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We prescribe ADHD medications to help with focus and impulsivity, but what happens when someone stays on them for years? Today, we're digging into new research that links long-term ADHD medication use to higher cardiovascular risk. It's not a reason to panic, but it is a reason to look twice at the dosages, duration, and how we follow up.
Publication Date: 10/26/2026
Duration: 19 minutes, 25 seconds
Transcript:
MARA GOVERMAN: We prescribe ADHD medications to help with focus and impulsivity, but what happens when someone stays on them for years? Today, we're digging into new research that links long-term ADHD medication use to higher cardiovascular risk. It's not a reason to panic, but it is a reason to look twice at the dosages, duration, and how we follow up.
JOSH FEDER: Welcome to the Carlat Psychiatry Podcast. I'm your host, Dr. Josh Feder, the editor-in-chief of the Carlat Child Psychiatry Report and co-author ofthe Child Medication Fact Book for Psychiatric Practice, Second Edition (2023).
MARA GOVERMAN: And I'm Mara Goverman, a licensed clinical social worker in Southern California with a private practice and an avid reader of the Carlat Psychiatry Reports. Today, we look at a Swedish study that examines cardiovascular risk in people who take ADHD medications, both stimulants and non-stimulants, over time. The study researchers tracked over 278,000 individuals with ADHD or ADHD medication use across 13 years using a nested case-control design. They focused on cardiovascular outcomes such as hypertension, arterial disease, arrhythmias, strokes, and heart attacks.
JOSH FEDER: They compared over 10,000 people who developed cardiovascular disease with matched controls who didn't, adjusting for a whole range of things: psychiatric comorbidities, diabetes, obesity, even socioeconomic factors.
MARA GOVERMAN: And the findings? Each year of ADHD medication use bumped up cardiovascular risk by 4%. That risk seemed to level off after three years, but it adds up. By year five, stimulant users had a 25% increase in risk compared to those not on ADHD medications.
JOSH FEDER: That's particularly true for hypertension. They found an adjusted odds ratio of 1.72 for those on medications three to five years and 1.80 after five years. So, hypertension is really the standout here.
MARA GOVERMAN: The researchers also noticed dose-related risk. People on higher doses, over 1.5 times the defined daily dose, like more than 45 milligrams of methylphenidate, had greater cardiovascular risk. That was true across age and gender.
JOSH FEDER: And it was really interesting: non-stimulants like atomoxetine and guanfacine had a lower risk profile, especially early on, but the signals are still there. It's just not about stimulants.
MARA GOVERMAN: Okay, let's talk about what this means clinically because we're not looking at a massive spike in risk, but it's enough to make you pause and think, especially if someone's already got cardiovascular concerns.
JOSH FEDER: We also have to think about the flip side, right? ADHD itself increases risk for diabetes, obesity, and cardiovascular problems over time. That's not theoretical; it's well documented. And so, in my patients, I have so many adult patients in particular, but also the little ones too, who have slightly elevated blood pressure, and I worry about it. I feel I'm a little bit more careful about it than a lot of the primary care doctors who I talk with about these things. So, for instance, I feel more comfortable when people, when adults and teens are at 130 over 70 or below, which is decent blood pressure, as long as they're not fainting, something like that. Here in Southern California, it's a problem with hydration in hot weather a lot of the time. But that aside, right, and for old people, you have to make sure they're hydrated, and maybe they need a little bit higher blood pressure just so they don't end up falling down or even having a watershed stroke. And what you don't want, for instance, is people walking around with, say, in the 190s for systolic blood pressure, and then the high 80s or 90s for diastolic blood pressure, because the problems over time can add up, right? It ends up giving you microvascular damage over time and hurting end organs like kidneys and your heart and your brain. I'm really very careful about it because of that. I don't see my primary care colleagues getting quite as excited. So, I have a rather low threshold for mixing in, for instance, guanfacine with a stimulant because it tends to lower blood pressure; guanfacine was originally a blood pressure medication. It's well-tolerated and can help a little bit with the ADHD symptoms. It's FDA-approved for ADHD, but it's not all that strong; if you're going to have blood pressure problems with your stimulants and the stimulants are working really well, adding some guanfacine in can make it a decent mix. Or perhaps bupropion as an ADHD medication, perhaps off-label, to mix with the stimulant, so maybe you can have a lower stimulant dose in that case, and maybe do a little bit better in terms of blood pressure. But I really do pay attention to this. And with the kids, in our Child Medication Fact Book for Psychiatric Practice, we have different blood pressure percentile bands for kids at different ages and sizes. So, you can see for what age and how big they are in terms of height, weight, that sort of thing, what the like 95% limit is for blood pressure in particular so that you can kind of know whether a child already has kind of high blood pressure for their age and size. And if you're adding stimulants, a lot of times you look at their blood pressure; maybe it's not that much higher, but maybe it's already into kind of a range that you, you really don't want to see at that age. So those are some of the things that I think about when I'm prescribing stimulants and thinking specifically about hypertension.
