Stimulants can feel incredible (to some people).
Not in the same way that “I had a good night of sleep” can feel incredible. More like: “the world is sparkling, everything is wonderful, I can start anything” incredible. It verges on euphoria and it happens because these medications are potent dopaminergic agents. They activate the receptors in your brain that tell you things are EXTREMELY INTERESTING.
That subjective feeling is the entire problem. Don’t get me wrong, I have no inherent concern with people feeling supranormal. I have no issue with prescribed medications making folks feel better…that’s why I prescribe antidepressants, after all. And stimulants have a long history of being (mostly ineffectively) used as antidepressants since the 1930s. None have FDA approval for this indication, btw.
Because the locked-in/hyperinterested feeling is so strong, we confuse it with a large objective improvement in attention. But when you actually measure attention and cognitive performance, the gains are usually small-to-moderate.¹ And then, in the background, the long-term risks start accumulating. Not to be too cynical, but there is nothing free in this world. And the bargain you make with prescription stimulants is no different. Certain costs just stay hidden for a long time.
This post is about that mismatch:
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Big subjective glow-up vibes (not performance)
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Small-to-moderate objective focus gains
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Real long-term physiological and psychiatric risk
So, how much do stimulants improve focus in people without ADHD?
Surprisingly (or not for regular readers of Attention, Please), much less than most people think.
When you “borrow” an Adderall from your friend you might feel like you hammer through a week’s worth of tasks in a day. But, well, the data consistently does not agree. A meta-analysis of “smart drugs” in healthy, non-sleep-deprived adults found methylphenidate’s overall cognitive effect size was ~0.21 (small).¹ Amphetamine was found to have essentially no effect (and Modafinil in the middle). That’s the average across cognitive domains.
The domains with the stronger signals were still mostly small-to-moderate:
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Sustained attention: ~0.42
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Inhibitory control: ~0.27¹
That’s not nothing. But it’s not what people think they're getting when you hear most prescription stimulant users report their experience.
And in a perhaps more “real-world-ish” experiment (complex optimization tasks) that might more closely match what you have to do in a white-collar office job, methylphenidate, dextroamphetamine, and modafinil increased effort but reduced the value/quality of the solution compared to placebo.² Translation: you may work harder, feel more locked in, and still produce worse work.
This is not the first study to demonstrate that, sure, output might go up, but quality does not…and remind me again, why are you taking these medications?
So yes--stimulants can make you feel like a beast at work. But the measured improvement in attention is small, and sometimes the vibesy “feeling” is the main effect, which yields more, poorer work. Then why do you feel good even when your work is objectively garbage? Well, you aren’t an unbiased judge of the quality of your work when you are dosed on stimulants. They make you more interested in (boring, perhaps) work, and they make you less able to tell that your work is of lower quality.
The work feels more interesting, your output feels more interesting, but objectively, consistently, nearly-universally, your work is worse. There’s just a lot more of it. If your work quality doesn’t really matter, you are just inputting data into spreadsheets, yeah, Adderall might get you to the finish line faster or make you suffer less from the process. But these medications essentially put a ceiling on the creativity you have access to in your own brain.
In Adults with ADHD: slightly better signal, still usually “small-to-moderate”
If you actually have ADHD (genuinely diagnosed in a rigorous way by a licensed professional), the medication effects are larger than in healthy users. But they still typically land in the small-to-moderate range depending on what you’re measuring and can't be generally be classified as life-changing when looking at objective data.
When you measure ADHD symptoms, stimulant effects commonly cluster around ~0.3–0.5 (small-to-moderate).³
But when you measure more objective neurocognitive performance (attention tasks, working memory tasks, inhibition tasks), the effects can look smaller and more domain-specific:
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Executive function meta-analytic signals like sustained attention (~0.4), response inhibition (~0.4), working memory (~0.2) show up as small-to-moderate.⁴
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Broad meta-analytic estimates of neurocognitive improvement can be small on average.⁵
So: even in adult ADHD, “focus/attention improvement” is often small-to-moderate. Which matters, because the cultural narrative sounds like, even if you have ADHD: stimulants turn your brain into a laser. And they do in a way. They make whatever is in front of you feel quite interesting, but just like leaving a laser focused on a single point for too long, they can just burn through the target, not etching out some beautiful design. It just consumes the target, it doesn’t elevate it.
