Concerta vs Vyvanse for Adult Hyperactive ADHD with Anxiety
For an adult with hyperactive ADHD and comorbid anxiety, start with either Concerta or Vyvanse—both stimulants are first-line and equally appropriate, as stimulants improve anxiety symptoms in most patients with this combination and have 70-80% response rates for ADHD. 1, 2
Why Stimulants Are the Right Choice Despite Anxiety
Stimulants do not worsen anxiety in most patients with ADHD—the Multimodal Treatment of ADHD (MTA) study demonstrates that ADHD patients with comorbid anxiety actually have better treatment responses to stimulants than those without anxiety 2
Stimulants often improve anxiety symptoms indirectly by reducing ADHD-related functional impairment, with rapid onset of action typically within days 1, 2
The American Academy of Child and Adolescent Psychiatry recommends starting with a stimulant medication as first-line treatment for adults with ADHD and comorbid anxiety 2
Choosing Between Concerta and Vyvanse
Neither medication has superior efficacy—the choice depends on practical considerations:
Concerta (methylphenidate extended-release) offers dosing of 18-72 mg once daily in the morning, with gradual release throughout the day 3
Vyvanse (lisdexamfetamine) is dosed at 20-30 mg initially, titrated by 10 mg weekly to a maximum of 70 mg daily 3
Concerta is resistant to diversion (cannot be ground up or snorted), making it well-suited for patients where abuse potential is a concern 3
Vyvanse is a prodrug converted to dextroamphetamine, offering similar abuse-deterrent properties through its delayed activation mechanism 4
Head-to-head comparisons between long-acting methylphenidate and lisdexamfetamine are lacking, so the choice is empirical 4
Practical Starting Algorithm
Start with either medication using extended-release formulations to achieve all-day coverage and minimize rebound symptoms: 2
Begin Concerta at 18-36 mg once daily in the morning, or Vyvanse at 20-30 mg once daily 3, 2
Titrate based on response over 2-4 weeks—methylphenidate can be increased weekly, Vyvanse by 10 mg weekly 3, 2
Monitor for both ADHD symptom improvement AND anxiety response within the first 2-4 weeks 2
What to Monitor
Height, weight, blood pressure, pulse at baseline and regularly during treatment 2
Anxiety symptoms specifically—if anxiety worsens (uncommon), consider dose reduction before switching medications 2
Sleep and appetite changes as common adverse effects 2
Sequential Treatment if Needed
If both ADHD and anxiety improve with stimulant monotherapy: Continue without modification 2
If ADHD improves but anxiety persists: Add an SSRI to the stimulant regimen rather than switching medications, as SSRIs are first-line for anxiety and can be safely combined with stimulants 1, 2
If anxiety clearly worsens despite adequate trial: Consider atomoxetine (60-120 mg/day) as a non-stimulant alternative, though it has lower effect size and slower onset (2-4 weeks) compared to stimulants 2
Common Pitfalls to Avoid
Do not assume anxiety is a contraindication to stimulants—this is outdated thinking contradicted by current evidence 2
Do not use bupropion as first-line for this presentation—it is inherently activating and can exacerbate anxiety or agitation, making it potentially problematic for patients who are already hyperactive 1
Do not prescribe benzodiazepines for the anxiety component—they may reduce self-control and have disinhibiting effects in ADHD patients 1
Avoid MAO inhibitors concurrently with stimulants due to risk of hypertensive crisis 1