Stimulant medications have long been considered the “gold standard” for treating ADHD. When I tell colleagues I don’t prescribe them, I often get pushback: “But it’s the first-line treatment for ADHD!” In my functional and integrative psychiatry practice, I am upfront: I do not prescribe stimulants for ADHD. For patients who are interested in stimulant treatment, I provide referrals to trusted colleagues who do. This decision is not about denying that ADHD exists or that stimulant medication provides great outcomes for many patients. ADHD is real. The struggles are real. The difficulties with inattention, task initiation, focus, emotional regulation, impulsivity, and self-esteem can profoundly impact a person’s relationships, work, education, and sense of self. However, after years of clinical experience and a review of the literature, I do not believe the benefits of stimulants outweigh the risks. Instead, I’ve had excellent outcomes using a combination of non-stimulant medications, functional and integrative approaches, ADHD coaching, and by also addressing and treating co-occurring conditions such as anxiety, depression, trauma, OCD, and bipolar disorder.

The risks we pretend aren’t there

Stimulants are not without risks, both acute and cumulative. Yet the cardiovascular consequences, in particular, remain underappreciated. Years ago, I inherited a 22-year-old patient who had been prescribed stimulants since childhood by an Ivy League-trained psychiatrist, but had not once received an ECG. In the U.S. it often isn’t deemed necessary unless there is a personal history of cardiac issues, or a familial history of sudden cardiac death. When this patient’s ECG results came in via fax they revealed a prolonged QTc interval (490ms), a cardiac abnormality that can trigger Torsades de Points (TdP), ventricular tachycardia, ventricular fibrillation, and sudden death. She also carried a diagnosis of an eating disorder, had a low BMI, and was prescribed a selective-serotonin-reuptake-inhibitor (SSRI) that also had the risk of possible QT prologation. These compounding risk factors, malnutrition, low BMI, eating disorder, and stimulant use, placed her at heightened cardiac risk, yet no one had monitored her cardiac function the entire time she was on stimulant medication (since age seven years old). (Case adapted from author’s clinical experience.)

Her case is not unique. A recent large-scale retrospective study presented at the 2024 American College of Cardiology Annual Meeting found that young adults prescribed stimulants had a 57 percent higher risk of developing cardiomyopathy, a weakening of the heart muscle after eight years of use, compared to matched controls. While the absolute risk was low, the relative increase was substantial, and the potential for long-term cardiac remodeling cannot be ignored.

A dear friend and colleague lost her vibrant, healthy, and active 12-year-old daughter to sudden cardiac death. She had no prior symptoms. No warnings. Her loss haunts me, not only as a parent, but as a provider. I can’t help but wonder: could routine cardiac screening, like the school-based ECGs in Japan or the mandatory athlete screenings in Italy, have saved her life?

This raises a deeper concern. If sudden cardiac death can occur in otherwise healthy children, with no stimulant exposure and no warning signs, what, then, is the risk in those exposed to medications that are known to elevate heart rate, increase blood pressure, and prolong the QT interval? Large-scale studies have not conclusively linked stimulant use to sudden cardiac death in children, but such outcomes are rare and often underreported. The absence of conclusive evidence does not mean an absence of risk, particularly when we are medicating millions of children without routine cardiac evaluation.

In Japan, universal ECG screening in children has identified serious but silent cardiac anomalies in 0.3 percent of children, potentially preventing future tragedies. Italy’s program of screening all children in sports led to an 89 percent reduction in sudden cardiac death among young athletes.

These aren’t abstract statistics. They are lives saved, or lost, based on whether or not we choose to look. In the U.S., we routinely require cardiac clearance before sports participation, but not before prescribing powerful sympathomimetic agents like methylphenidate or amphetamine salts, drugs known to elevate heart rate, increase blood pressure, and, in rare but documented cases, precipitate catastrophic cardiovascular events.

If we demand an ECG for a student to run cross-country, why don’t we demand the same caution before starting them on a daily, long-term stimulant?

The psychiatric costs we overlook

The risks of stimulants are not just cardiac. Psychiatric side effects including anxiety, depression, insomnia, mood lability, mania, and, in rare cases, psychosis should give clinicians pause. A major 2022 meta-analysis found that anxiety and depression are not rare side effects of ADHD medications in children and adolescents, they’re common. Yet only 11 percent of clinical trials even measured these outcomes. That’s not just a gap in data; it’s a blind spot in how we assess safety. Meanwhile, post-marketing surveillance tells a very different story. Reports of anxiety, mood changes, depression, and even suicidality appear far more frequently once these medications are used in real-world settings, outside the tightly controlled conditions of clinical trials. A comprehensive 2023 review confirmed that all stimulant medications carry a risk of psychosis, although rare, with amphetamine-based medications carrying the highest risk compared to methylphenidate. These psychiatric effects aren’t common, but when they do occur, the consequences can be serious. Despite this, psychiatric side effects remain significantly underreported, and we still lack sufficient long-term safety data. In other words: what we don’t track, we can’t prevent. And what we don’t report, we don’t warn families and patients about.

