What is the best course of treatment for a patient with Attention Deficit Hyperactivity Disorder (ADHD), previously treated with Vyvanse (lisdexamfetamine), who stopped due to undesirable side effects, and now presents with inconsistent sleep patterns, anxiety, and energy crashes, despite having a good support system and a healthy environment?

PMHNP Note: Adult ADHD with Comorbid Anxiety and Sleep Disturbance

Chief Complaint

Patient seeking treatment for ADHD, previously treated with Vyvanse but discontinued due to intolerable side effects and decreased workload demands.

History of Present Illness

• ADHD History: Diagnosed [DATE], previously treated with Vyvanse (lisdexamfetamine) but discontinued due to disliking medication effects
• Current Functional Impairment: Runs 2 businesses remotely, travels frequently between [STATE], [STATE], and [STATE]
• Sleep Disturbance: Inconsistent sleep schedule, poor sleep quality, difficulty initiating sleep. No history of sleep apnea
• Energy Pattern: Good energy until afternoon crash
• Anxiety: Morning anxiety 5-6/10 severity, keeps patient in bed temporarily upon waking
• Mood: Denies depression, manic symptoms, or mood disorders
• Appetite: Adequate
• Support System: Lives in healthy home environment, good support system

Assessment & Differential

Primary Diagnosis: ADHD, previously treated, currently untreated with functional impairment across multiple domains (work productivity, sleep regulation, anxiety symptoms)

Comorbid Considerations:

• Morning anxiety likely related to untreated ADHD-associated executive dysfunction
• Sleep disturbance may be both contributing to and exacerbated by untreated ADHD
• Afternoon energy crashes consistent with circadian dysregulation and possible ADHD-related executive function deficits

Treatment Plan & Recommendations

Primary Pharmacological Intervention

Restart long-acting stimulant therapy with a different formulation than previous Vyvanse. 1 The American Academy of Child and Adolescent Psychiatry recommends long-acting stimulant formulations as first-line treatment for adult ADHD due to better medication adherence, lower risk of rebound effects, and more consistent symptom control throughout the day. 1

Specific medication options:

• Concerta (methylphenidate OROS): Start 18 mg every morning, titrate by 18 mg weekly based on response up to 54-72 mg daily maximum 1, 2

  • Rationale: Approximately 40% of patients respond to methylphenidate but not amphetamines (and vice versa), making this an appropriate alternative since patient discontinued Vyvanse 2
  • Concerta's OROS delivery system provides ascending plasma levels with consistent all-day coverage and is tamper-resistant 1
  • Maximum daily dose 60 mg for adults 1

• Alternative if methylphenidate preferred: Extended-release methylphenidate formulations provide once-daily dosing with 8-12 hour symptom coverage 1

Critical point: The presence of anxiety does NOT contraindicate stimulant use. 1 Stimulants can directly improve executive function deficits by enhancing dopamine and norepinephrine in prefrontal cortex networks, which can indirectly reduce anxiety related to functional impairment. 1 The MTA study demonstrated that stimulant response rates actually increased in subjects with comorbid anxiety disorder. 2

Monitoring Parameters

Baseline assessment (prior to initiating stimulant): 1, 3

• Blood pressure and pulse
• Screen for cardiac disease, structural cardiac abnormalities, cardiomyopathy, serious cardiac arrhythmia, coronary artery disease 3
• Screen for risk factors for developing manic episodes 3
• Assess family history for tics or Tourette's syndrome 3

Ongoing monitoring: 1, 4

• Blood pressure and pulse at each medication adjustment and periodically during stable treatment
• Anxiety symptom tracking to ensure comorbid anxiety is not worsening 1
• Sleep quality assessment
• Appetite and weight monitoring
• Functional improvement across multiple settings (work productivity, home, social functioning)

Non-Stimulant Alternatives (If Stimulants Contraindicated or Not Tolerated)

