Cognitive Behavioral Therapy Beneficial for Adults With ADHD

Caroline Cassels

August 25, 2010

August 25, 2010 — Cognitive behavioral therapy (CBT) may offer significant benefit in adult patients with attention-deficit/hyperactivity disorder (ADHD) who, despite medication, continue to experience clinically significant symptoms, new research suggests.

A randomized clinical trial conducted by investigators at Massachusetts General Hospital in Boston shows individuals who received CBT in addition to their regular ADHD medication had a superior response compared with their counterparts who received relaxation therapy with educational support in addition to their usual medication regimen.

"[Based on these findings] ADHD patients who continue to have symptoms despite medication use should be considered potential candidates for CBT," principal investigator Steven Safren, PhD, told Medscape Medical News.

The study is published in the August 25 issue of the Journal of the American Medical Association.

According to investigators, approximately 4.4% of adults in the United States have ADHD, a disorder characterized by impairing levels of inattention, hyperactivity, and impulsivity.

Although medication is the current treatment of choice, many adults with ADHD cannot or will not take medication, the study authors note. In addition, said Dr. Safren, most patients taking medication, although considered responders (defined as patients who experience a ≥30% reduction in ADHD symptoms), continue to experience clinically significant symptoms, highlighting the need for "alternative and next step strategies.

"[ADHD] is a very impairing and distressing disorder, and while medications help, they don't teach people skills to cope with their problems. This treatment is a relatively easy, short-term, skills-based treatment that teaches patients self-management skills to further reduce their symptoms," he said.

A previous pilot study of CBT by Dr. Safren and colleagues in this patient population showed those taking medication who received CBT had greater symptom reduction compared with those taking medication alone (Behav Res Ther. 2005;43:831-842).

On the basis of these positive results, the team launched the current efficacy study, which included 86 symptomatic adults who met Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria for ADHD and who were already treated with medication in the community setting but were still reporting clinically significant symptoms.

The study was conducted at a single center between November 2004 and June 2008 with follow-up through July 2009. Participants were randomized to receive 12 individual sessions of CBT or 12 individual sessions of relaxation with education.

The study's primary outcome measures were improvement from baseline in ADHD symptoms as assessed by the ADHD rating scale and Clinical Global Impression (CGI) scale and at 6- and 12-month follow-up. Participants were evaluated by an assessor blinded to the assigned study group.

The study had a secondary outcome measure of self-report of ADHD symptoms.

Of the total study cohort, 79 completed treatment and 70 completed follow-up assessments.

Developed by Dr. Safren and colleagues for the initial pilot study, the CBT intervention focuses on psycho-education about ADHD, training in organizing and planning, learning skills to reduce distractibility, cognitive restructuring, and relapse prevention (Mastering Your Adult ADHD: A Cognitive Behavioral Treatment Program Therapist Guide and Mastering Your Adult ADHD: A Cognitive Behavioral Treatment Program Client Workbook, Oxford University Press).

At study completion, investigators found that compared with the relaxation group, those in the CBT group achieved superior symptom reduction.

"Those who received the cognitive intervention did significantly better in terms of symptoms on the Clinical Global Impression scale, which is a global rating of distress and impairment, as well as the ADHD rating scale," said Dr. Safren.

He also noted that there was a greater proportion of responders in the CBT group compared with the relaxation group for both the CGI scale (53% vs 23%) and the ADHD rating scale (67% vs 33%).

Furthermore, he said, CBT appeared to have a durable effect, with responders and partial responders maintaining their gains at 6- and 12-month follow-up.

There is a larger body of evidence-based research supporting the use of CBT for anxiety disorders, depression, and now ADHD vs traditional psychotherapy, and yet it is underused, said Dr. Safren. Part of the problem, he said, is that most programs at the master's and PhD level don't offer CBT training.

The upshot, he added, is there just are not enough clinicians trained in CBT.

The investigators' next research steps include examining whether CBT may be useful in patients who will not, or cannot, take ADHD medications. In addition, said Dr. Safren his team would also like to study the impact of the intervention in adolescents with ADHD.

The study was funded by the National Institutes of Health.

JAMA. 2010;304:875-880.

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