Rethinking ADHD

None of this is to minimize the reality of ADHD. ADHD is a real neurodevelopmental disorder that has challenges across many domains. These challenges often ripple into every part of life, deeply affecting work, relationships, academic performance, and self-esteem. But are stimulants the best, or only, answer? Decades of follow-up research suggest they may not be. The landmark MTA study found that while stimulants improved symptoms at 14 months, the benefits had largely disappeared by 36 months, with no lasting improvements in learning outcomes. Some researchers have suggested that what we are often labeling as ADHD, rather than a true neurodevelopmental disorder, may in many cases be the result of overdiagnosis or mislabeling, particularly when symptoms stem from chronic sleep deprivation, trauma, rigid classroom environments, nutritional deficiencies, PTSD, or screen-related overstimulation. That’s why ADHD demands careful, nuanced evaluation by clinicians who are well trained in both its neurodevelopmental origins and the many environmental, emotional, physiological, and even medical factors that can mimic or amplify its symptoms. Misdiagnosis doesn’t just lead to inappropriate treatment, it risks missing the real root of a person’s suffering.

Response to common objections

Some critics may argue: “Yes, there are risks, but they’re rare. And untreated ADHD also carries risks: school failure, accidents, depression, even suicide.” These concerns are valid. Untreated ADHD can be profoundly impairing and should not be minimized. However, acknowledging the risks of stimulants is not the same as denying the condition or withholding care. Rather, it’s about ensuring that treatment is individualized, evidence-informed, and safety-conscious. As clinicians, we are trained to evaluate risk-benefit ratios. But that evaluation is only meaningful if we acknowledge all of the risks, especially the ones that are inconvenient to the current standard of care.

What informed consent should include

Patients and families deserve to know:

• Stimulants can, in rare cases, trigger life-threatening cardiac complications.
• The risk increases with longer duration of stimulant use.
• Cardiac risk may be amplified when combined with other medications that affect cardiac conduction, including:
  • SSRIs
  • Antipsychotics
  • Certain antibiotics
• Underlying vulnerabilities such as electrolyte abnormalities, low BMI, or genetic predispositions may further elevate risk.
• That adverse psychiatric outcomes are common and underreported.
• That long-term benefits may diminish after a few years.
• That non-stimulant medication as well as functional, integrative, and behavioral approaches exist.

Informed consent means equipping families/patients with all the facts, not just the convenient ones.

The influence of industry

Industry-funded studies are significantly more likely to report favorable results for stimulant medications. That doesn’t make the research invalid, but it does call for discernment. We must critically evaluate where our guidelines come from, how they’re shaped, and who benefits. Responsible medicine requires transparency, skepticism, and above all, integrity.

My multimodal, individualized approach to ADHD

In my practice, I use a comprehensive, patient-centered model that emphasizes accurate diagnosis, functional supports, and non-stimulant interventions. This includes:

• Thorough diagnostic evaluation:
  • Comprehensive initial psychiatric and medical evaluation (including appropriate labs)
  • Formal ADHD assessment using:
    • Validated psychometric instruments
    • Structured diagnostic interviews
    • Collateral input from parents, partners, or teachers
• Pharmacologic support (when indicated):
  • Non-stimulant medications as clinically appropriate
• Functional and integrative interventions:
  • Functional and integrative psychiatry
  • Behavioral and lifestyle optimization:
    • Sleep hygiene
    • Exercise
    • Environmental structuring
• Skill-based and coaching support:
  • ADHD coaching
  • Executive functioning training
• Treatment of co-occurring conditions:
  • Targeted therapy for:
    • Anxiety, depression, trauma
    • OCD, bipolar disorder, and related conditions
• Sustainable, root-cause focus:
  • Address underlying contributors to distress
  • Build long-term systems of support beyond symptom suppression

Through this integrative, multidimensional approach, I’ve seen patients achieve meaningful and lasting progress without the use of stimulants.

Where do we go from here?

My call is not to ban stimulants. It’s to dethrone them as the automatic, reflexive treatment for every patient with ADHD. That would mean:

• Mandatory cardiac screening before stimulant trials.
• Better post-marketing surveillance for psychiatric side effects.
• Greater research investment in non-pharmacologic interventions.
• Insurance reimbursement for behavioral, ADHD coaching, and integrative modalities.
• Patient-centered, individualized care that puts safety first.

Conclusion

ADHD is real. So is the suffering it causes. But the reflexive reliance on stimulant medications as the “gold standard” deserves serious reevaluation. Rare but catastrophic cardiac events. Psychiatric destabilization. Diminishing long-term efficacy. These are not theoretical concerns, they are real-world outcomes that demand our attention. We owe it to our patients, especially our children, to do better. To weigh risks honestly. To screen appropriately. And to pursue safer, more holistic strategies whenever possible.

Carrie Friedman is a dual board-certified psychiatric and family nurse practitioner and the founder of Brain Garden Psychiatry in California. She integrates evidence-based psychopharmacology with functional and integrative psychiatry, emphasizing root-cause approaches that connect neuro-nutrition and gut–brain science, metabolic psychiatry, immunology, endocrinology, and mind–body lifestyle medicine. Carrie’s clinical focus bridges conventional psychiatry with holistic strategies to support mental health through nutrition, physiology, and sustainable lifestyle interventions. Her professional writing explores topics such as functional medicine, autism, provider well-being, and medical ethics.