Stimulant prescriptions are rising — how worried should you be about psychosis?
STUDY: Jangra D et al, J Addict Med 2026;
STUDY TYPE: Systematic review and meta-analysis
FUNDING: Government (India)
Background
Stimulant prescriptions in the US rose nearly 60% between 2012 and 2022, and nonmedical stimulant use is also climbing, particularly among young adults. Both contexts carry some risk of psychosis, but the nature and magnitude of that risk differ dramatically depending on whether we’re talking about methylphenidate at guideline doses or methamphetamine smoked or injected in high quantities. This meta-analysis is the first to compare those two contexts.
The Study
Seventy-seven studies (n = 687,912) were included: 9 on therapeutic use and 68 on nontherapeutic use. Therapeutic studies predominantly involved oral methylphenidate or amphetamine at guideline doses, mostly in children and adolescents with ADHD. Nontherapeutic studies were overwhelmingly adults using high-dose methamphetamine via intravenous or smoked routes.
The difference in psychosis rates was stark. Pooled prevalence of stimulant-induced psychosis was 0.2% (95% CI: 0.0–0.3) in therapeutic users versus 32.8% (95% CI: 25.5–40.2) in nontherapeutic users. The incidence of new-onset psychosis in therapeutic use was 0.6% (95% CI: 0.3–0.9). Incidence data for nontherapeutic users were too inconsistent to pool.
In therapeutic cases, psychosis typically emerged after prolonged use or in people with preexisting psychiatric vulnerability and generally resolved with dose reduction or discontinuation. In nontherapeutic cases, psychosis was characterized by acute onset, persecutory delusions, auditory hallucinations, and a high risk of recurrence.
Practice Implications
Before starting a stimulant, ask about personal and family history of psychotic or manic episodes.
Around 1 in 166 patients develop new psychosis on a stimulant
That doen’t mean all these cases are caused by a stimulant, although other studies point to a causative role, especially for amphetamines where the risk is approximately double that of methylphenidates.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
What’s Your Take? Share in Comments
- Do you see a greater risk of psychosis in certain patients? With certain meds or doses?
