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Home » Risk of Psychosis With Stimulants in ADHD Patients

Risk of Psychosis With Stimulants in ADHD Patients

June 11, 2019
Pavan Madan, MD
From The Carlat Child Psychiatry Report
Issue Links: Learning Objectives | Editorial Information | PDF of Issue
Pavan Madan, MD Dr. Madan has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Review of: Moran LV et al, N Engl J Med 2019;380(12):1128–1138

In 2007, the FDA required stimulant manufacturers to warn of possible psychosis with stimulants. But what is the real incidence? This study set out to find and discern if there is a difference between methylphenidate and amphetamine classes of medications.

Drawing from two large commercial insurance databases, researchers looked at over 333,000 patients with ADHD ages 13–25 years who were prescribed a stimulant between 2004 and 2015, matching 110,923 methylphenidate users with an equal number of amphetamine users. The authors excluded patients with confounding variables (eg, glucocorticoid prescription) and adjusted for unmeasured confounders (eg, cannabis use). They defined “stimulant-induced psychosis” as a new psychotic illness within the follow-up period (median 4–5 months) along with a prescription for an antipsychotic within 60 days of that diagnosis.

Over the years 2005 to 2014, prescription of amphetamine salts increased 3.8 times, while that of methylphenidates increased only 1.6 times. It was notable that internists and family practice doctors tended to use amphetamines most often, prescribing amphetamines in 72.5% of stimulant prescriptions, with psychiatrists at 62.7% and pediatricians 51.6%.

The overall risk of psychosis was 1 in 660, with onset of psychotic symptoms occurring after a median 128 days. The risk in the amphetamine group was double compared to the methylphenidate group (237 episodes or 0.21% vs 106 episodes or 0.10%).

Amphetamine-related psychosis occurred more in younger children and those treated by ­non-psychiatrists (about 80% of patients). In the hands of internists and family practice doctors, the hazard ratio was 1.78, for pediatricians it was 1.7, and for psychiatrists it was 1.38.

CCPR’s TAKE
Amphetamines, such as Adderall, are more likely to lead to psychosis than methylphenidate, though the actual prevalence is quite low. We recommend extra caution in the use of stimulants (especially amphetamines) in those with other risk factors for psychosis (eg, family history of psychosis, cognitive or behavioral signs of prodromal psychosis, or concurrent cannabis use). In the broader picture, methylphenidate is usually better tolerated in any case and probably a ­better first-line medication.
Child Psychiatry
KEYWORDS adhd adolescents amphetamine child_psychiatry children free_articles medication methylphenidate pediatric psychosis research-update stimulant teens
Pavan Madan, MD

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Issue Date: June 11, 2019
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Table Of Contents
Note From the Editor-in-Chief
Medications for Depression
Practical Approaches to Vetting Clinical Research
FDA Approves Adhansia XR
First Non-Drug Treatment Approved by FDA for Treating Children With ADHD
Prescribing Patterns for Children With Anxiety Disorders
Melatonin for Insomnia in Patients With Autism
Steroid-Induced Psychosis in the ­Pediatric Population
Risk of Psychosis With Stimulants in ADHD Patients
Transcranial Magnetic Stimulation (TMS) for Depression in Children and Adolescents
CME Post-Test - Depression in Children and Adolescents, CCPR, Summer 2019
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