What is the preferred initial treatment approach for a patient diagnosed with both generalized anxiety disorder (GAD) and attention deficit hyperactivity disorder (ADHD)?

From the Guidelines

When treating a patient with both generalized anxiety disorder (GAD) and attention deficit hyperactivity disorder (ADHD), the preferred initial treatment approach is to address the condition causing the most significant functional impairment first, with a focus on treating GAD with an SSRI, such as sertraline or escitalopram, combined with cognitive behavioral therapy, before initiating ADHD treatment with either stimulants or non-stimulant options like atomoxetine. This approach is supported by the most recent evidence, including a study from 1, which highlights the importance of considering the potential benefits and limitations of non-stimulant medications, such as atomoxetine, in the treatment of ADHD, particularly in patients with comorbid anxiety disorders. Key considerations in treating patients with both GAD and ADHD include:

• The potential for stimulant medications to worsen anxiety symptoms, as noted in the example answer
• The efficacy of non-stimulant medications, such as atomoxetine, in treating ADHD with comorbid anxiety, as supported by studies like 1
• The importance of regular monitoring for symptom improvement and medication side effects, with dose adjustments made accordingly, as emphasized in the example answer
• The potential benefits of combining cognitive behavioral therapy with medication treatment for GAD, as suggested by the example answer In terms of specific treatment options, the evidence suggests that:
• SSRIs, such as sertraline (starting at 25-50mg daily, gradually increasing to 50-200mg) or escitalopram (10-20mg daily), are effective in treating GAD, as noted in the example answer
• Non-stimulant medications, such as atomoxetine (40-100mg daily), may be preferable for patients with significant anxiety, as suggested by studies like 1
• Stimulants, such as methylphenidate (starting at 5-10mg once or twice daily), may be effective in treating ADHD, but should be used with caution in patients with comorbid anxiety disorders, as noted in the example answer.

From the Research

Treatment Approach for GAD and ADHD

The preferred initial treatment approach for a patient diagnosed with both generalized anxiety disorder (GAD) and attention deficit hyperactivity disorder (ADHD) involves a combination of pharmacotherapy and psychotherapy.

• Pharmacotherapy: Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are recommended as first-line treatments for GAD 2, 3. However, for patients with comorbid ADHD, adjunctive treatment with atomoxetine may be beneficial 4.
• Psychotherapy: Cognitive behavioral therapy (CBT) is the psychotherapy with the most evidence of efficacy for anxiety disorders, including GAD 2.
• Treatment Considerations: When selecting a treatment, clinicians should consider patient preference, current and prior treatments, medical and psychiatric comorbid illnesses, age, sex, and reproductive planning, as well as cost and access to care 2.

Comorbidity Considerations

The comorbidity between ADHD and anxiety disorders can change the clinical presentation, prognosis, and treatment of patients with ADHD across their lifespan 5. Individuals with comorbid ADHD and anxiety disorders may benefit from adjunctive psychosocial or adjunctive pharmacotherapy interventions to cognitive behavioral treatment 5.

• Adjunctive Treatment: Atomoxetine can be used as an adjunctive treatment in adult patients with ADHD and comorbid partially responsive anxiety symptoms 4.
• Unique Mechanism of Action: Low-dose aripiprazole treatment in adolescents and adults with comorbid ADHD and anxiety disorders could be an intriguing avenue of exploration due to its unique mechanism of action 5.