Cognitive Behaviour Therapy in Medication-treated Adults With ADHD and Persistent Symptoms

A Randomized Controlled Trial

Brynjar Emilsson; Gisli Gudjonsson; Jon F Sigurdsson; Gisli Baldursson; Emil Einarsson; Halldora Olafsdottir; Susan Young

Disclosures

BMC Psychiatry. 2011;11(116) 

In This Article

Background

In the last decade ADHD among adults has become increasingly recognized as a complex disorder characterized by high rates of comorbidity and social dysfunction, including mood disorders, anxiety, alcohol and drug abuse, educational failure, occupational problems, interpersonal relationship problems, delinquency and crime.[1–4] Population surveys estimate the prevalence of ADHD in adults to be around 2.5%.[5]

Many adults do not obtain their diagnosis until their adult years yet even when ADHD has been recognized and treated in childhood psychiatric and psychosocial outcomes are bleak.[6,7] The costs associated with the disorder are serious and long-term.[8]

In addition to high rates of comorbidity, adult ADHD has been associated with maladaptive personality (i.e. a disorganized personality style) and maladaptive coping strategies which limits the internal resources available to the individual.[9,10] Thus treatments need to not only target symptom reduction, but aim to improve quality of life by addressing the multiple problems that impair daily social and emotional functioning.[11]

International guidelines[8,12] recommend multimodal treatment for adults with ADHD comprising of psychoeducation, pharmacotherapy and cognitive behaviour therapy (CBT). The need for non-pharmacological interventions is underpinned by the finding that some adults do not respond to drug treatment and those who do may only experience a partial response.[13] In the past few years prescribing has increased for treating ADHD,[14] yet psychological treatments have not paralleled this growth.[2,15]

Research on the effectiveness of psychopharmacological treatments in ADHD adults has been extensive compared with evaluations of psychological interventions. Only six randomised controlled studies have been published and these all report effectiveness of CBT interventions in medicated patients. CBT provided on an individual basis has been evaluated by Safren and colleagues[16] who randomly assigned 31 patients receiving medication to receive 15 sessions of CBT or treatment as usual. They found that combined medication and CBT had a greater effect for independent evaluator ratings of ADHD symptoms, impairment and depression and for self-reported ADHD symptoms and anxiety. They later conducted another study randomizing medicated patients to either 12 sessions of CBT or relaxation with educational support and found similar results for ADHD symptom reduction.[17] Importantly, improvements for those who responded to treatment were maintained at 12 month follow up. In a study of 29 adults with ADHD (medication not controlled for) comparing 10 sessions of individual CBT with 20 sessions of cognitive training (CT; training of attention, executive functions and working memory) and a control condition, a significant effect was only found for self-reported inattention. No effect was found on independent evaluations, or on independent and self-ratings for measures of ADHD symptoms, depression or quality of life.[18]

Group interventions are attractive for clinical delivery as they are cost effective, thus group interventions were recommended by the National Institute for Health and Clinical Excellence [NICE] as the first line psychological treatment. Solanto and colleagues[19] evaluated a 12 session group CBT programme by randomly assigning 88 patients receiving medication to receive either CBT or supportive therapy. The CBT condition had lower treatment dropout and found significant effect for self-report, collateral report and independent evaluator ratings of inattention symptoms. No significant effect was found for comorbid problems (depression, anxiety and self-esteem) or for organization and planning skills. A similar pattern of outcome was reported by Hirvikoski and colleagues[20] who randomly assigned 51 medicated adults to 14 sessions of dialectical behaviour therapy (DBT) or a loosely structured discussion group. A significantly greater reduction in ADHD symptoms was self-reported at the end of DBT group treatment but no significant difference was found for comorbid depression, anxiety, sleep problems, stress or functional impairment. Stevenson et al.,[21] randomized 43 medicated patients to an eight week cognitive remediation therapy (CRT) group programme or treatment as usual and found a significant effect for ADHD symptoms, organizational skills and reduction in feelings of anger for those who completed the programme. The group programme introduced the novel element of individual coaching sessions for participants between group sessions. The treatment gains for the CRT condition were maintained at one year follow up except for state anger.

The only non-randomized controlled study that has been reported indicated that CBT can be effective even when provided in intensive bursts. Bramham and colleagues[22] provided an intensive 3-day intervention (one day per month for 3 months) to medicated patients and compared outcome with waiting list controls. The intervention included psychoeducation and CBT drawing on modules from the Young-Bramham programme[23] on topics of ADHD symptoms, emotional control, relationship skills, time-management, problem solving, and preparing for the future. A significant effect was found for those receiving CBT on measures of psychoeducation (an ADHD knowledge quiz), self-efficacy and self-esteem. No significant effect was found for anxiety and depression.

The findings from these studies suggest that the provision of psychological treatment in medicated patients - whether delivered in individual or group sessions - is effective in treating ADHD symptoms and has an additive effect over and above medication alone. The findings for treating comorbid problems however are limited and need to be studied further. Nevertheless comorbidity in adult ADHD is so common that group interventions that target symptoms, comorbid and associated problems will have a better chance of conferring health gain by making global improvements to self-efficacy, self-esteem and quality of life. If this can be achieved, this will be a cost-effective intervention that may reduce multiple presentations to health care services.[6,24]

This study aimed to investigate the effectiveness of the R&R2 ADHD cognitive behavioural group treatment which has been developed to treat ADHD symptoms and common comorbid problems. Medicated patients were randomly assigned to either receive CBT (the CBT/MED condition) or treatment as usual (TAU/MED condition). The primary outcomes of interest were changes in ADHD symptoms following treatment. Secondary outcome measures were anxiety, depression, emotional control, social functioning and antisocial behaviour. It was hypothesized that the CBT/MED condition would show significantly greater improvements than the TAU/MED condition on primary and secondary outcome measures and that this effect would be maintained at follow-up.

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