ADHD Treatment Guide

We consider the procedure described below to be fundamentally sensible. However, these are merely thoughts from a scientific point of view, which cannot represent a therapeutic recommendation for action in individual cases.
In each case, an individually tailored therapy plan must be developed by a physician or psychotherapist.
Our presentation here serves only to make medical recommendations more transparent to those affected and their families and to promote a capacity for dialogue with the treating physician and therapist.

National treatment guidelines and guidance exist in the Americas¹, Europe², Canada³, and Germany⁴, among others.

• 1. First step: Secure diagnosis
• 2. Second step: Acute measures
  • 2.1. Treatment prioritization for ADHD with comorbidities
  • 2.2. Acute ADHD symptom elimination through medication
    • 2.2.1. Adults: amphetamine medication before methylphenidate (test several preparations) before atomoxetine before guanfacine
    • 2.2.2. Children and adolescents: Methylphenidate (test multiple preparations) before amphetamine medications before guanfacine before atomoxetine
    • 2.2.3. Dosage principles
      • 2.2.3.1. No caffeine when dosing stimulants (IMPORTANT!)
      • 2.2.3.2. Slow dosing
      • 2.2.3.3. Keep dosage aid table
      • 2.2.3.4. Nonresponder treatment
      • 2.2.3.5. Ensure all-day coverage
      • 2.2.3.6. Treatment-resistant ADHD:
      • 2.2.3.7. Development of tolerance to stimulants / habituation effects
      • 2.2.3.8. Medication breaks
    • 2.2.4. Effect sizes of different drugs
    • 2.2.5. Goals of an optimal medication setting
  • 2.3. Many other small treatment steps
• 3. Third step: Therapy measures
  • 3.1. Psychotherapy to reduce symptoms
  • 3.2. Environment Interventions
  • 3.3. Psychoeducation
  • 3.4. Group experience with other affected people
• 4. Fourth step: comorbidities and medications review
  • 4.1. Comorbidities
  • 4.2. Drug Review
• 5. Treatment prioritization for comorbidities
  • 5.1. Prioritization according to the severity of the disturbance pattern
    • 5.1.1. Comorbidity more severe than ADHD
    • 5.1.2. ADHD more severe than comorbidity
    • 5.1.3. ADHD and comorbidity equally severe
  • 5.2. Treatment guidelines for specific comorbidities
    • 5.2.1. ADHD and depression:
    • 5.2.2. ADHD and addiction

1. First step: Secure diagnosis¶

• Questionnaire AND tests, self-perception AND other-perception history, elementary school report cards or other reports from kindergarten and early school years
  • Caution: high self-interest in testing can lead to outcome as in non-affected (attention follows intrinsic control)
• Family history
  • Genetic causes
  • Pregnancy and birth complications
  • Attachment Disorders
  • Physical or sexual abuse
  • Psychological abuse or low-threshold psychological stress
• Complete differential diagnosis
  • Exclude deficiency symptoms: Blood count (thyroxine (thyroid), zinc, iron, magnesium, B1, B12, B6, D3, folic acid, etc.)
  • Exclude acute stress situation
  • IQ test
  • Exclude dominant disorders with similar symptoms
    More on the topic ⇒ Differential diagnostics
• Identify comorbidities
  • For treatment prioritization, see below 5.
  • See more at ⇒ Comorbidities in ADHD

2. Second step: Acute measures¶

2.1. Treatment prioritization for ADHD with comorbidities¶

• See here under 5.

2.2. Acute ADHD symptom elimination through medication¶

⇒ Medication for ADHD - Overview

• Of those affected who would be helped by medication, only about 20 to 25% receive medication. Of those not affected, less than 1 % receive medication that they do not need.⁵
• Cardiovascular testing is recommended prior to treatment with stimulants.⁶

2.2.1. Adults: amphetamine medication before methylphenidate (test several preparations) before atomoxetine before guanfacine¶

For adults, the most helpful* Prioritization of medications is ⁷⁸
*Health insurer approvals may deviate from this

• Amphetamine drugs before

• Methylphenidate (test several preparations) before

• Atomoxetine before

• Guanfacin

• Lisdexamphetamine (Vyvanse)

  • Usually works better and is better tolerated in adults
  • Nonresponders: approx. 20
  • About 30% of adults who switch from MPH to Elvanse switch back again⁹
    • Too fast dosing in too high steps increases nonresponder rate

