Differentiating Between Methylphenidate Use and Misuse: Clinical Insights From University Students and Academic Staff in Türkiye

Abstract

Background

Methylphenidate (MPH) is widely prescribed for attention deficit hyperactivity disorder (ADHD), but non-medical use is increasing, particularly in academic settings, for cognitive enhancement. This study aims to distinguish individuals using MPH for ADHD treatment from those misusing it by analyzing clinical and behavioral characteristics.

Material/Methods

This retrospective study was conducted at a university-affiliated psychiatric outpatient clinic in Türkiye. Data were collected from structured psychiatric evaluations by a single psychiatrist between January and December 2024. A total of 135 individuals who requested MPH were included. Misuse was defined as use without an ADHD diagnosis, exceeding the prescribed dose, or use through non-oral routes. Participants were categorized into 4 groups based on diagnosis and misuse patterns. Data on demographics, psychiatric history, MPH use, and follow-up attendance were analyzed using descriptive and comparative methods.

Results

Of the 135 participants, 3% were ADHD-diagnosed misusers, 33.3% were ADHD-diagnosed non-misusers, 11.9% were non-ADHD misusers, and 51.8% were non-ADHD non-misusers. Non-ADHD misusers were older (mean age 25 vs 22 years, P<0.001), had later MPH initiation (23 vs 15 years, P<0.001), more often held a PhD (Doctor of Philosophy) or an equivalent higher degree (23.3% vs 2.0%, P<0.001), had lower follow-up attendance (32.6% vs 93.9%, P<0.001), and preferred short-acting MPH (73.3% vs 20.4%, P<0.001). ADHD-diagnosed individuals were more likely to have a family psychiatric history (69.4% vs 21.0%, P<0.001).

Conclusions

Misuse patterns differ significantly from medically indicated use. Strengthening diagnostic accuracy and implementing effective monitoring protocols in academic settings are essential for preventing misuse and supporting ADHD treatment.

Introduction

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by symptoms of inattention, hyperactivity, and impulsivity [1]. It affects both children and adults, often leading to academic difficulties, impaired social relationships, and occupational challenges [2].

Recent global estimates suggest that the prevalence of persistent adult ADHD is approximately 2.58%, while the prevalence of symptomatic adult ADHD reaches 6.76%, adjusted for global demographic distribution [3]. However, these figures tend to vary significantly across countries and populations. In Türkiye, most ADHD prevalence studies have primarily focused on children, with limited data available on adults and university students. Notably, 2 university-based studies using the Adult ADHD Self-Report Scale have reported varying rates of ADHD symptom prevalence among Turkish university students. One study found that 15.55% of students exhibited high levels of symptoms, while another reported a rate of 6%, indicating notable variability in symptom reporting across university students and academic staff [4,5]. In a separate study among medical students, 17.2% were found to be at risk for ADHD, according to self-report screening measures [6].

ADHD is treated using both pharmacological and non-pharmacological approaches, with stimulant medications, particularly methylphenidate (MPH), considered a first-line treatment option [7]. In the United States and many other countries, amphetamine-based stimulants are also commonly prescribed. However, in Türkiye, amphetamine-based stimulants are not approved for ADHD treatment, and MPH is the only stimulant medication that is routinely prescribed for this indication [8]. Importantly, MPH is strictly regulated in Türkiye and cannot be obtained without a prescription [9]. At the time of this study, only specialists (psychiatrists/child and adolescent psychiatrists) were authorized to prescribe MPH; family physicians and pediatricians were not permitted to do so. Furthermore, all ADHD medications in Türkiye are approved solely for this diagnosis, and their use is closely monitored by health authorities [10]. These regulations serve to control access and limit the potential for non-medical use.

