Does Strattera Help with Anxiety?
Strattera (atomoxetine) does not directly treat anxiety disorders as a primary indication, but there is evidence supporting its use in ADHD patients with comorbid anxiety, where it may improve both ADHD symptoms and anxiety without worsening anxiety symptoms. 1
Context and Primary Indication
- Atomoxetine is FDA-approved exclusively for ADHD treatment, not for anxiety disorders as a standalone condition 2, 3
- Despite being initially developed as an antidepressant, evidence does not support its efficacy for depression or anxiety as primary diagnoses 1
Evidence for ADHD with Comorbid Anxiety
Clinical Trial Data
- In ADHD patients with comorbid anxiety disorders, atomoxetine has demonstrated that it does not worsen anxiety symptoms 2
- A 12-week double-blind, placebo-controlled trial of 176 pediatric patients (ages 8-17) with ADHD and comorbid anxiety disorders (separation anxiety, generalized anxiety, or social phobia) showed atomoxetine did not worsen anxiety as measured by the Pediatric Anxiety Rating Scale 2
- A separate 16-week trial in 442 adults (ages 18-65) with ADHD and social anxiety disorder confirmed atomoxetine did not worsen anxiety symptoms on the Liebowitz Social Anxiety Scale 2
Guideline Recommendations
- Current ADHD treatment guidelines identify atomoxetine as a reasonable first-line option specifically when ADHD co-occurs with anxiety disorders 1
- Guidelines note "some evidence supporting the use of atomoxetine in ADHD with comorbid anxiety" 1
Clinical Considerations for Comorbid ADHD and Anxiety
When Atomoxetine May Be Preferred
- Patients with ADHD and comorbid anxiety who cannot tolerate or do not respond to stimulants 1, 4
- Patients at risk for substance abuse (atomoxetine has no abuse potential and is not a controlled substance) 1, 3, 5
- Patients who prefer non-stimulant treatment 3, 5
Treatment Approach
- When ADHD is the primary condition with comorbid anxiety, stimulants remain first-line and often improve both ADHD and anxiety symptoms 4
- However, atomoxetine shows "impressive efficacy for both ADHD and anxiety disorder symptoms" and may be considered as an alternative first-line agent 4
- If anxiety symptoms persist despite ADHD treatment, adding cognitive-behavioral therapy is strongly recommended and considered superior to medication alone 4
- In moderate to severe comorbid anxiety, SSRIs can be added to ADHD medications with appropriate caution 4
Adjunctive Use for Partially Responsive Anxiety
- Limited evidence suggests atomoxetine may be used adjunctively with SSRIs/SNRIs in adults with ADHD and partially responsive generalized anxiety 6
- An open-label study (n=29) showed significant anxiety reduction when atomoxetine was added to ongoing SSRI/SNRI treatment in adults with both conditions 6
- This represents off-label use and requires careful monitoring 6
Important Caveats
Onset of Action
- Treatment effects with atomoxetine are not observed until 6-12 weeks after initiation, unlike stimulants which work within hours 1
- This delayed onset must be considered when managing acute symptoms 1
Efficacy Limitations
- Atomoxetine has medium-range effect sizes for ADHD, smaller than stimulants 1
- It is generally recommended as second-line treatment for ADHD when stimulants are first-line 1
Safety Monitoring
- Postmarketing reports include anxiety as an adverse event, though controlled trials showed no worsening 2
- Black-box warning exists for suicidal ideation (higher incidence than placebo in meta-analysis) 3
- Monitor cardiovascular parameters (heart rate, blood pressure) 2, 3
Bottom Line
Atomoxetine should not be prescribed solely for anxiety disorders. However, it represents a valuable option for patients with ADHD and comorbid anxiety, particularly when stimulants are contraindicated, not tolerated, or when substance abuse risk is a concern. The medication treats the ADHD without exacerbating anxiety symptoms and may provide modest anxiety improvement as a secondary benefit. 1, 2, 4