Dr. Kristen Stuppy is a pediatrician who is passionate about sharing information to help others make informed decisions. She has a special interest in ADHD and has served on the board for ADHDKC.org since it began in 2012.
Finding the best medication for ADHD management includes finding one that is affordable. Is a generic version the answer?
If you’ve had problems finding a medication for ADHD that you can afford, you’re not alone. In years past generic medications were equivalent to the name brand and were always a lot cheaper.
In recent years many new versions of methylphenidate (ritalin) and amphetamines (adderall) have come on the market and generic versions of many of the older medicines have become available.
The FDA has rules that generic medications must have the same amount of active ingredient and be available in the same forms (pill vs liquid) as the original medication. They can often be sold at a much lower cost because the company does not need to spend money researching and developing the medicine. They also offer competition to the original company, which can bring costs down.
Types of Medications for ADHD
A very useful resource that has ADHD medications grouped by type, dosages offered, if they have generic versions available, if they can be put into food or drink, and more is available from the Cohen Children’s Medical Center. This fantastic list of medications can help you and your doctor look at your insurance medication list to pick a medication that is affordable.
Most often the short acting medications are less expensive than the long acting medications. The short acting medications typically last 3-4 hours, whereas the long acting medications last 6-12 hours. Because it is difficult to take medications mid-day for many people, the long acting medications are typically favored.
In general there are stimulants (amphetamines and methylphenidates) and non stimulants (atomoxetine, guanfacine, and clonidine) that are approved to treat ADHD.
Stimulants are controlled substances because they have the potential to be abused and misused. When they are used appropriately for ADHD they have been shown to help prevent drug and alcohol abuse but they require close monitoring by the prescriber.
Which treatment should be first?
This article is about medical treatments, but that does not mean that behavioral therapy isn’t helpful. For preschool aged children, parent training in behavior management is the first treatment preferred. Parent training in behavior management is recommended for at least a part of the treatment regimen for children of all ages with ADHD.
The American Academy of Pediatrics ADHD Guidelines recommend stimulants as first line medical treatment in most instances. One is not preferred over the other. Individuals may respond better to one type of medication over another, but until the medications are tried, it can be difficult to know which will work best.
Family history can help. If a parent or sibling does best on one type of medication, it makes sense to try that medication first.
Pharmacogenetic testing is specifically not recommended in the most recent guidelines. Most insurance companies will not pay for this expensive testing because it has not been shown to be beneficial.
It is important to have close follow up with your prescriber with new medications and routine follow up as long as medications are used. These visits should assess how well they’re working as well as any side effects noted. It can take several medication trials before the right one is found.
I’m a pediatrician who treats many with ADHD, but when my own child was starting treatment it took a few tries before we found the right one. I talk about this and more in A Conversation About ADHD.
Side effects are similar with both types of stimulants, but some people tolerate one medication better than another.
Common side effects include appetite suppression, sleep problems, headaches, stomach aches, and mood changes.
Most of the time either a dose adjustment or change in medication can help alleviate the side effects.
Encouraging eating at times the medication is not active can help with the daytime appetite decrease.
Common long acting amphetamines include Adderall XR, Vyvanse, and Dexedrine spansules. There are others, such as Adzenys XR and Dyanavel, that do not have generic versions available.
Adderall XR is a long acting medication composed of dextroamphetamine saccharate, amphetamine aspartate, dextroamphetamine sulfate, and amphetamine sulfate. This is often referred to as mixed amphetamine salts. It lasts about 8-10 hours.
Vyvanse is a prodrug that lasts 10-12 hours. Prodrug means that it is chemically inert until it interacts with an acid in the gastrointestinal tract. It does not have any mood altering effects if it is crushed, injected or snorted, so it does not have the resale value of other stimulants. This is a potential reason that some insurance companies prefer this over more expensive medications.
Dexedrine spansules are made up of dextroamphetamine sulfate. They are less commonly used compared to Adderall XR, but they are available as a generic and name brand. The long acting form lasts about 8 hours.
