Mythbusting the ADHD Meds and Psychosis Claims

A recent and much-ballyhooed study revealed that teens and young adults who took Adderall or other amphetamines for their attention deficit hyperactivity disorder (ADHD) had a higher risk of developing psychosis than those who received methyphenidates stimulants, including Ritalin.

This news alarmed parents, as these are first-line medications for ADHD.

“This is not something parents should worry about,” says Dr. Eugene R. Hershorin, director of developmental and behavioral pediatrics with the University of Miami Health System, who says that out of thousands of ADHD patients, he has “seen this happen maybe three times.”

What’s more, when the psychotic symptoms do show up — usually sensory hallucinations such as the feelings of bugs crawling on the skin — the solution is simple:  stop the meds, which then gets rid of the hallucinations and other sensations.  “If we see it on Adderall, we wait a day or two and try Ritalin,” he says. “Is it possible to experience it with both? Yes, but I’ve never seen it.”

It is estimated that about 10 percent of U.S. children are diagnosed with ADHD, a developmental disorder whose symptoms include inattention, hyperactivity, and restlessness or impulsivity. Recommended drug treatment, if needed, calls for either methylphenidate or amphetamine, but medication is just one line of intervention. Once a child is diagnosed, pediatricians may also recommend behavioral intervention and changes to home routine as well as adjustments within the classroom.

The study, published in the New England Journal of Medicine, followed 221,486 teens and young adults ages 13 to 25 with ADHD. All had been prescribed a stimulant, half of them amphetamines and half methylphenidates. One out of every 660 had a psychotic episode. Of those, the amphetamine group was twice as likely as those on methylphenidate to suffer an episode.

“It’s interesting but not surprising,” Dr. Hershorin says. “We’ve been aware of this for some time.”

In fact, since 2007 manufacturers have added a warning to drug labels, explaining that stimulants could cause “treatment-emergent psychotic or manic symptoms in patients with no prior history.”

One study comparing the two drugs is not enough information to decide a course of action for a patient, says Dr. Hershorin, particularly because this study was based on national databases of insurance claims and not conducted through randomized, controlled clinical trials, which is the gold standard of science research. What’s more, it did not look at family history of psychosis.

“It’s not enough information to favor one drug over another,” he says.

“The risk is still very low on both.”

While about one-third of patients respond well to both, Dr. Hershorin examines several factors before deciding which one to prescribe, if medication is needed at all. If an older sibling with ADHD is responding well to one kind of drug, it is likely he would recommend the same one. He also considers the child’s own metabolism. Amphetamines suppress appetite and may do double duty by helping overweight or obese children lose weight.

Both drugs have been on the market for decades, methyphenidates since 1945, amphetamines since 1950. Both also raise the levels of the neurotransmitter dopamine, which is an essential factor in numerous brain functions, but they do this in different ways. Methylphenidate blocks dopamine from being removed from the brain. Amphetamines block dopamine from being removed and increase its production.

The study also found that prescription for stimulants to treat ADHD have gone up over the period examined by researchers. Teens and young adults were four times more like to receive a prescription for amphetamines (Adderall) in 2015 than they were in 2004. They were 1.6 times more likely to receive one for methylphenidates (Ritalin). But, as Dr. Hershorin points out, both drugs have been shown to be effective in controlling what can be the debilitating effects of ADHD.

In the end, the study’s results are perhaps best used to raise awareness of the risks and rewards of any medication.  “I think parents should always be informed,” he adds.  “It’s a good way to start a conversation.”

Tags: ADHD, adolescent psychiatry, amphetamines, Dr. Eugene R. Hershorin, methylphenidate