• Methylphenidate:

  • If not effective: test several other MPH preparations
  • Different MPH preparations can have very different effects
  • Effect differences are rather individual than typical for the preparation
  • Nonresponders: approx. 30
    • Too fast dosing in too high scraps increases nonresponder rate

2.2.2. Children and adolescents: Methylphenidate (test multiple preparations) before amphetamine medications before guanfacine before atomoxetine¶

For children and adolescents, the most helpful* Prioritization of medications:
*Health insurer approvals may deviate from this

• Methylphenidate¹⁰ ago
• Amphetamine drugs before⁷⁸
• Guanfacin before
• Atomoxetine

The guidance on methylphenidate and amphetamine medications in the previous section on adults applies equally to children and adolescents.

2.2.3. Dosage principles¶

In our experience, many mistakes are made during dosing, which not only prevent an optimal effect, but often enough prevent any effect at all. Therefore, the dosage instructions should be followed very urgently,
See in detail at ⇒ Dosage of medication for ADHD

The main topics are:

2.2.3.1. No caffeine when dosing stimulants (IMPORTANT!)¶

Caffeine should be completely omitted without compromise when dosing stimulants.
Around 50% of those affected experience symptoms typical of overdose (up to severe overdose) when stimulants are added to a caffeine intake that was previously tolerated without problems. In addition to a high level of shakiness, other side effects will also be drastically increased.
After successful dosing with stimulants, caffeine can be carefully added again. The difference is that those affected then know that any side effects that now occur are not the result of the stimulants
We also know reports of individual sufferers who - after years of taking stimulants - still react to even decaffeinated coffee with a slight tremor.

2.2.3.2. Slow dosing¶

• low initial dose (2.5 mg unretarded MPH / single dose or equivalent for other medications)¹¹¹²
• at least 5 days / dose level
• Dosing increments max. 2.5 mg unret. MPH / single dose
• optimal dose is very individual¹¹¹²
• Dose level can individually exceed “recommended maximum dose” of 60 mg / children, adolescents / day or 80 mg / adults / day (esp. rapid transfusion)
• Effect of slow dosing:
  • reduces side effects
  • prevents skipping the appropriate dose due to the sometimes very narrow therapeutic range¹¹¹²

2.2.3.3. Keep dosage aid table¶

• daily symptom note
• especially consideration of the menstrual cycle in women
• Download: ⇒ Dosage aid table in the ADHD forum of ADxS.org

2.2.3.4. Nonresponder treatment¶

• MPH: 30% Nonresponder
  • in case of non-effect of MPH:
    • Check gastric acid
    • Change active ingredient
  • in case of inappropriate side effects:
    • change preparations first
      • amazing individual side effect reactions
        • Person A does not tolerate preparation A and B is fine, person B exactly the opposite: unpredictable
      • Preparation alternatives e.g.:
        • unretarded
        • Medikinet retard / Adult
        • Ritalin LA / Adult
        • Concerta
        • Kinecteen
    • then change active ingredient
      • Sequence recommendation see above 2.2.1. and 2.2.2.
• AMP: 20 % Nonresponder
• over 40 % of those affected are helped by a change of preparation in the first 3 months¹³
• when set with MPH and AMP with nonresponder metabolism, only about 10 to 15% nonresponders remain for both stimulants¹¹¹²