MPH misuse is associated with a range of well-documented risks, including the development of tolerance, dependence, and somatic complications such as cardiovascular and neurological effects, particularly when used without medical supervision [11,12]. It has also been linked to psychological adverse effects, including occurrences of psychotic symptoms and the worsening of pre-existing psychiatric conditions [13]. Nevertheless, demand for MPH among university students and academic staff continues to rise. Studies from both international and national contexts indicate a steady increase in MPH misuse within university settings, often driven by students’ efforts to enhance cognitive performance under academic pressure [14]. In Türkiye, a recent study conducted among medical students found that peer influence, performance expectations, and dormitory-based social dynamics were key contributors to non-prescription MPH use, underscoring the growing prevalence of this behavior within academic institutions [15]. Similarly, another study involving medicine, pharmacy, and dentistry students in Türkiye reported that psychostimulant use, particularly during exam periods, was often motivated by low satisfaction with academic performance, peer influence, and the perceived need to enhance cognitive abilities, further supporting the contextual rise in stimulant misuse among high-achieving student groups [16].

At the same time, rising stimulant demand may not solely reflect misuse, but also point to unmet treatment needs among adults with ADHD. Some studies have indicated a significant decline in ADHD treatment rates during the transition from adolescence to adulthood, particularly after individuals age out of pediatric services [10]. Adult psychiatry services have also been described as insufficiently prepared to manage ADHD, with clinicians reporting limited training and diagnostic confidence [17]. In university settings, this discontinuity may contribute to self-directed stimulant use, making it increasingly difficult to distinguish between appropriate medical use and misuse.

This study aimed to differentiate individuals seeking MPH for clinically indicated ADHD treatment from those engaging in non-medical use, by analyzing their clinical and behavioral characteristics. The study sought to identify indicators that can assist in early recognition of potential misuse by evaluating diagnostic profiles and patterns of medication-related requests. Our findings may enhance diagnostic accuracy, inform ethical and evidence-based prescribing practices, and ensure appropriate access to treatment while minimizing the risk of misuse.

Material and Methods

Ethical Approval

Ethical approval for this study was obtained from the Gazi University Ethics Committee, and all procedures were conducted in accordance with the principles of the Declaration of Helsinki (Decision No: E-77082166-604.01-1148748). This study involved the retrospective analysis of clinical records from individuals who had previously received psychiatric evaluations at the same institution. All psychiatric assessments had been conducted as part of routine clinical care by a single psychiatrist. Prior to analysis, the records were fully anonymized in compliance with the ethics committee’s standards and national data protection regulations. No personal, academic, or institutional identifiers were used, stored, or disclosed at any stage of the research. Information regarding sensitive behaviors, such as substance misuse or non-oral routes of administration, was reported in aggregate form without any potentially identifying details.

No artificial intelligence (AI) or large language model (LLM) tools were used in the study design, data analysis, or content generation of this manuscript. The authors used ChatGPT (OpenAI, GPT-4) exclusively to check for typographical errors and enhance the fluency of author-written text.

Study Design and Participants

This study was conducted as a retrospective clinical analysis at the Gazi University Central Campus Psychiatric Outpatient Clinic. The study population consisted of university students and academic staff who underwent psychiatric evaluations between January 1, 2024, and December 31, 2024, and specifically requested prescription stimulant medications. Participants included undergraduate, graduate (master’s), and PhD students, as well as academic staff, primarily faculty members such as professors from various university departments.

The inclusion criteria required participants to be university students or academic personnel aged 18 years or older who sought MPH during a psychiatric evaluation and had a complete electronic medical record with detailed psychiatric anamnesis. Individuals who did not request stimulant medications or had incomplete medical records were excluded from the study.

A total of 163 participants who requested MPH during their psychiatric evaluation were initially assessed. However, due to missing information in the electronic anamnesis forms, only 135 participants were included in the final study sample. This selection ensured that all participants met the study criteria and had complete data for analysis.

Data Collection and Variables

All psychiatric evaluations were conducted by a psychiatrist following DSM-5 diagnostic criteria. Data were obtained retrospectively from the electronic medical record system of the psychiatric clinic. During each patient evaluation, clinicians completed a structured psychiatric anamnesis section, which included detailed information on psychiatric history, diagnosis, medication use, and treatment requests. This standardized documentation ensured consistency and completeness in the collected data, allowing for a comprehensive evaluation of MPH-seeking behavior.

