Stimulants, Psychosis, and Stressors 5/7/2021

ADHD is a common neurobiological condition among school-age children (Wolraich et al., 2019). The American Academy of Pediatrics recommends primary care providers treat ADHD in school age youth 1) with referrals to evidence supported psychosocial treatment (such as Parent Training In Behavior Management) or other outpatient individual, family and group educational and treatment interventions, and 2) with prescription of an FDA approved medication (stimulants, alpha agonists, atomoxetine, see full list here www.ADHDMedicationGuide.com).  Prescribing these agents should incorporate ongoing oversight and management of the various more common potential side effects of these agents that include: g.i. and appetite disturbance, irritability or dysphoria, sleep onset difficulties, tics and others, as well as for the risk of more severe psychiatric decompensation with either psychotic or other severe mental health problems.

When compared to non-stimulant FDA approved medications (atomoxetine, alpha agonists) stimulants, such as methylphenidate and amphetamine have a larger effect size (1.0 vs. ~0.7). As a result, these medications are often first line treatment for ADHD.  When prescribed and monitored appropriately, stimulant medications rarely induce major psychiatric side effects such as psychosis and/or exacerbate other disorders, but for some vulnerable youth, particularly adolescents, and in circumstances where the medications are misused (including in combination with illicit substances such as other stimulants or high potency marijuana, amongst others) serious problems can arise.

Whether the ongoing stressors associated with the Covid pandemic, including familial loss, financial strain and other issues, either on their own or in combination with co-occurring substance use  (legal as with ADHD stimulant agents or with illicit drugs) will lead to increased incidence of psychotic and/or other major potentially persisting psychiatric disorders remains to be evaluated.  Clearly as the pandemic has gone on there have been increased symptoms of anxiety and depression in children and adolescents generally (Zeytinoglu et al., 2021; Twenge, 2021) and those challenged with attentional difficulties have been additionally stressed by the challenges of remote learning and the distanced interpersonal environment.

While for some, efforts to enhance the capacities of youth who have challenges with focusing and attentiveness with prescriptions for stimulant or other ADHD medications, ongoing careful oversight, reassessment and monitoring for risk behaviors are recommended approaches.  What impact the pandemic has had and will have on the emergence of psychotic and/or major affective symptoms and pathologies in youth remains to be studied and better understood.  Historically, stressful life changes can exacerbate psychosis and other emotional disorders in vulnerable and at-risk populations, and we likely have seen and will continue to see instances of this among our youth in 2021 and beyond.

In summary, stimulant misuse and abuse is a common cause of psychotic symptoms (Henning et al., 2019) and it is important to consider that stimulant overuse, including higher therapeutic doses of FDA approved stimulants, can also cause these symptoms, as Henning, Kurtom and Espiridion’s referenced case below.  This also reminds us to screen for family history of psychotic and other mental illness in all of our ADHD patients.  Caution with the use of stimulants with youth at risk of experiencing psychotic symptoms is strongly recommended, and psychiatric consultation would be recommended for situations of concern.

References:

Henning, A., Kurtom, M., & Espiridion, E. D. (2019). A Case Study of Acute Stimulant-induced Psychosis. Cureus11(2), e4126. https://doi.org/10.7759/cureus.4126

Wolraich ML, Hagan JF, Allan C, et al; Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactive Disorder. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2019;144(4):e20192528. Pediatrics. 2020 Mar;145(3):e20193997. doi: 10.1542/peds.2019-3997. Erratum for: Pediatrics. 2019 Oct;144(4): PMID: 32111626.

Zeytinoglu, S., Morales, S., Lorenzo, N. E., Chronis-Tuscano, A., Degnan, K. A., Almas, A. N., Henderson, H., Pine, D. S., Fox, N. A. (2021) A Developmental Pathway from Early Behavioral Inhibition to Young Adults’ Anxiety During the COVID-19 Pandemic. Journal of the American Academy of Child and Adolescent Psychiatry. doi: 10.1016/j.jaac.2021.01.021

Twenge, J; The mental health of youth and their parents during the pandemic; presentation at 6th Annual CICAMH conference, 3/19/21; San Diego

 

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