Samuel R. Weber, MD Physician Lead, Logan Psychiatry Intermountain Health Budge Clinic Logan, Utah
Anne-Marie Duchemin, MD Professor Adjunct Department of Psychiatry and Behavioral Health The Ohio State University College of Medicine Columbus, Ohio
Disclosures The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
With or without an accurate ADHD diagnosis, prescribing stimulants presents certain risks (Table 223-40). One of the more well-known risks of stimulants is addiction or misuse.23 An estimated 5 million American adults misused prescription stimulants in 2016.24 Despite stimulants’ status as controlled substances, long-term concurrent use of stimulants with opioids is common among adults with ADHD.25 College students are particularly susceptible to misusing or diverting stimulants, often to improve their academic performance.26 At 1 university, 22% of students had misused stimulants in the past year.27 Prescribing short-acting stimulants (rather than extended-release formulations) increases the likelihood of misuse.28 Patients prescribed stimulants begin to receive requests to divert their medications to others as early as elementary school, and by college more than one-third of those taking stimulants have been asked to give, sell, or trade their medications.29 Diversion of stimulants by students with ADHD is prevalent, with 62% of patients engaging in diversion during their lifetime.15 Diverted stimulants can come from family members, black market sources, or deceived clinicians.30 Although students’ stimulant misuse/diversion often is academically motivated, nonmedical use of psychostimulants does not appear to have a statistically significant effect on improving grade point average.31 Despite a negligible impact on grades, most students who take stimulants identify their effect as strongly positive, producing a situation in which misusers of stimulants have little motivation to stop.32 While some patients might ask for a stimulant prescription with the rationale that liking the effects proves they have ADHD, this is inappropriate because most individuals like the effects of stimulant medications.33
The use of stimulants increases the risk for several adverse psychiatric outcomes. Stimulants increase the risk of anxiety, so exercise caution when prescribing to patients with a comorbid anxiety disorder.34 Stimulants can also worsen irritability and insomnia, 2 issues common among patients with ADHD.32 Use of stimulant medications can trigger manic episodes. Viktorin et al35 found a >6-fold increase in manic episodes among patients with BD receiving methylphenidate monotherapy compared to those receiving a combination of methylphenidate and a mood stabilizer.35 The use of methylphenidate and amphetamine can lead to new-onset psychosis (or exacerbation of pre-existing psychotic illness); amphetamine use is associated with a higher risk of psychosis than methylphenidate.36
General medical adverse effects are also possible with stimulant use. Stimulants’ adverse effect profiles include appetite suppression, dry mouth, and nausea. Long-term use poses a risk for stunting growth in children.1 Using stimulants during pregnancy is associated with higher risk for neonatal morbidity, including preterm birth, CNS-related disorders, and seizures.37 Stimulants can raise blood pressure and increase heart rate. Serious cardiovascular events associated with stimulant use include ventricular arrhythmias, strokes, and transient ischemic attacks.38
Nonstimulant ADHD treatments are less risky than stimulants but still require monitoring for common adverse effects. Atomoxetine has been associated with sedation, growth retardation (in children), and in severe cases, liver injury or suicidal ideation.39 Bupropion (commonly used off-label for ADHD) can lower the seizure threshold and cause irritability, anorexia, and insomnia.39 Viloxazine, a newer agent, can cause hypertension, increased heart rate, nausea, drowsiness, headache, and insomnia.40
Sensible diagnosing
Given the challenges in accurately diagnosing ADHD in adults, we present a sensible approach to making the diagnosis (Table 3). The first step is to rule out other conditions that might better explain the patient’s symptoms. A thorough clinical interview (including a psychiatric review of symptoms) is the cornerstone of an initial diagnostic assessment. The use of validated screening questionnaires such as the Patient Health Questionnaire-9 and General Anxiety Disorder-7 may also provide information regarding psychiatric conditions that require additional evaluation.
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