2.2.3.5. Ensure all-day coverage¶

• ADHD does not end after school
  • a treatment should not only establish a school ability
  • Homework, social life and family life suffer quite significantly under ADHD
• Manufacturer’s data on duration of action (rarely achieved in practice)¹¹¹²
  • unretarded MPH acts 2.5 - 3.5 hours / single dose
    • 4 to 5 single doses
    • hardly feasible in the long term, especially with children
    • for dosing, unretarded MPH is nevertheless advantageous, as it can be regulated most finely
  • half-day-retarded MPH acts 5 - 6 hours / single dose
    • 2 doses + if necessary unretarded MPH for residual coverage
    • Second dose idR 50% to 75% of first dose
  • all-day-retarded MPH acts for 10 - 12 hours
  • Attentin (unretarded AMP) acts 5 - 6 hours
    • 2 doses and, if necessary, unretarded MPH for residual coverage
    • Second dose idR 50% to 75% of first dose
  • L-amfetamine (Vyvanse) is effective for approx. 10 - 12 hours
    • 1 dose and unretarded MPH for residual coverage, if necessary
  • Guanfacin
    • Mirror drug, 1 x daily
  • Atomoxetine
    • Mirror drug, 1 x daily
  • If daily coverage is not achieved
    * Multiple doses taken throughout the day (up to 3 whole-day retardant doses)
    * Retarded preparations can also be supplemented by non-retarded ones
  • Fast metabolizers require more frequent doses / day rather than higher single doses
    • in approx. 50 % of those affected, the duration of effect of stimulants is only 50 % of the manufacturer’s specification
    • mostly super fast metabolizers (fast metabilizing CYP gene variant)
    • multiple dosing even of whole gestretards during the day
    • Combination medication for fine-tuning / for difficult cases
    • in particular:
      • 50% ATX for full day treatment of emotional dysregulation
      • 50 % MPH or AMP, as usually better effect on drive / concentration
    • Rebound treatment
    • Rebound particularly frequent with MPH
    • Remedy:
      • Take second dose in time for it to kick in before first dose runs out in rebound
      • unretarded MPH shortly before the end of the last dose
        • 1/4 to 1/3 of what would correspond to a daytime treatment dose
        • Example: 20 mg half-day sustained-release MPH corresponds to 2 x 10 mg unretained MPH. Here, therefore, 2.5 to 3.5 mg unretarded MPH 30 min before the end of the last retarded dose.

2.2.3.6. Treatment-resistant ADHD:¶

REVIEW on options for action in treatment-resistant ADHD: Cortese et al.¹⁴

• Optimize stimulants
• try alternative monotherapies
• Try non-stimulants
• combined pharmacotherapy
• Use off-label medications that have been shown to help with ADHD
• treat comorbid diseases

2.2.3.7. Development of tolerance to stimulants / habituation effects¶

REVIEW on options for action in treatment-resistant ADHD: Cortese et al.¹⁴

• Development of tolerance is rather rare¹⁵, but possible in some cases¹⁶¹⁷
  • ADHD sufferers showed significant recurrence of hyperactivity and inattention after 2 years of taking MPH when discontinued¹⁸¹⁹
  • A meta-analysis of 87 randomized placebo-controlled double-blind trials found no evidence of habituation effects with prolonged use of:²⁰
    • Methylphenidate
    • Amphetamine drugs
    • Atomoxetine
    • α2-antagonists (guanfacine, clonidine)
  • Caution: studies on tolerance development to MPH in rats that investigated drug administration (intravenous, rapid dopamine increase)²¹ are unlikely to be transferable to the effect of drug administration (oral/patch, slow dopamine increase); moreover, particularly high doses were often given
• higher dosage increases risk of habituation²²²³ and in this respect possibly consequence of overdose
  • when taken orally / patch, stimulants can always be discontinued without problems
• steady dose increase in short intervals of stimulants is not a solution
  • to be distinguished from once or twice dose adjustment in the first year
• short drug vacation can help sensitive sufferers reduce tolerance buildup
  • Dose lower on weekends
  • Skip weekends
  • several weeks break can restore long-term effect after that((
• Change of the active substance
  • from MPH to AMP
  • from AMP to MPH
  • If the substitute is less effective, it may help to switch back after about a month. It was reported that in many cases the tolerance disappeared after one month.²³
  • Combination medication
    • reduced stimulant content may contribute to reduced tolerance formation

2.2.3.8. Medication breaks¶

Many physicians recommend that their patients take a medication break of at least one week at least once a year to determine whether medication administration is still required. In this context, it is hardly conceivable that a state of “no longer needing” has occurred without the (previously unchanged) medication already being perceived as no longer appropriate. Normally, a decreasing “need” at a constant dosage would have to produce symptoms of overdose. We therefore suspect that cases in which the affected persons no longer notice any difference from the previous medicated state during the medication break are more likely to be related to reduced demands in the environment (holidays/vacation) or to a development of tolerance.

