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If you or a loved one take prescription amphetamines like Adderall, don’t panic. This post will unpack these new findings, examine the facts, and offer actionable tips.
A recent study revealed that 81% of adults taking prescription amphetamines at high doses stand a chance of developing psychosis.[1]
Attention deficit and hyperactivity disorder (ADHD) affects about 10% of children in the U.S. between the ages of 4 and 17, and for many, it continues into adulthood. [1][2] A study published in January 2024 reported a noticeable rise in prescriptions for stimulant medications, particularly among young adults. [3]
The link between high doses of ADHD medications and psychosis
A recent study published in The American Journal of Psychiatry showed that people taking high doses of stimulants (more than 30 mg of dextroamphetamine equivalents or 40 milligrams (mg) of Adderall) have a five-fold increased risk of developing psychosis.[4]
The "5-fold increased risk" is a relative measure that pertains to the particular sample/conditions of the study, meaning that it is not a guarantee for everyone.
Researchers reviewed medical records of patients hospitalized at McLean Hospital from 2005 to 2019.
From this sample pool, the researchers identified two groups. One is the target group consisting of 1,374 people hospitalized who presented with first-onset psychosis. The other, the control group, consisted of 2,748 people who were hospitalized for anxiety and depression (other mental health conditions).
Participants receiving any prescription amphetamine had a 63% risk of developing psychosis or mania, the findings showed. That percentage increased to 81% for those taking an amphetamine at what is considered a high dose (30 mg or more). While this suggests a potential link between high dosage and psychosis, further studies are required to confirm a causal relationship.
However, the principal author, Dr. Lauren Moran, still cautions us. She said:
“This is a rare but serious side effect that should be monitored by both patients and their doctors whenever these medications are prescribed.”[4]
A 2019 study also showed a correlation between psychosis and high doses of stimulant medications used to treat ADHD.[5] However, they did not identify, as with the previous study, a specific dose-dependent relationship. Interestingly, both studies indicate that methylphenidate or Ritalin, also a stimulant, does not show an increased risk of psychosis.
Common ADHD medications
ADHD medications can be categorized into two groups:
- Stimulants: [6]
| Common Drugs | Brand names |
|---|---|
| Methylphenidate | Ritalin, Concerta, Daytrana |
| Amphetamines | Adderall, Vyvanse, Dexedrine |
| Dexmethylphenidate | Focalin |
These agents increase dopamine and norepinephrine in the brain, essential for attention and impulse control, which improve focus and reduce hyperactivity and impulsivity in ADHD. [7]
- Non-Stimulants:
| Common Drug | Brand name |
|---|---|
| Atomoxetine | Strattera |
Nonstimulants like atomoxetine are selective norepinephrine reuptake inhibitors. They raise your levels of norepinephrine, a neurotransmitter that plays a crucial role in focus and attention.[8]
| Common Drug | Brand name |
|---|---|
| Guanfacine | Intuniv |
Blood pressure medications like guanfacine are other non-stimulants that are FDA-approved to treat ADHD. [7]
What is psychosis
Psychosis is a collection of symptoms that affect the mind, where the person seems to have lost contact with reality.[9] These symptoms include:
Delusions
Delusions are unshakeable beliefs that feel real, like being sure you’re under surveillance or have superpowers. They can be bizarre or just unlikely, but they are always vivid. There are many types of delusions:
- Persecutory: Believing someone is out to harm you. Someone might think or say that the CIA is on their trail and tracking their cell phone.
- Grandiose: Thinking you have special abilities or a mission. For example, “I’m the son of a Greek god, and I control the weather.”
- Erotomanic: Being convinced someone loves you secretly.
Hallucinations
This usually occurs as auditory hallucinations, also known as paracusia, characterized by hearing voices or sounds that aren't there. Hallucinations can also extend to seeing, feeling, or smelling nonexistent things.
Disorganized thought
Disorganized thoughts manifest as jumbled speech—ideas jump around or become incoherent (word salad). Word salad could sound like: “Purple breastmilk the table, shouting apples, moonfish barking electricity, eating by the seaside, Jump!”
Disorganized behavior
Disorganized behavior disrupts daily life—tasks and activities become confusing, or actions seem out of place. Catatoniacan be a feature where someone is either frozen or intensely restless.
Negative symptoms
Negative symptoms involve losing interest or emotion. They are like someone fading whose once-loved activities no longer bring joy, and self-care becomes difficult.
