What non-stimulant medication options are available for a patient with ADHD, anxiety, and depression, currently taking bupropion (Wellbutrin) 150mg XL and oral contraceptive, with a history of borderline hypertension?

Non-stimulant Medication Options for ADHD with Anxiety and Depression

Atomoxetine (Strattera) is the most appropriate non-stimulant medication option for your ADHD with comorbid anxiety and depression, especially given your history of borderline hypertension and current use of bupropion and oral contraceptives. 1

First-line Non-stimulant Options

Atomoxetine (Strattera)

• Mechanism: Selective norepinephrine reuptake inhibitor
• Dosing:
  • Starting dose: 40mg daily
  • Target dose: 1.2mg/kg/day (for adults typically 80mg daily)
  • Can be taken once daily or divided into morning and evening doses
• Benefits for your situation:
  • FDA-approved for ADHD in adults 2
  • Shows efficacy for ADHD with comorbid anxiety 1
  • "Around-the-clock" effects (unlike stimulants) 1
  • Fewer cardiovascular effects than alpha-2 agonists 1
  • Less impact on appetite and growth compared to stimulants 1
  • Compatible with your current medications

Guanfacine Extended-Release (Intuniv)

• Mechanism: Alpha-2 adrenergic agonist
• Considerations:
  • May cause somnolence/fatigue (evening dosing preferred) 1
  • Can cause hypotension - potentially beneficial with borderline hypertension but requires monitoring 1
  • May be more suitable if sleep disturbances are a primary concern 1

Clonidine Extended-Release (Kapvay)

• Mechanism: Alpha-2 adrenergic agonist
• Considerations:
  • Similar to guanfacine but with more pronounced sedation
  • Can cause significant hypotension 1
  • Evening dosing generally preferred due to somnolence 1

Important Considerations for Your Specific Case

1. Medication Interactions:

   • Atomoxetine can be safely used with bupropion, though monitoring for increased blood pressure is advised
   • No significant interactions with oral contraceptives

2. Borderline Hypertension:

   • Atomoxetine may cause mild increases in blood pressure and heart rate in some patients (5-15%) 1
   • Guanfacine and clonidine typically decrease blood pressure, which might be beneficial but requires careful monitoring 1

3. Anxiety and Depression:

   • Despite being initially developed as an antidepressant, evidence doesn't strongly support atomoxetine's efficacy for depression 1
   • However, there is evidence supporting atomoxetine for ADHD with comorbid anxiety 1
   • Your current bupropion therapy may continue to address depression symptoms

4. Timeline for Effects:

   • Unlike stimulants, non-stimulants have a delayed onset of action:
     • Atomoxetine: 6-12 weeks for full effect 1
     • Guanfacine/Clonidine: 2-4 weeks 1
   • A trial period of at least 6-8 weeks is recommended before evaluating atomoxetine's efficacy 3

Monitoring Recommendations

• Blood pressure and heart rate: Before starting treatment and at regular intervals
• Side effects: Appetite changes, sleep quality, mood changes
• Therapeutic response: Executive function improvement, anxiety levels, overall functioning
• Follow-up: Every 3-4 weeks during dose titration, then every 3-6 months once stabilized 4

Potential Side Effects

Atomoxetine:

• Initial somnolence and gastrointestinal symptoms (especially if dose increased too rapidly)
• Decreased appetite
• Rare: Increased suicidal thoughts (FDA black box warning) 1
• Very rare: Hepatitis 1

Guanfacine/Clonidine:

• Somnolence, dry mouth, dizziness, irritability
• Bradycardia, hypotension
• Abdominal pain
• Rebound hypertension if abruptly discontinued (requires tapering) 1

Implementation Strategy

1. Starting atomoxetine:

   • Begin with lower doses (40mg daily) for 1 week
   • Gradually increase to target dose (typically 80mg for adults)
   • Consider divided dosing initially to minimize side effects
   • Continue your current bupropion and oral contraceptive

2. Evaluation timeline:

   • Expect gradual improvement over 6-12 weeks
   • Full assessment of efficacy should not be made until at least 6-8 weeks of treatment

3. If atomoxetine is ineffective or poorly tolerated:

   • Consider guanfacine extended-release as an alternative
   • Approximately 50% of patients who don't respond to stimulants will respond to atomoxetine 3

Remember that non-stimulants generally have a more modest effect size (0.7) compared to stimulants (1.0), but may provide better tolerability and continuous coverage throughout the day 4.