We reported this review in accordance with the Scale for the Assessment of Narrative Review Articles guidelines (SANRA) (31). SANRA is a validated tool designed to improve the quality, transparency, and reproducibility of narrative reviews (31). Key SANRA domains addressed in this review include justification of the article’s importance, appropriate referencing, transparent literature search, scientific reasoning, and balanced presentation of relevant literature (31). The aim of this review was to broadly understand the current literature on the availability of AMPH-derived stimulants for individuals with ADHD in Saudi Arabia. We selected to perform a narrative review after scoping searches revealed that the evidence base comprised a small number of observational studies and substantial grey literature (national guidelines, formulary documents, regulatory circulars). Given this heterogeneity, a formal systematic review would have yielded few studies and excluded critical policy sources. Narrative synthesis, guided by the SANRA quality framework (31), therefore offered the most suitable method for integrating multidisciplinary evidence and generating policy-relevant conclusions. In this narrative review, we summarized and reported the available published work as well as grey literature regarding challenges related to AMPH-based stimulants access and availability for physicians when treating individuals diagnosed with ADHD.

We comprehensively searched the current available literature for published work including PubMed, PsycINFO, and EBSCO from inception until March 1, 2025. Key terms (with their terminologies) included (ADHD OR “attention deficit hyperactivity disorder”) AND (psychostimulants OR amphetamine OR dextroamphetamine) AND (Saudi Arabia). Details on search terms were provided in Supplementary Table 1 . Additionally, we searched other potentials sources for grey literature work such as regulatory agencies’ websites including the Saudi Ministry of Health (MOH; https://www.moh.gov.sa/Pages/Default.aspx(, Saudi Food and Drug Authority (SFDA; https://www.sfda.gov.sa/en), and the Saudi ADHD Society (https://adhd.org.sa/en/). The reference lists of the included studies were also carefully examined by two reviewers (the first author; MMA and the second author; NZA) manually to locate other potentially relevant studies.

We included peer-reviewed articles that included participants diagnosed with ADHD. We also included national guidelines, formulary documents, regulatory circulars, and relevant grey literature that addressed AMPH-based treatment in ADHD and included data or commentary specific to Saudi Arabia. Articles without regional specificity, editorials, and non-medication-focused reports were excluded. Articles were included if they were written in English and Arabic.

Two independent reviewers (the first author; MMA) and (the second author; NZA) screened all potential records retrieved through the search process. Initial screening was based on titles and abstracts. Full texts were retrieved for records that met the eligibility criteria or required further evaluation. Discrepancies during screening or full-text review were resolved through discussion or consultation with a third reviewer (the last author; MMA) when needed. The selection process is illustrated using a PRISMA-style flow diagram (see Figure 1 ). We extracted data using a standardized data extraction sheet. Data extracted included: study characteristics (author and year of publication), study design, as well as sample characteristics including age, sex, and percentage receiving treatment. Further, data extracted included treatment regimen and stimulant class (i.e., MPH or AMPH based stimulants). Finally, main findings related to AMPH availability in Saudi Arabia was reviewed for all included articles.

In this narrative review, we conducted a qualitative synthesis from all included studies report AMPH-based stimulant availability for individuals with ADHD in Saudi Arabia. We conducted a qualitative narrative synthesis of the included sources, structured around three analytical domains:

We reported our findings regarding: (i) study characteristics: authors (year), and study design; (ii) primary findings relevant to AMPH availability in Saudi Arabia; and (iii) clinical practice protocols and guidelines for individuals with ADHD in Saudi Arabia. Key findings were organized into thematic summaries with representative examples from included sources. No quantitative synthesis (meta-analysis) was performed due to the heterogeneity of study types and the nature of the data. Grey-literature sources were appraised based on their origin (e.g., government agency, academic society), internal consistency, relevance to the review question, and publication recency. Priority was given to documents issued by authorities that play key roles in ADHD diagnosis and management (e.g., Ministry of Health), or recognized scientific bodies. We recorded the issuing institution, year, and content scope for each document ( Table 1 ).

A total of 211 records were identified of which 204 records sourced from PubMed, six records from EBSCO, and one through citation search (manual search). Additionally, six records were identified from organizations’ work. After removing six duplicate records, a total of 205 sources remained for screening. During the title and abstract screening phase, 158 records were excluded due to irrelevance to our study’s aim, leaving 46 records for the full-text screening phase. Out of the 46 articles, 25 reports were excluded for reporting wrong outcomes, six reports included wrong populations, six reports used ineligible study design, and 3 reports investigations from wrong intervention, yielding 6 reports that were included in the analysis from the databases search. In addition, one report was included by the citation manual search and six reports were included from organizations’ work. The total number of articles/reports that were included in the final analysis is 13 (19, 32–43) ( Figure 1 ).

