The sharp increase in stimulant prescriptions for Attention-Deficit/Hyperactivity Disorder (ADHD) has sparked an ongoing debate about their benefits and risks. A report by IQVIA, a healthcare data analytics company, found that prescriptions for stimulant medications in the U.S. rose by 45.5% between 2012 and 2021, with the steepest rise occurring during the COVID-19 pandemic (IQVIA, 2022). This trend raises important questions: Are we seeing a genuine rise in ADHD diagnoses, or are other factors influencing this surge? And, are there significant risks to stimulant therapies for ADHD?

While improved awareness and diagnosis likely play a role, researchers are increasingly concerned about overdiagnosis. Academic pressures, parental expectations, and even the pursuit of cognitive enhancement may be driving more individuals toward ADHD diagnoses. A CDC study found that nearly 20% of high school boys had received an ADHD diagnosis, leading to concerns about whether all cases truly reflect neurodevelopmental disorders or if external pressures shape these diagnoses (CDC, 2013). A more recent study by Visser et al. (2021) found that many children on Medicaid received ADHD diagnoses from primary care physicians without standardized testing, raising further questions about diagnostic accuracy.

Parental pressure can significantly influence the rise in ADHD diagnoses and stimulant prescriptions. A 2021 study by Jayanti Owens, published in Social Science & Medicine, found that children with parents who actively intervene in their education are more likely to be diagnosed with ADHD. The study suggests that some parents, eager to support their children's academic success, may push for diagnoses and medication even when comprehensive evaluations are lacking. In some cases, physicians may feel pressured to prescribe stimulants based solely on parental reports, rather than objective testing. This dynamic raises concerns about potential overdiagnosis and the unnecessary use of stimulant medications in children, particularly in highly competitive academic environments.

Meanwhile, emerging research highlights the potential risks of high-dose stimulant use, particularly in adults. A study from McLean Hospital found a significant link between high doses of amphetamine-based medications like Adderall and increased risk of psychosis and mania in individuals aged 16–35. These findings add weight to the argument that prescribing stimulants requires careful risk-benefit analysis, especially at higher doses.

The McLean study, published in the American Journal of Psychiatry, analyzed data from over 1,300 individuals admitted to the hospital for a first episode of psychosis or mania, comparing them to a control group of over 2,700 patients hospitalized for other psychiatric conditions. The results were striking: individuals taking high doses of amphetamines (40 mg or more of Adderall) faced a more than fivefold increased risk of developing psychosis or mania. This dose-dependent relationship suggests that as stimulant intake rises, so does the risk of severe psychiatric effects. Importantly, the study focused on adults aged 16–35, the age range most vulnerable to first-episode psychosis and schizophrenia, leaving open questions about how these medications affect younger children.

Dr. Lauren Moran, the study’s lead author, was motivated by her clinical experiences. She and her colleagues repeatedly encountered patients experiencing their first psychotic episode, many of whom had histories of high-dose stimulant use. This observation prompted a more systematic investigation. The research team examined electronic health records from Mass General Brigham patient encounters between 2005 and 2019, controlling for other variables such as substance use. Their analysis revealed that among individuals taking prescription amphetamines, an estimated 81% of psychosis or mania cases might have been prevented had they not been on high doses.

Interestingly, the study found no significant increase in psychosis risk with methylphenidate (Ritalin) use. This distinction reinforces the idea that different stimulant medications carry different risk profiles, an important consideration for clinicians when selecting treatments. The researchers also proposed a biological mechanism to explain their findings: high doses of amphetamines can trigger a surge in dopamine, a pattern similar to the neurochemical changes seen in psychosis.

These findings should be interpreted with nuance. The study was conducted at a psychiatric hospital in the Boston area, which may limit its generalizability. Electronic health records, while valuable, also vary in completeness. However, the strength of the association between high-dose amphetamine use and psychosis, combined with a plausible biological explanation, warrants serious attention. While the study focused on adults, its implications for children remain uncertain. The developing brain may respond differently to stimulants, and appropriate doses for children are generally lower than those studied in this research. Further investigation is necessary to determine long-term effects in younger populations.

These findings do not suggest that stimulant medications should be avoided entirely. For many individuals with ADHD, they are highly effective in managing symptoms and improving quality of life. However, they reinforce the need for cautious prescribing, particularly when it comes to dosage. Dr. Moran emphasizes that there is little evidence supporting the notion that higher doses provide greater benefits, raising the question of whether the potential advantages outweigh the increased risks. This concern is particularly relevant for individuals predisposed to psychosis or mania, as well as for younger patients whose brains are still developing.

The study serves as a reminder that even beneficial medications carry risks. Clinicians and patients must work together to weigh these risks carefully, explore alternative treatment options when appropriate, and maintain ongoing monitoring. This is especially crucial for individuals with a personal or family history of bipolar disorder, schizophrenia, or schizoaffective disorder. If someone taking high-dose Adderall experiences personality changes, they should seek medical guidance immediately. The same applies to children on stimulants—parents should consult a pediatrician if concerning symptoms emerge.

The conversation around ADHD treatment continues to evolve, shaped by emerging research and a commitment to patient safety. Striking a balance between recognizing the challenges of ADHD and addressing the potential risks of medication—especially at higher doses—is critical. This new research offers a valuable perspective, helping clinicians, patients, and families make more informed decisions. The surge in prescriptions during the pandemic underscores the importance of reassessing how ADHD is diagnosed and treated, ensuring that those who truly need medication receive it while minimizing unnecessary exposure to potential risks.

References

IQVIA. (2022). *The Use of Medicines in the U.S. 2022.*
Centers for Disease Control and Prevention (CDC). (2013). *Mental health surveillance among children—United States, 2005–2011.* MMWR, 62(Suppl 2), 1-35.