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The MGH Psychiatry Academy needs to stipulate that, though clinically informed, the statement below is anecdotal, reflecting the judgment and opinion of the contributing author.
By asking for ADHD medication advice in a teen with other psychiatric issues, we can assume that the treating clinician considers ADHD to have serious impact on this teen’s functioning. It may be that this teen has full combined type symptoms for example, with reckless impulsivity and disabling inattention and disorganization. This degree of symptoms and impairment may cause great distress and conflicts with parents/teachers, and peers, leading to academic failure and at-risk behaviors. It would not be unusual for such a teen to have some degree of mood or anxiety symptoms – eg sadness/hopelessness or tension/worry – related to the ADHD symptoms and/or to her resultant failures. If these symptoms appear secondary to ADHD, are not consistent with full MDD or a clinical anxiety disorder or associated with other related symptoms, such as suicidality, it would be reasonable to begin with a standard first line ADHD medication (stimulant). Gradual titration, watching for worsening (vs improving) mood or anxiety, would be reasonable.
Clinically, a similar approach can be undertaken with the Bulimia comorbidity. If this severely compromised teen with ADHD has periodic bulimic symptoms as well, yet day to day the primary impairment is ADHD – it could be reasonable to begin with a first line stimulant. Again, gradual initiation/titration can be done while watching for mood changes and, in particular keeping an eye on appetite and weight stability.
However, I do agree that a reasonable alternate to the stimulants is the FDA approved atomoxetine – whether atomoxetine has an independent impact on mood or anxiety symptoms remains an area of investigation. If atomoxetine is chosen, I would consider divided dosing, and gradual dose escalation – which may improve the tolerability, ie, lessen GI upset.
Finally, as per recent AACAP guidelines (Plizka, 2007), ADHD in the presence of comorbidity will likely best respond to a combined approach, with therapy and pharmacotherapy. Communication with the teen’s therapist, who monitors her on a weekly basis, can provide valuable details/insight into which disorder is most impairing/primary and thus which disorder is the initial pharmacologic target. The therapist can provide additional updates as well re the course of these comorbid issues, once an ADHD medication is begun.
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