Bupropion and adult ADHD

[thelastpsych]

I have a few adult patients in my practice with ADHD: I try to be very thougthful when giving this diagnosis, often interviewing other family members, more than 1 visit, standarized tests and such. These patients often have comorbid anxiety or depression, and when that is the case, I usually choose bupropion to try and treat more than 1 condition with just 1 drug. I've read the literature (Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis - PubMed ; Bupropion for attention deficit hyperactivity disorder (ADHD) in adults - PubMed) and there seems to be at least a solid evidence on this use, specially with comorbidities. Thing is, some patients don't seem to respond all that well, at least compared to when I use amphetamines or metylphenidate - do you guys see that often in your clinical practice? Is bupropion a drug that you consider in these cases?

Thanks in advance!

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[Sushirolls]

I get a few people responding to it.
Often times people elect the medicine for depression an "ADHD" in part because I won't consider prescribing a stimulant until their depression is in remission and they've got their OSA workup for obesity/snoring.

Not suprising, they have OSA, get it treated, the wellbutrin helps with the depression some, and several months later they've stopped saying they have ADHD their MSW or Psychologist put in their head.

 

[comp1]

I mean bupropion has mild to moderate stimulant effects, I'm sure it does a little something that you could get statistical significance on. It also has diversion possibilities, but less so than the full stimulants.

 

[FlowRate]

I've had plenty of patients who found it helpful for ADHD. We had a recent presentation from our clinical pharmacy specialists about evidence base of ADHD in adults and the confidence intervals of effect size for the four main types of adult ADHD treatments (amphetamines, metyhlphenidates, bupropion, atomoxetine) are overlapping, even if the center point of the effect sizes differ a little. The research is also shows that the overall effect size of ADHD medications for adults are lower than for children and behavioral interventions possibly more effective than for children.

Also, there's the whole complication of stimulants likely having more of a "procebo" effect from the stimulant high.

 

[comp1]

I would find it really surprising that they could demonstrate behavioral interventions being more effective in real world practice...I guess you could maybe design a very narrowly and tightly controlled study to somehow show it, but it's a heck of a lot easier to pop a pill in the real world, ADHD or not.

 

[FlowRate]

I would find it really surprising that they could demonstrate behavioral interventions being more effective in real world practice...I guess you could maybe design a very narrowly and tightly controlled study to somehow show it, but it's a heck of a lot easier to pop a pill in the real world, ADHD or not.

In case my phrasing was off, IIRC was more that behavioral interventions (alone) for adults have a little more effect size / evidence of benefit than behavioral interventions (alone) for children. The comparison was adults vs children rather than behavioral interventions vs meds.

 

[clozareal]

I would find it really surprising that they could demonstrate behavioral interventions being more effective in real world practice...I guess you could maybe design a very narrowly and tightly controlled study to somehow show it, but it's a heck of a lot easier to pop a pill in the real world, ADHD or not.

Once someone hits adolescence, CBT for ADHD seems to work better than waitlist controls for ADHD symptoms.

I don't know if they've compared therapy/behavioral interventions versus stimulant treatment in adolescents or adults. Would be interested to see if that data exists.

 

[tr]

I switch women who are planning to conceive from stimulants to bupropion quite often. My experience is that for most people, there is some efficacy for focus but not as much as with the stimulant. It's more effective for some than others, but they are usually able to make do for the limited duration of the pregnancy.

I will say that bupropion doesn't treat anxiety and often exacerbates it. My clinical impression is that bupropion is actually more anxiogenic than stimulants.

 

[clozareal]

I switch women who are planning to conceive from stimulants to bupropion quite often. My experience is that for most people, there is some efficacy for focus but not as much as with the stimulant. It's more effective for some than others, but they are usually able to make do for the limited duration of the pregnancy.

I will say that bupropion doesn't treat anxiety and often exacerbates it. My clinical impression is that bupropion is actually more anxiogenic than stimulants.

I talk to them about the risk of stimulants in pregnancy. Newer data shows that amphetamine stimulants seem safer in terms of cardiac malformation compared to methylphenidates so I would consider switching over for the first trimester. My first choice would be to take a stimulant holiday though if their ADHD isn't as severe and second is bupropion like you said. Even if it doesn't control the ADHD symptoms as well, the benefits outweigh the risks in my opinion for bupropion.