Children with eating problems or growth issues may benefit from a break in medication for several weeks during the vacations to build up weight reserves for the upcoming school season or to catch up on length growth (which, if affected at all, is usually only delayed by MPH).²⁴

2.2.4. Effect sizes of different drugs¶

• Effect strength at optimum setting:
  • Amphetamine drugs: 1.1-1.5
  • Methylphenidate: 1.0-1.3
  • Guanfacine: 0.8
  • Atomoxetine: 0.65

2.2.5. Goals of an optimal medication setting¶

• Enable experience of what life without ADHD can be and feel like (allows sufferers to intrinsically define goals for non-drug therapy)
• Establish therapy capability (bring attention and concentration to the level required for learning more functional ways of acting)
  • Increasing treatability with dopaminergic ADHD medications, as dopamine increases or restores neuroplasticity²⁵
  • In ADHD, growth hormones, which are necessary for neuroplasticity (learning), are decreased. Stimulants increase the levels of growth hormones.
• The goal is not to completely eliminate all ADHD symptoms **
  • ADHD sufferers differ from non-affected people only in the number of symptoms they have frequently. Non-affected people also have some symptoms frequently.
  • Single prominent symptoms should be treated singularly if possible (e.g. impulsivity with lowest doses of SSRI, aggressiveness with low doses of antipsychotics) instead of trying to treat them with ADHD medications, as this would lead to too much broad intervention

2.3. Many other small treatment steps¶

The points mentioned here should always be considered in ADHD treatment, as they can usually make a further helpful contribution without showing significant side effects. The points do not represent alternatives, but should all be considered.
However, their effect strength (even in combination of all possibilities) is considerably lower than the above-mentioned relevant drugs. If it were otherwise, the reports of successful treatment without the relevant drugs would be legend. Newcomers to this topic can obtain information in affected person forums, such as the ⇒ ADHD forum of ADxS.org

• Vitamins and minerals
  Determine blood values and dose to upper limits or above. More on this at* ⇒ Vitamins, minerals, dietary supplements for ADHD*
  • Vitamin D3
    • October to May essential in Germany
    • Very important in ADHD, essential in depression. Prescribing serotonergic or noradrenergic antidepressants (which in our opinion have considerably stronger side effects than ADHD drugs) without first checking the D3 level is, in our opinion, malpractice (except in severe depression)
  • Zinc
  • Magnesium
  • Iron
  • B12
  • B 6
• Omega-3/Omega-6 fatty acids
• Sleep problems
  • Treat offensively
  • Avoid benzodiazepines and SSRIs. If necessary, trimipramine, amitriptyline or trazodone (each at low doses)
  • Melatonin (unretarded, especially helpful in ADHD)
  • Light therapy
  • See more at ⇒ Sleep problems with ADHD
• Initiate drug treatment of mild remaining comorbidities, if possible, only after analyzing the impact of ADHD medications (idR after about 6 months)
• Test and exclude food intolerances
  • Effect size with existing intolerance and consistent avoidance: 0.25
  • See more at * ⇒ Nutrition and diet for ADHD*
• Test and exclude allergies
• Test and treat chronic low-threshold inflammation (very difficult)
  • Inflammatory problems in ADHD may indicate problems with adenosine balance, which strongly influences dopamine
  • More on this at * ⇒ Endurance sports, fitness training in the article Non-medicinal treatment methods*
• Lots of sports and exercise²⁶
  • Endurance exercise has a significant effect size in reducing the symptomatology of ADHD (and other mental health problems such as depression)
    • Effect strength of weight training, on the other hand, is lower
  • Sport must be fun for it to be practiced sustainably
  • Endurance sports
    • Increases stress resistance, shuts down stress systems (for 24 - 48 hours)
    • Effect size in the optimal case (e.g. 5 x 1 hour / week) up to 0.7
  • See more at ⇒ Sleep problems in ADHD
• Healthy diet
  • Avoid sugar²⁷
  • Avoid bad fats (saturated fatty acids, trans fats; e.g. deep-frying fat)²⁶
  • Abundant antioxidant foods (vegetables, fruits)²⁶
    • Helps to reduce antioxidant stress

3. Third step: Therapy measures¶

3.1. Psychotherapy to reduce symptoms¶

Here it is only insignificantly important which form of therapy is chosen (exception: mindfulness-based therapies are better suited than cognitive therapies, depth psychological therapies are only of use for unpleasant experiences to be worked through and psychoanalysis is basically unsuitable for ADHD). It is much more important that the patient feels very comfortable and accepted by the therapist. This does not at all mean a cuddly therapy, where the therapist would only tell the patient what the patient wanted to hear, but the positive acceptance and the basis of trust, which are the indispensable foundations for a successful therapy. Without these minimum conditions, the best form of therapy and the greatest experience of the person treating the patient will be useless. Therefore, a great deal of patience is required here in the selection of the appropriate therapist.
It is further important that it is not a matter of a single therapeutic measure, but that as long and as many therapeutic measures take place until a satisfactory condition has been reached.