The analyzed variables included demographic characteristics such as age, gender, and educational or professional status (undergraduate, graduate, or faculty member). Comorbid substance use was assessed, including cigarette, alcohol, and other substance use. Additionally, the study investigated the age of onset of attention-related concerns, whether participants engaged in MPH sharing with peers, and their adherence to follow-up examinations.

Participants were categorized into 4 groups based on ADHD diagnosis and MPH misuse behavior: ADHD-diagnosed misusers, ADHD-diagnosed non-misusers, non-ADHD misusers, and non-ADHD non-misusers. MPH misuse was identified through a combination of patient self-report and clinician documentation during psychiatric evaluations. Misuse behaviors were defined as use without an ADHD diagnosis, use exceeding the prescribed dose, or use via non-oral routes such as nasal inhalation. The misuse criteria were guided by the US Food and Drug Administration definition of prescription stimulant misuse [18], which includes use without a prescription, in higher doses, more frequently or for longer durations than prescribed, or in any way not directed by a physician. These behaviors were identified based on clinical notes recorded during structured psychiatric interviews, where information on medication use patterns and administration routes was typically documented. Participants in the non-ADHD non-misuse group had no history of MPH use.

Statistical Analysis

Statistical analyses were performed using SPSS version 25. Descriptive statistics were presented as frequencies (n) and percentages (%) for categorical variables, while median (minimum–maximum) values were reported for continuous variables due to their non-normal distribution.

To assess the normality of the distribution of continuous variables, the Shapiro-Wilk test was applied. As the data did not meet the assumption of normality, non-parametric tests were used for the statistical analyses.

We used the chi-square test or Fisher’s exact test for categorical variables, depending on expected cell counts, and used the Mann-Whitney U test for comparisons of continuous variables between ADHD and non-ADHD groups.

Due to the unequal sample sizes among the 4 study groups (notably, only n=4 for ADHD-diagnosed misusers), statistical comparisons across all groups were not performed. Instead, analyses were limited to comparisons between ADHD and non-ADHD groups to ensure statistical reliability.

A significance level (alpha) of 0.05 was set for all statistical tests. No a priori sample size calculation was performed, as this study was retrospective in nature and included all eligible participants within the defined data collection period.

Results

A total of 135 individuals seeking MPH at a university-affiliated psychiatric outpatient clinic were included in this study. Group distribution was as follows: ADHD-diagnosed misusers (n=4, 3%), ADHD-diagnosed non-misusers (n=45, 33.3%), non-ADHD misusers (n=16, 11.9%), and non-ADHD non-misusers (n=70, 51.8%).

Table 1 presents the sociodemographic and clinical characteristics of the study participants, categorized into 4 groups based on ADHD diagnosis and MPH misuse behavior. Males were more common in the non-ADHD misusers group (75%, n=12). PhD (Doctor of Philosophy) students were more frequent in the non-ADHD misusers group (43.8%, n=7), while undergraduate students made up the majority in all other groups (eg, 86.7%, n=39 in the ADHD-diagnosed non-misusers group). The age of attention deficit onset was earlier in ADHD-diagnosed groups compared to non-ADHD groups (median 14 vs 20 years, respectively). Substance use behaviors were reported among misusers (100%, n=4 in ADHD-diagnosed misusers). Psychiatric disorders in the family were more frequently recorded in ADHD-diagnosed individuals (eg, 100%, n=4 in ADHD-diagnosed misusers; 66.7%, n=30 in ADHD-diagnosed non-misusers). Short-acting MPH was the most commonly used formulation among misusers (eg, 75%, n=12 in non-ADHD misusers). The primary recommendation source for MPH was psychiatrists among ADHD-diagnosed misusers (n=4, 100%) and ADHD-diagnosed non-misusers (n=42, 93.3%), while peers were the main source among non-ADHD misusers (n=15, 93.8%) and non-ADHD non-misusers (n=40, 57.1%). MPH sharing was reported among misusers (100%, n=4 in ADHD-diagnosed misusers; 87.5%, n=14 in non-ADHD misusers). Follow-up attendance rates were lower among misusers (12.5%, n=2 in non-ADHD misusers).