 

[ObsequiousAplomb]

I switch women who are planning to conceive from stimulants to bupropion quite often. My experience is that for most people, there is some efficacy for focus but not as much as with the stimulant. It's more effective for some than others, but they are usually able to make do for the limited duration of the pregnancy.

I will say that bupropion doesn't treat anxiety and often exacerbates it. My clinical impression is that bupropion is actually more anxiogenic than stimulants.

Why do you switch stimulants to bupropion for pregnancy? It's not any safer than other stimulants. Not any less safe either. So why switch?

 

[clozareal]

Why do you switch stimulants to bupropion for pregnancy? It's not any safer than other stimulants. Not any less safe either. So why switch?

There's a risk of cardiac malformation with methylphenidate that isn't there for bupropion.

 

[tr]

Why do you switch stimulants to bupropion for pregnancy? It's not any safer than other stimulants. Not any less safe either. So why switch?

Stimulants are associated with a very significant increase in risk for hypertension and pre-eclampsia, which is not present for bupropion.

Newport et al JCP 77(11): 16369

Prenatal Psychostimulant and Antidepressant Exposure and Risk of Hypertensive Disorders of Pregnancy

Will the psychiatric medication that your female patient is already taking be a risk factor for development of hypertension, preeclampsia, or eclampsia when she is pregnant? In this study, researchers were able to disentangle this complex relationship and determine which patients may be at risk.

www.psychiatrist.com

Women under 35 with no other risk factors for hypertensive disorders of pregnancy, if they want to stay on the stimulant I am usually fine with that. I track bp closely and d/c stimulant if it rises. Guessing the horse is already out of the barn by then though.

For women with baseline hypertension, hypertension in a previous pregnancy, advanced maternal age, or other risk factors for HDP/preE, my recommendation is to d/c the stimulant for pregnancy.

 

[whopper]

It's FDA approved for ADHD.

From personal experience I've seen it help several patients with their ADHD but I never see an overwhelmingly significant difference. Of the ADHD patients who took it and felt a benefit, several of them say the benefit is noticeable, but not much more than this.

Also, and this isn't taught in textbooks, I've noticed Welbutrin reduces anxiety, but only if the person has ADHD. I've seen several patients with bad anxiety that's helped by dopamine-enhancing meds. If this occurs, from what I've seen this is almost always cause of ADHD. It's to the degree where IMHO if someone has excessive anxiety that person should be screened for ADHD.

Wellbutrin can help with weight loss, depression, smoking cessation and ADHD. The problem is a patient could be in need of all of these, take Wellbutrin and none of the above to all of them could benefit.

 

[Celexa]

I've noticed Welbutrin reduces anxiety, but only if the person has ADHD. I've seen several patients with bad anxiety that's helped by dopamine-enhancing meds. If this occurs, from what I've seen this is almost always cause of ADHD.

This has been my experience as well.

 

[Atreides]

It's FDA approved for ADHD.

It's a good medication for ADHD but it is not FDA approved. The only FDA approved non-stimulants for ADHD in adults are atomoxetine and viloxazine.

 

[clozareal]

From personal experience I've seen it help several patients with their ADHD but I never see an overwhelmingly significant difference. Of the ADHD patients who took it and felt a benefit, several of them say the benefit is noticeable, but not much more than this.

As a CAP, I've seen it be lifechanging for children and their families. My experience with adults is similar to yours.

 

[thelastpsych]

Also, and this isn't taught in textbooks, I've noticed Welbutrin reduces anxiety, but only if the person has ADHD. I've seen several patients with bad anxiety that's helped by dopamine-enhancing meds. If this occurs, from what I've seen this is almost always cause of ADHD. It's to the degree where IMHO if someone has excessive anxiety that person should be screened for ADHD.

That was actually my intuition, but I hadn't seen anyone say it like that. I've seen some patients get both a GAD and ADHD diagnosis - will try and use bupropion in these cases, or anything with a more dopaminergic/noradrenergic tonus.

 

[Stagg737]

As someone who has taken and frequently prescribes Wellbutrin for "adult ADHD" (not adult onset, adults who probably have it but were never diagnosed or treated) I often find it to be mildly to moderately helpful for adults who I'm confident have ADHD. Usually I'm told it's pretty helpful and they do notice a difference, but do still struggle with symptoms. Depending on how bad the symptoms are I may trial stims, but for a lot of adults who are seeing me the first time for ADHD, they've usually compensated enough that Wellbutrin alone is good enough as long as they tolerate it.

