Cortese, Samuele, Garcia-Argibay, Miguel, Oliver, Dominic, Chang, Zheng, Farhat, Luis C., Bloch, Michael H., Salazar-de-Pablo, Gonzalo, Larsson, Henrik, Solmi, Marco, Correll, Christoph U. and Fusar-Poli, Paolo (2025) Psychotic symptoms during pharmacological treatment of ADHD: clinical considerations and research needs. The Lancet Psychiatry. (doi:10.1016/S2215-0366(25)00248-2).
Abstract
In this Personal View, we address key questions to support evidence-based prevention and management of psychotic symptoms that may occur during ADHD pharmacotherapy. We begin by examining evidence showing a significantly increased occurrence of psychotic disorders in individuals with ADHD, independent of ADHD medications (pooled relative effect, odds ratio or hazard ratio = 4·74, 95% CI, 4·11-5·46). We then examine whether ADHD medications play a causal role, noting that current evidence does not support such a link, at least for methylphenidate. We explore how vulnerability to psychosis varies across individuals. Regarding the different steps involved in prescribing ADHD medications, we discuss the importance of balancing potential risks - like emergence of psychotic symptoms - against the demonstrated benefits of pharmacological treatment for ADHD. Next, we present strategies for screening individuals for vulnerability to psychosis prior to initiating ADHD medication. We then offer guidance on the clinical management of psychotic symptoms that may arise during ADHD pharmacotherapy, including considerations of dosage and medication type. Finally, we identify key research priorities in this area. Overall, this article provides an empirical framework, grounded in evidence and clinical practice, to guide the next steps in the field.
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