MARA GOVERMAN: So my take-home message from what you just said is to have a thorough intake, including some family history, and take the time to talk with the primary care physician, so that you don't miss anything.
JOSH FEDER: That's part of it, and the other part is to track vital signs. So, I have a black bag. I check vital signs. I've been doing it my whole career. I never stopped after medical school when I started doing more psychiatry. I know a lot of our colleagues rely on other people to do the physical exams and the vital signs, but somebody needs to be doing it, and you hope that whoever's doing it uses good technique, right? So, feet flat on the floor, sitting up, and your arm supported so that it's pretty much at the level of your heart. And I always do the same arm. Usually, it's the right arm, supported, sitting, so that if somebody asks me later on, "Doctor, how did you do that blood pressure?" I can say, "Well, this is how I do it. I do it that way every time, unless I can't, in which case I write it down.” Sometimes we do sitting and standing if we're worried about some kind of hypotension, or even lying down if we're worried about postural orthostatic tachycardia syndrome. But having said all that, make sure that blood pressure and pulse are things that you're tracking, and if you're not doing it yourself, that you have a reliable way of somebody doing that on a reasonably regular basis, which for most growing kids is minimally quarterly, and for adults, for me, it's minimally every six months or so; that's usually the rate at which I follow those things, and if there's a problem, more often.
MARA GOVERMAN: So, do you recommend to families to buy blood pressure and oximeter meters, for them to, to track?
JOSH FEDER: Well, yeah, I do particularly adults or teens, if they'll do it, you can get an AHA, American Heart Association, [validated] device at a lot of pharmacies. And they don't cost too much. I mean, they're usually, maybe $50 to $70, and they're good for a couple years before they might fall out of standard. So, after a couple years, maybe it's worth getting it somehow checked or just replace it; and a lot of those are the ones that self-inflate, and you sit there, and you do it. A lot of times the recommendation is to do it three times and take the average. And a lot of times what you'll find if you do this yourself is you'll have a higher pressure when you're just sitting down, and you're busy, and then the next couple of them are a lot lower because you're sort of more relaxed. But it's really important to think about if you're walking around with blood pressure that tends to be a little bit higher. How much of that is because you need it for the activity that you're doing, if it's a physical activity? How much of it has to do with a reactivity of your blood pressure to stresses in the moment? Which means, or which may mean, that you are at some higher cardiovascular risk over time, even if when you sit down, you can settle down, you can lower it; that's good. But it's not great that when you're in your daily life, your pressure is running high. Let me just add that I'm not a cardiologist and don't pretend to be one; these are my clinical thoughts as a psychiatrist working in collaboration with primary care doctors and with cardiologists. So that's another thing. I get EKGs on anyone 18 and older, even if they have a clean cardiac history. If they don't have a clean cardiac history, I'm definitely getting a cardiology consultation and an EKG on a kid or an adult. But if there's no history, I start getting EKGs at 18 and try to get them periodically every five years or so, because your heart starts changing once you become adult-ish and then an adult, and you don't want to miss something and then be using maybe a medication that theoretically might be problematic. Canada, a number of years ago, wanted to take Adderall off the market because they worried about higher rates of sudden death in kids who were taking dextroamphetamine salts. And over the years, that hasn't really been borne out, so I'm not terribly worried about it. But that's why this article is so interesting, because it starts to give us an update on some of these issues. In terms of those cardiovascular problems of not having taken care of yourself, to me, that looms greater in my mind than the ones that are related to using stimulants, as long as you've got good follow-up and you're treating hypertension if it comes up.
MARA GOVERMAN: You may see that play out in practice with patients who go years untreated, struggle with weight, metabolic issues, or risky behaviors. So, pulling back on medications completely isn't the answer either.
JOSH FEDER: But it does mean, as I said, we pay attention to cardiovascular monitoring, regular blood pressure checks, lifestyle counseling. And we've already talked a little bit about blood pressure, but lifestyle counseling- how do you get that to work? There are so many efforts, like I hear from insurance companies who have programs. They'll call you, can be in touch; that is one of the bigger challenges in clinical life is helping support people to make lifestyle changes like exercise and-
MARA GOVERMAN: Meditation.
JOSH FEDER: And better eating.
MARA GOVERMAN: And sleeping.
JOSH FEDER: If you can just get people to walk around the outside part of the inside of their grocery store so they, they can get fruits and vegetables and proteins that your grandmother would recognize as food, rather than the inside aisles of the grocery store that have ultra-processed food, that would be a good start.
MARA GOVERMAN: And consider avoiding doses beyond what's needed, especially if someone's doing okay at a moderate dose. You may find that non-pharmacologic support helps reduce the need to escalate doses over time.
