Stimulant medication is the primary treatment for ADHD, especially with regard to improving concentration. However, other medications are often prescribed along with stimulants to help control side effects, comorbid (i.e., co-occurring) symptoms of depression or other mood disorders, or when stimulants are not working.
Antidepressants are the second line of treatment and may be used in combination with stimulants in order to maintain treatment effects throughout the night. They are not as helpful with concentration, but can be quite effective in reducing impulsivity and improving social problems. Typically, antidepressants take a while to build up to optimal doses in the body, so symptom improvement may take a few weeks. However, benefits can last for up to 24 hours. Antidepressant often used with people who have ADHD include:
- Bupropion (Wellbutrin) - This medication is an atypical antidepressant (an antidepressant medication that does not fit into any of the other medication categories) that can be very helpful in reducing irritability. The appropriate pediatric dosage has not been established, but Wellbutrin is frequently used "off label" or outside of the recommended label instructions with children. Potential side effects include weight loss, anxiety, headaches, dry mouth and confusion. In rare cases, more serious side effects can occur such as allergic reactions, heart palpitations and seizures.
- Tricyclics (Desipramine, Imipramine) - Tricyclic antidepressants may require lower dosages to treat ADHD than when used to treat depression. They have a quicker onset of action than most other non-stimulant medications. Tricyclics block norepinephrine and dopamine receptors in the brain (causing the brain to produce higher levels of these neurotransmitters), which seems to decrease impulsivity, inattention, and poor concentration. The primary side effects of this medication include slowed or irregular cardiac conduction and exacerbation of untreated glaucoma. The risk versus the benefit must be carefully weighed for each individual.
Other medications that are prescribed for ADHD, and used alone or with a stimulant medication, include:
- Atomoxetine (Strattera) - This is the first official FDA approved, non-stimulant medication for ADHD (as suggested above, other nonstimulants have been used "off-label"). This medication seems to block norepinephrine receptors in the brain (resulting in increased norepinephrine production), which increases attention and controls hyperactivity and impulsivity. Although Strattera is used frequently to treat ADHD, studies suggest that its overall effectiveness is not as great as stimulants.
Strattera came under fire in 2006 with a warning that children may have increased suicidal thinking early in the treatment process. The increased rate of suicidality is low (.4% or .5 out of 1,357 patients), but children starting treatment with Strattera should be closely monitored for suicidal thinking or behaviors, clinical worsening of ADHD symptoms, or unusual behaviors. Parents and caregivers must be aware of the need for close observation and communication with the prescriber.
- Clonidine (Catapress or Dixarit) - The medication is usually used to treat high blood pressure but has been used for individuals with ADHD to help them better manage frustration, as well as reduce angry outbursts and violent behavior. Clonidine is often used for ADHD in children who have tics, in combination with a stimulant medication. It can be particularly helpful for children with tendencies to over focus, or become absorbed in a specific activity. This medication is thought to work by inhibiting the release of the neurotransmitter norepinephrine in certain parts of the brain . People with heart disease should not use Clonidine because the lowered blood pressure can present additional risks. The medication can also exacerbate depressive symptoms.
- Anticonvulsants (e.g., Tegretol) are anti-seizure medications that are sometimes used for ADHD children who have seizure disorders, particularly those that are difficult to treat. Some children with ADHD have seizures accompanied by outbursts of anger and aggressive behavior (rather than the more stereotypic loss of consciousness), and these medications can have a calming and maturing effect on them. Some children may require a combination of stimulant medication and anticonvulsants.