And even for adults with ADHD, the quality of the output is poorer on stimulants. You may finish the assignment, it perhaps wouldn’t have gotten done without the medication, but I’ve seen so many people conflate “finishing” with “putting out my best work” when stimulants just don’t really do the latter.
How the bill starts to come due: The 2024 cardiovascular data
Now comes the part that we, within the psychiatric community, haven’t discussed enough, mostly because there really hadn’t been much published about it that was high quality.
We also tend to underplay long-term risks when we are treating patients (other than maybe TD in antipsychotics) because either we are unaware of longer-term risks, there are fewer studies highlighting these risks, we implicitly think our patients will stop medications before these risks become relevant, or more nefariously, we don’t want to scare off customers (gross, but it happens).
A 2024 JAMA Psychiatry paper from a large case control study in Sweden found that longer cumulative duration of ADHD medication use was associated with increased risk of cardiovascular disease--especially hypertension and arterial disease.⁶
The hypertension numbers I now highlight to every patient I’m discussing stimulants with:
Compared with nonuse:
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3 to ≤5 years cumulative use: adjusted odds ratio (AOR) 1.72 for hypertension
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5 years cumulative use: AOR 1.80 for hypertension⁶
This means the longer you stay on these meds, the more likely you are to end up with a blood pressure problem. And for reference, roughly 30-60% of adults (starting ADHD meds after age 25) are still taking prescription stimulants at 5 years.⁷ So when I consider starting a stimulant for a patient, these are relevant risks because many of them will be on it for years.
Apart from this long-term study, the broader cardiovascular literature has been saying the same quiet thing for years: stimulants produce modest elevations in resting heart rate and blood pressure.⁸ “Modest” doesn’t mean harmless when you keep the stressor on your heart and vessel walls for years, maybe decades.
If you’re already edging into metabolic issues (~90% of American adults), poor sleep, high baseline stress, too much caffeine, too little cardio, too much brain-rotty TikTok scrolling--you’re basically building the perfect microenvironment for stimulant-driven hypertension and the predictable sequelae. All for higher output, lower quality work?
Psychosis/mania risk: it’s not rare enough to ignore
A 2024 American Journal of Psychiatry case-control study looked at incident psychosis/mania in young people and found:
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Past-month prescription amphetamine use was associated with ~2.68x increased odds of psychosis/mania
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High doses (>30 mg dextroamphetamine equivalents) were associated with ~5.28x increased odds⁹
That “>30 mg dextroamphetamine equivalents” corresponds roughly to doses people don’t even think of as extreme (for example, ~40 mg of mixed amphetamine salts, and higher-dose Vyvanse equivalents).⁹
This matters because “stimulant drift” is a common clinical phenomenon from well-meaning prescribers and magic-pill-seeking recipients:
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You start at a dose that “works”: the world is shining.
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The initial sparkle fades over weeks-to-months.
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You get the dosage increased, the sparkle briefly glimmers back.
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The side effects rise faster than the benefits.
And the scary part is that the first warning signs of too much medication often look like “productivity”:
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less sleep, more confidence, more talking, more grand plans, more intensity
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until it’s not productivity anymore, it’s genuinely transitioned into psychopathology: anxiety, racing thoughts, insomnia, maybe even paranoia or mania
Bear in mind, the 2.7-5.3x increase in psychosis/mania is from a very low base rate, so this isn’t happening often, but when people nonchalantly speak about stimulants like they are as benign as multivitamins, this just has no basis in reality. If something 4x’s your risk for a severe psychiatric symptom constellation, people need to be made aware of what can happen.
