‘Safety First: Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness’ recommends that patients at risk of suicide, including all patients with a recent history of self-harm, who are treated with psychotropic drugs should receive modern, less toxic drugs and/or supplies lasting no more than 2 weeks.

NICE Clinical Guideline on ADHD (Sept 2008) advises:

Drug treatment for children and young people with ADHD should always form part of a comprehensive treatment plan that includes psychological, behavioural and educational advice and interventions. When a decision has been made to treat children or young people with ADHD with drugs, healthcare professionals should consider:

• methylphenidate for ADHD without significant comorbidity
• methylphenidate for ADHD with comorbid conduct disorder
• methylphenidate or atomoxetine when tics, Tourette’s syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present
• atomoxetine if methylphenidate has been tried and has been ineffective at the maximum tolerated dose, or the child or young person is intolerant to low or moderate doses of methylphenidate

Drug treatment for adults with ADHD should always form part of a comprehensive treatment programme that addresses psychological, behavioural and educational or occupational needs.

Following a decision to start drug treatment in adults with ADHD, methylphenidate should normally be tried first.

MHRA Drug Safety Update (Mar 2009) advises:

The benefits of methylphenidate continue to outweigh the risks when used to treat ADHD in children aged 6 years or older and adolescents. Treatment must be under the supervision of a specialist in childhood behavioural disorders. Patients should be monitored during treatment, which should be interrupted at least once a year to determine whether continuation is needed.

More detailed advice includes contraindications to methylphenidate, pretreatment screening and ongoing monitoring.

Under ongoing monitoring, the following is advised:

• Blood pressure and pulse should be recorded on a centile chart at every dose adjustment and then at least every 6 months
• Height, weight, and appetite should be recorded at least every 6 months on a growth chart 
• Methylphenidate could cause or worsen some psychiatric disorders such as depression, suicidal thoughts, hostility, anxiety, agitation, psychosis, and mania. Development of new, or worsening of preexisting, psychiatric symptoms should be monitored at every dose adjustment and then at least every 6 months, and at every visit
• Prescribers should look out for signs of diversion (transfer of the medicine from the individual for whom it was prescribed to one for whom it is not prescribed), misuse, and abuse of methylphenidate
• Patients who develop symptoms such as palpitations, exertional chest pain, unexplained syncope, dyspnoea, or other symptoms suggestive of heart disease during methylphenidate treatment should undergo prompt specialist cardiac evaluation

MHRA Drug Safety Update (Mar 2009) advises:

Atomoxetine is associated with treatmentemergent psychotic or manic symptoms in children and adolescents without a history of such disorders. If such symptoms occur, consideration should be given to a possible causal role of atomoxetine and discontinuation of treatment.