There are several long acting methylphenidate medicines that have generic versions. These include Concerta, Metadate ER, Focalin XR, Ritalin LA and Metadate CD. (There are others that do not yet have generic versions.)
Metadate CD releases methylphenidate from beads (30% immediate release and 70% extended release) to mimic the effect of 2 doses of immediate-release methylphenidate.
Ritalin LA is also a once-daily agent designed to mimic the effect of the 2 doses of immediate-release methylphenidate. The capsule releases methylphenidate from beads: 50% immediate release and 50% delayed release. It tends to last about 6-8 hours, so it isn’t sufficient for a full school day plus homework for most kids.
The active ingredient in Focalin XR is similar to ritalin, but half of the ritalin molecule is removed, which often helps minimize the side effects. Focalin XR is a 50% immediate-release and 50% delayed-release agent that is similar to using the immediate release Focalin twice a day.
Concerta uses a unique mechanism to release the medication over time. There is an outer covering that immediately starts working, followed by a chamber that slowly and consistently releases medicine over the next several hours. It tends to work for a total of 10-12 hours and avoids the mid-day drop in effectiveness that is common to other forms of long acting medicines.
Generic for Concerta
Unfortunately the laws regarding generic substitutions were written before some of the new technology of medication was invented. The FDA is once again allowing substitutions that use a different delivery system than the original Concerta. I discuss this separately on my other blog if you want more information.
Side effects of atomoxetine include stomach aches, sleepiness, slowed growth (during the first 2 years of treatment), and rarely hepatitis.
Blood Pressure Medicines
Guanfacine and clonidine affect the blood pressure and heart rate. Both are available in short and long acting forms and have generics available.
They can lead to tiredness, dry mouth, dizziness, irritability, headache, and abdominal pain. Most of these side effects are minimized by slowly increasing the dose. Neither should be stopped abruptly due to side effects.
Of course cost is not the only thing to consider when choosing a medication, but if you cannot afford it, you will not be able to continue it. It must be affordable to be a reasonable choice.
There are two things you must check to estimate how much a medication will cost.
One resource to find the cash price is GoodRx. This site allows you to search for any medication and lists how much various pharmacies charge. It also allows you to print out coupons, which may or may not be able to be used with your insurance. They often have a link to less expensive alternatives, which is a very helpful function to estimate if you will be able to afford a medication.
The second thing to always check before starting a long term medication is your insurance formulary and preferred pharmacy.
The insurance formulary is a list of how much different medications will cost if you use your insurance plan. Some will allow you to use coupons with insurance, some won’t.
You will also need to know if you can get your medications cheaper as a 90 day prescription. Many insurance companies will not allow a 90 day supply of controlled substances (methylphenidates and amphetamines) but will allow the non-controlled substances (guanfacine, clonidine, and atomoxetine).
Your prescriber will not know which medication is cheapest for you because each individual insurance plan varies – in other words, one Blue Cross Blue Shield plan differs from another Blue Cross Blue Shield plan. One Aetna plan varies from another Aetna plan. The same with United Healthcare and all the other insurance plans. They have many plans that all sound similar.
You can often access this list online by logging into your insurance plan’s website. If you cannot find this list, you will need to speak with someone at your insurance company. When you make this call, be sure to have a list of medications to check easily available. I recommend asking about each of the medicines listed on the Cohen Children’s Medical CenterADHD Medication Guide.
When looking at medications, be sure to look for subtle differences, such as an “ER” or “XR” after the name. These indicate a long acting form of a medication and often cost more than the short acting version of the same active ingredient.
Also check the amount in each pill. For example, methylphenidate ER 30mg is probably a generic for Metadate CD, but methylphenidate ER 36mg is a generic for Concerta (though it doesn’t specify which generic). If you’re not sure what all the medications are, bring the full list with you to your ADHD (or any chronic condition) appointments.
Before you start a new medication, if you have new insurance, or if it is the start of a new year, log into your insurance portal to look up medications before your appointment with your prescriber.
