Can Adderall Cause Psychosis?

“Psychotic” is one of those words we inappropriately bandy about in everyday conversation, using it to describe someone who is too demanding or whose behavior or temperament we dislike. But, medically speaking, psychosis is no joke.

Psychosis is an abnormal state marked by an inability to recognize reality.

During a psychotic episode, a person may experience:

• Irrational thoughts or delusions (strongly held false beliefs)

• Hallucinations (hearing or seeing things that aren’t there)

• Disorganized speech and behavior

• Agitation

• Impaired judgment

• Mood swings

• Inability to engage in social interactions or cope with normal activities

One rare cause of psychosis is the ADHD medication Adderall (amphetamine-dextroamphetamine), and other stimulants. The symptoms of Adderall-induced psychosis mimic those of schizophrenia, a more common cause of psychosis.

“People who are more susceptible to Adderall-induced psychosis generally fall into two categories: those who abuse the medication in high doses and people with a family history of psychosis or pre-existing mental health conditions,” explains Ryan Sultan, MD, director of Integrative Psych in New York City and the Mental Health Informatics Lab at Columbia University.

Pre-existing conditions that increase vulnerability include:

• People with bipolar disorder who are already at an increased risk for manic or mixed episodes, which can have psychotic features.

• A family history of psychotic disorders may increase the risk of stimulant-induced psychosis due to possible genetic predispositions.

• People with schizophrenia or schizoaffective disorder are already at a baseline risk for psychosis, and adding stimulants could exacerbate these symptoms.

• People with ongoing, serious sleep deprivation or severe stress may also be more susceptible.

Although inherent vulnerabilities may increase a person’s risk, Adderall, and other stimulants, can provoke psychosis even in people with no family or personal history of mental illness.

How often does this happen? That’s difficult to pin down. Existing studies haven’t established cause and effect. According to a 2019 study published in the New England Journal of Medicine that used databases to assess 221,846 adolescents and young adults with ADHD for whom methylphenidate (Ritalin) or amphetamine was prescribed, 343 patients received a new diagnosis of psychosis and a subsequent prescription for an antipsychotic medication. The percentage of patients who had a psychotic episode was 0.10% among those who received methylphenidate and 0.21% among patients who received amphetamine.

The authors concluded that the risk of new-onset psychosis was approximately 1 in 660 patients who received a prescription for stimulants for ADHD, but the risk was about twice as high among patients who started amphetamine as among patients who started methylphenidate.

Although the frequency of amphetamine-associated psychosis was double that of methylphenidate—a finding that attracted news attention—the study methodology could not establish causality. Still, the study and others like it helped inform both doctors’ and patients’ decision-making when it comes to prescribing ADHD medication.

Schizophrenia is a serious, complex, and chronic mental disorder caused by genetic, environmental, and neurobiological factors. Psychotic episodes are a hallmark of the illness and can be controlled with antipsychotic drugs. So while it is possible for stimulant-induced psychosis to trigger or worsen existing mental health conditions, “there is no definitive evidence that an episode of Adderall-induced psychosis can trigger schizophrenia,” says Dr. Sultan. However, “it can certainly complicate the diagnostic process.”

“Amphetamines like Adderall can induce psychosis that mimics the symptoms of schizophrenia, making it challenging to determine whether the psychotic episode is drug-induced or an early manifestation of a schizophrenia spectrum disorder,” explains Dr. Sultan, who treats people with ADHD, anxiety, and substance use disorders.

And this is especially problematic if a person hides their use of Adderall and other substances—including marijuana or alcohol—thereby masking drug use that could instigate a psychotic episode.

Should someone with a history of addiction or mental illness take Adderall?

“It’s not a straightforward yes or no,” says Dr. Sultan. “If someone has ADHD and requires medication, stimulants like Adderall can be the most effective treatment. It’s crucial to weigh the potential benefits of the medication (improved concentration, decreased impulsivity) against the risks (potential exacerbation of psychiatric symptoms).

“Each case needs an individualized assessment, and in some cases, careful monitoring or alternative treatments might be considered.”

“People who struggle with mood and/or psychotic disorders can also have ADHD,” says psychiatrist Peter Zafirides, MD, president of Central Ohio Behavioral Medicine, a practice focused on the management of depression, anxiety disorders, ADHD, bipolar disorder, and schizophrenia.

However, prescribing a stimulant like Adderall to someone with a history of addiction or mental illness “requires very careful consideration, clear instruction about the effects and side effects of the medication, and the cooperation of the patient and their family,” he stresses.

According to Dr. Zafirides, the distinguishing difference between Adderall psychosis and a formal thought disorder like schizophrenia is the short duration of the psychosis. Amphetamine-induced psychotic episodes often resolve once the drug clears the bloodstream, usually between four and six hours (though it can take longer depending on the formulation).

Dr. Sultan agrees that the most important step in treating Adderall psychosis is discontinuing the drug under medical supervision with the understanding that “in some cases antipsychotic medication and supportive care may be needed,” he says.

When the psychotic symptoms resolve upon cessation of the substance, “we know that the psychosis is due to the effects of the drug,” says Dr. Zafirides. “I don’t think I’ve ever had a case in my 25-plus-year career of a stimulant-induced psychosis that hasn’t resolved after we stopped the medication.”

Adderall is a Schedule II controlled substance, a designation that means it’s addictive with a potential for misuse and serious side effects. And as you now know, one of those side effects can be psychosis.

If you have ADHD or think you do, find a psychiatrist or doctor thoroughly fluent in treating that condition. The physician should do a thorough evaluation of your symptoms, ask about your concerns, and explore your family and personal history. Don’t hold back. Tell the physician about any past or current drug use—including cannabis.

When starting on medication for ADHD, begin with a low dose and keep it low as long as you can.

“There’s a dose-related effect with Adderall and the risk of psychosis,” says Dr. Sultan. “Higher doses generally increase the risk of side effects, including psychosis. This is why it’s important to start with the lowest effective dose and monitor closely for any adverse effects.”

Can ADHD stimulant medications cause psychosis?

Yes. While Adderall-induced psychosis can potentially affect anyone, people with the following conditions are more vulnerable:

• Those with pre-existing mental health conditions and/or a family history of bipolar disorder, schizophrenia, or schizoaffective disorder

• People who abuse the medication

• People with a history of alcohol, marijuana, or other drug and substance misuse or addiction

• Recreational amphetamine users

• People with severe depression

• People under severe stress or experiencing intense sleep deprivation

Can Adderall cause a manic episode?

Stimulants like Adderall increase dopamine levels in the brain. Elevated dopamine is associated with increased risk for mania and psychosis. In people with bipolar disorders and those predisposed to mania, stimulants may precipitate or exacerbate manic episodes. And while the drug doesn’t usually cause a “high” when taken for ADHD in prescribed dosages, when taken in excess, Adderall can heighten energy and confidence and trigger a temporary manic-like feeling of euphoria.

Can you fully recover from Adderall-induced psychosis?

Yes. While amphetamines can trigger temporary psychotic episodes, these episodes typically resolve once the drug is out of the system. When the psychotic symptoms resolve upon cessation of the substance, we know that this is due to the effects of the drug and not due to an underlying formal thought disorder such as schizophrenia.

What are the side effects of Adderall?

Adderall’s common side effects include:

• High blood pressure

• Sweats and/or shakes

• Insomnia

• Dilated pupils

• Seizures