In all therapy measures, it must be ensured that the therapist knows all ADHD symptoms relevant to treatment. Often enough, doctors and therapists are still subject to the fatal error that ADHD is limited to the diagnosis-relevant symptoms of DSM or ICD. Therapists who do not want to accept the original symptoms of ADHD beyond DSM / ICD as such should be avoided. Otherwise, there is a concrete danger that the affected person will be assigned responsibility for behaviors that in reality stem from ADHD itself. Such a thing can cause further deterioration for the affected person instead of improvement.

Appropriate types of therapy may include:

• Mindfulness-based (behavioral) therapy (MBCT) to improve self-awareness, to improve self-control over symptoms, and to learn and practice mindfulness-based stress reduction (MBSR) and stress reduction techniques (e.g., 8-week intensive MBCT + MBSR courses)
  Especially in ADHD-HI, the vicious cycle of inability to recover should be broken, which helps maintain the continuous operation of the HPA axis.
• Neurofeedback for long-term improvement of self-control (6 months to 2 years)
  • SMR training to improve impulse control and against sleep problems
  • Theta-beta training to improve the regulation of activation
  • SCT training to reduce overactivation or increase underactivation
  • Especially recommendable seems to be a combination of Theta-Beta-Training or Z-Score-Training and SCP-Training (simultaneously or consecutively)
• If necessary, cognitive behavioral therapy for self-esteem problems, social behavior problems. Here ⇒ Rejection Sensitivity: fear of rejection and criticism as a specific ADHD symptom note. Cortisolergic stress arises especially in subjectively self-esteem-threatening situations.
• If necessary, depth psychological therapy for the treatment of serious experiences / experiences
• If necessary, trauma therapy (EMDR) for traumatic experiences
• For children up to age 6 or 10: parent-centered therapy; child-centered therapy ineffective.

3.2. Environment Interventions¶

• Eliminate stressors
• Optimal design of the working and learning environment, e.g.
  • Eliminate superfluous stimuli
  • Enable sufficient arousal
• Conversations with relationship people to create mutual understanding
  • If necessary, systemic therapy (family therapy, parent therapy) to change ingrained problem patterns
• Life and career focus on things that really matter
  • More on this at ⇒ Motivation problems in ADHD.

3.3. Psychoeducation¶

• Acquire knowledge about the causes, correlations, effects and possibilities of influence
  • Read books about ADHD (several)
  • Youtube videos of professionals (lectures)
  • Attend lectures (e.g. from ADHS Deutschland e.V.)
  • Visit self-help groups, preferably if led by a person with professional experience (to be found, for example, at ADHS Deutschland e.V.)

3.4. Group experience with other affected people¶

• An ADHD diagnosis is already accompanied by the realization of being different from others, in both a negative and a positive sense. This realization is often associated with great hopes for improvement of the life situation.²⁸
• The experience that other people have gone through or are going through the same thing often causes amazing relief for ADHD sufferers
  • Feeling of coming home among like-minded people
  • Self-esteem enhancement
  • Exchange of experience
  • Willingness to address the issue

4. Fourth step: comorbidities and medications review¶

4.1. Comorbidities¶

• After 9 to 12 months of ADHD treatment, check for persistence of comorbidities
• Specific drug treatment if necessary (note interactions, e.g. caution with SSRIs)
• If necessary, select specific ADHD medications that also have a positive effect on comorbid disorders

  • Atomoxetine acts noradrenergically and dopaminergically on PFC and striatum, stimulants noradrenergically and dopaminergically on striatum only.
    ⇒ Atomoxetine in ADHD Atomoxetine is reported to be beneficial in severe ADHD-I or SCT.

  • Note problem with serotonin reuptake inhibitors in ADHD-I.
    ⇒ Comments on serotonin reuptake inhibitors (SSRIs) in ADHD

  • In ADHD with bipolar disorder:
    Whether ADHD medications (especially for bipolar 1) can have a mood-destabilizing effect is controversial. In contrast: Barkley²⁹
    It is recommended to treat Bipolar Disorder first and then ADHD (see above).