This was my personal experience taking it as well. Specifically, I consciously noticed that during conversations I was less impulsive and able to stop myself from interrupting others far more easily. When I would go off it for a few days I'd interrupt a lot more unintentionally. It also helped me actually get tasks done, maybe not so much with actual concentration but would get distracted and go down rabbit holes doing other things when I'm supposed to be doing a task a lot less. Example, I was working on notes and took a "quick break" to watch a video. Ended up watching various "Shaqtin a Fool" videos for the next hour before realizing I was supposed to be finishing up notes. Didn't really help with overall organization, "feeling driven by a motor", or most other symptoms.

 

[whopper]

A bit of self-disclosure, I have ADHD. I took Wellbutrin, but not for ADHD, but to see if it helped with weight loss cause for a few months I was pre-diabetic. My ADHD, I had under control (I should've been medicated in medical school but was able to handle school up until medical school without meds).

I did notice myself a bit calmer. In fact the first few days on the medication it sedated me convincing me my ADHD suspicions were not locked-in confirmed. After that and raising it to 300 mg daily impulse eating was off the table. I could eat a piece of cheesecake and stop right there where as before I'd have problems stopping. Now whether or not the impulse eating was cause my ADHD was better or cause dopamine reduces appetite or both is anyone's guess.

I stopped Wellbutrin cause at 300 mg daily it caused a fine hand tremor only noticeable to me when I engaged in delicate hand movements. I like to build model kits and paint miniatures so that hand tremor really screwed with that hobby. No one else noticed it but me. Painting eyes on metal miniatures was impossible. IF I didn't have those hobbies, however, I might've stayed on the medication.

 

[clozareal]

I did notice myself a bit calmer. In fact the first few days on the medication it sedated me convincing me my ADHD suspicions were not locked-in confirmed. After that and raising it to 300 mg daily impulse eating was off the table. I could eat a piece of cheesecake and stop right there where as before I'd have problems stopping. Now whether or not the impulse eating was cause my ADHD was better or cause dopamine reduces appetite or both is anyone's guess.

Why would sedation convince you that you didn't have ADHD? I occasionally see sedation/calming effect for stimulants for those with ADHD, particularly those with hyperactivity. It's as if I calmed them down too much. It seems dose dependent and some of my patients or their parents don't want to go to higher doses of stimulants because of it.

 

[Merovinge]

Why would sedation convince you that you didn't have ADHD? I occasionally see sedation/calming effect for stimulants for those with ADHD, particularly those with hyperactivity. It's as if I calmed them down too much. It seems dose dependent and some of my patients or their parents don't want to go to higher doses of stimulants because of it.

I agree, there's a fine line between mental calm and high level of functioning versus actually being unable to complete tasks due to a blasé indifference from oversaturation of dopamine. Most people have a dosage of stimulants such that higher dosages cause less functional improvement.

 

[whopper]

Why would sedation convince you that you didn't have ADHD?

It convinced me THAT I DID HAVE ADHD. Before it was just a strong suspicion. The problem is with the DSM's criteria anyone could claim they have ADHD given the right amount of tedious work thrown on their lap.

I mentioned this in another thread but if you got 100 guys with ADHD and told them their job was to stare at beautiful naked women and rate them from a 1 to 10 I bet you none of them would show ADHD sx. Get these same guys and ask them to do their taxes, all of them would have problems. I have a crass chauvinistic example only to prove the point quickly and easily.

 

[clausewitz2]

Why would sedation convince you that you didn't have ADHD? I occasionally see sedation/calming effect for stimulants for those with ADHD, particularly those with hyperactivity. It's as if I calmed them down too much. It seems dose dependent and some of my patients or their parents don't want to go to higher doses of stimulants because of it.

Close to pathognomic (not literally, I know) when someone's total sleep time increases significantly after they start stimulants.

 

[clozareal]

It convinced me THAT I DID HAVE ADHD. Before it was just a strong suspicion. The problem is with the DSM's criteria anyone could claim they have ADHD given the right amount of tedious work thrown on their lap.

I mentioned this in another thread but if you got 100 guys with ADHD and told them their job was to stare at beautiful naked women and rate them from a 1 to 10 I bet you none of them would show ADHD sx. Get these same guys and ask them to do their taxes, all of them would have problems. I have a crass chauvinistic example only to prove the point quickly and easily.

