Treatment of Severe Anxiety, Panic Attacks, and ADHD
Rationale for Adding a Stimulant
- The American Academy of Child and Adolescent Psychiatry recommends stimulants as the first-line treatment for ADHD, even in patients with comorbid anxiety disorders 1, 2
- Clinical trials have shown that patients with ADHD and comorbid anxiety have a robust response to stimulants, contrary to earlier concerns 1, 2
- The onset of stimulant treatment is rapid, allowing quick assessment of whether ADHD symptoms improve 1
- Reducing ADHD symptoms through stimulant treatment can have a substantial positive impact on anxiety symptoms 1
Treatment Algorithm
- The American Academy of Child and Adolescent Psychiatry suggests adding a stimulant medication to bupropion 150mg for patients with severe anxiety, panic attacks, and ADHD who have shown improvement on bupropion but could not tolerate a higher dose 1
- Begin with a short-acting formulation to assess tolerability, then consider switching to extended-release 3
- Options include methylphenidate (5-20mg three times daily) or dextroamphetamine (5mg three times daily to 20mg twice daily) 2, 4
Special Considerations
- Start with a low dose of the stimulant and titrate gradually to minimize side effects 3
- For methylphenidate, multiple daily doses may be required due to its 3-5 hour duration of action 3
- Regular assessment of blood pressure, pulse, and weight is necessary when using stimulants 6
Alternative Approaches if Stimulants Fail
- Alpha-2 adrenergic agonists (guanfacine, clonidine) are effective for ADHD with comorbid anxiety and sleep disorders 6
- Atomoxetine provides "around-the-clock" effects for ADHD symptoms and may take 6-12 weeks until effects are observed 6