Second-line options: 1

1. Atomoxetine: 60-100 mg daily

   • Provides 24-hour coverage as non-controlled substance
   • Requires 6-12 weeks to achieve full therapeutic effect (significantly longer than stimulants)
   • Effect size approximately 0.7 compared to stimulants (1.0)
   • May be particularly useful given patient's substance-free profile and desire to avoid controlled substances

2. Extended-release guanfacine or clonidine: 1

   • Effect sizes around 0.7
   • Can be administered in evening to leverage sedative effects for sleep disturbances
   • Particularly useful as adjunctive therapy if stimulant monotherapy insufficient

Addressing Sleep Disturbance

Primary strategy: Optimize ADHD treatment first, as untreated ADHD commonly causes sleep initiation difficulties and poor sleep quality. 1

If sleep problems persist after adequate ADHD treatment:

• Consider adding extended-release guanfacine or clonidine dosed in evening 1
• Address sleep hygiene and circadian rhythm regulation
• Rule out other primary sleep disorders if symptoms persist

Addressing Morning Anxiety

Expected outcome: Morning anxiety (5-6/10) will likely improve with adequate ADHD treatment, as anxiety is often secondary to ADHD-related functional impairment. 1

If anxiety persists after 6-8 weeks of optimized stimulant therapy: 2

• Consider adding SSRI (fluoxetine or sertraline) to stimulant regimen
• SSRIs can be safely combined with stimulants with no significant drug-drug interactions 2

Behavioral Interventions

Strongly recommend: 1

• Cognitive Behavioral Therapy (CBT) focusing on time management, organization, planning, and adaptive behavioral skills
• CBT is most effective when combined with medication rather than monotherapy
• Mindfulness-Based Interventions for managing inattention symptoms, emotion regulation, and executive function

Physical exercise: 5

• Strongly encourage as adjunctive intervention
• Provides additional benefits for ADHD symptoms, executive function, and social impairment
• Moderate to high intensity interval training combined with cognitive tasks particularly suitable

Critical Pitfalls to Avoid

1. Do not assume patient's previous negative experience with Vyvanse means all stimulants will be poorly tolerated. 2 Individual response to methylphenidate versus amphetamine is idiosyncratic—approximately 40% respond to both, 40% respond to only one. 2

2. Do not prescribe immediate-release methylphenidate for "as-needed" use. 1 ADHD requires consistent daily symptom control to prevent functional impairment across multiple settings. Sporadic dosing fundamentally misunderstands ADHD pathophysiology. 1

3. Do not discontinue effective ADHD treatment solely due to concerns about "taking medication forever." 1 Untreated ADHD is associated with increased risk of accidents, substance abuse, criminality, and functional impairment. 1

4. Do not avoid stimulants due to comorbid anxiety. 1 Anxiety does not contraindicate stimulant use and often improves with adequate ADHD treatment.

Follow-Up Schedule

• Week 1-4: Weekly visits during initial titration to assess response and monitor for side effects 2
• After stabilization: Monthly follow-up during maintenance phase 2
• Reassessment: Periodic evaluation to determine whether continued treatment remains necessary based on functional impairment and symptom burden 1

Patient Education Points

• Long-acting formulations provide once-daily dosing, addressing desire to minimize medication burden while maintaining therapeutic efficacy 1
• ADHD is a chronic condition requiring consistent treatment for optimal functional outcomes 1
• Common side effects include decreased appetite, sleep disturbances, increased blood pressure/pulse, and headaches 1, 3
• Report immediately: chest pain, shortness of breath, fainting, new psychiatric symptoms (hallucinations, mania), or signs of peripheral vasculopathy 3

Contraindications to Stimulant Therapy

Absolute contraindications: 3

• Known hypersensitivity to amphetamine or methylphenidate products
• Use with MAO inhibitor or within 14 days of last MAO inhibitor dose
• Known structural cardiac abnormalities, cardiomyopathy, serious cardiac arrhythmia, coronary artery disease, or other serious cardiac disease

Relative contraindications requiring careful consideration: 1, 3

• Uncontrolled hypertension
• Active substance abuse disorder (consider non-stimulant alternatives)
• History of psychotic disorder or mania