“But it’s prescribed (so I can’t be misusing it)”
This is the other under-discussed risk: dependence and use disorder in people who started with legitimate prescriptions.
A 2025 JAMA Psychiatry analysis found that among U.S. adults using prescription stimulants:
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~25.3% reported misuse
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~9.0% met criteria for prescription stimulant use disorder (PSUD)¹⁰
And here’s the key detail people miss: PSUD wasn’t limited to obvious “abusers.” Many people with PSUD reported patterns consistent with dependence-like use even without the stereotypical behaviors.¹⁰
A summary of the same dataset reports that even among those who used only their own prescribed stimulants, about 7.8% still met criteria for PSUD.¹¹
So if you’re thinking, “I’m safe, I’m not crushing and snorting it, I’m not buying it off someone,” cool. That’s not the full definition of the problem and not indicative of you not being at risk for a substance use disorder despite someone sending you a script with your name on it. One in four PRESCRIBED these medications REPORT misusing them.
I don’t know off the top of my head what that would actually represent in terms of actual frequency of misuse, but I’d imagine there is a relatively large subset of people who misuse who WOULD NOT ACTIVELY REPORT this, so let’s take this as an absolute floor with the real number possibly in the ~30-40% range.
The other things psychiatrists notice, but patients don’t
Some of the most corrosive stimulant effects aren’t dramatic plunges into psychosis. Per above, yes, this can happen, but no, for the vast majority of folks taking these (legitimately or not), you will never experience this. The really subtle stuff can be almost imperceptible shifts:
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Sleep debt you stop noticing (until you’re brain is essentially relying on stimulants to function at all)
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Irritability that becomes your personality; we often see it as an emergent “edginess” that almost feels like aggression/hostility that can creep up on a person over months or years of stimulants
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Anxiety that can be completely new, challenging to treat and often underappreciated because so many of the typical somatic symptoms of anxiety can be misinterpreted as “common” side effects of stimulants (racing heart, shortness of breath, shaking, muscle tension, headaches)
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Appetite suppression you interpret as “discipline” or even see as a benefit, though often can be loss of muscle mass rather than fat mass due to insufficient protein intake
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A flattened reward system where normal life feels dull without artificial chemical activation of those over-tapped dopamine receptors⁸
This is the perfect setup for getting yourself trapped: you tell yourself the medicine makes ordinary life tolerable, which makes stopping feel impossible, but you’ve only gotten here because of the background worsening of so many things from the medicine in the first place.
Finally: the mortality question -- yes, ADHD meds correlate with fewer “unnatural deaths" but it's not so straightforward
A big Swedish registry study in JAMA (2024) used a target-trial emulation design and found that starting ADHD medication was associated with lower all-cause mortality and lower unnatural-cause mortality over two years.¹²
Here are the actual numbers:
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All-cause mortality (2-year): 39.1 per 10,000 (initiators) vs 48.1 per 10,000 (non-initiators)
Risk difference: -8.9 per 10,000; HR 0.79 ¹² -
Unnatural-cause mortality (2-year): 25.9 per 10,000 vs 33.3 per 10,000
Risk difference: -7.4 per 10,000; HR 0.75 ¹²
And the “where is that benefit coming from?” details matters: a big portion of the unnatural-cause signal is accidental poisoning (risk difference -6.0 per 10,000; HR 0.47).¹²
So yes: in actual ADHD populations, there’s a plausible story where treatment reduces some combination of accidents, impulsive disasters, substance-related morbidity/mortality, and certain external-cause deaths.
But there's a problem with reporting this as gospel: the protective signal depends on who is getting the medication.