Table 1.

Sociodemographic and clinical characteristics of individuals seeking methylphenidate (n=135) at a university-based psychiatric clinic, by ADHD diagnosis and misuse pattern.

Variable/Group		ADHD-diagnosed misusers	ADHD-diagnosed non-misusers	Non-ADHD misusers	Non-ADHD non-misusers
n (%)		4 (3%)	45 (33.3%)	16 (11.9%)	70 (51.8%)
Median age (min–max)		24 (19–29)	22 (18–33)	25.5 (23–32)	25 (19–55)
Gender n (%)	Female	2 (50%)	20 (44.4%)	4 (25%)	36 (51.4%)
	Male	2 (50%)	25 (55.6%)	12 (75%)	34 (48.6%)
Educational level n (%)	University	3 (75%)	39 (86.7%)	9 (56.2%)	40 (57.1%)
	Master’s	1 (25%)	5 (11.1%)	0 (0%)	17 (24.3%)
	PhD	0 (0%)	1 (2.2%)	7 (43.8%)	12 (17.1%)
	Professor	0 (0%)	0 (0%)	0 (0%)	1 (1.4%)
Repeating a grade		4 (100%)	16 (35.6%)	7 (43.8%)	28 (40%)
Median age of onset (min–max) for cases with attention deficit		14 (7–15)	14 (5–20)	20 (17–25)	20 (15–45)
Cigarette smoking		4 (100%)	18 (40%)	15 (93.8%)	41 (58.6%)
Alcohol use disorder		2 (50%)	0 (0%)	5 (31.3%)	8 (11.4%)
Substance use disorder		3 (75%)	3 (6.7%)	4 (25%)	4 (5.7%)
Presence of psychiatric disorders in the family		4 (100%)	30 (66.7%)	2 (12.5%)	18 (25.7%)
Medication	Short-acting MPH	1 (25%)	9 (20%)	12 (75%)	51 (72.8%)
	Intermediate-acting MPH	0 (0%)	15 (33.3%)	0 (0%)	0 (0%)
	Long-acting MPH	0 (0%)	16 (35.6%)	1 (6.3%)	13 (18.6%)
	Multiple MPH formulations	3 (75%)	5 (11.1%)	3 (18.7%)	6 (8.6%)
Primary source of information about MPH	Psychiatrist	4 (100%)	42 (93.3%)	0 (0%)	0 (0%)
	Peers	0 (0%)	2 (4.4%)	15 (93.8%)	40 (57.1%)
	Internet/social media	0 (0%)	1 (2.3%)	0 (0%)	19 (27.1%)
	Instructors	0 (0%)	0 (0%)	1 (6.2%)	11 (15.8%)
MPH sharing		4 (100%)	3 (6.7%)	14 (87.5%)	0 (0%)
Follow-up attendance		2 (50%)	44 (97.8%)	2 (12.5%)	26 (37.1%)

ADHD – Attention Deficit Hyperactivity Disorder; min – minimum; max – maximum; PhD – Doctor of Philosophy; Prof – Professor; MPH – methylphenidate.

Table 2 presents the most frequently observed psychiatric and medical comorbidities across the 4 study groups. Psychiatric conditions were evaluated excluding ADHD as a primary diagnosis. Generalized anxiety disorder was the most common psychiatric comorbidity among both ADHD-diagnosed non-misusers (n=10, 22.2%) and non-ADHD non-misusers (n=26, 37.1%), while substance-related disorders such as alcohol use disorder (n=5, 31.2%) and cannabis use disorder (n=3, 75.0%) were particularly prevalent in misuser groups.

Table 2.