4.2. Drug Review¶

• After completion of non-drug therapy measures (regularly, e.g. annually), check whether medication is still required
  • Adjustment if necessary
  • Reduction if necessary
  • Termination if necessary
• Regular physical checkup when medication is administered
• Dosage: to attempt to eliminate all ADHD symptoms through medication would be malpractice. Unaffected individuals have 9 of 32 symptoms (of the total symptom list ⇒ Symptom total list according to manifestations) frequently; affected persons have 26 of 32 symptoms frequently. To try to completely eliminate even the “healthy” 9 symptoms would inevitably lead to overdose.

We have witnessed astonishing changes in patients as a result of medicinal and therapeutic measures, and in some cases the quality of life has improved immensely within just one year.
The changes were particularly impressive in those affected who, with patience and consistency, took advantage of every opportunity that presented itself for improvement. For hardly any of the patients, all the perceived forms of therapy proved to be useful. According to our perception, the most successful patients were those who did not expect a certain success from individual measures, but who consistently tried one measure after the other until a satisfactory condition was reached. Once one therapeutic measure was completed, the next one followed, but only as much at a time as was easily manageable.

5. Treatment prioritization for comorbidities¶

5.1. Prioritization according to the severity of the disturbance pattern¶

5.1.1. Comorbidity more severe than ADHD¶

• Primary treatment of comorbidity
• E.g. major depression, bipolar 1,³⁰³¹ addiction, psychosis, severe anxiety
• For depression, anxiety and addiction at the same time under parallel treatment of the mostly causative ADHD.³²
• Specialized treatment may be needed for comorbid anxiety with ADHD.³²

5.1.2. ADHD more severe than comorbidity¶

• Primary treatment of ADHD as a leading disorder.³⁰
• Mild emotional dysregulation, mood swings, mild impulsivity or aggressiveness, mild anxiety disorders, or dysphoria (especially dysphoria with inactivity) are improved with ADHD treatment.³³³¹³⁴

5.1.3. ADHD and comorbidity equally severe¶

When in doubt, we would prefer ADHD treatment.
Treatment for ADHD can significantly reduce symptoms of comorbidities - even eliminating them.³⁵
We also believe that consideration of the side effects of medications, so that the treatment with the fewest side effects is preferred, should usually lead to prioritization of ADHD treatment.

5.2. Treatment guidelines for specific comorbidities¶

5.2.1. ADHD and depression:¶

• Note difference dysphoria / major depression in ADHD
  ⇒ Depression and dysphoria in ADHD
• Always check D3 blood levels and thyroid hormones before antidepressant administration for moderate or mild depression
• Summary of the Texas Children’s Medication Algorithm for ADHD-HI and MDD by Burleson Daviss (2018) Moodiness in ADHD - A Clinicians Guide, p. 99 (modified)^{3738 39}
  • Impairment from ADHD-HI worse than from MDD:
    • Start stimulant monotherapy according to ADHD-HI algorithm.
      • When thereupon:
      • ADHD-HI, but does not address depression:
        Add SSRI for the treatment of depression
      • ADHD-HI and depression remain the same:
        Change to a new stimulant class
        • From MPH to AMP or from AMP to MPH
          • Amphetamine medications, unlike MPH, have concomitant mild antidepressant effects and therefore have an advantage over MPH in comorbid depression…. ⇒ Amphetamine medication in ADHD
        • If MPH and AMP unsuccessful:
          • Change to Guanfacin
        • If guanfacine also unsuccessful:
          • Switch to atomoxetine
      • ADHD-HI and/or depression exacerbation:
        Switch to SSRI⁴⁰⁴¹
  • Impairment from MDD worse than from ADHD-HI⁴⁰ or suicidal ideation/suicidal behavior³⁸:
    • Start SSRI monotherapy⁴⁰
      • When thereupon
        • Depression, but does not address ADHD-HI:
          Add stimulants to treat ADHD-HI
        • Depression stays the same or gets worse:
          Switch to another SSRI
      • When thereupon
        • Depression but does not address ADHD-HI:
          Add stimulant to treat ADHD-HI.
        • Depression stays the same or gets worse:
          Switch to non-SSRI antidepressant, eg.
          • Bupropion³⁰
          • If bupropion unsuccessful:
            Nortriptyline, desipramine, or venlafaxine³⁰

5.2.2. ADHD and addiction¶

• Addiction or alcohol abuse should be stabilized first, but can be treated simultaneously with ADHD.³³ In particular, there is no longer any reason to withhold stimulants as ADHD medications from addicts and to treat them solely with atomoxetine, which is significantly less effective and has considerably more side effects.⁷