In Table 1, we summarize the main characteristics of the included study. Characteristics of the included studies/reports vary significantly in terms of sample size, study design, and/or treatment regimens. The studies that included participants’ data (n=4) had sample sizes varied between 105 and 245 individuals with ADHD, with all studies using a cross-sectional study design. The remaining studies consisted of consensus statements (19), longitudinal trend analyses (41), and guideline adaptations (35, 42, 43). The cross-sectional studies included children, adolescents, and adults with ADHD. Specifically, Al-Mohsen et al. (2020) (32) included young children (M age= 4.0 ± 1.7 years), whereas Alghamdi et al. (2022) (40) focused on older participants (M age= 21.4 ± 1.8 years). However, some studies, such as Al-Haidar (2003) et al. (34), included children through adolescents from early ages to 18 years, whereas Alsubaie et al. (2024) (33) included children and adults of ages less than 3 years to older than 17 years. The proportion of female participants in the included studies varied, although some studies did not report this information (sex distribution).

The percentage of participants receiving treatment also differed remarkably. Specifically, Al-Mohsen et al. (2020) (32) reported a relatively high treatment rate (62.1%), while Alghamdi et al. (2022) (40) found that only 2.0% of their sample was receiving pharmacological treatment. Al-Haidar et al. (2003) (34) indicated that 23.6% of patients were on medication, and Alsubaie et al. (2024) (33) did not provide details on medication received.

In terms of treatment regimens, many studies examined pharmacological treatments (33, 34, 36, 38–40, 43), while others investigated both pharmacological and behavioral treatments (32, 37, 42). The stimulant medications reported in the studies included MPH and AMPH. One study by Bashiri (2021) (35) and guidelines provided by the Saudi ADHD Society, acknowledged the use of both MPH and AMPH which were relatively recent. Other reports, such as the MOH guidelines, focused primarily on MPH without inclusion of AMPH stimulants.

In Table 2, we summarize the main findings related to amphetamine availability for individuals with ADHD in Saudi Arabia. Al-Mohsen et al. (2020) (32) conducted a study on Saudi mothers’ perceptions of ADHD treatment. The study revealed that concerns regarding the side effects of stimulant medications were a major factor influencing treatment adherence. Furthermore, the study found that a limited number of mothers (<26%) were aware that MPH is a medication for ADHD. In addition, that study highlighted caregiver perceptions and stigma-related concerns were main barriers in managing ADHD among Saudi mothers. Alghamdi et al. (2022) (40) investigated ADHD prevalence among university students in Saudi Arabia. The findings indicated that only 2% of diagnosed students had ever received pharmacological treatment, suggesting significant under-prescription and limited access to AMPH stimulants.

Al-Haidar et al. (2003) (34) conducted a retrospective patient records review of ADHD treatment in a psychiatric clinic in Saudi Arabia. The study found that only 23.6% of children diagnosed with ADHD were prescribed psychostimulants, while antidepressants were more commonly used as an alternative. Alsubaie et al. (2024) (33) examined ADHD medication adherence of children in Saudi Arabia. The study found that extended-release MPH was the most commonly prescribed stimulant, while AMPH stimulants were rarely prescribed. Further, this study demonstrated that prescriber behavior, including concerns about medication side effects and parental hesitation may have an effect on prescribing AMPH stimulants.

Faraone et al. (2021) (19) identified access to stimulant medication as a critical factor for successful treatment outcomes. It highlighted that restrictions on AMPH stimulants in some countries, including Saudi Arabia, have led to increased reliance on non-stimulant alternatives, which may not be as effective. Bashiri et al. (2021) (35) reviewed ADHD diagnosis and treatment in Saudi Arabia and adapted the NICE guidelines related to ADHD diagnosis and management. This study identified a lack of standardized protocols for prescribing stimulant medications in Saudi Arabia. The study also listed AMPH stimulants as a treatment option (if available), indicating a potential gap in availability. Moreover, the study indicated other barriers to AMPH prescription, including clinical uncertainty and provider variability. Chan et al. (2023) (41) conducted a multinational longitudinal study on ADHD medication consumption from 2015 to 2019. The study found that AMPH -based stimulants had the highest annual increase in global consumption. However, their availability remained limited in Saudi Arabia, due to regulatory restrictions and supply inconsistencies.

