Looking out the Window, by Refaela Revach
When a child presents with ADHD, there’s a 5-9 fold higher chance they’ll develop psychosis or bipolar disorder later in life
STUDY: Thapar A et al, Molecular Psychiatry 2026
STUDY TYPE: Perspective review (narrative synthesis of the literature)
FUNDING: Wolfson Centre for Young People’s Mental Health (Wolfson Foundation)
Background
ADHD’s link to depression and anxiety in adulthood is well known. Less recognized is its tie to bipolar disorder and psychotic disorders. This review looks at the risks and what we can do to mitigate it.
The authors examined five competing explanations for the ADHD-psychosis link, using 26 studies published since 2020:
- Early misdiagnosis
- Stimulant-induced psychosis
- Similar environmental risks for ADHD and psychosis
- Shared psychiatric comorbidity
- Shared neurodevelopmental biology
Results
Childhood ADHD has been linked to roughly 9 times the risk of later bipolar disorder and almost 5 times the risk of a psychotic disorder in prior meta-analyses.
ADHD medication itself doesn’t appear to explain the link, at least with methylphenidate. This stimulant wasn’t linked to a higher psychosis risk in large registry studies, and one recent study suggests it may even lower it.
Less is known about amphetamines. These are used as the animal model for psychosis and mania, and they carry higher odds of psychosis than methylphenidate (about 1.6 times, rising past 5 times at high doses).
Environmental exposures for ADHD and psychosis overlap, such as substance use and childhood adversity, but no study has directly tested whether they explain the link.
The strongest biological lead is genetic: ADHD, autism, and schizophrenia share rare, high-risk gene variants, pointing to overlapping neurodevelopmental roots rather than one disorder causing the other.
Practice Implications
- Watch for emergency of bipolar or psychosis in children with ADHD, especially those with family histories of those disorders.
- For children at high risk, methylphenidate is safer than amphetamines, and clonidine/guanfacine are safer than both. Other nonstimulants (atomoxetine, viloxazine) have an antidepressant structure that can raise the risk of mania.
- Just as critical, look for sleep apnea in childhood ADHD, a common cause of the symptoms.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
