Before You Start Adderall or Vyvanse: The Safety Checklist Your Doctor Should Never Skip

A guide to the heart and mental health checks that make stimulant treatment safe.

Many people receive stimulants without the basic safety checks that prevent problems later. This is what a deliberate evaluation should look like.

What Screening Should Be Done Before Starting a Stimulant?

Hannah, 32, finally booked the ADHD evaluation she had avoided for years, imagining the clinician would either hand her Adderall after five questions or refuse entirely. What happened felt different: a structured conversation, a clear plan, and the sense that someone was thinking with her, not over her.

Stimulants like Concerta (methylphenidate), Ritalin (methylphenidate), Adderall (mixed amphetamine salts), and Vyvanse (lisdexamfetamine) can improve focus, planning, and follow-through. They can also increase heart rate and blood pressure. Good screening does not have to be complicated, but it must be intentional.

1. Clarify Why You Are Considering A Stimulant

Your clinician should explore:

• When attention and organization began to decline

• How symptoms affect work, school, and home

• What you have already tried, including sleep changes, therapy, coaching, or non-stimulants

• Whether symptoms appear everywhere or only in specific situations

If burnout, depression, or chronic sleep loss is the primary issue, stimulants can complicate the picture. A clear diagnostic formulation makes every later decision safer.

2. Take a Focused Medical and Cardiac History

Stimulants do not cause structural heart disease, but they can stress a vulnerable system. Your clinician should ask about:

• Fainting or dizziness with exertion

• Chest discomfort, racing heart, or shortness of breath

• Congenital heart problems or abnormal EKGs

• High blood pressure or thyroid disease

• Family history of sudden death at a young age

When James mentioned an uncle who collapsed at 39, his clinician ordered an EKG. It came back normal, and both had clarity instead of guesswork.

3. Check Vitals and Do a Brief Exam

This includes:

• Blood pressure

• Heart rate

• Weight and height

• A short cardiac and general exam

The goal is not a full workup, just a safe baseline.

Stimulants, Five Things That Matter Before the First Dose

Check	Why It Matters
Cardiac and family history	Reveals silent heart issues before potential of raising heart rate or blood pressure
Baseline blood pressure and pulse	Helps detect real medication related changes
Mood, bipolar, and psychosis history	Prevents activating mania or psychosis
Substance use patterns	Guides whether use of stimulant or non-stimulant is appropriate
Planned follow up	Prevents “set and forget” prescribing

4. Look Closely at Mood, Anxiety, and Sleep

ADHD rarely exists alone. Your clinician should ask about:

• Anxiety or panic

• Depression

• Sleep timing and quality

• Trauma history

• Past hypomanic episodes

• Paranoia or hallucinations

If mood or trauma symptoms are dominant, stimulant plans may need adjustment.

5. Ask Honest Questions About Substance Use

This is about safety, not judgment. Your clinician may ask about:

• Alcohol patterns, including binge use

• Cannabis use

• Cocaine or non-prescribed stimulant use

• Opioids or sedatives

• Times when substance use felt out of control

Even modest alcohol or cannabis use can change how stimulants feel. In some cases, long-acting stimulants or non-stimulants like Strattera (atomoxetine), Intuniv (guanfacine), Kapvay (clonidine), or Qelbree (viloxazine) are safer.

6. Use Rating Scales and Collateral Information

Tools like the ASRS or reports from partners or teachers help establish a baseline. Months later, they help answer whether the medication is working or if you are just used to being on it.

7. Decide When Extra Tests Are Needed

Extra tests may be indicated if:

• There are cardiac symptoms

• Family history raises concern

• Blood pressure or heart rate is already elevated

• Thyroid disease, anemia, or other problems are suspected

• Pregnancy is possible with long-term treatment planned

The goal is targeted testing, not excessive testing.

Bottom Line

Good screening prevents the medication decision that seems easy now but creates bigger problems later.

FAQs

1. How long does screening take?

Usually one extended visit, or a week or two if tests or outside information are needed.

2. Do I need to cut caffeine?

Not required, but more than 200 mg daily may need adjustment once the stimulant is effective.

3. What if my blood pressure is borderline?

Repeat readings or home checks often clarify.

4. Can I start a stimulant if I have a history of substance use?

Sometimes yes, with long-acting options or non-stimulants and closer monitoring.

Further Reading

CDC, ADHD in Adults: 

https://www.cdc.gov/adhd/articles/adhd-across-the-lifetime.html

NIMH, ADHD Topic Page: 

https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd

NIMH, ADHD: What You Need to Know:  https://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder-what-you-need-to-know

Authorship

Frederic Kass, MD — Professor Emeritus of Psychiatry, Columbia University Medical Center; former Clinical Vice Chair, Department of Psychiatry Profile: Medical News Today

Erica Gettenberg, MD — Board-Certified in Adult, Child, and Adolescent Psychiatry; expertise in mood and anxiety disorders and ADHD. LinkedIn: Erica Gettenberg, MD

All vignettes are fictional and for educational purposes only. This is not a substitute for professional medical advice.