What adjustments can be made to the medication regimen of an adult patient with Attention Deficit Hyperactivity Disorder (ADHD) and an affective disorder, currently taking Adderall (amphetamine and dextroamphetamine) 5mg and Wellbutrin (bupropion) 150mg, who reports difficulty focusing in the evening despite improved emotional symptoms?

Medication Adjustment for Evening ADHD Symptoms

Increase the Adderall dose or add an afternoon/evening dose to address the wearing-off effect that is causing difficulty focusing in the evening. 1

Understanding the Problem

Your patient is experiencing a classic "wearing-off" phenomenon where the 5mg Adderall dose (likely taken once or twice daily) is not providing adequate coverage into the evening hours. 1 The fact that she feels emotionally better suggests the Wellbutrin is addressing the affective disorder component, but her ADHD symptoms are breaking through later in the day. 2

Primary Recommendation: Optimize Stimulant Coverage

Dose Titration Strategy

• The current 5mg dose is at the very low end of the therapeutic range - adults with ADHD typically require total daily doses of 10-50mg of mixed amphetamine salts, with many patients needing 20-40mg daily for optimal symptom control. 1, 3

• Start by increasing to 10mg in the morning (or 5mg twice daily if she's currently taking it once daily), then titrate upward by 5-10mg weekly until evening symptoms resolve. 1

• Maximum daily doses for adults generally reach 40mg for amphetamine salts, though some patients may require up to 0.9 mg/kg or 65mg total daily dose with clear documentation that lower doses were insufficient. 1

Dosing Schedule Options

• Add a third afternoon dose (around 3-4 PM) of 5mg to specifically target evening symptom coverage, as the American Academy of Child and Adolescent Psychiatry explicitly recommends adding a third dose after school/work to help with homework and social activities. 1

• Alternatively, consider switching to a long-acting formulation (Adderall XR, lisdexamfetamine/Vyvanse) that provides more consistent all-day coverage with once-daily dosing, which improves adherence and reduces rebound effects. 3, 4

Why This Approach Takes Priority

• Stimulants work within days, allowing rapid assessment of whether the dosing adjustment resolves her evening focus problems, unlike non-stimulant alternatives that require weeks to months. 2, 4

• The Wellbutrin is already addressing her mood symptoms (she reports feeling emotionally better), so there's no need to adjust that medication. 2

• Bupropion (Wellbutrin) has only modest effects on ADHD symptoms with effect sizes around 0.34-0.50, significantly less than stimulants which have effect sizes of 1.0. 5, 6 It's serving as an adjunct for her affective disorder, not as primary ADHD treatment.

Monitoring During Titration

• Obtain weekly symptom ratings during dose adjustment, specifically asking about evening focus, task completion, and any side effects like insomnia or appetite suppression. 1

• Monitor blood pressure and pulse at each dose increase, as stimulants can elevate cardiovascular parameters. 3

• Watch for sleep disruption - if the afternoon dose causes insomnia, adjust timing earlier (give by 3 PM) or reduce the evening dose. 1

• Track appetite and weight at each visit, as appetite suppression is common but manageable. 1

Common Pitfalls to Avoid

• Don't assume the current 5mg dose is adequate - this is a starting dose, and 54-70% of adults with ADHD respond to stimulants when properly titrated. 7, 8, 9

• Don't add another medication before optimizing the stimulant dose - the evidence strongly supports maximizing stimulant efficacy first. 1, 2

• Don't worry that stimulants will worsen her affective symptoms - she's already reporting emotional improvement on Wellbutrin, and there are no significant drug interactions between amphetamines and bupropion. 2

• Don't underdose out of caution - systematic titration to optimal effect is more important than strict mg/kg calculations, with 70% of patients responding optimally when proper titration protocols are followed. 1, 4

Alternative if Stimulant Optimization Fails

If after reaching 30-40mg daily of Adderall she still has evening breakthrough symptoms despite adequate daytime control:

• Consider adding extended-release guanfacine (1-4mg) in the evening, which provides additional ADHD coverage and can help with sleep onset. 3, 2

• Atomoxetine is NOT recommended here because it causes somnolence and fatigue as primary side effects, which would worsen her ability to focus in the evening. 3, 2