This can help prevent the need for multiple prescriptions for medications that are not affordable. You can work with your prescriber to help find the most cost effective medication that will work for you.
What can you do when worry sets in? How can you stop the panic? Check out these ways to calm the chaos in your mind when you start to worry and panic.
People with ADHD are often overly sensitive or have true anxiety and panic attacks. What can we do to stop the panic?
We all can get stuck in a rut. Catastrophizing is common. When we catastrophize, it’s as if the sky is falling and we lose the ability to cope.
Learning to cope when life throws problems and stressors in our way builds our resilience. Being resilient helps us to be successful.
Let’s look at ways to stop the negative thinking of panic.
1. Lean on a friend or family member.
Most of us recognize how good we feel when we help someone else out, yet we hesitate to ask for help. Why is that? When we’re in need, there are many people who can help.
It’s preferable if you can talk to someone who is at least in their mid-20s. Their maturity can offer many benefits. If you’re not sure who you can talk to, think of the many adults in your life who would be happy to listen. Parents, aunts, uncles, grandparents, coaches, teachers, neighbors… there are many people who care about you.
If you choose to talk to a peer, choose wisely. Some people can’t take the pressure of hearing negativity. Others will shut you out. And of course many kids overshare other people’s business, so don’t talk about things that are private with peers.
Don’t roll your eyes and presume mindfulness won’t help.
Mindfulness trains your brain to be aware of your body and environment without judgement.
Yes, it takes time to learn how to be mindful, but a lot of research shows that mindfulness can help with anxiety, chronic pain, stress, focus, and more.
Mindfulness is often referred to as a practice for a reason. You should practice it often, but there are no right or wrong ways to do it.
If you can’t sit still, don’t. It’s okay to get up and walk while being mindful.
When your brain keeps thinking of things, don’t get upset. Just redirect.
Start simple with breathing. You breathe every day, so you can do this step. Take deep belly breaths. Nice and slow. Focus on the breathing.
And this is something that can be done nearly anywhere.
5. Sing or listen to your favorite tune
What better way to get into a good mood? Listen to a favorite song. Sing along!
Research has shown that listening to music can reduce anxiety, blood pressure and pain. It can also help sleep quality, mood, mental alertness, and memory.
Pick your favorite feel good songs and make a playlist that you can pull up when needed.
We’ve all heard that exercise helps our bodies, but many people minimize the value it has for our mental health.
Regular exercise helps our mindset in general, but if you have the opportunity to work out when you’re upset, it can help lift your mood.
Combine numbers 5 and 6 and workout to some great tunes!
7. Change the scene
If you’re getting worked up, it can help to get up and walk around.
Especially if you are worried you will say or do something you’ll regret, leave the situation if you can.
If you can go outside, even better. Fresh air can be mood-lifting.
8. Think about what has gone right.
We tend to ruminate about what’s wrong. Negative thoughts are all we can think about. We need to learn to stop this rumination.
When you recognize that you’re ruminating, accept that you’re having whatever thoughts you’re having. Recognize that the thoughts might not be accurate and allow the thoughts to pass rather than trying to block them out. Trying to block out negative thoughts will just cause increased intensity of the thoughts you’re trying not to have. You can replace negative thoughts with positive thoughts: what is going right? What is the best possible outcome? How can you turn the situation around?
If this is hard, start to make it a practice to write down at least one thing at the end of each day that went well. Your hard studying paid off. You met a new friend. You had a good hair day. Whatever it is, keeping a list gives you something to reflect upon when you’re really down. Doing this daily also helps your brain practice finding the good in things. Like anything, practice makes things easier. It is really hard to find good things to think about when you’re in a bad place, but it gets easier when you’ve practiced when you’re not in a foul mood.
9. Be silly
You have to use this one sparingly.
Obviously in the middle of class you can’t start being silly, but if you’re able to get to a place that you can do a silly dance or anything silly to unwind: do it. Acting the part can help relax you and set the mood.