The 2019 MOH Protocol for ADHD management (42) outlined several barriers to accessing ADHD medications in Saudi Arabia, including the limited availability of AMPH stimulants. The protocol emphasized the need for improved access and consistent medication supply to ensure effective ADHD management. The Saudi ADHD Society CPG (2020) (37) recommended MPH and AMPH stimulants (lisdexamfetamine) as primary treatments for ADHD in Saudi Arabia. However, the guidelines acknowledged existing barriers to accessing these medications and discussed the consequences of limited stimulant availability on treatment outcomes. The Council of Health Insurance (CHI) (2024) Indication Update (43) added lisdexamfetamine to the CHI formulary, recognizing the need for expanded ADHD treatment options. This step came after several calls for improving access to AMPH stimulants for this population in Saudi Arabia.

The Saudi ADHD Society has published three reports regarding AMPH limited availability (36, 38, 39). The first was the Saudi ADHD Society Updated Recommendations (44), which called for improved access to ADHD medications, particularly AMPH stimulants. This report highlighted the need for regulatory changes to support better ADHD management in Saudi Arabia. The second report of the Saudi ADHD Society (Adult Treatment) (36) examined challenges in adult ADHD treatment in Saudi Arabia. This report noted that limited access to AMPH stimulants restricted treatment options, which force clinicians to rely on non-stimulant medications or behavioral interventions. The report called for policy reforms to enhance access. The third report by the Saudi ADHD Society (Medication Availability FAQ) (38) addressed concerns about ADHD medication access in Saudi Arabia. It highlighted issues such as inconsistent supply of AMPH stimulants, regulatory restrictions, and the need for policy adjustments to improve medication availability. This report also indicated the update of lisdexamfetamine by the Saudi FDA.

Both the MOH (42) and the Saudi ADHD Society (37) Clinical Practice Guidelines (CPGs) acknowledge that stimulant medications, specifically MPH and AMPH, are the primary pharmacological treatments for ADHD. The MOH Protocol notes that while MPH (e.g., Ritalin) is widely available and used as the first-line treatment, AMPH stimulants such as lisdexamfetamine and dexamfetamine are not as commonly prescribed. Additionally, the protocol highlights that the off-label use of second-generation antipsychotics (e.g., Risperidone, Aripiprazole) has increased, which may be partly due to barriers in accessing AMPH stimulants. Similarly, the Saudi ADHD Society CPG acknowledges that MPH is the most commonly used stimulant in Saudi Arabia, whereas AMPH stimulants such as lisdexamfetamine and dexamfetamine are less frequently prescribed. This CPG also states that AMPH stimulants should be considered for patients who do not respond adequately to MPH stimulants. Despite their efficacy, regulatory hurdles and concerns about potential misuse and diversion have made the use of AMPH stimulants more restrictive.

Both the MOH (42) and the Saudi ADHD Society CPGs (37) emphasize the necessity of AMPH stimulants for effective ADHD management. The MOH Protocol asserts that stimulant medications remain the most effective pharmacological treatment for ADHD, particularly for individuals who exhibit moderate to severe symptoms that interfere with daily functioning. The protocol further highlights that when MPH is ineffective or poorly tolerated, AMPH should be considered as an alternative. The Saudi ADHD Society CPG reinforces the need for expanded access to AMPH stimulants (37), citing evidence from international ADHD treatment guidelines, such as NICE and the American Academy of Pediatrics (AAP), that support their efficacy. They also stress that untreated or poorly managed ADHD can lead to poor academic performance, increased risk of comorbid psychiatric disorders, and higher rates of substance misuse and criminal behavior. Thus, the Saudi ADHD Society guideline (37) strongly recommends improving access to AMPH treatments to ensure optimal patient outcomes. Additionally, the Saudi ADHD Society CPG calls for regulatory changes to facilitate the approval and distribution of AMPH stimulants, ensuring that they are available as part of the national ADHD treatment framework. A few years after this call, the Saudi FDA has approved lisdexamfetamine for patients with ADHD in public and private healthcare settings.

Several limitations should be acknowledged in this narrative review. First, potential biases may have been introduced during the identification, selection, and interpretation of the included literature. These biases could stem from the selective inclusion of studies, the inclusion of grey literature, or subjective judgment in evaluating the findings. As typical in narrative reviews, the interpretation of evidence and selection of themes may reflect author judgment rather than objective appraisal. Furthermore, the inclusion of grey literature and policy documents, although valuable, may have introduced variability in the quality and reliability of the information. Finally, the narrative approach allowed inclusion of policy documents and introduced subjectivity inherent in qualitative synthesis of evidence. Additionally, due to the nature of the included grey literature, reviewers were not blinded to document origin, which may introduce bias despite our use of independent screening and data verification. Therefore, the findings should be interpreted with caution.