I'm taking Adderall (amphetamine and dextroamphetamine) 20mg every 24 hours, but it's not helping my Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD), and I've had an alcohol use disorder for 15 years, what should I do?

Discontinue Adderall and Address Alcohol Use Disorder and Depression First

You should stop the Adderall immediately, as amphetamines are contraindicated in patients with active substance use disorders and are not indicated for treating MDD or GAD. 1, 2 The ACC/AHA guidelines explicitly recommend discontinuing or decreasing amphetamine doses, and considering behavioral therapies instead. 1

Why Adderall Is Not Helping

Adderall is not an appropriate treatment for your primary conditions (MDD and GAD), and using it in the context of active alcohol use disorder creates significant risks:

• Stimulants like Adderall have no established efficacy for treating major depressive disorder or generalized anxiety disorder as primary conditions 2
• The American Academy of Child and Adolescent Psychiatry explicitly cautions about using stimulants in patients with substance abuse disorders due to risks of misuse, diversion, and worsening of substance use 2
• Amphetamines can elevate blood pressure and create cardiovascular risks, particularly problematic in someone with alcohol use disorder 1
• Your 15-year history of alcohol use disorder and recent relapse ("started alcohol") represents an active contraindication to stimulant therapy 2

Recommended Treatment Algorithm

Step 1: Address Alcohol Use Disorder Immediately

Your active alcohol use must be treated first, as it significantly worsens both depression and anxiety outcomes:

• Patients with comorbid MDD/GAD and substance use disorders show greater depression severity, longer illness duration, more treatment intolerance, and worse remission/response outcomes 3, 4
• Combined pharmacotherapy and cognitive behavioral therapy is the evidence-based approach for alcohol use disorder 1
• Consider medications for alcohol use disorder such as naltrexone or acamprosate combined with behavioral therapy 1
• Nearly one-third of patients with MDD have concurrent substance use disorders, and this comorbidity yields higher suicide risk and greater impairment 4

Step 2: Treat Major Depressive Disorder

Once alcohol use is being addressed, initiate appropriate antidepressant therapy:

• SSRIs (selective serotonin reuptake inhibitors) are the first-line treatment for MDD and can be safely used in patients with substance use disorders 2, 3
• SSRIs are weight-neutral with long-term use and have the strongest evidence base for depression 2
• Patients with comorbid MDD and substance use disorders may require more aggressive, multi-faceted treatment targeted at reducing psychological comorbidity 3
• Treatment outcomes for depression can still be effective in patients with substance use disorder comorbidity, though response rates may be somewhat lower 4

Step 3: Address Generalized Anxiety Disorder

GAD treatment should be integrated with depression treatment:

• SSRIs also have efficacy for generalized anxiety disorder and can treat both conditions simultaneously 2
• Avoid benzodiazepines, as they may reduce self-control and have disinhibiting effects in patients with substance use disorders 2
• Individuals with GAD and substance use disorder show higher psychiatric comorbidity rates and higher use of alcohol and drugs to relieve anxiety symptoms 5

Critical Monitoring Points

During treatment transitions, monitor for:

• Suicidal ideation, which is elevated in patients with comorbid depression and substance use disorders (higher rates of suicide attempts documented) 3, 6
• Worsening alcohol use, as patients often use substances to self-medicate anxiety and depression symptoms 5, 6
• Treatment adherence, as patients with dual diagnoses show more intolerance and attrition from treatment 3

Common Pitfalls to Avoid

• Do not assume a single medication will treat all three conditions (ADHD symptoms, if truly present, depression, and anxiety) - there is no evidence supporting this approach 2
• Do not continue stimulants hoping they will eventually help - they are not indicated for your primary diagnoses and pose risks with active substance use 1, 2
• Do not delay addressing alcohol use - substance use disorders significantly worsen treatment outcomes for both depression and anxiety and must be treated concurrently 3, 4
• Do not use tricyclic antidepressants due to their greater lethality in overdose, which is particularly concerning given elevated suicide risk in patients with comorbid depression and substance use disorders 2

Schedule an urgent appointment with your prescriber to discuss discontinuing Adderall and initiating appropriate treatment for alcohol use disorder, major depression, and generalized anxiety disorder. 1, 2, 3