JOSH FEDER: We see this all the time. Well, two things, right? One is that when you've got kids with ADHD, you don't want to use more than you need because if you slow them down so that they're not causing trouble at all, they're probably not learning very well. We know this, right? So, you need to keep a little bit of spunk in the kid if they're spunky. Taking the edge off, I get it, right? Keep them safer. But you don't, you don't want to turn a kid into somebody who's not really connecting, relating, communicating, and learning from all that relating and communicating. So that's one thing. The other thing is so much depends on responsive caregiving. So, if you've got a teacher who can't tolerate a child who's a little bit active and says, in a very rigid way, "You've got to have your hands where I can see them and not be fidgeting," da, da, da, da, da, da, da, da, you're probably going to run into more trouble. On the other hand, if you have a teacher who says, "Yeah, you can just sort of do whatever you want," well, sometimes they'll be distracted, they'll be doing whatever they want. So, you have to figure out what's the balance there, if you're a teacher or parent or any other caregiver, of being able to tolerate some of the shenanigans that these kids do, but at the same time be somewhat structured. In fact, I had a case recently where the person did really well in a reasonably structured classroom, but they did have tremendous difficulty outside of the structure of the classroom with peers, which is another reason why medication can be helpful; it can help you with some of the impulsivity with peer interactions. So, a lot to think about.
MARA GOVERMAN: Right. So, you're adding on to that. You're talking about paying attention to sensory integration issues and also supporting with strategies to help the person stay calm and regulated enough to stay in the environment, learn how to calm their bodies, and to attend.
JOSH FEDER: Yeah, and there's often a role for our colleagues who are speech pathologists, OTs helping people to learn to communicate better, and occupational therapists who work on sensory kinds of needs and guide us with some of these kids so that we can do better with them. So, if I'm running with a kid in my courtyard, sometimes I get a lot more thinking and feeling ideas and all those things out of them than if they're trying to sit in front of me and look at me. Could be a real problem. But I think the summary message here is you need to check in. Does the patient still need the medication at the current dose? Once you've been rolling at a certain dose, maybe you can be scrolling back on it a little bit and figure out other ways to support function through structure or therapy, and checking in on those issues is pretty easy to skip when things are going fine. And so, you just don't want to be complacent. So, in all our algorithms for our Child Medication Factbook (2023), for instance, we have the beginning, which is partly non-pharmacological, right? It's rare that we say start with medication. And the end, which says, "Do you still need to be on this medicine, or do you still need to be at this dose?" So, if we all think clinically in those terms, we're going to use medications in a more focused and useful way without overusing them.
MARA GOVERMAN: So, you're talking about adding to the well-being of the patient, the family, and school, and how long do you want to keep them on that, and you have to check in with all of those people.
JOSH FEDER: You do. And busy clinicians, it's not so easy. But I keep a mnemonic in my head. I keep the HEADSS mnemonic. Home, education or work, activities and friends, drugs and substances, and sex and intimate relationships and stuff like that.
MARA GOVERMAN: You may want to think about sleep too. If sleep is off, focus is off, and that's often what gets interpreted as ADHD worsening when it's really poor sleep hygiene.
JOSH FEDER: I am so glad you brought that up, Mara. If there's one thing, we've talked about the epidemic of poor sleep in Americans and especially in kids. Staying up late, doing all kinds of things with electronics, stuff like that, and they look worse the next day. They're more agitated. They don't focus well.
MARA GOVERMAN: But sleep hygiene, the recipes are very difficult to be consistent with.
JOSH FEDER: Right. And so just giving people a list, and we've talked about this before, it doesn't work. But cognitive behavioral therapy for insomnia breaks down those elements of good sleep hygiene. Getting up at the same time every day, not lying awake in bed, not having chocolate or caffeine late in the day.
MARA GOVERMAN: When you watch television, what you're watching, the phone, the blue screens.
JOSH FEDER: Right.
MARA GOVERMAN: All of that.
JOSH FEDER: So, all that is really important, but you have to break it down and spend time on it. We can do that as clinicians if we get good at it. We can get colleagues to help us with it, but it's kind of got to get done, and then you won't necessarily need as much or maybe any medication. So, yeah, cheers to you for bringing that up, and getting back to our topic, which was cardiovascular disease and ADHD, we can't say these medications cause cardiovascular disease. ADHD itself is tangled up with all those risk factors like we talked about: obesity, inactivity, lower health literacy.
MARA GOVERMAN: But the association is there, and it's a reminder to keep the big picture in mind. Treat ADHD, yes, but also monitor the body that lives with it. Well, that's all for today. Thanks for joining us for this discussion. It's inspired by Dr. Feder’s article in our April/May/June 2025 newsletter. Check it out for more insights on today's topic.
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JOSH FEDER: I hope this conversation helps our listeners make informed choices. If you found this discussion helpful, subscribe for more episodes on mental health and psychiatric care, and please share it with others who may need to hear this message. And remember, when we look for good things, more good can follow.
The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 CreditsTM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.