Ah I see. I think I read it wrong. That's right that motivation plays a big factor in ADHD. That's why I'm more interested in tedious, rote, repetitive tasks that a person has to do for ADHD diagnosis when it comes to inattention and distractibility. Parents get so confused why a kid can focus for 8 hours on video games but not 1 hour on their homework. Or when a patient really likes a subject in school (math) and can do it for a really long time, but not other subjects that they don't care as much about.

 

[aim-agm]

Bupropion has relatively mediocre Ki (20x less than dextroamphetamine) and achieves ~20-25% occupancy (Bupropion occupancy of the dopamine transporter is low during clinical treatment - PubMed), which is grossly consistent with the reported mild to moderate improvements in symptoms patients report.

Something I've been wondering about is whether response to bupropion is reliably useful diagnostically and in predicting response to methylphenidate and/or amphetamines? For example, if a patient does not have any response to bupropion does that reliable evidence against presence of ADHD and indicate that stimulants would not be expected to have specific benefit?

 

[Stagg737]

Bupropion has relatively mediocre Ki (20x less than dextroamphetamine) and achieves ~20-25% occupancy (Bupropion occupancy of the dopamine transporter is low during clinical treatment - PubMed), which is grossly consistent with the reported mild to moderate improvements in symptoms patients report.

Something I've been wondering about is whether response to bupropion is reliably useful diagnostically and in predicting response to methylphenidate and/or amphetamines? For example, if a patient does not have any response to bupropion does that reliable evidence against presence of ADHD and indicate that stimulants would not be expected to have specific benefit?

Would be interested in data, but anecdotally I'd say no. I've had several patients who felt like they did not benefit from Wellbutrin or had minimal benefit (more likely from improvements in depression) who did well on 20-30 mg of Adderall and have been stable on it for years. I'm seeing one of them this afternoon.

 

[ObsequiousAplomb]

Bupropion has relatively mediocre Ki (20x less than dextroamphetamine) and achieves ~20-25% occupancy (Bupropion occupancy of the dopamine transporter is low during clinical treatment - PubMed), which is grossly consistent with the reported mild to moderate improvements in symptoms patients report.

Something I've been wondering about is whether response to bupropion is reliably useful diagnostically and in predicting response to methylphenidate and/or amphetamines? For example, if a patient does not have any response to bupropion does that reliable evidence against presence of ADHD and indicate that stimulants would not be expected to have specific benefit?

I have no idea why you would think that to be the case. Response to methylphenidate doesn't predict response to amphetamine. Both are in nearly all aspects superior to bupropion for this indication. Why would you try the least likely to work thing first when it isn't really any better tolerated?

 

[clozareal]

I have no idea why you would think that to be the case. Response to methylphenidate doesn't predict response to amphetamine. Both are in nearly all aspects superior to bupropion for this indication. Why would you try the least likely to work thing first when it isn't really any better tolerated?

Agree. I would much rather use SSRI + stimulant than bupropion for depression + ADHD.

 

[annoyedpsychiatrist]

in general i have significantly better outcomes with stimulants. Sometimes in my bipolar patients who have a hx of possibly ADHD, could be a consideration, or someone with significant cardiovascular issues.

 

[FlowRate]

Something I've been wondering about is whether response to bupropion is reliably useful diagnostically and in predicting response to methylphenidate and/or amphetamines?

Response to medication, whether bupropion or amphetamine or methylphenidate, is not diagnostically useful.

 

[annoyedpsychiatrist]

ive yet to see someone who doesn't have a positive response to an amphetamine subjectively, lol. When you find that patient let me know

 

[clozareal]

ive yet to see someone who doesn't have a positive response to an amphetamine subjectively, lol. When you find that patient let me know

it's mostly that the side effects preclude getting to a high enough dose for a positive response. Also when i use it in kids, you rely less on subjective response and more on observable behavior by teacher/parent.

 

[whopper]

Response to medication, whether bupropion or amphetamine or methylphenidate, is not diagnostically useful.

If I see a dopamine-enhancing med causing noticeable and significant reduction in anxiety and even sedation it's pretty safe the say the person does have ADHD.

