Physicians, every time they initiate a medication treatment, are faced with the question of what possible positive and negative effects this medication may have on this specific individual, both in the short and long term. When it comes to ADHD medications, elevated heart rate and blood pressure are common side effects that are always part of the pre-treatment and ongoing assessment. This is because, if you live with a high heart rate and elevated blood pressure year after year, it can lead to heart problems over time.

However, we don’t know much about whether the quite moderate increases in heart rate and blood pressure associated with ADHD-medications have any negative health consequences in the long term. It’s been difficult to find the answers to questions like this because randomized controlled trials (RCTs) controlling for confounding and excluding chance spanning over many years are expensive, time-consuming, and difficult to perform. Prior to the study by Zheng et al in JAMA Psychiatry, one of the studies with the longest follow-up period, compared young people using ADHD medication with age-matched peers without treatment for 2 years. It showed a slight increase in blood pressure during the day but not at night. The researchers concluded that since the heart gets to rest all night, it probably recovers during that time.

Unfortunately, there are almost no studies that extend beyond 2 years, but Zhang et al follows individuals with ADHD aged 6 to 64 years for 14 years. The results show that individuals using ADHD medications had an increased risk of cardiovascular disease compared to those not using ADHD medication. The risk increased by 4% for each year the medication was used in the first 3 years before it stabilized. However, the absolute risk was low.

So, what does this mean in clinical practice? Should physicians stop prescribing ADHD medications to avoid harming their patients? And should patient refrain from using ADHD medications out of fear of developing heart problems?

No, certainly not! Firstly, it is important to weigh potential risks against proven benefits. Research shows, for example, that central stimulant ADHD medications are effective and reduce the risk of serious outcomes such as accidents, suicides, and criminal activities. Recommending people who use medication to stop based solely on potential cardiovascular risk does not take the broader picture into account. Clear recommendations require more research and studies that also include individuals over 65 years old.

In summary, we welcome well-conducted and large epidemiological studies that examine both risks and benefits of ADHD treatment in adults. Zhang and the research group behind this study are highly experienced and skilled researchers. There has been a lack of well-made research on adults and the long-term effects of medication, and this study is a significant contribution to the growing knowledge base.

However, it is also important to note that:

1. This is an observational study where it is not certain whether there is a causal relationship and in which direction it goes. The increased risk of cardiovascular disease could also be due to other medications or lifestyle factors linked to both ADHD and cardiovascular disease. ADHD itself is strongly associated to a higher risk of cardiovascular disease based on various negative consequences of untreated ADHD.
2. There is a long list of medications that can increase the risk of high blood pressure to a similar extent as found in this study.
3. These results apply at the group level, and as a patient, there is no need to be overly concerned about personal health. In clinical practice, a risk-benefit assessment is always made for each individual patient, weighing the increased risk that higher blood pressure may entail against the gains that ADHD treatment can provide. Physicians regularly follow up with their ADHD patients, focusing specifically on blood pressure and other signs and symptoms of cardiovascular disease during the course of treatment.
4. The increased risk in the study applied only to those with doses 1.5 times higher than the recommended daily dose. If you are within normal ranges, you likely have no increased risk at all.

We would like to emphasize the importance of precision when diagnosing, treating, and following up on psychiatric disorders. ADHD is no exception. We also believe it is crucial to highlight the importance of precision medicine and precision health, meaning always starting from an individual-specific risk-benefit analysis. This is especially true when it comes to individuals with ADHD, as it is such a heterogeneous group of people.

/Team Letterlife

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Lets change the paradigm for female mental, physical and sexual health together!

by Lotta Borg Skoglund

The male body has been, and still is, the societal and medical norm. But females are not just smaller men. Even though an overwhelming number of girls and women testify to how much their hormones affect how they feel and function in their everyday life there is very little actual, scientific evidence of their experiences. Females have namely been less likely to be included in scientific studies on both physical and psychiatric disorders, generating a substantial knowledge gap between the sexes favoring boys and men. This lack of sex- and gender specific data is a risky business for females since inadequate knowledge of biological sex differences have long-term consequences for girls and women worldwide. For an extensive overview of how gender biased data creates a world designed by and for boys and men affecting everything from governmental policies, scientific research and medical practice to technological innovation, urban planning, and the media, I urge you to read award-winning Caroline Criado Perez´ loud and clear call for change, through her powerful book– Invisible Women¹.