Using ADHD medications safely
If you’re taking ADHD medication, it’s crucial to follow your doctor’s directions; this will help maximize benefits and reduce side effects. Here are some essential guidelines:
- Learn all you can about the medication you are taking.
- Be patient. Finding the proper medication and dose for you or your child takes trial and error.
- Start with a low dose and adjust gradually (titrate up) to find the lowest effective therapeutic dose.
- Track how the medication makes you feel, i.e., impacts on your mood, behavior, any side effects, and noted symptom relief.
- If stopping, taper off slowly with your doctor’s guidance to avoid withdrawal symptoms.
Here are some valuable tips to ensure a holistic approach to safety:[10][11]
- Use as directed by your doctor.
- If you have any adverse effects, call your doctor.
- Store medications safely and securely.
- Don't exceed the prescribed dosage per day.
- Don't give your prescription to other people. This is known as “diversion.”
- Go to the doctor regularly for your check-up.
- Your medication must be taken daily at the same time.
- Inform your physician of other drugs you are taking.
- Limit caffeine.
Recognizing early warning signs of psychosis
These behaviors listed are warning signs for developing psychosis. We must keep in mind that all people have their oddities, and it can sometimes be difficult to distinguish these signs or behaviors from types of behavior resulting from different mental health or social/personal problems:[12]
- Trouble concentrating
- Trouble thinking clearly
- A decline in self-care and personal hygiene
- Isolating oneself
- Being suspicious or uneasy about others
- Decline in school performance or work performance
- Showing strong or inappropriate emotions or having no emotions
What to do if you suspect psychosis
If you’re experiencing a psychotic episode, it’s natural to feel distressed. However, during such a time, you might not fully recognize what’s happening or feel able to seek help on your own.
That is why friends and family need to know what to do when this happens.
Remember, this can be highly distressing and is often a stigmatized condition. Try to approach this with compassion and with the utmost care.
- Obtain immediate help. If someone is showing symptoms of a psychotic episode, such as hallucinations or delusions, call 911 or go to the nearest emergency room.[13]
- Try not to escalate the situation. Avoid getting into an argument, and try to be understanding, reassuring, and calm.
- Take the person to a quiet, safe environment.[14]
Long-term effects and concern
Stimulants can cause many long-term adverse effects. The long-term adverse effects of stimulants include the following:[15]
- Anxiety and Depression
- Headaches
- Weight loss and malnutrition
- Insomnia- Sleep disturbances
- Psychosis
- Paranoia
- High blood pressure
- Increased heart rate
- Seizures
- Irregular heartbeat
- Adverse cardiovascular events, like heart attack or stroke
- EKG abnormalities
- Coronary artery disease (heart disease)
- Dental issues/decay (especially when misused)
- Dependence on the substance (abuse)
- Cognitive decline
Risk for substance abuse in ADHD stimulant medication
Surprisingly, there is a low risk of abuse among people who have ADHD using stimulant medications under medical supervision.[16] However, in 2022, about 4.3 million people in the U.S. reported abusing prescription stimulants.[17] Stimulant drugs are often abused by people who use them recreationally, especially when using different modes of administration, such as snorting or injecting, which is associated with high levels of acute psychotic episodes.
The reason behind this is manifold, as people who use stimulants recreationally suffer from insomnia, and combined with the high dosage of stimulants, it is sometimes hard to tell which one of the two (the stimulants or insomnia) is the culprit causing the symptoms of psychosis.[18]
Conclusion: Balancing ADHD treatment with risk awareness
When considering stimulant ADHD medication, it's pivotal to take into account potential side effects, like psychosis, the risk of misuse/abuse, and any history of mental illness. Over-prescribing is another concern, as demonstrated here, that high doses of amphetamines have been linked to rare cases of psychosis. If you're taking these medications, know when to consult your doctor.
As Dr. Will Cronenwett, specialist psychiatrist, said:
“I would counsel patients who have a personal or family psychiatric history of serious mental illness, including things like bipolar disorder with mania or schizophrenia … if these sorts of illnesses are in the family tree, then that’s somebody who might want to be very careful about how much of these medicines they use and in what doses.”[19]
However, it's also important to remember that ADHD medications can be incredibly effective at managing symptoms when taken correctly. Working closely with healthcare providers, following prescribed dosages, and regularly discussing any side effects or concerns can ensure that the benefits of these medications are maximized while minimizing risks.
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