ADHD Drugs Linked to Cardiovascular Disease

Service users taking drugs to treat ADHD may be at increased risk for hypertension and arterial disease

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A new study published in JAMA Psychiatry finds that long-term use of ADHD drugs is linked to an increased risk of cardiovascular disease.

According to the current research, led by Le Zhang of the Karolinska Institutet in Sweden, service users are at a 4% greater risk of cardiovascular disease (CVD) for each year of ADHD drug use. The largest increase in risk for cardiovascular disease occurs in the first three years of ADHD drug use. Children and adults see a similar pattern of risk when these drugs are used long-term. The authors write:

“This large, nested case-control study found an increased risk of incident CVD associated with long-term ADHD medication use, and the risk increased with increasing duration of ADHD medication use. This association was statistically significant both for children and youth and for adults, as well as for females and males. The primary contributors to the association between long-term ADHD medication use and CVD risk was an increased risk of hypertension and arterial disease. Increased risk was also associated with stimulant medication use.”

The goal of the current research was to examine the link between the use of drugs meant to treat ADHD and the risk of developing CVD. To achieve this goal, the authors used several databases that track diagnoses, prescriptions, and demographics of people residing in Sweden. They used the National Inpatient Register for data on diagnoses, the Swedish Prescribed Drug Register for data on prescriptions, the Longitudinal Integrated Database for Health Insurance and Labour Market studies for socioeconomic data, and the Swedish Cause of Death Register for data on participant deaths.

The authors examined data from everyone living in Sweden aged 6-64 who received an ADHD diagnosis or drugs to treat ADHD between January 1, 2007, and December 31, 2020. Data on 278,027 service users were explored for inclusion in the study.

19,192 service users were excluded due to having a CVD diagnosis before using ADHD drugs, being prescribed ADHD drugs to treat something other than ADHD,  and emigrating or dying before the start of the research. Of the 258,835 service users who met the inclusion criteria, 10,842 received a CVD diagnosis after using drugs meant to treat ADHD. After excluding those with short follow-up periods (3 months or less) and those without a matched control case, the authors had 10,388 service users with a cardiovascular disease diagnosis paired with 51,672 control cases (with no CVD when the research began).

In the overall sample used in the current research, ADHD drug use for 1 to 2 years is associated with a 4% – 9% increased risk of CVD. 2 – 3 years of drug use is associated with a 10% – 15% increased risk of CVD. 3 – 5 years of drug use is associated with 23% – 27% increased risk of CVD. More than five years of drug use is associated with a 20% – 23% increased risk of CVD.

For people between the ages of 6 and 24, ADHD drug use for 1 – 2 years is associated with a 5% – 8% increased risk of CVD. 2 – 3 years of drug use is associated with an 18% – 21% increased risk of CVD. 3 – 5 years of drug use is associated with 22% – 25% increased risk of CVD. More than five years of drug use is associated with a 30% – 35% increased risk of CVD.

For people between the ages of 25 – 64, ADHD drug use for 1 – 2 years is associated with a 5% – 10% increased risk of CVD. 2 – 3 years of drug use is associated with a 6% – 12% increased risk of CVD. 3 – 5 years of drug use is associated with 23% – 29% increased risk of CVD. More than five years of drug use is associated with a 16% – 19% increased risk of CVD.

The authors note that the increased risk of CVD when taking ADHD drugs was mainly present for two conditions: hypertension and arterial disease. The use of ADHD drugs for 3 – 5 years was linked to a 72% increased risk of developing hypertension and a 65% increased risk of developing arterial disease. At five years of ADHD drug use, service users are at 80% increased risk for developing hypertension and 49% increased risk of developing arterial disease. The present research found no increased risk for the use of ADHD drugs in developing arrhythmias, heart failure, ischemic heart disease, thromboembolic disease, or cerebrovascular disease.

The authors acknowledge several limitations to the current study. They used recorded diagnoses of CVD for their analyses, which could have missed some service users with CVD that had not yet been diagnosed. This means the association between ADHD drug use and CVD may be stronger than the present research indicates.

The authors used data on prescriptions of ADHD medication, but there is no guarantee that service users took their medication as prescribed. Due to confounding variables and the observational nature of the study, this research cannot speak to causality, meaning the researchers simply observed a link between ADHD drug use and CVD. They cannot say if the ADHD drugs actually caused CVD. The present research also excluded service users with pre-existing CVD. The data was collected exclusively in Sweden, so generalizability to other populations is limited. The authors conclude:

“The results of this population-based case-control study with a longitudinal follow-up of 14 years suggested that long-term use of ADHD medication was associated with an increased risk of CVD, especially hypertension and arterial disease, and the risk was higher for stimulant medications. These findings highlight the importance of carefully weighing potential benefits and risks when making treatment decisions on long-term ADHD medication use.”