Most frequent psychiatric and medical comorbidities among ındividuals seeking methylphenidate (n=135), by ADHD diagnosis and misuse pattern.

Group/variable	Psychiatric comorbidities	Reported medical comorbidities
ADHD-diagnosed misusers (n=4)	Cannabis use disorder (n=3, 75.0%) Alcohol use disorder (n=2, 50.0%) Tic disorder (n=1, 25.0%)	Severe obesity (n=1, 25.0%)
ADHD-diagnosed non-misusers (n=45)	Generalized anxiety disorder (n=10, 22.2%) Obsessive-compulsive disorder (n=5, 11.1%) Major depressive disorder (n=3, 6.7%)	Severe obesity (n=4, 8.9%)
Non-ADHD misusers (n=16)	None (n=7, 43.8%) Alcohol use disorder (n=5, 31.2%) Generalized anxiety disorder (n=5, 31.2%)	None
Non-ADHD non-misusers (n=70)	Generalized anxiety disorder (n=26, 37.1%) Major depressive disorder (n=23, 32.9%) None (n=22, 31.4%)	Hypertension (n=1, 1.4%)

ADHD – attention deficit hyperactivity disorder. Psychiatric comorbidities were identified excluding ADHD as a primary diagnosis. “None” indicates absence of any additional psychiatric diagnosis or reported medical comorbidity. Individuals may have more than 1 diagnosis; therefore, the sum of n or% may exceed group totals.

Table 3 presents the clinical, demographic, and behavioral comparisons between ADHD and non-ADHD groups. The median age was lower in the ADHD group (P<0.001). PhD and higher education levels were more common in the non-ADHD group (P<0.001). The median age of attention deficit onset was lower in the ADHD group (P<0.001), while the median age of first MPH use was also lower (P<0.001). Cigarette smoking was more common in the non-ADHD group (P=0.023). Psychiatric disorders in the family were more frequent in the ADHD group (P<0.001). Short-acting MPH use was higher in the non-ADHD group (P<0.001). Follow-up attendance was higher in the ADHD group (P<0.001).

Table 3.

Clinical and behavioral distinctions between ADHD and non-ADHD ındividuals seeking methylphenidate (n=135).

Variable/group		ADHD n (%)	Non-ADHD n (%)	P value
Median age (min–max)		22 (18–33)	25 (19–55)	<0.001
Gender	Female	22 (44.9%)	40 (46.5%)	0.5
	Male	27 (55.1%)	46 (53.5%)
Educational Level	University	42 (85.7%)	49 (57%)	<0.001
	Master’s	6 (12.2%)	17 (19.8%)
	PhD or higher	1 (2%)	20 (23.3%)
Repeating a srade		20 (40.8%)	35 (40.7%)	0.566**
Median age of onset for attention deficit		14 (5–20)	20 (15–45)	<0.001
Median age of First MPH use		15 (7–24)	23 (18–30)	<0.001
Psychiatric comorbidity		31 (63.3%)	58 (67.4%)	0.706**
Cigarette smoking		22 (45.0%)	56 (65.0%)	0.023 * *
Alcohol and substance use disorder		2 (4%)	11 (12.8%)	0.085**
Presence of psychiatric disorders in the family		34 (69.4%)	18 (21%)	<0.001
Medication	Short-acting MPH	10 (20.4%)	63 (73.3%)	<0.001
	Intermediate-acting MPH	15 (30.6%)	0 (0%)
	Long-acting MPH	16 (32.7%)	14 (16.2%)
	Multiple MPH formulations	8 (16.3%)	9 (10.5%)
Follow-up attendance		46 (93.9%)	28 (32.6%)	<0.001 *

^*Fisher’s exact test was used for categorical comparisons when expected cell counts were low.

ADHD – attention deficit hyperactivity disorder; min – minimum; max – maximum; PhD – Doctor of Philosophy; MPH – methylphenidate.