Be careful to not offend anyone or be hurtful in your humor and silliness.
10. Find perspective
Run through questions that help put your worries into perspective.
What are you really worried about?
How likely is it that your worry will come true? Use evidence to support your answer.
If your worry comes true, what is the worst thing that will happen?
If your worry does come true, what’s the most likely thing that will happen?
If your worry does come true, what are the chances that things will be okay
Sensory items can help calm our minds. Think of sounds, smells, textures, and visually relaxing things.
Squishy play doh or silly putty
White noise machines
Chewable jewelry – if you don’t know what this is, just search “chewelry”
Noise reducing headphones
Rock or sway
Run your fingers through a bin of sand, dry rice, or dry beans
Aromatherapy – Use candles, diffusers, or scented objects. Jasmine, vanilla and other scents might relax you.
Glitter jar – make your own!
Cognitive Behavioral Therapy (CBT) is very effective for anxiety management. Ask your physician to help find a good therapist for you.
If you’re not willing or able to work with a therapist, there are some interesting options to try online. These are not meant to replace professional help, but they help to remove the most common roadblocks to working with a therapist: cost, time, and not wanting to talk to a real person. Learning online might help you see what can be done with therapy and open your mind to finding a therapist.
Woebot is a free app that uses artificial intelligence to teach CBT. It can help you think through situations and learn about yourself with intelligent mood tracking.
MindShift™ CBT uses scientifically proven strategies based on Cognitive Behavioral Therapy (CBT) to help you learn to relax and be mindful, develop more effective ways of thinking, and use active steps to take charge of your anxiety.
What’s Up? is a free app currently only available for iOS users using some of the best CBT (Cognitive Behavioral Therapy) and ACT (Acceptance Commitment Therapy) methods to help you cope with Depression, Anxiety, Anger, Stress and more!
NEW! Common Sense Media is a well known resource to assess if a movie, game, or other media is appropriate for kids. They now have a list of mental health apps with suggested ages and rankings. Check it out on Common Sense Media Apps to Help Mental Health!
There are many traits common to people with ADHD that can make them seem self centered or conceited. Learning about them can help loved ones understand behaviors and people with unintended behaviors work on having expected behaviors.
Most people with ADHD are very empathetic and kind, but can come off as self centered and uncaring. Why is there this discrepancy? What can you do to help others realize that you really do care about them and not just yourself?
Many of the traits of ADHD can make a person seem self absorbed. Let’s go over a few of them. Once you understand why you do what you do and how those actions are perceived by others, can you think of ways that you can help others to recognize that your actions do not mean what they seem to mean?
1. Time management and awareness
Many people with ADHD have significant problems with time awareness. This makes it easy to run late. All. The. Time.
When you’re often late to meet ups with friends (or forget about them all together), they can see you as not caring.
What to do about it…
Working on improving time management and organization might be a long process, but it’s worth it.
Use post it notes as reminders – put them where you’ll see them when you need them (a note on your backpack to remember your project or in the bathroom to remind you to brush your teeth)
Set your alarm to remind you to leave on time (have it go off when you should start putting on shoes and doing other getting ready to leave stuff, not just when you need to leave)
Look at your schedule each morning and on Sunday evenings
Don’t overschedule – anticipate more time than you’ll need for things so you’re not rushed
Ask for help – friends would be happy to help you stay on top of things if you ask
It might not be obvious to others how much mental preparation is needed to shift gears. If you’ve been planning to do something and plans change, it is disappointing. When your mind is finally in the zone and someone interrupts, it’s frustrating.
It’s hard for people to understand why a sudden change in plans is met with resistance. This is especially true when we often seem impulsive. Resistance to change in plans seems contradictory to the impulsiveness that often comes out.
What to do about it…
If you tend to lash out at people when they alter plans, the first step to change the behavior is to recognize it. Learn to recognize triggers. Whenever you note a trigger, learn what you can do to help yourself have a positive reaction.