Previous research has found that long-term use of ADHD drugs is linked to growth suppression. The addictive nature of these drugs also means service users can experience withdrawal symptoms when attempting to discontinue their use. ADHD drug use has also been linked to hallucinations. Adults receiving treatment for ADHD report a low quality of life, and experts have said that in most cases, the risks associated with ADHD drugs outweigh the benefits.

 

 

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Zhang, L. et al. (2023). Attention-Deficit/Hyperactivity Disorder Medications and Long-Term Risk of Cardiovascular Diseases. JAMA Psychiatry. doi.org/10.1001/jamapsychiatry.2023.4294. (Link)

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27 COMMENTS

  2. First, it is a basic understanding of every physician that prescribes any medication that medications have risks, and those risks must be balanced against the benefits. Medication for ADHD is no different. The second fact is that ADHD is not a benign, trivial condition. A vast data base has shown that individuals with untreated ADHD can suffer considerable and serious morbidity. They have significantly higher deaths-by-all causes rates for their age groups. This is due in part to car accidents and substance abuse. Though the exact cause is unknown, there is also a higher risk of suicide. However, that may be due in part to the fact that they have higher rates of divorce, being fired from work, arrest, poor education, difficult relationships, and generally suffering from not living up to their potential. I have diagnosed many previously undiagnosed adults with ADHD and started them on stimulants, and it is that latter issue that first and invariably becomes apparent. In short, the majority say that it was a miracle, and that it was like a light switch went on in their head. They could think, organize, get their work done, interact with friends, etc. “It’s the first time I can sit and read a book.” It’s the first time I can sit and watch a movie with my girlfriend.” They fervently wish they had been diagnosed and treated sooner. If issues such as hypertension arise during treatment with stimulants, it is one of the easiest medical problems to treat. Not everyone must be started on stimulants for ADHD. Some mild cases of ADHD can improve with therapy. However, it is clear to me, to every psychiatrist I have spoken with about it, and to every patient I have ever treated for ADHD, that the benefits of stimulants greatly outweigh the risks.

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    • Multiple long-term studies show no significant advantages to those taking stimulants vs. those who don’t when diagnosed with “ADHD” in childhood, other than the accidents you mention, and I believe clearly overstate in your comments. Delinquency rates, HS graduation, college enrollment, social skills, not even self-esteem scores were better for those taking stimulants. This has been confirmed since Barkley and Cunningham’s first review in 1978, confirmed by Swanson’s “Review of Reviews” in 1993, and in the OSU medication effectiveness study back in 2002 or so. Also confirmed by the Raine study in Australia, the Quebec study, a comparison study between Finnish and US kids who had very different medication rates but similar outcomes, and more.

      Read Whitaker’s works if you want to fully understand what’s going on at MIA. Not everything is the way the professionals have told you it is.

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      • Interesting comment. You deserve a thoughtful response. First though, I must confess that my first response was wondering how you could be describing a clinical universe so utterly different than the one I have experienced treating hundreds of adults with ADHD over the last 30 years. You seemed to suggest that ADHD was indeed a trivial condition. I assume that some treatments may have made a difference in the reviews you noted. However, you convey that meds made no difference whatsoever. I then realized that in my own adult practice, I saw patients that had come to me in desperation after years of not doing well in life. They always knew something was wrong, and were almost always told that there was something very wrong with them. But they were never diagnosed or treated. These are the individuals I have seen do extraordinarily well on stimulants.
        Then, one can turn to the literature to see how disastrous ADHD in adults can be. For example, ADHD is seen in about 5% of the population. However, compared with published general population prevalence, there is a fivefold increase in prevalence of ADHD in youth prison populations (30.1%) and a 10-fold increase in adult prison populations (26.2%). (Young, S., Moss, D., Sedgwick, O., Fridman, M., & Hodgkins, P. (2015). A meta-analysis of the prevalence of attention deficit hyperactivity disorder in incarcerated populations. Psychological Medicine, 45(2), 247-258.) The odds of dying are significantly higher among those adults with ADHD than among those without ADHD net of exogenous sociodemographic controls (adjusted odds ratio = 1.78, 95% confidence interval = 1.01, 3.12). (London, Andrew S., and Scott D. Landes. “Attention deficit hyperactivity disorder and adult mortality.” Preventive medicine 90 (2016): 8-10.) Adults with self-reports of diagnosed ADHD in the community were significantly less likely to have graduated high school (83% vs. 93% of controls; p < = .001) or obtain a college degree (19% vs. 26%; p < .01), were less likely to be currently employed (52% vs. 72%; p < = .001), and had significantly more mean job changes over 10 years (5.4 vs. 3.4 jobs; p < = .001). They also were significantly more likely to have been arrested (37% vs. 18% of controls; p < = .001) or divorced (28% vs. 15%; p < = .001) and were significantly less satisfied (p < = .001) with their family, social, and professional lives. (Biederman, Joseph, et al. "Functional impairments in adults with self-reports of diagnosed ADHD: A controlled study of 1001 adults in the community." Journal of Clinical Psychiatry 67.4 (2006): 524-540.) This just goes on and on, and I lack the energy or desire to exhaust the available information that shows that adults with untreated ADHD do not do well.

