What medication can be used for a patient on Vyvanse (lisdexamfetamine) 30mg daily for Attention Deficit Hyperactivity Disorder (ADHD) who is experiencing anger outbursts and seeking treatment for Post-Traumatic Stress Disorder (PTSD)?

Medication Recommendations for PTSD in a Patient on Vyvanse with Anger Outbursts

Primary Recommendation

An SSRI (selective serotonin reuptake inhibitor) should be added to the current Vyvanse regimen to address PTSD symptoms and anger outbursts. 1 This approach allows the patient to continue effective ADHD treatment while directly targeting trauma-related symptoms with evidence-based pharmacotherapy.

Treatment Algorithm

Step 1: Optimize Current Stimulant Therapy

• First assess whether the Vyvanse 30mg is adequately controlling ADHD symptoms, as stimulant optimization can indirectly reduce anger outbursts by improving impulse control and emotional regulation. 1
• If ADHD symptoms remain problematic, consider increasing Vyvanse dose before adding additional medications, as suboptimal ADHD treatment can manifest as irritability and emotional dysregulation. 2
• The anger outbursts may be partially ADHD-related rather than purely PTSD-driven, and stimulants have been shown to reduce antisocial behaviors including fighting and aggressive outbursts. 1

Step 2: Add SSRI for PTSD and Persistent Anger

• If ADHD symptoms improve on Vyvanse but anger outbursts and PTSD symptoms persist, add an SSRI to the stimulant regimen. 1
• SSRIs are the treatment of choice for PTSD and can be safely combined with stimulants without significant drug-drug interactions. 3
• SSRIs are weight-neutral with long-term use and have the strongest evidence base for treating trauma-related symptoms. 3
• Common SSRI options include sertraline or paroxetine, which have FDA approval for PTSD treatment.

Step 3: Consider Adjunctive Agents if Severe Aggression Persists

If anger outbursts remain severe and dangerous despite optimized Vyvanse plus SSRI:

• Mood stabilizers (lithium or divalproex sodium) can be added to the stimulant. 1
• Divalproex sodium demonstrates a 70% reduction in aggression scores and is particularly effective for explosive temper and mood lability, with dosing of 20-30 mg/kg/day divided BID-TID. 4
• Alpha-agonists (guanfacine or clonidine) are alternative adjunctive options that can help with both ADHD symptoms and aggression, with guanfacine dosed at 1-4mg daily. 1, 4

Step 4: Reserve Atypical Antipsychotics for Severe Cases

• If aggression is pervasive, severe, persistent, and poses acute danger, adding low-dose risperidone (0.5-2 mg daily) to the stimulant may be justified. 1, 4
• Risperidone has the strongest controlled trial evidence for reducing aggression when combined with ADHD medications. 4
• Monitor for metabolic syndrome, weight gain, movement disorders, and prolactin elevation. 4

Critical Clinical Considerations

Psychotherapy is Essential

• Trauma-focused cognitive behavioral therapy (TF-CBT) should be implemented as the primary treatment for PTSD, not medication alone. 4
• Medication should not be the sole intervention; psychosocial interventions are essential for addressing trauma-related symptoms. 4
• The combination of pharmacotherapy and psychotherapy provides superior outcomes compared to medication alone for PTSD.

Important Pitfalls to Avoid

• Do not assume a single antidepressant will effectively treat both ADHD and PTSD - no single antidepressant is proven for this dual purpose. 3
• Avoid using bupropion as the primary antidepressant in this case, as it is a second-line agent for ADHD at best and may exacerbate anxiety or agitation. 3
• Never use MAO inhibitors concurrently with stimulants due to risk of hypertensive crisis; at least 14 days must elapse between discontinuation of an MAOI and initiation of stimulants. 3
• Avoid adding multiple medications simultaneously - try one medication class thoroughly (6-8 weeks at therapeutic doses) before switching or adding another agent. 4
• Do not prescribe benzodiazepines for anxiety in patients with ADHD and PTSD, as they may reduce self-control and have disinhibiting effects. 3

Monitoring Parameters

• Assess for suicidality, particularly during early stages of SSRI treatment, and inquire systematically about suicidal ideation. 3
• Monitor blood pressure and heart rate if alpha-agonists are added. 4
• Monitor liver function tests if divalproex sodium is added. 4
• Screen for development of new psychiatric comorbidities that might be contributing to worsening symptoms. 3

Special Note on Vyvanse and PTSD

Interestingly, there is emerging case report evidence suggesting that lisdexamfetamine (Vyvanse) itself may have beneficial effects on PTSD symptoms, particularly intrusive thoughts and nightmares, potentially through dopaminergic mechanisms. 5 This supports continuing the current Vyvanse regimen while adding targeted PTSD treatment rather than switching medications.