Almost three years ago, I wrote the book “ADHD – From Girls to Women, Getting on the Radar”. This book is for many reasons very close to my heart. Not the least since I was entrusted writing some of my patients’ lived experiences of being a girl and a woman with ADHD. I could never have imagined how well the book would be received. In countless emails, texts, phone calls, messages on social media, cheers on buses, and in jogging tracks you are all saying the same thing: finally, someone is taking girls’ and women’s ADHD symptoms and hormones seriously! Standing on the shoulders of giants and great role models such as Svenny Kopp, Sandra Kooij and Susan Young who fought for girls and women with ADHD long before I even knew what ADHD was, I set out to find others that were as passionate as I was to be part of the solution, of the movement.

Together with leading entrepreneurs and scientists, we have started the Letterlife-journey, our goal is to build the first digital tool for sex- and gender specific data collection to improve precision health for girls and women with ADHD. This blog will walk you through the back story of our passionate advocating for sex- and gender influenced mental health research and clinical practice and why we predict that empowering digital tools like Letterlife bare the potential to close the gaps in health outcomes between girls and boys, women and men.

The fact is that females with ADHD are un- or misdiagnosed years longer than males. This leaves a sizable group of girls and women on their own and at risk for developing psychiatric and somatic comorbidity, and considerable health care and pharmacological utilization. Even though women keep telling us that their hormones affect their mood, relationships, and quality of life little has been done to getting these female specific challenges of ADHD on the radar. But there is some light in the tunnel. A recent research article from Harvard Review, by Aril Handy and colleagues² show clearly how the menstrual cycle affect female mental health. In short, this article show that women are more likely to experience symptoms of relapse in psychiatric disorders during the luteal phase of their menstrual cycle (i.e., when estrogen is overshadowed by increasing progesterone). Even though ADHD was not specifically explored in this article, testimonies from women with ADHD of all ages strongly suggest that hormones interplay with ADHD-symptoms as well. Many of my patients refer to the days leading up to menstruation, the postpartum period, and the years around menopause as “the danger zone” and that their ADHD is “out of control” during these periods. Unfortunately almost everyone also tells me that it’s almost impossible to realize this as it’s going on, but rather they look back at the terrible consequences of family conflicts, embarrassing work related meltdowns or regrettable and impulsive decisions and wonder “how the h..l” they ended up in this mess (again). Indeed, a study by Dorani and collegues³ support their testimonies showing that females with ADHD suffer from PMS/PMDD, experience postpartum depression severe climacteric symptoms more often than women without ADHD.

Needless to say, we feel very strongly about changing a society and standard of care that continues to act as if the male is the norm. To this end we will, together with lead patient users, patient organizations, leading researchers, clinicians, social entrepreneurs, and data engineers, develop the first tool for self-monitoring of ADHD-symptoms, hormonal fluctuation and lifestyle factors with the specific aim of:

1. Reducing the time from symptom to diagnosis and treatment in females with ADHD.
2. Improving precision medicine, mitigate co-morbid mental and somatic health problems, optimize, and tailor ADHD-medication and increase the use of tolerable contraceptives for female ADHD.
3. Increasing self-awareness, facilitate informed self-care, decrease polypharmacy, and optimize health care utilization for girls and women with ADHD.

Letterlife operate beyond the diagnostic criteria for ADHD and focus on individual ADHD-profile and neuropsychological processes. This, together with daily tracking of hormonal fluctuation, medication intake and real-life health factors such as diet, sleep, exercise, relationships, and addictive behaviors we can create a unique brain map for every single person with ADHD. The goal? To improve physical, mental, and sexual health and quality of life through improved self-awareness!

By understanding how your ADHD-brain is wired you can start connecting the dots on the most important things in your life. For many, increased self-knowledge is sufficient and empowering enough to start making the preferred and long-term lifestyle changes. Many appreciate the transparent and realistic shared decision making and the pragmatic and holistic focus on what is relevant in your unique life. Again, the goal is always the same: better health, restored self-esteem and improved quality of life!

We look forward to change the paradigm for female physical, mental and sexual health together with you!

1. Invisible women, Criado-Perez Caroline, Abrams Press 2019, ISBN: 9781419729072.
2. Handy et al., Psychiatric Symptoms across the Menstrual Cycle in Adult Women: A Harv Rev Psychiatry. 2022 Mar-Apr 01;30(2):100-117. doi: 10.1097/HRP.0000000000000329.
3. Dorani F, Bijlenga D, Beekman ATF, van Someren EJW, Kooij JJS. Prevalence of hormone-related mood disorder symptoms in women with ADHD. Journal of psychiatric research 2021;133:10-15.

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Become a Beta User

We are developing Letterlife in collaboration with expert patients, clinics, and researchers. Become a beta user and shape the future of Letterlife.