Participants were affiliated with a broad range of academic departments, including the Faculty of Medicine, Faculty of Engineering, Faculty of Science, Faculty of Technology, Faculty of Education, Faculty of Health Sciences, Faculty of Dentistry, Faculty of Nursing, and Faculty of Pharmacy. Overall, the highest representation among individuals seeking MPH was from the Faculty of Medicine (n=29, 21.5%), followed by the Faculty of Education (n=23, 17.0%), and both the Faculty of Engineering and the Faculty of Science (each n=22, 16.3%). Among ADHD-diagnosed misusers (n=4), the most common affiliation was the Faculty of Science (n=2, 50.0%). In the ADHD-diagnosed non-misusers group (n=45), the most frequent affiliation was also the Faculty of Science (n=9, 20.0%). Non-ADHD misusers (n=16) were most commonly affiliated with the Faculty of Medicine (n=8, 50.0%). Lastly, among non-ADHD non-misusers (n=70), the highest representation was from the Faculty of Education (n=13, 18.6%). Although data collection spanned the full calendar year (January to December 2024), most stimulant-related psychiatric evaluations (n=128, 94.8%) occurred during the academic year, defined as September to June in the university calendar.

Two students from the non-ADHD misusers group, who were friends, reported intranasal MPH use (not shown in tables).

Discussion

This study aimed to differentiate individuals who seek MPH as part of clinically indicated ADHD treatment from those who use it for non-medical purposes. By analyzing demographic, clinical, and behavioral characteristics across these groups, the findings contribute to a more nuanced understanding of stimulant-seeking behavior in university students and academic staff. This distinction may inform improved diagnostic vigilance and guide clinicians in identifying potential misuse patterns during psychiatric evaluations.

As in many other countries, non-medical use of prescription stimulants has become a growing concern among young populations in Türkiye, particularly university students [19]. This issue is further amplified by the rising prescription rates of MPH, which, while medically justified in ADHD treatment, have raised concerns about misuse in both clinical and academic settings [13]. Our study reflects this pattern, as the largest proportion of participants belonged to the non-ADHD non-misusers group. While these individuals did not report misuse, their active pursuit of MPH raises important concerns about accessibility and demand beyond clinically indicated cases.

Moreover, MPH-seeking behavior appears to be shaped by factors such as age, gender, and educational status. Notably, non-ADHD misusers tended to be older and to request MPH outside of clinically indicated contexts. Previous research has suggested that stimulant misuse, particularly for academic performance enhancement, develops more frequently in later academic stages or in adulthood [15,20]. A recent study from Türkiye similarly reported that stimulant misuse was more prevalent among students in faculties of medicine, dentistry, and pharmacy, particularly when preparing for residency exams or during residency itself, which may help explain the observed age differences [16].

Gender differences were particularly evident among MPH misusers. Males were overrepresented in the non-ADHD misusers group, whereas the ADHD-diagnosed non-misusers group had a more balanced gender distribution. Although most studies report higher rates of stimulant misuse among males [12], some have found no significant gender differences [21]. One plausible explanation for the observed disparity is the difference in exposure opportunities. Garnier-Dykstra et al, in a longitudinal study of over 1200 U.S. college students, found that males were more frequently offered prescription stimulants for non-medical use than females, despite similar usage rates once opportunity was accounted for [22]. This suggests that greater access may partly underlie the higher rates of misuse observed among males in our study. In addition, Smith, DeSantis, and Martel, in a large-scale survey of over 2700 U.S. undergraduate students, found that males were more likely to use nonprescribed psychostimulants for recreational and social motives, engage in risky behaviors following use, and perceive such use as more morally acceptable and less harmful than females [23]. These findings highlight the role of both behavioral traits and gender-related attitudes in shaping stimulant misuse patterns.