Now all this said a person could have ADHD and have no benefit with any of the ADHD approved meds but this is not likely. A person with ADHD could also have a bad response to one ADHD med but possibly a good response to another. The structures and mechanisms of Methylphenidates vs Amphetamines despite similarities could still yield very different responses. So yes giving ADHD med and not seeing a benefit is not diagnostically useful. Even if one sees a "benefit," if this benefit is not an improvement in ADHD such as euphoria or increased energy, this still doesn't provide one useful info if this person has ADHD or if this medication is a good option. Remember anyone, ADHD or not, could have a "benefit" with a stimulant which is why these meds can be abused. They want the "benefits" of euphoria, increased energy and partying all night.

When I see increased calm, peace of mind, decreased hyperactivity, reduction in anxiety, sedation, then I feel solid this person has ADHD and that medication could be considered for an appropriate treatment.

 

[FlowRate]

If I see a dopamine-enhancing med causing noticeable and significant reduction in anxiety and even sedation it's pretty safe the say the person does have ADHD.

Now all this said a person could have ADHD and have no benefit with any of the ADHD approved meds but this is not likely. A person with ADHD could also have a bad response to one ADHD med but possibly a good response to another. The structures and mechanisms of Methylphenidates vs Amphetamines despite similarities could still yield very different responses. So yes giving ADHD med and not seeing a benefit is not diagnostically useful. Even if one sees a "benefit," if this benefit is not an improvement in ADHD such as euphoria or increased energy, this still doesn't provide one useful info if this person has ADHD or if this medication is a good option. Remember anyone, ADHD or not, could have a "benefit" with a stimulant which is why these meds can be abused. They want the "benefits" of euphoria, increased energy and partying all night.

When I see increased calm, peace of mind, decreased hyperactivity, reduction in anxiety, sedation, then I feel solid this person has ADHD and that medication could be considered for an appropriate treatment.

If you have someone with such a convincing symptomatic response to meds then it's the fact that they had such obvious and plentiful ADHD symptoms in the first place that should have clenched the diagnosis, not the fact of their responding to the med.

 

[clozareal]

If you have someone with such a convincing symptomatic response to meds then it's the fact that they had such obvious and plentiful ADHD symptoms in the first place that should have clenched the diagnosis, not the fact of their responding to the med.

Depends on if they have enough symptoms to meet criteria for ADHD. ADHD ≠ stimulant deficiency.

If they don't have enough symptoms, doesn't mean they still wouldn't benefit from a stimulant though for their few symptoms causing impairment though.

 

[FlowRate]

Depends on if they have enough symptoms to meet criteria for ADHD. ADHD ≠ stimulant deficiency.

If they don't have enough symptoms, doesn't mean they still wouldn't benefit from a stimulant though for their few symptoms causing impairment though.

Right, we're in agreement--the point I'm making is that presumably they had sufficient symptoms to meet criteria for the diagnosis. So when all of the symptoms that made the patient meet criteria for ADHD have resolved from starting a med, it's not the fact that the symptoms resolved that means they have ADHD, it's that they had sufficient symptoms for the diagnosis in the first place.

 

[Stagg737]

Agree. I would much rather use SSRI + stimulant than bupropion for depression + ADHD.

Why? If Wellbutrin works well for both for a patient, why make them take more pills? Especially if one is a controlled substance that’s a PITA to prescribe?

For an adult with depression who’s never been treated for ADHD imo Wellbutrin is worth an initial trial, with or without an SSRI on board.

 

[FlowRate]

Why? If Wellbutrin works well for both for a patient, why make them take more pills? Especially if one is a controlled substance that’s a PITA to prescribe?

For an adult with depression who’s never been treated for ADHD imo Wellbutrin is worth an initial trial, with or without an SSRI on board.

Plus bupropion alone is way less likely to have sexual adverse effects than SRI+stim.

 

[Merovinge]

ive yet to see someone who doesn't have a positive response to an amphetamine subjectively, lol. When you find that patient let me know

I imagine you mean in adults? In kids it's very common to dislike taking stimulants, especially Adderall-class stims which have more side effects. I can't tell you how many kids are near fistcuffs with parents who want them to take the medication but hate the emotional/appetite/sleep changes from it.

 

[annoyedpsychiatrist]

I imagine you mean in adults? In kids it's very common to dislike taking stimulants, especially Adderall-class stims which have more side effects. I can't tell you how many kids are near fistcuffs with parents who want them to take the medication but hate the emotional/appetite/sleep changes from it.

yeah im talking about my adults, mainly those in their 40s+. younger people i often have to convince them to take the med, with the older population, they're begging for it.