Have a talk with those close to you about why you don’t like to suddenly change plans. They won’t know how you feel if you don’t share it, and most people who care about you will help accommodate if you understand. You might need to remind them when you’re in the moment, but it’s best to have the first conversation at a time in advance.
3. In the zone
If you’re in the zone getting stuff done, it is really frustrating to be interrupted. You know that you’ll have to re-enter the zone, which can take a long time and a ton of energy.
Most of us know what it feels like to be deep in concentration only to have someone ask a question or make a noise that ruins it. The mental energy to get back into the zone is huge. How do you handle the situation?
Your reaction may not be appropriate – there’s that impulsivity at work. If you yell, blurt unkind words, or try to ignore the interruption, it will not be received well. You will seem self centered if you lash out.
What to do about it…
Learn to take a few big breaths before you react to a disruption.
Give your mind a chance to settle. You were able to get into the zone once, you can do it again.
A little break can help.
Exercise has been proven to help our focus, so if you can take a quick walk – even if just to the bathroom – it might help.
Mindfulness can really help here. It needs to be practiced, but it only takes a moment to help clarify your mind. For more mindfulness tips and several free apps to help guide your mindfulness, see my Pinterest Mindfulness board. If you use mindfulness regularly, you will notice less stress overall.
Healthy food can renew your energy. Just be careful to not overeat out of anger or boredom.
Working memory is like the RAM in a computer. It’s where information is temporarily held while constructing a sentence or forming an idea, solving an equation, remembering where we put something. If the information is “valuable” we then store it in long term memory, like saving to a disk, from which we can pull the information later. Information that doesn’t seem valuable, such as names or dates, isn’t stored.
Forgetting details is common among people with ADHD.
When it comes to forgetting birthdays, anniversaries, and other important dates, it can make you appear uncaring.
Many people with working memory problems fear that their thought will be gone if they don’t blurt it out right away. Unfortunately, interrupting others is socially inappropriate. If you do it often, you come off as self absorbed.
What do do about it…
If you struggle to recall your thoughts, jot stuff down quickly to trigger your memory.
If you find yourself interrupting others, practice looking for pauses in a conversation. Use that pause to speak your mind.
Use reminders. Put important dates and events in your calendar. Look at your calendar daily.
Play games that help you practice short term memory.
ADHD can lead to many problems with communication.
As mentioned above, working memory problems can lead to communication problems. If a thought pops into your head, you’re likely to share it right away. It doesn’t matter if someone else is talking. You don’t want to forget it, so you blurt it out.
It’s also common that if someone interrupts when you are talking, you get very upset because it breaks the line of concentration. That’s especially common among people with ADHD because it’s so hard to retain a line of thinking, but people might find it annoying that you interrupt them but won’t tolerate being interrupted.
Maintaining eye contact during a conversation might be really difficult. You might tend to look around the room or out the window when someone’s talking to you. This can be perceived as not paying attention.
A similar issue is found during class when you’re listening to the teacher, but doodling or playing with a button on your shirt. This can make it appear that you’re not paying attention, even when you are.
It’s also really easy for you to become bored with a conversation. This means you might suddenly change the topic to something unrelated. This can make others in the conversation feel that you don’t appreciate what they’re saying. Maybe you don’t. But there are social norms that others can follow that help them wait patiently for others to finish before changing the subject.
It can even be hard for you to keep on track with your own thoughts. You can be talking about one topic, then something leads you astray, leaving others confused. Your brain might be ahead of your words, so your sentences lose their meaning to others.
What to do about it…
It sounds silly, but practice does help. Sometimes we get frustrated with ourselves and just stop trying, but then we never get better at communicating.
Watch others in group settings to see how they interact and how others perceive what they say and do. Replicate the things that are well perceived and avoid doing the things that are not appreciated.
Mantra: don’t interrupt.
It isn’t uncommon for people with ADHD to be overly sensitive. This happens after years of being told you’re doing things wrong, being too loud, forgetting stuff, and the million other ways you get negative feedback.
Rejection sensitivity can lead you to become upset at friends for no apparent reason from their point of view. They might feel like you push them away because they don’t understand that their response hurt your feelings.