Educational level and faculty affiliation both appeared to influence MPH-seeking behavior in our sample. Many non-ADHD misusers were at postgraduate academic stages and were predominantly physician residents affiliated with the Faculty of Medicine. This group is typically subject to intense academic and clinical demands and may also have greater access to prescription medications due to their professional environment. The intersection of postgraduate training and medical faculty affiliation highlights how both academic intensity and structural access can shape MPH-seeking behavior. Furthermore, PhD or higher education levels were more common among non-ADHD individuals than among those with an ADHD diagnosis, suggesting that such MPH-seeking behavior reflects academic and occupational pressures rather than clinically indicated need. These findings align with previous research indicating that stimulant misuse is more prevalent among postgraduate students – particularly those in medical fields – compared to undergraduates [15,16].

Faculty-level data further reinforced this pattern. The Faculty of Medicine had the highest overall representation among MPH seekers and was most frequently associated with non-ADHD misusers. In contrast, the Faculty of Education was more commonly represented among non-ADHD non-misusers; however, this may be partially attributable to its large student population on campus, which could lead to higher overall representation in the sample. Taken together, these findings suggest that affiliation with academically intense faculties contributes to increased MPH-seeking behavior in academic environments, consistent with prior reports of elevated non-medical stimulant use in clinical and health-related academic disciplines [16,24].

The high rate of grade repetition in both ADHD-diagnosed misusers and non-ADHD misusers further supports this link, suggesting that academic struggles drive MPH use regardless of ADHD diagnosis. While ADHD is associated with learning difficulties, grade repetition among non-ADHD misusers indicates that MPH may be sought as a coping mechanism rather than for clinical treatment. Additionally, the timing of MPH-seeking visits provides further evidence of this association, as nearly all visits occurred during the academic year (September-June). This reinforces the strong link between MPH demand and academic workload, suggesting that periods of increased academic pressure influence stimulant-seeking behavior. This interpretation is supported by national prescription data from Türkiye, which revealed a seasonal pattern in MPH use – the highest prescription rates were recorded during March to May, a period when very important central examinations take place, while the lowest rates occurred during the school holiday months of June to August [9].

Our study found a significant difference in the median age of ADHD symptom onset and the median age of first MPH use between ADHD and non-ADHD groups. ADHD-diagnosed individuals experienced attention deficit symptoms earlier than non-ADHD misusers. This distinction is further supported by Sibley et al, who conducted a longitudinal, multi-informant evaluation of 239 individuals from childhood to adulthood using parent, teacher, and self-reports. They found that most apparent late-onset ADHD cases were better explained by comorbid psychiatric conditions, heavy substance use, or transient cognitive changes. Notably, there was no evidence for adult-onset ADHD independent of a complex psychiatric history [25]. These findings highlight the need to assess symptom onset in MPH-seeking individuals to distinguish clinical necessity from potential misuse.

When examining clinical characteristics, although a higher prevalence of comorbidities was expected in ADHD-diagnosed individuals [26], our study found no significant difference in overall comorbidity prevalence between ADHD and non-ADHD groups. One possible explanation for this unexpected finding is the high prevalence of substance use behaviors among misusers, regardless of ADHD status. Our study found that both ADHD misusers and non-ADHD misusers had higher rates of smoking, alcohol, and substance use, with no significant difference in these behaviors between ADHD and non-ADHD groups. Additionally, this finding aligns with prior research indicating that stimulant misuse often coexists with other substance use tendencies, independent of ADHD diagnosis [13]. Therefore, careful assessment of cooccurring substance use disorders in individuals seeking MPH is crucial to distinguishing clinically justified ADHD treatment needs from potential misuse risk.

Another important clinical finding is the differentiation between ADHD and non-ADHD groups based on psychiatric disorders in the family. ADHD-diagnosed misusers had the highest rate of a family history of psychiatric disorders, followed by ADHD-diagnosed non-misusers. Psychiatric disorders in the family were more common among ADHD individuals compared to non-ADHD groups. Considering this pattern, family history of mental health problems may be a relevant factor to consider in the diagnostic evaluation of ADHD [27,28].