A JAMA Psychiatry (2025) nationwide Swedish study sought out to answer a question relevant to the more "liberal" prescribing of stimulants popular in the US and highlighting the limitations of the JAMA 2024 study: as ADHD medication prescribing rises and the treated population broadens (i.e. gets less acute), do the “real-world outcome” benefits change? The answer they found was that the protective associations weaken over time as prescription prevalence rises (in Sweden, from 0.6% to 2.8%).¹³ The paper shows the same drift across outcomes I'd intuitively expect: as more higher-functioning/lower-risk people get medicated, the “reduced traffic crash/injury/crime” effect gets diluted.¹³ Some very small, very severely affected patient population with debilitating ADHD (which definitely exists) needs stimulants to not crash their cars/not pay attention when taking other medications/substances, but these stimulant medications are NOT life saving to the many folks taking them to boost their Excel output.
If you’re a “high-functioning adult with ADHD” who mainly wants help grinding through a day of spreadsheets, you probably weren’t at high baseline risk of dying from an unnatural cause in the first place. So the mortality “benefit” becomes a rounding error.
But the risk exposures don’t ever become rounding errors. You’re still taking a drug class that pushes blood pressure up and--per the long-duration cardiovascular data we already covered--is now tied to meaningfully higher odds of hypertension over years.⁶
Going further on the direct issue about stimulants and mortality, a Journal of Clinical Psychopharmacology (2025) study looked at mortality risk using two very different "lenses": FAERS (the FDA adverse event reporting system) and an EHR-based self-controlled case series. They found:
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In FAERS, dextroamphetamine and methylphenidate (and the stimulant class overall) were associated with higher reporting of sudden death (RR ~2.0 overall; ~2.24 for dextroamphetamine; ~2.30 for methylphenidate).¹⁴
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In the EHR SCCS, dextroamphetamine, methylphenidate, and the stimulant class were associated with all-cause mortality in the post-initiation risk window (RR ~3.5 for stimulant class; ~4.0 dextroamphetamine; ~4.1 methylphenidate), with higher relative risk at older ages of first use (except lisdexamfetamine).¹⁴
Do I think those ~2-4x magnitudes are “the truth” in a causal sense? No. Both "lenses" are biased/confounded but the correct response is definitely not to flatly ignore the paper.
If the supposed mortality upside is mostly about external-cause prevention in genuinely high-risk, quite severe ADHD populations, and that upside is already weakening as prescribing broadens…then for the low-risk, high-functioning adult, the risk-benefit math shifts toward "you’re mostly just increasing CVD/psychosis/other risk." ¹² ¹³ ¹⁴
How stopping stimulants tends to feel: not great, Bob
Ok, you get it, after this litany of issues, maybe this class of medications isn’t the solution to all of life’s problems. (And just to be candid, I haven’t even really covered the plethora of box-insert warnings for stimulants, there’s a whole lot more that can happen that is not pleasant!) But a caveat first: this isn’t medical advice. If you’re on prescription stimulants, talk to your prescriber before changing anything.
Especially if you’re on higher doses, have comorbid mood issues, or have been on them a long time. THIS IS NOT ADVICE!
With that said, here’s the basic shape of what people report when they come off stimulants (especially after long-term daily use):
Common short-term physiological symptoms:
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fatigue, sleepiness, “lead suit” body
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low mood, anhedonia, irritability
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brain fog, slowed thinking
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increased appetite ¹⁵ ¹⁶
What can make it psychologically hard:
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no instant-on “spark” whenever you like
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boring tasks feel actually boring and wholly uninteresting
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you realize how much of your life has been propped up by prescription chemicals¹⁶
A clinical review of stimulant withdrawal describes an early crash phase followed by a longer period where mood, energy, and sleep can stay altered for a while.¹⁵ The ASAM/AAAP guidelines on stimulant use disorder emphasizes support during withdrawal and early recovery, because this is the high-relapse zone and generally feels more challenging than people believe the process will be.¹⁶
A practical off-ramp (theoretically)
If you’re stopping under direct clinical supervision, the broad principles you can discuss with your physician are generally:
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taper instead of abruptly discontinuing (especially if you’ve been on high doses or long duration)
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ferociously protect sleep (knowing you will be much more tired than normal, trust it)
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expect a temporary focus/motivation dip (seems obvious, but people still get surprised by it)
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stick to the basics: exercise, sunlight, consistent sleep/wake time, non-fried/high-quality food
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reduce other stimulants (caffeine) if they’re now compensatory, and you will be tempted to over-drink coffee given your predictable lethargy
Why my patients often tell me they've decided to D/C
Because a lot of people eventually realize:
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they weren’t actually more focused, they were artificially interested in tasks and work quality didn’t improve
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the “benefit” was often a drive/euphorigenic effect, not a cognition effect and there were a lot of little side effects that eventually just wore them down
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their cardiovascular system is not getting younger, they have other risk factors, or just want to minimize factors that are completely within their control for CVD
If you truly need stimulants, okay, some do. The JAMA 2024 paper gives an important perspective on the actual life-saving nature of these meds for a select group. This IS NOT most adults currently prescribed psychostimulants in the US. So if you are getting a prescription because it is convenient or because you didn’t previously know about the risks (or very modest benefits), at least let the final choice to continue with this regimen be an adult decision: small-to-moderate objective gains against real long-term risk.
