treatments for anxiety disorders.

Evidence on Atomoxetine for Anxiety

In ADHD Patients with Comorbid Anxiety

• The FDA label for atomoxetine specifically mentions studies in ADHD patients with comorbid anxiety disorders, noting that "atomoxetine did not worsen anxiety in these patients" 1. This suggests a neutral or potentially positive effect on anxiety when it co-occurs with ADHD.

• A study examining atomoxetine in children with ADHD found it was more effective than methylphenidate in reducing anxiety symptoms from the fourth week of treatment 2.

• In adults with ADHD and comorbid partially responsive anxiety symptoms, atomoxetine showed promise as an adjunctive treatment to SSRIs or SNRIs 3.

• Another study found that atomoxetine alone or combined with fluoxetine was effective for treating ADHD with comorbid symptoms of depression or anxiety 4.

For Primary Anxiety Disorders

• The 2023 Japanese Society of Anxiety and Related Disorders guideline does not include atomoxetine among recommended treatments for social anxiety disorder 5. The guideline specifically states that "other classes of drugs (e.g., antiepileptics and analogs, antipsychotics, benzodiazepines, beta blockers, monoamine oxidase inhibitors [MAOIs], norepinephrine reuptake inhibitors [NARIs], noradrenergic and specific serotonergic antidepressants [NaSSAs], reversible MAOIs, serotonin 2 antagonist and reuptake inhibitors [SARIs], and other antidepressants) have not been adequately studied."

• Current treatment guidelines for anxiety disorders primarily recommend SSRIs and SNRIs as first-line pharmacological treatments 5, 6.

Recommended First-Line Treatments for Anxiety

For treating anxiety disorders, the evidence supports:

1. SSRIs (fluoxetine, fluvoxamine, paroxetine, sertraline, escitalopram) as first-line pharmacotherapy 5, 6

   • High response rate with number needed to treat (NNT) = 4.70
   • Similar dropout rates to placebo, suggesting good tolerability

2. SNRIs (particularly venlafaxine) as another first-line option 5, 6

   • Response rate similar to SSRIs (NNT = 4.94)
   • Dropout rate similar to placebo

3. Cognitive Behavioral Therapy (CBT) as an effective non-pharmacological treatment 5, 6

Clinical Implications

• For primary anxiety disorders: Choose an SSRI or SNRI as first-line pharmacotherapy, not atomoxetine.

• For patients with comorbid ADHD and anxiety: Atomoxetine may be a reasonable choice that could address both conditions, particularly when:

  • The patient has risk factors for substance abuse 7
  • The patient has comorbid tics or Tourette's disorder 1
  • Stimulant medications are contraindicated or not preferred 5, 7

Monitoring and Adverse Effects

If atomoxetine is used (primarily for ADHD with comorbid anxiety):

• Monitor for common side effects: headache, abdominal pain, decreased appetite, nausea, somnolence 7
• Be aware of potential cardiovascular effects: slight increases in heart rate and blood pressure 7
• Watch for rare but serious adverse events: suicidal ideation (black box warning) and liver injury 7
• Dosing typically starts at 0.5 mg/kg/day and may be increased to a target of 1.2-1.4 mg/kg/day 1

Conclusion

For treating anxiety as a primary condition, SSRIs and SNRIs remain the first-line pharmacological options with the strongest evidence base. Atomoxetine should be considered primarily for patients with ADHD who have comorbid anxiety, rather than for anxiety alone.