It would be lovely to see something positive in the media about mental health treatment. But aside from pharmaceutical commercials that seem to indicate their drug will make your life a series of joyful activities in a sunny park or perfectly clean house, the only news we ever hear is negative. When the stimulant shortage was in the news, they could have highlighted the fact that people with Executive Function impairments who were already struggling to navigate a complex system now faced this additional challenge. But instead all the coverage pushed the narrative that people prescribed stimulants just use them to compensate for laziness, or even to get high. So, you already have a highly stigmatized disorder, it’s become virtually impossible to obtain the medicine to treat it, and now you get to be called a junkie, too. Again.
It's reached the point where we hardly expect anything else from the media. But I did expect better from McLean Hospital. You probably heard a few weeks ago about the study linking high doses of Adderall to increased risk of psychosis. It was in all the papers. Like, seriously, it was in ALL the papers. And since science and statistics are complicated, the common takeaway was the usual “Psych Med Bad!” And besides, people don’t really need it – they should just try harder.
Two points: first, this is not “news” – it has been known for a very long time that excessive doses of stimulants are hazardous. But the study, and the coverage, point out that there is no “upper dose limit on its drug label.” Umm… excuse me? The upper dose limit on a drug label is for an over-the-counter medicine, so that a person who buys a large bottle can see what is the recommended dose, and then if they choose to exceed that, the "no, really, take too much and it can kill you" limit.
A prescription medication comes in a prescription bottle with instructions specifying the amount to take per dose, and the of number of doses per day. The difference being while you could buy a year’s supply of Tylenol and ignore the label (bad idea – don’t do that; more than 4000mg in a day causes liver damage), you can only get one month’s supply of Adderall at a time, and running out early leads to serious discussions with your prescriber. Those instructions the prescriber told the pharmacy to put on the bottle aren’t drawn from reading “the drug label” – they are from following standards of care and reviewing current research. For Adderall, those say the maximum dose is generally 40mg and high doses increase the risk of high blood pressure, insomnia, and psychosis. And have for years – nothing new here.
The second problem is the fact that most people don’t understand statistics. In this study, they looked at 1374 patients with psychosis, and matched them to 2748 patients hospitalized for other issues. Then they looked at how many in each group had been taking Adderall recently, and the dose, and comparing those numbers led to them finding of those taking Adderall who had psychosis, 81% of the risk of psychosis could be connected to the Adderall if they took a high dose.
The thing is, most people don’t know what to do with those numbers. Many would read that and come away with the idea that 81% of people taking Adderall are psychotic. Or will be. Maybe only those on high doses. Maybe all of them.
Those with more math skills will realize that you probably need to apply that 81% to something. Unless you can pay for a copy of the journal to read the original study, the only numbers you get to see is how many patients they reviewed. But word problems always include the important numbers, right? So it must be that 81% of those 1374 psychotic patients would have been fine if they hadn’t taken Adderall, right? Uh… no. 81% of the people who both had psychosis AND took Adderall might have been less sick if they took less Adderall, or none. It sure would have been nice to know how many patients were actually in that “took Adderall and also had psychosis” group, but they didn’t tell us that.
To make this relevant to the general population, even better than “How many people with psychosis took Adderall?” would be “How many people taking Adderall developed psychosis?” (And again, many people don't realize those are very different questions -- not everyone is into Venn Diagrams.) If you dig into this doctor’s previous study, we can find that number. In 2019, looking at over 200,000 people who took Adderall or Ritalin, they found that psychotic symptoms developed in… 343 of them. Tragic for them, of course, but this is less than a 0.2% chance.
(And if you’re willing to go into the weeds a bit more, they somehow with a straight face have the statement that “no increased risk was seen with Ritalin” immediately followed by saying it’s “plausible” that Adderall could cause psychosis because it increases dopamine. As does Ritalin. Which showed no increased risk.)
So, the accurate takeaway?
If you’re prescribed Adderall, you should only take the amount prescribed.
Which we already knew.
If you’re prescribing Adderall, you should prescribe the lowest effective dose, and should not prescribe more than 40mg/day.
Which we already knew.
And if you want your study to get mentioned a lot or want to sell more papers, see if you can include the words “Adderall” and “Psychosis” in the title.
Which, sadly, we also already knew.
The plan is, when a post gets more views than the previous one, I'll write another. And that worked well -- suddenly saw 32 views on the last one, and so wrote this.
So, when this one tops 32.... I'll write again. I would be GREAT if anyone wants to send me topics! The hardest part is always trying to guess what would be of interest...