Don’t let the good vibes at the beginning fool you. Nothing in this life is free.
References
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Roberts CA, Jones A, Sumnall H, Gage SH, Montgomery C. How effective are pharmaceuticals for cognitive enhancement in healthy adults? Eur Neuropsychopharmacol. 2020;38:40–62.
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Bowman E, Coghill D, Murawski C, Bossaerts P. Not so smart? “Smart” drugs increase the level but decrease the quality of cognitive effort. Sci Adv. 2023;9(24):eadd4165.
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Cortese S, Adamo N, Del Giovane C, et al. Comparative efficacy and tolerability of medications for ADHD in children, adolescents, and adults: a systematic review and network meta-analysis. Lancet Psychiatry. 2018;5(9):727–738.
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Tamminga HGH, Reneman L, Huizenga HM, Geurts HM. Effects of methylphenidate on executive functioning in adults with ADHD: a randomized placebo-controlled trial. Eur Neuropsychopharmacol. 2016;26(4):645–656.
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Pievsky MA, McGrath RE. The neurocognitive profile of ADHD: a meta-analysis. Clin Psychol Rev. 2018;59:101–115.
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Zhang L, Li L, et al. Attention-Deficit/Hyperactivity Disorder Medications and Long-Term Risk of Cardiovascular Diseases. JAMA Psychiatry. 2024;81(2):178–186.
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Brikell I, Chang Z, et al. ADHD medication persistence and adherence in adults: a population study. Lancet Psychiatry. 2024.
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Torres-Acosta N, O’Keefe JH, O’Keefe EL, Lavie CJ. ADHD stimulant medications and cardiovascular risk. J Am Coll Cardiol. 2020.
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Moran LV, et al. Risk of Incident Psychosis and Mania With Prescription Amphetamines. Am J Psychiatry. 2024.
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Han BH, et al. Prescription Stimulant Use Disorder Among US Adults. JAMA Psychiatry. 2025.
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(Subgroup estimate referenced in-text: “~7.8% in the last year.”)
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Li L, Chang Z, D’Onofrio BM, et al. ADHD Pharmacotherapy and Mortality in Individuals With ADHD. JAMA. 2024;331(10):850–860.
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Li L, Coghill D, Sjölander A, et al. Increased Prescribing of Attention-Deficit/Hyperactivity Disorder Medication and Real-World Outcomes Over Time. JAMA Psychiatry. 2025;82(8):830–837.
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Morrow JP, Moreton U, Xu T, et al. The Association Between Stimulant Medication Use and Mortality. J Clin Psychopharmacol. 2025;45(6):554–561.
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Li MJ, Shoptaw SJ. Clinical management of psychostimulant withdrawal: review of the evidence. Addiction. 2023;118(4):750–762.
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Clinical Guideline Committee (CGC) Members; ASAM Team; AAAP Team; IRETA Team. The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder. J Addict Med. 2024;18(1S Suppl 1):1–56.