        Perhaps, if you take a large population of children diagnosed with ADHD, with mild, moderate, or severe cases, with good diagnosticians and bad, treated skillfully or treated poorly, with a range of medications with varying effectiveness by pediatricians, family practitioners, as well as psychiatrists, it is possible that there may not be substantial effects of meds over all. Nonetheless, in regard to the hundreds of adults I have treated over 30 years, with the psychopharmacology I have studied, and the literature I am familiar with, I completely disagree with you, though I do appreciate your thoughts. Best wishes to you.

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        • Anecdotes are not scientific evidence except in the crudest sense. I’m not saying the drugs have no effects or that “ADHD” is trivial or that people so diagnosed don’t do worse than the general population in a number of significant ways. I’m saying that, for instance, the claim that “untreated ADHD leads to delinquency” is false, because “treated” ADHD kid aren’t less likely to become delinquent. BOTH groups are more likely to commit criminal acts, though interestingly, I recall reading a study where those identified early on as non-aggressive “ADHD” types did not commit more criminal acts later. But it makes sense, impulsive people are more likely to do impulsive things, and committing crimes is often impulsive. The point is, IN THE COLLECTIVE, we do not reduce the delinquency rates by “medicating” the subjects. This does not mean a particular individual wouldn’t, say, feel better about school, improve their grades, or even say, “This stuff saved my life!” But those are anecdotes. Scientifically, we have to look at the overall effect, and overall, the effect of widespread stimulant use on the population is not large, if we look at the data rather than stories.

          I would submit to you that there are plenty of people whom you don’t know whose situations might have gotten worse to the same degree your client base got better. I don’t know what kind of selection bias you have in your population, but I worked with foster youth and saw plenty whose lives deteriorated after starting stimulants, particularly due to aggression toward others. Many ended up with more drugs and worse “diagnoses,” one ended up psychotic until she herself stopped the drugs and went back to her old “normal.” So anecdotes can tell many stories. Collective data is more reliable.

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          • Perhaps you don’t know what anecdotal evidence means, or perhaps you didn’t read his reply. Note the numerous studies he actually cites and effects with confidence intervals – these aren’t correlational, longitudinal studies (which are incapable of establishing causality), they are the product of extensive clinical research. You complain about anecdotes, then say “I’m saying that, for instance, the claim that “untreated ADHD leads to delinquency” is false, because “treated” ADHD kid aren’t less likely to become delinquent” – without citing any studies. You then mention that you recall reading some studies – maybe if you could link to them or at least provide citations so folks could read them too, you might be persuasive.

            The scare quotes for terms such as ADHD and diagnoses suggest a basic disrespect for the subject matter. Your off-hand dismissal of a solid rebuttal reflects a mindset anchored in opinion, not science.

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          • Here are the references I quoted. Barkley and Cunningham 1978. Swanson et al 2003. Oregon Medication Effectiveness Study 2002. Montreal ADHD Study. Raine study from Australia. Finnish comparison study to USA cohort. Not to mention Whitaker himself, who summarizes the extant literature.

            How are these not citations of clinical studies? Barkley in particular is a super pro-ADHD researcher. It seems you didn’t read my earlier posts yourself. My comments are firmly rooted in years of long-term research, which you’d know if you’d bothered to read Whitaker’s work before deciding you already know all about the subject. It’s not too late to educate yourself, but I get tired of repeating the same lessons for folks who don’t seem interested in seeing another viewpoint.