When analyzing medication preferences, our findings indicate that short-acting MPH was the most commonly used formulation across all groups. Non-ADHD individuals had a higher preference for short-acting MPH compared to ADHD individuals, while long-acting MPH was used less frequently. Non-ADHD misusers had the highest short-acting MPH use, reinforcing its association with misuse behavior [29]. The preference for short-acting MPH aligns with previous research, suggesting that non-medical users favor its rapid onset, perceived stronger effects, and shorter duration, making it ideal for immediate cognitive enhancement [30,31]. Additionally, cost differences may play a role in medication choice, as long-acting formulations are generally more expensive than short-acting alternatives in Türkiye.

MPH sharing was commonly reported among misusers, particularly in the non-ADHD misusers and ADHD-diagnosed misusers groups. The primary source of information about MPH also varied between groups. ADHD-diagnosed individuals most frequently identified psychiatrists as their source, whereas non-ADHD misusers primarily referred to peers and, to a lesser extent, instructors. These patterns align with prior findings suggesting that stimulant sharing and peer influence play an important role in non-medical MPH use [32]. Consistent with this, a recent study conducted among Turkish medical students found that those who used methylphenidate without medical advice were more likely to obtain the drug from peers and displayed stronger associations with addictive tendencies, further emphasizing the social transmission aspect of misuse [15].

Beyond MPH sharing, peer influence was also evident in other forms of misuse. Two non-ADHD misusers, who were friends, reported engaging in intranasal MPH use together. This aligns with research showing that peer influence plays a role in MPH misuse, particularly among individuals with a history of substance use [13]. In addition to oral misuse, MPH has been reported to be misused via alternative and riskier routes of administration. A recent case report from Türkiye described both intranasal and, more rarely, rectal administration of MPH, underscoring the diversity of misuse methods and their potential health risks [33]. Such non-oral routes pose significantly greater medical dangers, including mucosal damage, infections, and toxicity. Additionally, Blau-Most et al reported severe sinonasal damage from chronic intranasal MPH misuse, highlighting its potential health risks [34].

Follow-up attendance patterns further differentiate medical use from misuse. ADHD-diagnosed non-misusers had a considerably higher follow-up attendance rate compared to non-ADHD misusers, who rarely returned for follow-ups. This aligns with findings by Skoglund et al, who reported lower adherence to treatment among individuals with a history of substance misuse, suggesting that those seeking MPH for non-medical reasons may similarly be less likely to engage in long-term treatment monitoring [35].

The misuse of MPH is a growing concern among young people, particularly in academic settings [36,37]. This study sheds light on the clinical and behavioral dynamics driving MPH-seeking behavior, distinguishing genuine ADHD patients from those misusing stimulant medications.

This study has several strengths that enhance its clinical and academic relevance. First, it provides a detailed analysis of MPH-seeking behaviors among university students and academic personnel, a population with rising stimulant use yet limited research. Second, all psychiatric evaluations were conducted face to face by a single psychiatrist, ensuring diagnostic consistency. Third, the study setting, a university-affiliated clinic exclusively serving students and academic staff, allows for targeted insights into MPH use in academic environments.

Despite its strengths, this study has certain limitations. First, the sample size of certain subgroups, particularly ADHD-diagnosed misusers, was small, limiting the ability to perform robust statistical comparisons across all groups. Additionally, no a priori power or sample size calculation was performed due to the retrospective nature of the study, which may further limit subgroup comparisons. Second, the absence of long-term follow-up data prevented an assessment of changes in MPH-seeking behaviors over time, including potential transitions from occasional misuse to dependence. Finally, sociocultural and institutional factors specific to the university setting may limit the generalizability of these findings to broader populations.

Conclusions

This study examined MPH use and misuse patterns in an academic setting, highlighting distinctions between individuals with ADHD and non-medical users. Misuse was more common among older males in advanced academic stages and was associated with short-acting formulations and lower clinical follow-up.

These findings show the need to clearly separate misuse from appropriate medical use, particularly in academic environments where treatment demand may be complex. Prevention efforts should limit non-medical use without restricting access for individuals who require treatment.