What medication should be considered next for a patient with severe anxiety, panic attacks, and ADHD, who has shown improvement on Wellbutrin (bupropion) 150mg but did not tolerate 300mg?

Treatment Approach for Severe Anxiety, Panic Attacks, and ADHD in a Patient Partially Responsive to Bupropion

For a patient with severe anxiety, panic attacks, and ADHD who has shown improvement on bupropion 150mg but could not tolerate 300mg, a stimulant medication should be added as the next treatment step.

Rationale for Adding a Stimulant

• Stimulants are the first-line treatment for ADHD, even in patients with comorbid anxiety disorders 1
• Recent clinical trials have shown that patients with ADHD and comorbid anxiety have a robust response to stimulants, contrary to earlier concerns 1
• The onset of stimulant treatment is rapid, allowing quick assessment of whether ADHD symptoms improve 1
• Reducing ADHD symptoms through stimulant treatment can have a substantial positive impact on anxiety symptoms 1

Treatment Algorithm

1. Continue bupropion 150mg

   • Bupropion has shown efficacy in ADHD treatment, though it is considered a second-line agent 1, 2
   • The patient has already demonstrated partial response at this dose 2, 3

2. Add a stimulant medication

   • Begin with a short-acting formulation to assess tolerability, then consider switching to extended-release 1
   • Options include methylphenidate (5-20mg three times daily) or dextroamphetamine (5mg three times daily to 20mg twice daily) 1

3. Monitor response to combined therapy

   • If both ADHD and anxiety symptoms improve with the addition of a stimulant, continue the combination 1
   • If ADHD symptoms improve but anxiety remains problematic, consider adding an SSRI 1

Special Considerations

• Dosing: Start with a low dose of the stimulant and titrate gradually to minimize side effects 1
• Timing: For methylphenidate, multiple daily doses may be required due to its 3-5 hour duration of action 1
• Monitoring: Regular assessment of blood pressure, pulse, and weight is necessary when using stimulants 1

Alternative Approaches if Stimulants Fail

If stimulants are ineffective or not tolerated, consider these alternatives:

• Alpha-2 adrenergic agonists (guanfacine, clonidine):

  • Effective for ADHD with comorbid anxiety and sleep disorders 1
  • May take 2-4 weeks to observe effects 1
  • Common side effects include somnolence and hypotension 1

• Atomoxetine:

  • Provides "around-the-clock" effects for ADHD symptoms 1
  • May take 6-12 weeks until effects are observed 1
  • Not a controlled substance, which may be advantageous 1

Cautions and Pitfalls

• Avoid increasing bupropion beyond 150mg since the patient previously could not tolerate 300mg 1
• Monitor for drug interactions: Bupropion inhibits CYP2D6 and can increase concentrations of many medications including antidepressants and antipsychotics 4
• Be cautious with medications that lower seizure threshold when used with bupropion 4
• Timing of bupropion dosing: To minimize insomnia risk, administer the second dose before 3 PM if using twice-daily dosing 1

Monitoring and Follow-up

• Assess improvement in both ADHD and anxiety symptoms regularly
• Monitor for side effects of both medications
• If anxiety symptoms remain severe despite optimized ADHD treatment, consider adding an SSRI as recommended in anxiety disorder treatment guidelines 1