People with ADHD often seem outgoing because of their unlimited energy and talkative nature, but they also can have trouble being around a lot of people. Too much input and stimulation can be distracting, especially to the ADHD brain.
When people perceive you as the “life of the party” type personality, it can make it difficult to explain why you don’t want to go to an outing or event that will have a lot of people. It might seem to others that you feel above everyone else so don’t want to participate.
What to do about it…
Have an escape plan to leave early if the crowd is too overwhelming.
If you turn down an invite, be sure to let your friend know why. For example, if the crowd is just too overwhelming, let them know you’d rather do something with a smaller group.
Impulsivity can get us in trouble in the humor department, making people with ADHD seem uncaring and downright mean.
Sometimes saying a “funny” thought that pops into our minds is not the right thing to do. It might feel good to make people laugh, but if that laughter is at the expense of others, you will not be perceived as a nice person.
What to do about it…
Watch for real reactions when people are laughing. Are some people uncomfortable or upset about the joke? Those are the types of jokes that you want to steer clear of.
One good rule of thumb: Don’t make fun of other people or groups of people. You might hurt someone’s feelings, and that is never funny. (Even if it makes some people laugh.)
If you are careful, you can make fun of something temporary or non-identifiable, such as bad drivers or people who fall. This is easier to do if you include yourself in the group, such as joking about a time you fell or walked into a wall.
9. Outside the box thinking: good for leaders, hard on kids
Society and school teach us to conform. We should act as expected. Clothing styles dictate what we should wear.
Many people with ADHD are non-conformists. This can be a great trait because it can lead to new ideas and change. Leaders and inventors are non-conformists. This trait can help you make a difference in the world.
But if the expectation is that you work a math problem showing your work in a specific way, you need to do it that way. If you’re supposed to dress for a formal dinner or a group function, you can come off as uncaring if you show up in attire that doesn’t fit expectations.
What to do about it…
Keep being you!
Think outside the box and create as much as possible, but when a certain behavior is expected, try to conform.
This means if your teacher wants a project done a certain way, do it that way.
If you’re going to a location with a dress code, follow it as much as you can. Don’t wear something that will bring attention to you unless you’re supposed to be the center of attention, such as at your birthday party.
Remember to always stay in your role.
If your role is a student, let the teacher teach. When you earn the role of teacher, you can teach.
When you are the athlete, let the coach coach. If you earn the role of coach, you can coach.
When you hang out in a group, let others help to decide what to do. Take turns. Even if it’s not your choice, try to stay focused on the activity. Don’t let your friends think you think they are boring, even if the activity is boring to you. Find something in it that interests you.
If you’re motivated and learn knowledge as well as people skills along the way, one day you’ll be the leader. Then you can lead. Until then, you will be seen as bossy in a negative way if you try to take charge prematurely or inappropriately.
Check out what Jessica McCabe has to say about ADHD and relationships
Inspiring stories from people who were seen as failures. Others have risen above predictions — and you can too. Rise and thrive!
Do you feel like a failure? Moving forward in life is hard, especially when others tell you you’re not good enough. I often tell struggling kids and their parents that schools make good workers… people who do what they’re told. Teachers want you to show the work in the way they do it. They want you to follow a rubric of instructions. There’s often no room for individuality or ingenuity. In short, school isn’t designed to teach future leaders, inventors, or creators. Continue reading for inspiration if you feel like a failure. Others have risen above predictions — and you can too!
Students who are smart and natural leaders tend to struggle in that box we call school, but can shine in life!
If you’ve heard these things before, there are two options: cave and prove them right or thrive and prove them wrong.
Inspiration from others
Tell me about a time someone told you that you could not do something and you went ahead and succeeded out of spite.— Amanda Deibert 🏳️🌈 (@amandadeibert) April 19, 2019
This was posted on Twitter and is a fascinating and inspiring thread. If you need inspiration, read some of the stories below. For even more, click the link above.