 

[clozareal]

Why? If Wellbutrin works well for both for a patient, why make them take more pills? Especially if one is a controlled substance that’s a PITA to prescribe?

For an adult with depression who’s never been treated for ADHD imo Wellbutrin is worth an initial trial, with or without an SSRI on board.

Erm I should probably clarify in my posts that I treat mostly kids. This is for CAP. I usually start treatment with a stim or SSRI to treat anxiety/depression or ADHD first if they are comorbid, and then see what is left over. Sometimes when I treat the comorbid condition, they no longer complain of the cognitive issues as much. Sometimes when I treat the ADHD, they feel much better their anxiety/depression is much better. I do this especially if there's a therapist on board or I'm doing therapy with them to address residual symptoms.

However, many times the one medication isn't fully treating one or the other so I will use both. I would not want to use a less effective and less studied medication for ADHD (Wellbutrin) for most CAP. I would much rather use atomoxetine for anxiety + ADHD than bupropion in children/adolescents since the effect size for anxiety (0.5) is comparable to SSRIs and for ADHD (1.0) is comparable to stimulants.

For an older adolescent or adult, I do consider Wellbutrin higher for depression + ADHD. Of course if it worked well I would continue it rather than switch. It's just not my first choice.

Just to caveat: I don't care that stimulants are a controlled substance and PITA to prescribe if it's what is the most effective and best option for the patient as long as there are no red flags for diversion or abuse.

 

[Stagg737]

Erm I should probably clarify in my posts that I treat mostly kids. This is for CAP. I usually start treatment with a stim or SSRI to treat anxiety/depression or ADHD first if they are comorbid, and then see what is left over. Sometimes when I treat the comorbid condition, they no longer complain of the cognitive issues as much. Sometimes when I treat the ADHD, they feel much better their anxiety/depression is much better. I do this especially if there's a therapist on board or I'm doing therapy with them to address residual symptoms.

However, many times the one medication isn't fully treating one or the other so I will use both. I would not want to use a less effective and less studied medication for ADHD (Wellbutrin) for most CAP. I would much rather use atomoxetine for anxiety + ADHD than bupropion in children/adolescents since the effect size for anxiety (0.5) is comparable to SSRIs and for ADHD (1.0) is comparable to stimulants.

For an older adolescent or adult, I do consider Wellbutrin higher for depression + ADHD. Of course if it worked well I would continue it rather than switch. It's just not my first choice.

Just to caveat: I don't care that stimulants are a controlled substance and PITA to prescribe if it's what is the most effective and best option for the patient as long as there are no red flags for diversion or abuse.

I get that for kids and would probably take the same approach given effect sizes of SSRIs and stims in kids vs bupropion in general. Totally different for adults who haven't been treated for ADHD before or have functioned adequately without stims for years. For the caveat, sure. But again, for adults I'd rather avoid controlled substances or access issues where they can't get their meds when there's another option that may be just as effective and they can take consistently.

 

[clozareal]

I get that for kids and would probably take the same approach given effect sizes of SSRIs and stims in kids vs bupropion in general. Totally different for adults who haven't been treated for ADHD before or have functioned adequately without stims for years. For the caveat, sure. But again, for adults I'd rather avoid controlled substances or access issues where they can't get their meds when there's another option that may be just as effective and they can take consistently.

Is wellbutrin just as effective as stimulants for ADHD?

 

[Stagg737]

Is wellbutrin just as effective as stimulants for ADHD?

For some of my patients it has been, probably more because they couldn't tolerate stims. For untreated adults who have relatively mild symptoms I'd argue they probably don't need stims in the first place. I was talking about the previously mentioned ADHD + depression combo though.

 

[Penguin10]

Erm I should probably clarify in my posts that I treat mostly kids. This is for CAP. I usually start treatment with a stim or SSRI to treat anxiety/depression or ADHD first if they are comorbid, and then see what is left over. Sometimes when I treat the comorbid condition, they no longer complain of the cognitive issues as much. Sometimes when I treat the ADHD, they feel much better their anxiety/depression is much better. I do this especially if there's a therapist on board or I'm doing therapy with them to address residual symptoms.

However, many times the one medication isn't fully treating one or the other so I will use both. I would not want to use a less effective and less studied medication for ADHD (Wellbutrin) for most CAP. I would much rather use atomoxetine for anxiety + ADHD than bupropion in children/adolescents since the effect size for anxiety (0.5) is comparable to SSRIs and for ADHD (1.0) is comparable to stimulants.

