What is the best medication for a 13‑year‑old with anxiety, depression, and attention‑deficit/hyperactivity disorder?

Best Medication for a 13-Year-Old with Anxiety, Depression, and ADHD

Start with a stimulant medication (methylphenidate or lisdexamfetamine) as first-line treatment for the ADHD, then add an SSRI (fluoxetine or sertraline) if mood and anxiety symptoms persist after 6–8 weeks of optimized ADHD treatment. 1, 2

Treatment Algorithm Based on Symptom Severity

Step 1: Initiate Stimulant Therapy for ADHD

For adolescents (12–18 years), FDA-approved stimulant medications with the adolescent's assent represent the strongest evidence-based first-line treatment, even when depression or anxiety is present. 1 Depression and anxiety are not contraindications to stimulant use; both conditions can be managed concurrently. 2

• Stimulants work rapidly (within days), allowing quick assessment of ADHD response and potentially improving mood and anxiety symptoms indirectly by reducing ADHD-related functional impairment. 2
• Stimulants achieve 70–80% response rates when properly titrated, with effect sizes of approximately 1.0—the largest of any ADHD medication class. 1, 2
• High-quality data from the MTA study demonstrate that stimulants do not worsen anxiety; in fact, response rates were higher in patients with comorbid anxiety disorders. 2, 3

Specific Stimulant Options:

• Methylphenidate: Start at 5–20 mg three times daily for immediate-release, or use extended-release formulations for once-daily dosing with maximum 60 mg/day. 2
• Lisdexamfetamine (Vyvanse): Start at 20–30 mg once daily in the morning, titrate by 10 mg weekly up to maximum 70 mg/day. 2
• Mixed amphetamine salts (Adderall XR): Start at 10 mg once daily, titrate by 5 mg weekly up to 50 mg/day. 2

Long-acting formulations are preferred because they provide all-day symptom coverage, improve medication adherence, and reduce abuse potential compared to immediate-release preparations. 2

Step 2: Re-Evaluate After 6–8 Weeks of Optimized Stimulant Dosing

After achieving optimal ADHD symptom control at therapeutic stimulant doses, reassess mood and anxiety symptoms using standardized rating scales. 2

• If ADHD symptoms improve but depression or anxiety persists, add an SSRI to the stimulant regimen. 2
• SSRIs (fluoxetine 20–40 mg daily or sertraline 25–50 mg daily titrated based on response) are the treatment of choice for depression and anxiety in adolescents. 2
• The combination of stimulants plus SSRIs is well-established, safe, and has no significant pharmacokinetic interactions. 2

Step 3: Address Severe Mood Symptoms First (Exception)

If the mood disorder presents with severe features—psychosis, active suicidality, or marked neurovegetative signs—treat the depression first before initiating ADHD medication. 2 However, this scenario is the exception; in most cases of moderate depression with ADHD, concurrent treatment is appropriate. 2

Why Not Bupropion or Atomoxetine as Monotherapy?

No single antidepressant is proven to effectively treat both ADHD and depression. 2 While bupropion has some efficacy for ADHD, it is explicitly a second-line agent with smaller effect sizes (approximately 0.7) compared to stimulants (1.0). 1, 2

• Bupropion should only be considered when two or more stimulants have failed, caused intolerable side effects, or when active substance abuse is present. 2
• Atomoxetine has medium-range effect sizes (0.7) and requires 6–12 weeks to achieve full therapeutic effect, significantly longer than stimulants which work within days. 1, 2, 4
• Atomoxetine is positioned as second-line treatment after stimulant failure or when stimulants are contraindicated (e.g., substance abuse history, uncontrolled hypertension). 2, 4

Alternative Non-Stimulant Approach (If Stimulants Are Contraindicated)

If stimulants cannot be used due to cardiovascular concerns, active substance abuse, or patient/family refusal, start with atomoxetine (60–100 mg daily or up to 1.4 mg/kg/day) and add an SSRI for persistent mood/anxiety symptoms. 2, 4

• Atomoxetine has specific evidence supporting its use in ADHD with comorbid anxiety. 2, 3, 5
• The combination of atomoxetine plus SSRI is safe, though SSRIs can elevate atomoxetine levels through CYP2D6 inhibition, requiring dose adjustment. 2
• Atomoxetine carries an FDA black-box warning for increased suicidal ideation risk, requiring close monitoring during the first few months and at dose changes. 2, 4

Critical Monitoring Parameters

Baseline Assessment Before Starting Any Medication:

• Measure blood pressure and pulse in both seated and standing positions. 2, 6
• Obtain detailed cardiac history (syncope, chest pain, palpitations, exercise intolerance) and family history of sudden cardiac death, arrhythmias, or structural heart disease. 2, 6
• Screen for active substance use in adolescents. 2, 6
• Measure height and weight to track growth effects. 2, 6

During Titration:

• Obtain weekly ADHD symptom ratings and monitor blood pressure/pulse at each dose adjustment. 2, 6
• Track sleep quality, appetite changes, and any mood lability or irritability. 2, 6
• Screen systematically for suicidal ideation at every visit, especially when adding SSRIs. 2, 6

Maintenance Phase:

• Schedule monthly follow-up visits until symptom control stabilizes, then quarterly visits. 2
• Continue monitoring height, weight, blood pressure, and pulse at each visit. 2, 6

Essential Psychotherapy Integration

Pharmacotherapy alone is insufficient; combine medication with evidence-based psychosocial interventions. 2, 7

• Cognitive-behavioral therapy (CBT) specifically developed for ADHD is the most extensively studied and effective psychotherapy for treating ADHD with comorbid depression. 2
• CBT for anxiety should be added if anxiety symptoms persist despite medication optimization. 2, 5
• Combined treatment (stimulant plus behavioral therapy) yields superior functional outcomes compared to medication alone, with greater improvements in academic performance and conduct. 2, 6

Common Pitfalls to Avoid

• Do not assume a single antidepressant (like bupropion) will effectively treat both ADHD and depression; use a sequential approach starting with stimulants, then adding an SSRI if needed. 2
• Do not delay ADHD treatment while waiting to "stabilize" mild-to-moderate depression first; treating ADHD often improves mood symptoms by reducing functional impairment. 2
• Do not prescribe benzodiazepines for anxiety in this population, as they may reduce self-control and have disinhibiting effects. 2
• Do not use MAO inhibitors concurrently with stimulants or bupropion due to risk of hypertensive crisis; at least 14 days must elapse between discontinuation of an MAOI and initiation of these medications. 2
• Do not abruptly discontinue SSRIs or atomoxetine; taper gradually to prevent discontinuation syndrome. 2

Absolute Contraindications to Stimulants

• Active psychosis or mania 2
• Concurrent MAO inhibitor use (within 14 days) 2
• Symptomatic cardiovascular disease or uncontrolled hypertension 2
• Prior hypersensitivity to stimulants 2