And when the original poster was asked if she had a story of her own…
If you worry about headlines reporting new research findings, look at the facts before making a decision. Headlines are written to get your attention. They never tell the whole story and even statistics can be used inappropriately.
Headlines are designed to grab your attention. Recent headlines about Adderall and other ADHD medications are scary. This is another example of media misinterpreting a study with the headline. I’ve written before about Adderall being misrepresented by headlines.
In this post I will generally refer to stimulants by their common names. Adderall is in the amphetamine family and as used here could include other named medications in that family. Ritalin is in the methylphenidate family and as used here includes other medications in its family.
That sounds like a typical headline. It’s eye-catching, right? It won’t be something you forget if you take Adderall or are considering starting it.
If these medicines have been working well for you and you aren’t hearing or seeing things, you don’t need to stop them.
How can I say that? Am I not worried about someone becoming psychotic?
We always need to look at studies critically. The title of an article, or even the summary, can be misleading. Attempt to read the study itself, but if you are unable to, find a summary by an expert in the field.
Limitations in the study
This study actually fares well in many of the above things to consider when evaluating a study. It’s a respected journal and there’s a large sample size, but it’s not a double blind controlled study. It’s a review of insurance codes. This can be fraught with many problems.
The study was a review of codes from national insurance claim data. It included teens and young adults who were starting these medicines for the first time. They reviewed codes for diagnoses as well as prescriptions. They did not have any direct study of the patients. Anyone who was doing well on these medications already was excluded.
Unable to accurately assess disqualifiers
Anyone who had filled a prescription for a stimulant in the year prior to the study was disqualified. That means the many, many people who use stimulants with great benefit for years were not included. There is no comparison to total number of prescriptions for this.
We know that many people will self medicate with someone else’s medicine. There was no way to assess if they used someone else’s prescription medication, so there could be misrepresentation of new medication starts in the study population. This means even one of their qualifying conditions cannot be verified.
Inability to assess if patients accurately took medicine
We all know that people will fill prescriptions that they don’t take as directed.
There is no way to tell from this study design if the patients took their medicine regularly, or even at all.
Adderall has a larger street value than ritalin, so if more of the patients who were prescribed adderall diverted their medicine to someone else, they were still included in the psychosis number. This could sway the numbers making adderall look more problematic than ritalin because they weren’t being medicated. Said in another way: if people are more likely to take their medicine, they’re less likely to have psychosis.
This is just a thought. I have no way of knowing this information based on the study design. I include it because this is the way we must evaluate study results. We need to consider the results and other possibilities and explanations critically.
What does double the risk really mean?
The age range studied is one at which schizophrenia and other psychoses tend to develop.
They compared psychosis rates to people treated with methylphenidates versus amphetamines and found the risk was double in those starting amphetamines. Double sounds huge, but it was still very small numbers.
One big problem is that there was not a comparison to a baseline development of psychosis in people of the same age not on medication.
We would expect a small number of study participants to develop psychosis, whether they start the medicine or not. They did not attempt to compare this with their study population.
We also know that people with ADHD struggle more with mental health.
Their overall risk of psychosis may be higher, but since they didn’t compare the same age range of people (with and without ADHD) who did not start any new medications during the same time frame, we do not know that baseline.
The age groups in the studies are slightly different. We know that risk increases with age, so it should be further studied if the age range contributed to this difference.
Closer follow up matters
It is also possible that people who are starting a new medicine are more likely to be identified early in their psychosis.
Many adolescents and young adults rarely see physicians or other medical providers since they’re generally healthy. If they aren’t seeing someone who could identify psychosis, they would not get a diagnosis.
People who see someone who is prescribing stimulant medications are hopefully being assessed for mental health in general. It is expected that they are more likely to have problems identified.
This wouldn’t explain the difference between medicated groups, but could raise the incidence overall identified.
This study doesn’t convince me that the risk of psychosis is enough to avoid using it for the management of ADHD. Both amphetamines and methylphenidates have been used successfully in many people over the years.