Which is more effective for treating anxiety with Attention Deficit Hyperactivity Disorder (ADHD), Strattera (atomoxetine) or Wellbutrin (bupropion)?

Strattera (Atomoxetine) is More Effective Than Wellbutrin (Bupropion) for Anxiety with ADHD

For patients with comorbid anxiety and ADHD, atomoxetine (Strattera) is the preferred medication over bupropion (Wellbutrin) due to its established efficacy for ADHD symptoms while not worsening anxiety symptoms. 1

Medication Comparison

Atomoxetine (Strattera)

• First-line non-stimulant option for ADHD with established efficacy and favorable safety profile 1
• Target dose: 1.2 mg/kg/day (starting at 0.5 mg/kg/day) 1
• Mechanism: Selective norepinephrine reuptake inhibitor 2
• Particularly useful for patients with comorbid anxiety 1, 2
• Does not have abuse potential or controlled substance status 2, 3
• Demonstrated efficacy in multiple well-controlled trials with 28-30% reduction in ADHD symptoms (vs 18-20% with placebo) 3, 4

Bupropion (Wellbutrin)

• Not specifically recommended as first-line for ADHD with anxiety 1
• Starting dose: 37.5 mg every morning, increasing by 37.5 mg every 3 days 5
• Maximum dose: 150 mg twice daily 5
• Described as "activating" and should not be used in agitated patients 5
• Limited evidence for efficacy in ADHD (low-quality evidence per Cochrane review) 6
• May worsen anxiety due to its activating properties 5

Treatment Algorithm for ADHD with Anxiety

1. First-line treatment:

   • Atomoxetine (Strattera) starting at 0.5 mg/kg/day and titrating to 1.2 mg/kg/day 1
   • Can be administered once daily or split into two doses 2

2. Alternative options (if atomoxetine is ineffective or not tolerated):

   • Consider stimulant medications (may still be appropriate for patients with comorbid anxiety) 1
   • Alpha-2 agonists (clonidine, guanfacine) may be considered 1
   • Bupropion should be used with caution due to its activating properties 5

3. Combined approach:

   • For optimal outcomes, combine medication with behavioral interventions 1
   • Consider adding psychosocial intervention for anxiety if medication improves ADHD but anxiety persists 1

Important Considerations and Monitoring

• Monitor blood pressure and heart rate regularly with atomoxetine 1
• Atomoxetine carries a black box warning for suicidal ideation; regular assessment is essential 2
• Bupropion should not be used in patients with seizure disorders 5
• Atomoxetine may cause initial side effects including dry mouth, insomnia, nausea, and decreased appetite, but these are generally transient 7
• Follow up within 2-4 weeks after medication initiation 1

Common Pitfalls to Avoid

• Avoid using bupropion in already agitated patients as it can worsen anxiety symptoms 5
• Don't combine atomoxetine with monoamine oxidase inhibitors due to risk of serotonin syndrome 1
• Don't expect immediate results with atomoxetine; full therapeutic effect may take 4-8 weeks 2
• Don't overlook the need for regular monitoring of vital signs and side effects 1

The evidence strongly supports atomoxetine as the better choice for patients with comorbid ADHD and anxiety, with established efficacy for ADHD symptoms while not exacerbating anxiety, unlike the potentially activating properties of bupropion.