Nonstimulant Medications by Carole Jacobs and Isadore Wendel, Ph.D. MSCP
With the exception of Strattera, most other nonstimulant medications are generally considered second-line medications for adult ADHD. They tend to be prescribed for people who either had a bad response to stimulants, couldn't tolerate the side effects, or have co-existing psychiatric conditions that rule out stimulant drugs.
Selective Serotonin Reuptake Inhibitors
Prescribed for depression, anxiety, obsessive-compulsive disorder, and anger and aggression, SSRIs are most useful in alleviating coexisting symptoms of conditions accompanying adult ADHD. They work primarily by eliminating serotonin from the brain's synapses, though they may affect other neurotransmitters to a lesser degree.
Popular SSRIs include Prozac, the oldest SSRI, which has a long half-life but many known drug interactions; Luvox, which is similar to Prozac but has a shorter half-life and fewer drug reactions; Paxil, a short-acting SSRI which may pose problems with dosing and discontinuation syndrome; and Zoloft, another short-acting SSRI that also has an effect on dopamine and may offer some of the benefits of stimulant drugs.
Other SSRIs sometimes prescribed to adults with ADHD include Celexa and Lexapro. Both have longer half-lives than all other SSRIs except Prozac and fewer drug reactions than most SSRIs. Lexapro is often preferred because it is more potent and has fewer side effects.
SSRIs have several side effects, many of which are mild or which affect only a small percentage of people. The most troublesome side effects may include weight gain, drowsiness, irritability, and thinning hair or hair loss.
Serotonin/Norepinephrine Reuptake Inhibitors
These antidepressants impact the levels of both serotonin and norepinephrine, and are useful in treating depression, anxiety, and adult ADHD. However, they generally don't offer the symptom relief of stimulant drugs and are often prescribed when stimulant drugs don't work, or in addition to stimulant drugs.
One widely prescribed drug in this category is Effexor, which seems to stimulate energy as well as lead to a calming feeling. Although there are no controlled studies on the use of Effexor in adults with ADHD, several noncontrolled studies indicate that it may be especially helpful in treating adult ADHD with coexisting depression and/or anxiety. However, side effects of higher doses may increase blood pressure, and sudden discontinuation of Effexor could lead to nausea and vomiting.
Another popular drug in this category is Remeron, which works on serotonin, norepinephrine, and histamine to promote sleep, increase energy, and increase appetite. However, one major side effect is a dramatic increase in appetite and a constant craving for carbohydrates. Remeron also makes many people very drowsy.
TCAs, the first medications developed to treat depression, work by significantly inhibiting serotonin and norepinephrine reuptake. TCAs have negligible risk of abuse and are especially beneficial when treating ADHD adults who also have coexisting anxiety and depression. On the downside, it may take several weeks for the drugs to have a full clinical effect, and TCAs generally don't offer the relief of stimulants. Unfortunately, they do have overdose potential and should be monitored. TCAs prescribed for adult ADHD include Elavil, Sinequan, and Nortriptyline, all of which have sedating qualities. Elavil has the strongest sedative, while
Nortriptyline has the weakest.
Another TCA, Norpramine, has proven beneficial in adults with ADHD when given in small doses. Anafranil, another TCA, impacts serotonin levels and is often prescribed for ADHD adults also suffering from compulsive disorders.
Side effects of TCAs range from sleepiness and constipation to light-headedness and dry mouth. More serious conditions include cardiac problems and possible death by overdose.
Mono-amine Oxidase Inhibitors (MAOIs)
MAOIs help ADHD by blocking the breakdown of norepineph-rine, dopamine, and serotonin. Most frequently prescribed MAOIs include Nardil, Parnate, and Elderpril.
Because there are no controlled studies on the treatment of ADHD in adults with MAOIs and those using MAOIs must adhere to a strict diet to prevent an acute rise in blood pressure or hypertension, MAOIs are usually limited to adults with ADHD who have resisted other forms of treatment. They have also proven beneficial in treating adults with nonimpulsive adult ADHD symptoms and in ADHD adults who have coexisting depression and anxiety.
Bupropion SR and XL (Wellbutrin) has been used to treat ADHD. Bupropion increases dopamine and norepinephrine levels and is reported to have a moderate response in adults with ADHD, although the effect is not considered as strong as stimulants and may take several weeks to kick in.
A recent controlled study showed that the drug is effective in the treatment of ADHD symptoms in adults. Although the drug is chemically similar to amphetamine, it does not have the same potential for abuse. Drug manufacturers still warn that it should not be used by people with a history of substance abuse, bulimia, or seizure disorders.
Mood Stabilizers and Antihypertensives
Mood stabilizers are prescribed to help modulate irritability and rapid mood shifts. The most widely prescribed mood stabilizers include Lithium, Depakote, Tegretol, and Lamictal.
Antihypertensives are used to decrease hyperactivity and impulsivity in adults with ADHD and may also help relieve insomnia. Drugs commonly prescribed for adult ADHD symptoms include Catapres, Tenex, and various beta blockers, including Attenolol, Inderal, Nadolol, and Metaprolol. Catapres and Tenex are sometimes prescribed to eliminate tics, impulsivity, and aggression.
These drugs require closer medical monitoring. Blood tests and sometimes an EKG may also be required.
Other Medications for Adult ADHD
A few other medications have been used to treat adult ADHD.
Desyrel (trazodone) is a mild antidepressant that may be prescribed for those who have trouble falling asleep.
Buspar, a serotonin stabilizer, is sometimes prescribed to control anxiety in adults with ADHD.
Nicotinic analogues, or medications that act on some of the same brain receptors as nicotine, may also provide some relief. Although most research on ADHD has revolved around regulating the balance of neurotransmitters, some believe poor regulation of the nicotinic receptors may also be involved. Adults with ADHD are more likely to smoke cigarettes, and research showed improved symptoms in ADHD adults who wore the transdermal nicotine patch. More studies are needed to isolate which properties in the patch were responsible for symptom relief.