            And the author mentioned his “clinical experience” including a specific case, as I recall, which is 100% anecdotal. I am very clear what anecdotal evidence looks like.

            I think it would be nice if you would learn to respond without putting down the person you are disagreeing with.

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        • Thank you, Dr. Mendelson, for sharing your experience. I am one of those late-diagnosed people with ADHD for whom medication has been invaluable in managing my symptoms.
          I never want to go back to how my life was before treatment. I’ve had to, due to the current shortage of medication in my country, and it’s been an unwanted wake up call to how much I actually need this treatment – I was having some doubts before as to whether I was really benefiting from it.
          Since stopping treatment, I’ve self-harmed 3 times, had increased suicidal thoughts and emotional volatility, hugely decreased resilience to stress of any kind, and increased risk taking behaviour.
          I was forced to notice these changes, and it was impossible to attribute them to anything else other than the lack of treatment (I was on too low a dose and outside of any withdrawal window for it to be that).
          The point of this story? If adults with ADHD are asked to review the effectiveness of their treatment *while taking it*, or having taken it for a while, it’s likely they might say it’s not very effective. It doesn’t mean they’re right, or objective. I would also question the perception of effectiveness against the expectations of what effectiveness looks like – reaching a normal baseline might feel like treatment failure if the expectations are that “all my problems will disappear”.
          Moving on, thank you for arguing, better than I ever could, the human (or as some call it, “anecdotal”) side of science. Not listening to people like me would just be another kind of failure of care.

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    • ADHD drugs are amphetamines, which means they have the capacity to harm the cardiovascular system. Responsible M.D.’s look for reasons behind someone’s inability to focus before handing out amphetamines like Halloween candy.

      There can lots of different reasons why people have a hard time focusing: boredom, frustration, pent-up physical and/or creative energy, too much caffeine or sugar or non-typical learning/working styles. A lot of times problems focusing are rooted in past or present emotional issues from dysfunctional relationships (family, school, work).

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    • THIS. It’s not like we take medications “for a little help studying”. The world was not built for ND people. We suffer and fail trying to fit in, and just do life. Meds ARE like a miracle. I was undiagnosed til age 38. Suddenly I could have a long list of tasks and instead of being overwhelmed and panicky and paralyzed, I could just set to work and do things in a sensible time and order. I could choose what to pay attention to, instead of everything and nothing all at once. I stopped living in fear and dread that I had forgotten items, lost important documents, missed appointments or deadlines. Let’s also be real here- if people live long enough, CVD kills all of us. So you could say, the study proves they are more likely to die of natural causes. Rather than all the other ways ADHD people can die earlier than their peers.

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    • If a drug makes you feel good it doesn’t mean its good for you. Alcohol for example. Its all the same principle, your brain always fights back for the balance the drugs are destroying. See Dr. Peter Breggin about that. “All psychotropic drugs are neurotixins”. They are all nasty. So, we take them anyway for what they do for us. Is there no better solution? Has anyone studied the art of believing differently? Is there anyone with research to measure the difference between people who really change beliefs about themselves over time compared to those who don’t. Go on, I dare you! Build the study. Psychology can surely determine a matrix of what a person believes about themselves and offer them a new recipe of ideas that they could choose to positively believe, based on reasonable facts. Well, theres a hypothesis in the works anyway.

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    • Therapeutic vs. recreational dosages are hugely different.

      Furthermore, what usually ends up killing drugs addicts is whatever the drugs are cut or contaminated with. Many of the actual intended/wanted substances aren’t that dangerous.

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  4. MANY adults end up on stimulants after taking SSRIs (etal). for years and decades, often with no improvement or dramatic worsening of “depression”. “You don’t really know what it’s doing and you might get worse if you stop (the SSRI/SNRI antidepressant), per docs. Patient tries and DOES get worse, but it is actually withdrawal/ brain damage unmasked by the changing doses, even when done slowly and carefully. If patient is not aware, they feel that the doc was correct and the drug actually IS helping. Patient continues to worsen.

    At this point, some docs add a stimulant/ dopamine booster which works like MAGIC to lift the depression caused by the SSRI. Codes it as ADD (no H), but advises patient to stay on the serotonin drug, also. After losing decades of their life to serotonin drugs, finally feeling “normal” is worth just about any risk.

    ADHD drugs are also used for cognitive impairment/dementia.

