Does Strattera Lower Anxiety?
Strattera (atomoxetine) does not worsen anxiety in patients with ADHD and comorbid anxiety disorders, but it is not a primary treatment for anxiety—it should be combined with an SSRI if anxiety symptoms persist after ADHD treatment. 1, 2
Evidence for Atomoxetine's Effect on Anxiety
Clinical Trial Data in Comorbid ADHD and Anxiety
In pediatric patients (ages 8-17) with ADHD and comorbid anxiety disorders (separation anxiety, generalized anxiety, or social phobia), a 12-week double-blind trial demonstrated that atomoxetine at 1.2 mg/kg/day did not worsen anxiety as measured by the Pediatric Anxiety Rating Scale (PARS). 2
In adults (ages 18-65) with ADHD and social anxiety disorder, a 16-week trial using atomoxetine up to 100 mg/day (mean 83 mg/day) showed no worsening of anxiety as measured by the Liebowitz Social Anxiety Scale (LSAS). 2
Atomoxetine has evidence supporting its use specifically in ADHD patients with comorbid anxiety, making it a reasonable choice when both conditions are present. 1
Important Clinical Context
Atomoxetine does NOT treat anxiety as a primary indication—it simply does not exacerbate existing anxiety symptoms while treating ADHD. 2
If ADHD symptoms improve with atomoxetine but anxiety symptoms persist, the American Academy of Child and Adolescent Psychiatry recommends adding an SSRI (fluoxetine or sertraline) to the atomoxetine regimen, as SSRIs remain the treatment of choice for anxiety disorders. 1
The combination of atomoxetine plus SSRI has been specifically studied and shown to be safe and effective for patients with both ADHD and anxiety. 1
Comparison to Stimulants for Anxiety Comorbidity
Stimulants remain first-line treatment for ADHD even when anxiety is present, as they may indirectly improve mood and anxiety symptoms by reducing ADHD-related functional impairment. 1
The American Academy of Child and Adolescent Psychiatry recommends caution when using stimulants in patients with comorbid anxiety, though the MTA study showed stimulant response rates actually increased in subjects with comorbid anxiety disorder. 1
Atomoxetine may be preferred over stimulants when anxiety or agitation is prominent, as it has a calming rather than activating profile. 1
Practical Treatment Algorithm
Start with atomoxetine (target dose 1.2 mg/kg/day or 60-100 mg/day in adults) if ADHD and anxiety coexist, particularly if stimulants are contraindicated or the patient has prominent anxiety symptoms. 3, 2
Monitor anxiety symptoms using standardized scales during the 6-12 week period required for atomoxetine to reach full therapeutic effect. 3
If anxiety persists after ADHD symptoms improve, add an SSRI (fluoxetine or sertraline) rather than switching away from atomoxetine. 1
Consider alpha-2 agonists (guanfacine 1-4 mg daily or clonidine) as alternatives when anxiety or agitation is present, though evidence is less robust than for atomoxetine. 1
Critical Monitoring Requirements
Monitor for suicidality, particularly during the first few months of treatment or with dose changes, as atomoxetine carries an FDA black box warning for increased risk of suicidal ideation in children and adolescents. 3, 2
Track blood pressure and heart rate at baseline and regularly during treatment. 3
Be aware that postmarketing reports have documented anxiety as an adverse effect in some patients, though controlled trials showed no worsening. 2
Common Pitfalls to Avoid
Do not assume atomoxetine will actively reduce anxiety—it maintains anxiety at baseline levels while treating ADHD, but does not function as an anxiolytic. 2
Do not use atomoxetine monotherapy expecting it to treat both ADHD and anxiety disorders—add an SSRI if anxiety symptoms require specific treatment. 1
Avoid benzodiazepines in patients with ADHD, as they may reduce self-control and have disinhibiting effects. 1