Guidelines for Combining Sertraline and Atomoxetine in Patients with Depression/Anxiety and ADHD

Indications for Combination Therapy

Sertraline is recommended as a first-line treatment for depression and anxiety disorders, with demonstrated efficacy for both conditions, according to the American College of Physicians 1

For patients with both depression/anxiety and ADHD, consider starting with sertraline monotherapy for depression/anxiety, as recommended by the American Psychiatric Association 1
Begin with lower doses (25-50mg) of sertraline as SSRIs can initially increase anxiety symptoms, and titrate in 1-2 week intervals due to its shorter half-life, as suggested by the Journal of the American Academy of Child and Adolescent Psychiatry 2

Sertraline may interact with medications metabolized by CYP2D6, and atomoxetine is primarily metabolized by CYP2D6, which may lead to increased levels of atomoxetine, according to the Journal of the American Academy of Child and Adolescent Psychiatry 2
Be aware that sertraline has a discontinuation syndrome characterized by dizziness, fatigue, sensory disturbances, and anxiety when abruptly stopped, as reported by the Journal of the American Academy of Child and Adolescent Psychiatry 2

The American Academy of Child and Adolescent Psychiatry suggests combination treatment (CBT plus an SSRI) over monotherapy for anxiety disorders in children and adolescents 3
Parental oversight of medication regimens is essential in children and adolescents, as recommended by the American Academy of Child and Adolescent Psychiatry 3
Start with lower doses of sertraline as SSRIs can initially worsen anxiety symptoms in children and adolescents, according to the Journal of the American Academy of Child and Adolescent Psychiatry 4

Weekly monitoring for adverse effects, particularly increased anxiety, agitation, or suicidal ideation, is recommended during the initial phase of treatment, as suggested by the Journal of the American Academy of Child and Adolescent Psychiatry 2
Use standardized rating scales to assess symptoms of both conditions, as recommended by the American Academy of Child and Adolescent Psychiatry 3

Avoid rapid titration of either medication, particularly in anxiety disorders where gradual introduction is recommended, as suggested by the Journal of the American Academy of Child and Adolescent Psychiatry 2
Consider that sertraline has a discontinuation syndrome if doses are missed or treatment is abruptly stopped, as reported by the Journal of the American Academy of Child and Adolescent Psychiatry 2
Remember that citalopram/escitalopram may have fewer drug interactions than sertraline if drug-drug interactions are a concern, according to the Journal of the American Academy of Child and Adolescent Psychiatry 2