Can Jornay PM (methylphenidate) exacerbate panic attacks in a patient with attention deficit hyperactivity disorder (ADHD) and a history of anxiety?

Jornay PM and Panic Attacks

Jornay PM (methylphenidate) can be safely used in patients with ADHD and comorbid anxiety disorders, including those with panic attacks, as evidence demonstrates that stimulants do not exacerbate anxiety symptoms and may actually reduce them when properly dosed. 1

Evidence Supporting Stimulant Use in Anxiety

The American Academy of Child and Adolescent Psychiatry guidelines explicitly state that anxiety disorder is not a contraindication to methylphenidate treatment, as controlled studies have shown that children with comorbid anxiety disorder improve on methylphenidate. 1 This represents a reversal from earlier concerns, as early work suggesting ADHD children with comorbid anxiety had less robust responses to stimulants was not replicated in later, more extensive clinical trials. 1

Research consistently demonstrates that methylphenidate reduces rather than increases anxiety symptoms:

• A 2017 study found that methylphenidate significantly reduced state anxiety in adult ADHD patients during cognitive tasks, while controls showed no anxiety reduction. 2
• A 2016 comparative study showed both methylphenidate and atomoxetine reduced anxiety symptoms in children with ADHD over 8 weeks of treatment. 3
• The landmark MTA study found that treatment differences actually increased (favoring medication) when ADHD subjects had comorbid anxiety disorder. 1

Clinical Approach to ADHD with Panic/Anxiety

Proceed with a stimulant trial as first-line treatment, even in the presence of panic attacks or anxiety disorders. 1 The reduction in morbidity from treating ADHD symptoms can have substantial impact on anxiety symptoms themselves. 1

Treatment Algorithm:

1. Initiate Jornay PM at standard dosing with careful titration, as patients with anxiety may require lower initial doses. 4

2. Monitor for anxiety response after 2-4 weeks, as the ADHD symptom improvement often reduces secondary anxiety. 1, 5

3. If ADHD improves but panic/anxiety persists:

   • First pursue psychosocial interventions (cognitive behavioral therapy) for the anxiety. 1
   • If anxiety remains severe or doesn't respond to non-pharmacological treatment, consider adding an SSRI to the stimulant. 1

Important Caveats and Pitfalls

Avoid premature discontinuation based on anxiety concerns alone. 1 The package insert warning about anxiety disorder as a contraindication is not supported by controlled trial data. 1

One notable exception: A 2019 single-dose study found a possible delayed anxiety-provoking effect of methylphenidate when given as a single dose (not continuous treatment), which may be relevant to understanding initial adherence difficulties. 6 However, this finding contrasts with the overwhelming evidence from continuous treatment studies showing anxiety reduction. 3, 4, 2

Dosing considerations for anxious patients:

• Anxious ADHD patients may titrate to lower doses initially while minimizing side effects, though final therapeutic doses typically don't differ from non-anxious patients after 4 months. 4
• Taking Jornay PM (which is designed for evening administration with morning effect) as prescribed can help avoid timing-related anxiety exacerbation. 5

Monitor for stimulant-induced jitteriness, which can mimic or worsen panic symptoms, particularly during initial titration. 7 This is dose-dependent and typically resolves after the first week despite continued use. 7

When to Treat Anxiety First

Only if severe depression or anxiety is the primary disorder with very severe symptoms (psychosis, suicidality, or severe neurovegetative signs) should anxiety/depression be the initial treatment focus. 1 Otherwise, the rapid onset of stimulant treatment allows quick assessment of whether ADHD symptom reduction alone improves the panic/anxiety symptoms. 1