    I hate psychotropics with a passion, especially used in kids, but this is one class I’m on the fence about (in adults). Also, they work immediately, so one knows if it may help and does not get locked onto a drug that is nearly impossible to discontinue due to “withdrawal” that happens with serotoninergic drugs, benzos, anticonvulsants, etc.

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  5. No correlation to the disordered eating, poor diets, or many other compulsive behavior that could lead to the same diagnosis? How many of those counted stopped ADHD medication and started to self medicate with excess caffeine or street drugs? It’s not like this is a childhood disorder that magically goes away for everyone at adulthood. For females, it’s often not diagnosed until adulthood after a lifetime of being told they have either depression or anxiety.
    This isn’t a true study, this a correlation based on cherry picked facts.

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  6. I think it’s safe to say that the author has established a bias against ADHD medication. Given the other article of theirs promoted here.

    I don’t think I have seen medication referred to as “drugs” quite as often as I have seen in this article.

    “Medication – a substance used for medical treatment, especially a medicine or drug.
    “certain medications can cause dizziness””
    “Drug – a medicine or other substance which has a physiological effect when ingested or otherwise introduced into the body.
    “a new drug aimed at sufferers from Parkinson’s disease””

    Addicts don’t take ‘medications’, they take drugs. They do drugs, they are “druggies”… Do you see?

    The connotation alone that “drugs are bad”, and the word itself (regardless of the correct usage of the word) has a negative spin behind it.

    The authors use the correct verbiage “medication” in their study of correlation, but the article writer, Richard, can’t seem to use the word to save their life.

    And, I love the language of numbers even if I don’t understand it, but what I do know is that correlation does not equal causation. We have nothing but numbers, medical family history is not taken into account.

    Ischemic heart disease is the leading cause of death worldwide. ADHD is being more acknowledged and recognized by the medical community more and people who have been struggling their entire lives are finally getting exhausted enough to ask for a diagnosis. It stands to reason that some people with ADHD and being treated are likely to already be predisposed to heart disease, because statistics.
    Is it increased risk or increased diagnosis of ADHD?

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    • ADHD being “more recognized” would in no way make it more likely that people taking stimulants being more likely to develop heart problems. It’s not a new suggestion. Probably not a common event but it sounds like more common if you take stimulants. Knowing what we know about stimulants, the increased risk of heart disease associated with them should not be surprising.

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  7. Gee I think the last paragraph provides a clear synopsis of the author’s bias on this topic.
    Of course there a numerous studies that demonstrate profound improvements in the quality of life of ADHD patients on these medications but none are mentioned here.
    This study may actually be suggesting that ADHD patients are at increased risk of CVD as this is purely correlation and not causation.
    Further the risk is actually fairly small when compared to the risks associated with NSAIDs and Antipsychotics.
    So the statement that this risk may outweigh the benefit when the efficacy is strong and established and the etiology is clearer than just about any other neuropsychiatric disorder described is unsupportable.

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    • I so agree! It’s been fascinating to read all this so far, author bias notwithstanding. I am a medicated ADHD’er who has to juggle the KNOWN risk of impact on the heart as against the known risk of being unable to effectively function and take care of myself and my disabled kids .

      For now the benefit is so extreme that I daren’t consider stopping the meds. When we all are supported by state disability help, then things will be different.

      I guess when I can’t take them any more, and as we know exercise helps, I will spend half an hour on the treadmill and then do half an hour’s work. I just hope it’s half as effective as the meds have been for me.

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  8. I tend to think as adults we ought to be able to use whatever we like within the law to make things better for us – totally different story when it comes to children.

    We also need to stop lying to people telling them they have ‘adhd’ and that the drugs are medications treating this fiction- amphetamines tends to change the mind of most people that use them but being a drug they can also be unpredictable.

    The ‘meds’ or drugs are massively popular streets drugs for a reason.

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  9. I think as adults we ought to be able to use whatever we want to help us cope as long as its within the law. The trouble is people are so duped by the mental ill health industry that informed consent seems impossible. People now firmly believe in the fiction of ‘adhd’ and that amphetamines are ‘medications’.

    There’s a reason why these drugs are firm favourites on the streets – many people find amphetamines focus the mind, improve attention etc – this is simply the pharmacological effect on the nervous system for many people. Of course some folks experience paradoxical effects.

    The problem I have is that the disease mongering drug pushing con trick has not only duped millions of adults its also impacting millions of children. In my opinion this is dangerous and abusive .

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