ebook_ADHD2019_engl.

104 Rohde, Buitelaar, Gerlach & Faraone are no data to help predict who will respond to any of the ADHD medications, each new medication must be tried and tested one drug at a time. For those who have a partial response to a stimulant, it may be appropriate to consider adding in an alpha 2 agonist (guanfacine or clonidine), which have a very different adverse event and safety profile compared to one of stimulants and atomoxetine making combination treatment much safer than adding atomoxetine to a stimulant. SPECIAL CIRCUMSTANCES When ADHD occurs in association with other disorders some adjustment to the treatment plan may be required. Whilst there is often few formal evidence on whi- ch to base these decisions, the following recommendations can be made: ADHD + depression The clinician should determine which disorder requires to be addressed first. If it is the depression that is causing the most severe impairments and concern, then usual treatment guidelines for depression should be followed, after which, the ADHD symptoms can be addressed following the principles outlined above. Where the ADHD is to be treated first, stimulant medication, if required, should be titrated carefully as this may further lower mood. Otherwise treatment should follow the usual pathway with secondary treatments being offered for depression should this not resolve with treatment of the ADHD. The potential for drug × drug interactions should be remembered. This is particularly relevant for atomo- xetine and fluoxetine, both of which are metabolised by CYP2D6 and co-prescrip- tion can lead to increased levels of both drugs. ADHD + anxiety Whilst there is some evidence to suggest that those with ADHD with comorbid anxiety disorders do not always respond as well to methylphenidate as those wi- thout, this is not the same as saying that stimulants are ineffective in the presence of anxiety, and anxiety is certainly not a contraindication. The MTA study reported no adverse effects of anxiety on medication response for core ADHD or other outcomes but did suggest that parent rated outcomes for those with comorbid anxiety were improved by the addition of psychosocial treatment. 29 There is some evidence to suggest that atomoxetine may reduce anxiety symptoms in the presen- ce of ADHD and it may therefore be considered in such cases. However, a further assessment of additional psychological stresses on the child is always in order, and if these cannot be simply alleviated, then psychological treatment may have more to offer than repeated trials of medication.