What is the best medication for a teenager with Attention Deficit Hyperactivity Disorder (ADHD) and anxiety?

Best ADHD Medication for Teenagers with Anxiety

For teenagers with both ADHD and anxiety, atomoxetine (Strattera) is recommended as the first-line treatment option as it provides continuous symptom coverage without the rebound effects experienced with stimulants and has demonstrated efficacy for both ADHD and anxiety symptoms. 1

First-Line Treatment: Atomoxetine

• Atomoxetine is particularly beneficial for patients with ADHD and comorbid anxiety as it provides "around-the-clock" effects without the rebound/crash experienced with stimulants 1
• The American Academy of Child and Adolescent Psychiatry recommends atomoxetine as a first-line option for patients with ADHD experiencing emotional reactivity and anxiety symptoms 1
• Atomoxetine works by selectively inhibiting presynaptic norepinephrine reuptake in the prefrontal cortex, enhancing the impact of norepinephrine and optimizing executive and attentional function 2, 3
• Clinical trials have demonstrated that atomoxetine improves quality of life and emotional lability in addition to core ADHD symptoms 3

Dosing and Administration

• Start atomoxetine at a lower dose and titrate gradually over 2-4 weeks to a target dose of 1.2 mg/kg/day (maximum 100mg daily) 1, 4
• Atomoxetine can be administered as a single daily dose or split into two evenly divided doses to reduce side effects 4, 5
• Full therapeutic effect may take 4-6 weeks to achieve, requiring patience during the initial treatment period 1, 3

Monitoring and Side Effects

• Common side effects include decreased appetite, headache, stomach pain, and initial somnolence 4, 5
• Regular monitoring of vital signs is recommended as atomoxetine may cause statistically (but not clinically) significant increases in heart rate and blood pressure 5
• The FDA has a black box warning for increased risk of suicidal ideation in children and adolescents taking atomoxetine, requiring careful monitoring 4, 5

Alternative Treatment Options

If Atomoxetine Is Ineffective:

• Stimulants (methylphenidate or amphetamine derivatives) remain effective options for ADHD with comorbid anxiety, contrary to earlier concerns 6, 7
• The American Academy of Child and Adolescent Psychiatry suggests that after addressing anxiety symptoms, stimulants can be used for ADHD symptoms even in patients with comorbid anxiety 6
• For patients who cannot tolerate stimulants or atomoxetine, consider alpha-2 agonists such as extended-release guanfacine or clonidine, which may benefit both ADHD symptoms and emotional dysregulation 1, 4
• Bupropion (Wellbutrin), a norepinephrine and dopamine reuptake inhibitor, has shown efficacy in ADHD and may be considered as an alternative 1, 8

For Severe Anxiety with ADHD:

• If anxiety symptoms are severe and predominant, consider starting with an SSRI (fluoxetine or sertraline) followed by the addition of ADHD medication if symptoms persist 6
• SSRIs should be started at a low dose to minimize potential side effects, particularly initial anxiety or agitation 6

Combination Approaches

• For patients with significant anxiety and ADHD symptoms, a combination approach may be necessary 6, 7
• Treatment should begin with addressing the most impairing symptoms first (either anxiety or ADHD) followed by treatment of the other condition if symptoms persist 6
• Atomoxetine has been shown to be safe and effective in combination with stimulants if monotherapy is insufficient 3

Important Considerations

• Atomoxetine has a smaller effect size compared to stimulants but offers advantages of continuous coverage and potentially fewer impacts on sleep and anxiety 4, 5
• Atomoxetine has negligible risk of abuse or misuse and is not a controlled substance, making it particularly useful for patients at risk of substance abuse 5
• Non-pharmacological approaches such as Cognitive Behavioral Therapy (CBT) or Dialectical Behavior Therapy (DBT) should be considered as adjunctive treatments 1, 8