We know from patient
reporting that non-stimulant medications for ADHD does not work for everyone.  Until recently, it was thought that responding to the non-stimulant medication, Atomoxetine (Strattera), was a hit-or-miss  proposition.  Anecdotal reports and scientific journals report that Atomoxetine works very well in some patients and not at all in others.  Most of the scientific studies done on Atomoxetine have found that it works about as well as short acting stimulants in most patients but not nearly as well as the long acting or sustained release stimulants.    In fact, there may be some rhyme and reason to when the Atomoxetine will work and when it will not.  As more research studies are completed, a clearer picture has emerged of when Atomoxetine is most helpful.  The findings from these studies report that Atomoxetine is probably not useful in treating patients with ADHD and co-morbid Oppositional Defiance Disorder.

In most families, the treatment of co-morbidities such as ODD is as important as the treatment of the core symptoms of ADHD.  The percentage of individuals with co-morbid Oppositional symptoms in combined type ADHD and Hyperactive/Impulsive ADHD is amazingly high.  One study found that more than 50% of patients with the combined type of ADHD had oppositional symptoms.  That same study reported that greater than 40% of patients with hyperactive/impulsive ADHD exhibited symptoms of ODD.  If you have ever lived or worked with an individual with ODD you will understand how disruptive these symptoms are to a healthy social or family dynamic.  Most adults and families would consider Atomoxetine to be an ADHD treatment failure if the symptoms of ODD were  not improved while taking this medication.  It is estimated that 75% of ADHD is either the combined subtype (hyperactive, Impulsive, and inttentive) or hyperactive/impulsive subtype.  

If we do the math we can see that in 100 patients, about 33 will not be helped by Atomoxetine because of the lack of control of their ODD symptoms.   Atomoxetine is also most helpful when the patient has not already been treated with a stimulant medication, when the patient has had anxiety as a side effect of stimulant medication, when the patient has had a tic disorder side effect on stimulant medication, or in patients who can not or should not take stimulant medication.   Atomoxetine is also helpful when there is a coexisting reading problems.  Atomoxetine improved  visuospacial deficits in children with ADHD and reading difficulties.  Children with ADHD and reading difficulties are thought to have a very specific executive function deficit.  The connection between ADHD and visuospacial deficits are poorly understood and require more study but it is this same connection which is thought to be the reason why visual therapy improves attention in some children with ADHD.

Some other interesting facts about Atomoxetine include:

1. There is a subset of patient who do not respond at all to stimulants but do respond to Atomoxetine.

2. Atomoxetine may be better for morning control of symptoms than stimulants because of their steady duration of action.  The stimulants work only when they are at therapeutic levels which occurs typically 30-60 minutes after taking the medication.  Atomoxetine reaches it's full therapeutic potential in about 6 weeks though some individuals report improvement immediately.

3.  Atomoxetine works better for all types of ADHD at a daily dose of  1.4 mg/kg (0.65 mg per pound) when compared to the dose of .8 mg/kg (0.36 mg per pound) and once daily dosing of Atomoxetine is as effective and as well tolerated with regards to side effects as twice a day dosing.

4.  Side effects which required discontinuation of the medicine occurred in less than 10% of individuals started on Atomoxetine. The most common side effects in children and teenagers were upset stomach, decreased appetite, nausea or vomiting, dizziness, and tiredness.

Atomoxetine works extremely well in a specific subset of individuals with ADHD.  Knowing which groups may respond best to this medication will give patients the necessary information to best address their ADHD symptoms.  Further study into the effectiveness of Atomoxetine will allow us to better understand why this medicine is effective in certain people and totally ineffective in others. Tess Messer