Anxiety and Stimulants in children with ASD?

[shahseh22]

I have a 17 yo child with Autism I'm seeing in my clinic. He is on the moderate to severe range, due to variety of reasons, he wasn't diagnosed until age 16 (parents refused to believe he had any impairment, but he is quite severely impaired in several domains). I've been seeing him for a few months for his anxiety primarily which is signicantly better with Prozac 40 mg. However, he also appears to have ADHD symptoms as well and is performing very poorly in school. I encouraged parents to request an IEP which they did and it indicates several impairments with processing speed.

I feel he would benefit from a stimulant in addition to his SSRI, but I'm worried about his social anxiety getting worse. In addition, I don't want to switch his SSRI to something else as he did so well with it. I know Prozac has a lot of interactions with all the XR stimulants (increases their level), I was thinking to tell the parents to give Wellbutrin XL M-F and skip on holidays/weekends. I feel Wellbutrin will be less likely to exacerbate any anxiety symptoms.

What do you guys think?

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[Old&InTheWay]

I have no data to back this up, but many folks with ADHD I have talked to describe reduced anxiety symptoms when treated with stimulants. I could see how one’s mind and the world could feel more predictable and within one’s control with the reduction of ADHD symptoms.

Actually, just found this: Do stimulants protect against psychiatric disorders in youth with ADHD? A 10-year follow-up study. - PubMed - NCBI It’s a prospective study but seems to indicate that stimulant tx is protective of developing anxiety disorders.

Also: Treatment Implications for ADHD Youth with Mood and Anxiety Comorbidity

 

[shahseh22]

I feel like Prozac has helped with the anxiety so I don't want to get rid of it. However, the ADHD symptoms are pretty severe (can't even bathe self or clean self after using restroom, forgets where they put things, forgets to turn in homework), this is not typical 17 year old behavior. I feel like the kiddo really needs a stimulant but I worry about CYP2D6 inhibition from Prozac 40mg. Maybe I can prescribe one of those stimulant patches?

 

[Crayola227]

can you just not dose adjust if the main issue is that concurrent admin will just raise levels? is the issue that the meds you're thinking of are XL and don't come in some enough doses?

 

[Crayola227]

I could be totally off, but I always think of Wellbutrin possibly worsening anxiety? I would have thought so with stims except I will second the above, it seems like it worsens anxiety in people WITHOUT ADHD, and seems to just overall help if they do actually have ADHD.

 

[hamstergang]

can you just not dose adjust if the main issue is that concurrent admin will just raise levels?

I could be totally off, but I always think of Wellbutrin possibly worsening anxiety?

I agree with these. I don't think there's any evidence that Wellbutrin exacerbates anxiety less than stimulants, and it's not so clear that stimulants do this at all I thought.

If you're worried about inhibition of metabolism, you can use a low dose or start with a non-XR formulation. Or use a methylphenidate instead of an amphetamine, right? Or use a non-stimulant which has better evidence for treating ADHD than Wellbutrin does.

 

[hamstergang]

Also, if you were to use Wellbutrin for ADHD, is it immediately active like stimulants and can be given prn, or does it need to be given every day like when it's used for depression?

 

[WisNeuro]

. However, the ADHD symptoms are pretty severe (can't even bathe self or clean self after using restroom

Are we sure that these are secondary to ADHD? This patient sounds like they could benefit from ABA quite a bit.

 

[Crayola227]

I didn't even know that Wellbutrin was used for ADHD...

 

[shahseh22]

Are we sure that these are secondary to ADHD? This patient sounds like they could benefit from ABA quite a bit.

Unfortunately Medi-Cal doesn't cover ABA.

 

[shahseh22]

I didn't even know that Wellbutrin was used for ADHD...

Wellbutrin is used for ADHD routinely, especially in adults. Especially given the fact that stimulants are not covered after age 16 by a lot of insurance plans.

 

[shahseh22]

This is not quite true. By law, insurances in california, including Medi-cal are required to cover ABA if deemed medically necessary. In practice, in many/most counties, there usually aren't any ABA therapists in network with medi-cal plans but if the family kicks up enough of a fuss or complains to the department of managed care, they can eventually make it happen. it just takes a lot of effort.

Wow, so I'll just tell my patient's to kick up enough fuss. Do you have the contact info for the department of managed care?

Regional centers are also pretty resistant to taking anyone. I'm so frustrated with the whole entire system and the way these poor children go without services.

 

[MedMan80]

ADHD and ASD are quite comorbid, I've seen plenty of ASD kids all along the ADHD spectrum improve with stims.

 

[Jules A]

ADHD and ASD are quite comorbid, I've seen plenty of ASD kids all along the ADHD spectrum improve with stims.

I would also consider the likelihood there is an OCD component as that seems the trifecta I have often seen in moderate to severe ASD patients.

 

[shahseh22]

I would also consider the likelihood there is an OCD component as that seems the trifecta I have often seen in moderate to severe ASD patients.

If there is an OCD component, you would be making it worse by adding a stimulant, no?

 

[Wilf]

If it was me I'd strongly consider a trial of low dose Concerta or Metadate and see how the patient does. I doubt it would significantly worsen anxiety. If it seemed to help with ADHD symptoms I'd slowly titrate. OP are you in child and adolescent psychiatry?

 

[Mass Effect]

Also, if you were to use Wellbutrin for ADHD, is it immediately active like stimulants and can be given prn, or does it need to be given every day like when it's used for depression?

Pretty sure it has to be given every day as there is no immediate benefit from it. I've heard people say they "feel" it with the IR formulation, but whether that's true or not, the affect on ADHD would be questionable without daily dosing.

I didn't even know that Wellbutrin was used for ADHD...

It is, quite often.

 

[clausewitz2]

Pretty sure it has to be given every day as there is no immediate benefit from it. I've heard people say they "feel" it with the IR formulation, but whether that's true or not, the affect on ADHD would be questionable without daily dosing.



It is, quite often.

Given the popularity of insufflating Wellbutrin among a certain set I am quite sure they feel something but it may not be isomorphic to therapeutic effect.

 

[shahseh22]

If it was me I'd strongly consider a trial of low dose Concerta or Metadate and see how the patient does. I doubt it would significantly worsen anxiety. If it seemed to help with ADHD symptoms I'd slowly titrate. OP are you in child and adolescent psychiatry?

Why would you give Concerta or Metadate over Adderall in this scenario?

 

[Shufflin]

I wonder how high folks have dosed Wellbutrin to treat ADHD

 

[Jules A]

If there is an OCD component, you would be making it worse by adding a stimulant, no?

Generally speaking I haven't noted OCD to be exasperated by a stimulant in ASD or ID patients.

 

[Mass Effect]

I wonder how high folks have dosed Wellbutrin to treat ADHD

Typical dosing. You start at 150 mg/day. Can titrate up from there.

 

[shahseh22]

I wonder how high folks have dosed Wellbutrin to treat ADHD

usually 300-450 mg, in XL form.

 

[MedMan80]

I wonder how high folks have dosed Wellbutrin to treat ADHD

Usually up to 450, theoretically the SR/IR formulations can have more of a dopaminergic effect and may help with symptoms more than XL