For an older adolescent or adult, I do consider Wellbutrin higher for depression + ADHD. Of course if it worked well I would continue it rather than switch. It's just not my first choice.

Just to caveat: I don't care that stimulants are a controlled substance and PITA to prescribe if it's what is the most effective and best option for the patient as long as there are no red flags for diversion or abuse.

With comorbid anxiety/depression and ADHD do you typically address the issue the patient/family identifies as most significant first or do you have markers/framework for deciding order of operations?

 

[clozareal]

With comorbid anxiety/depression and ADHD do you typically address the issue the patient/family identifies as most significant first or do you have markers/framework for deciding order of operations?

It really depends on the phenomenology. If they can't focus because they are too stressed out about failing, get distracted easily because of fear, then I'll treat the anxiety first. If they can't get motivated or complete tasks because they don't find any point in doing them, I'll treat the depression first. If they keep getting distracted by novel stimuli or wanting to do something more fun, and then that causes them to not complete tasks or do things they're supposed to be doing and THEN they feel anxious/depressed about it, then I'll treat the ADHD first. This is done at the expense of delaying treatment for the others which may make some of the symptoms transiently worse. I try to conceptualize the case formulation with the patient/family to see if they agree or not and then to have an approach that tackles one before the other.

You're right in that sometimes it's not sequential to determine an order of operations and that it is comorbid and one is more significant than the other. In that approach, I tend to treat the anxiety/mood first. I do find that in adults, it's so rare to find ADHD without comorbid conditions.
Before treating mood/anxiety/ADHD though, I do try to treat substance abuse first (with exception of nicotine since the alpha-7 nicotinic receptor can help ADHD/memory). Sometimes their substance abuse is because of self-treatment for their underlying ADHD and it must be addressed together though.

With that being said, anxiety does improve over time with ADHD treatment. Meta-analysis suggests that treatment with stimulants significantly reduced the risk of anxiety when compared with placebo, with higher doses treating anxiety more. Some kids will experience anxiety with stimulants though. Stimulants improved anxiety over time (12 weeks in this study) in those with anxiety disorders and even those without.

 

[hamstergang]

I would much rather use atomoxetine for anxiety + ADHD than bupropion in children/adolescents since the effect size for anxiety (0.5) is comparable to SSRIs and for ADHD (1.0) is comparable to stimulants.

I completely agree with your treatment approach, but where are you getting these effect sizes from? I had thought that for ADHD, atomoxetine had an effect size of about 0.6.

 

[clozareal]

I completely agree with your treatment approach, but where are you getting these effect sizes from? I had thought that for ADHD, atomoxetine had an effect size of about 0.6.

Again, caveat that I treat mostly CAP. The study authors comment that atomoxetine may be more effective for ADHD if there is comorbid anxiety.

Here's the study: Atomoxetine treatment for pediatric patients with attention-deficit/hyperactivity disorder with comorbid anxiety disorder - PubMed

 

[Stagg737]

I completely agree with your treatment approach, but where are you getting these effect sizes from? I had thought that for ADHD, atomoxetine had an effect size of about 0.6.

Will have to read Clozareal's study, but last I talked with someone who was involved in ADHD med development they said that for kids stims had an effect size around 1.2, atomoxetine was around 0.8, Wellbutrin somewhere around 0.4-0.5, and clonidine/guanfacine around 0.2-0.3.

 

[clozareal]

Will have to read Clozareal's study, but last I talked with someone who was involved in ADHD med development they said that for kids stims had an effect size around 1.2, atomoxetine was around 0.8, Wellbutrin somewhere around 0.4-0.5, and clonidine/guanfacine around 0.2-0.3.

This is higher than I typically think. Stimulants have 0.7-1.0 effect size, 0.6-0.8 for alpha-2 agonists, and 0.5-0.7 for atomoxetine for ADHD symptoms. That sounds about right for wellbutrin although there aren't many trials in the CAP patient population nor the FDA approval which is why I would rather use these other agents. If a kid has a seizure on Wellbutrin when they haven't tried other first-, second-, or third-line FDA approved options, it wouldn't look good in court.

The study I linked has some nuance to it depending on if you calculate effect size with the placebo lead in or not (if you remove this placebo lead in, the effect size is higher at 1.0 but if you include them being on a placebo, it's 0.8).