SSRI Type Antidepressants for ADHD?

Question:  I am searching for help with an issue my adult son with a history of ADHD has run into.  As an adult, his physician put him on Paxil for his ADHD as other medications for ADHD were not as effective.  My son is functioning very well, has never been depressed, suicidal or any other issues associated with taking Paxil.  Seven months ago, my son had a flight physical by a certified FAA medical examiner, told the physician he was taking Paxil and the physician passed him, thus allowing my son to proceed with obtaining his private pilot’s license.  Now, seven months later, after he has completed all requirements, and has been flying the FAA sent him a letter stating they would not allow his medical exam due to him taking Paxil. 

My question is: Is Paxil used to treat adult ADHD?  What other drug could be used?  We have always been told that he does not produce enough dopamine therefore resulting in a chemical imbalance.  With the Paxil he is able to maintain focus and carry on a very normal, busy, independent life of a 32 year old single male.  Any information or help you may offer us would be greatly appreciated as we are going to try to fight this issue.  Personally I feel it is discrimination against ADHD. – S.B.

Answer:  Consensus of experts in the area of ADHD is that there are imbalances in the dopamine and norepinephrine brain systems, primarily due to genetics.  There are many sources of evidence to support this view.  There is disagreement as to whether the problem is primarily in the dopamine system or whether it’s primarily in the norepinephrine system or equally both.  It will probably turn out to be mainly dopamine in some people who are ADHD and norepinephrine in others and both in still others.   The problem is compounded by many factors, one of which is that dopamine and norepinephrine impact each other and may be high in some areas of the brain and low in others. 

There is currently no scientific evidence that serotonin modulators such as Paxil help ADHD.  Paxil has a very weak modulating effect on norepinephrine, but this is not believed to be clinically relevant (unless one takes very high doses).  Most SSRI’s, including Paxil, will actually lower dopamine levels.  Norepinephrine modulating antidepressants, tricyclics (desipramine, imipramine), Strattera (actually approved for ADHD but not depression, higher doses of Effexor (150 mg and above), Wellbutrin, and theoretically Cymbalta can help ADHD – though on average 1/2 as effective as stimulants. 

Your son benefits from Paxil.  What does this mean?  My guess is that your son is not ADHD, or at least that’s not what Paxil is helping.  Many other things can cause some of the symptoms of ADHD.  Sustained concentration requires ignoring distractions, either in the environment or from the mind (“What if …?”).  Anxiety means “danger” and danger means monitoring the environment more closely and thinking about all the relevant “What ifs.” 

Clinical depression involves deficiencies in one or more brain transmitter systems that frequently interferes with focus.  Also, calm, sustained focus activates more left brain functions, but stress, anxiety and depression activate the right brain more.  I recommend a complete reevaluation before any other steps are taken.  Dealing with the FAA reminds me of my days as an Air Force psychiatrist.  You can’t let logic or fairness cloud your thinking.  It’s all about the regulations.  How to deal with them would need to come after the evaluation.

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