Risk of Psychosis with Stimulant Use for ADHD

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New research suggests that there may be a small risk of new onset psychosis among teens and young adults with ADHD who are treated with stimulant medications. Using data from 2 insurance claims databases, researchers reviewed patients who were 13-25 years old with an ADHD diagnosis and taking prescription methylphenidate (n=110,923) or an amphetamine (n= 110,923). They identified those who also had a diagnosis for a psychotic episode with a prescription for an antipsychotic medication.

New-onset psychosis occurred in roughly 1 in 660 of the ADHD patients receiving prescription stimulants. The psychotic episodes included hallucinations, delusional disorder, and hearing voices. The risk differed among stimulants; 1 of every 486 amphetamine (eg, Adderall®, Vyvanse®) users developed psychosis, compared with 1 in 1,046 patients taking methylphenidate (eg, Ritalin®, Concerta®). Higher risks were linked with extended-release formulations and lisdexamfetamine.

Since the risk is low for patients who have been taking stimulants for a long time (and doing well on them), changing treatment is not advised. More importantly, patients with ADHD who are starting stimulants should be screened for a prior history or family history of bipolar or other psychiatric disorder, and possibly the use of cannabis. It may be best to avoid amphetamines in these patients.

• Moran L, et al. N Engl J Med. 2019;380:1128-38.

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