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

Results

Completion Rate

Of the 27 participants who started the CBT treatment, 20 participants completed, giving a completion rate of 74%. Four dropped out during the treatment phase without explanation, one due to moving out of the area, one due to illness in the family and one had to stop medication due to pregnancy. The dropout rate of 6 (22.2%) was similar for participants in the TAU/MED condition (i.e. they did not attend the end of treatment assessment). Two participants in the CBT treatment condition and four participants in the control condition did not complete all of the end of treatment assessments. A further three participants in the CBT treatment condition but no participants in the control condition did not complete the follow-up assessments.

A total of 35 participants completed self-reported questionnaires at the end of treatment and 32 at three month follow up; 34 participants attended the independent evaluation at the end of treatment and 21 at three month follow-up. To test for possible baseline differences between completers and non-completers a comparison was made on baseline IE measures between those who completed the follow-up measures and those who attended the baseline measures but did not complete all the post assessments (two tailed). For the CBT/MED condition there was no statistical difference at baseline between completers (n = 8) and non-completers (n = 18) on the CGI (t = .493, df = 24, p = .626) or on the K-SADS (t = .720, df = 24, p = .479). The same results were found for the TAU/MED condition where no statistical difference was found between completers (n = 13) and non-completers (n = 12) on baseline measures of CGI (t = .419, df = 23, p = .679) or K-SADS (t = .480, df = 23, p = .636).

Medication Changes

At baseline, methylphenidate dosages ranged between 18-180 mg, with a mean dosage of 60.5 mg. By the end of treatment, dosages had been increased for two participants in each condition and decreased for one participant in each condition. The dosage range for methylphenidate was 36-162 mg, with a mean dosage of 62.5 mg. At three-month follow-up dosages had been increased for one participant in each condition and decreased for two in the CBT/MED condition and one in the TAU/MED condition. The dosage range of methylphenidate at follow-up was 36-108 mg, with a mean dosage of 59.4 mg. Fischer's exact test revealed that there were no significant differences in proportions of medication change between the two conditions either at the end of treatment (P = .619) or at three month follow-up (P = .473). Table 1 presents the unadjusted means and standard deviations for each outcome measure at baseline, at the end of treatment and at three month follow up, for the experimental (CBT/MED) and control (TAU/MED) conditions. It also gives the effect sizes (Cohen's d) of the mean difference between the two conditions for the end of treatment and three-month follow-up assessments. Adverse events were recorded during the trial and one participant in the CBT/MED condition reported severe distress at the end of treatment due to changes in personal circumstances. This participant then received individual treatment and was not assessed at follow-up.

Effectiveness

Independent Evaluators' Outcome Measures (IE) After adjusting for baseline means the CBT/MED condition had significantly lower IE ratings than the TAU/MED condition on the K-SADS ADHD measure at the end of treatment (F(1,31) = 11.02, p < .01) with a large effect size. At three month follow-up a significant difference was maintained where the CBT/MED condition had lower IE ratings than the TAU/MED condition (F(1,18) = 7.60, p < .05) and the effect size remained large (see Figure 2).

Figure 2.

Independent evaluator rated changes in unadjusted means on the K-SADS ADHD measure.

On the CGI no significant difference was found between conditions at the end of treatment (p = .06) but the CBT/MED condition had significantly lower IE ratings at follow-up (F(1,18) = 9.16, p < .05) with a large effect size.

Self-report Outcome Measures After adjusting for baseline means the participants in the CBT/MED condition had significantly lower scores on the inattention scale of the BCS than those in the TAU/MED condition at the end of treatment (F(1,32) = 8.73, p < .05) and at three month follow-up (F(1,29) = 10.70, p < .01) with large effects sizes. The participants in the CBT/MED condition also scored lower on symptoms of hyperactivity/impulsivity on the BCS both at the end of treatment (F(1,32) = 7.27, p < .05) and at three month follow-up (F(1,29) = 20.30, p < .001) with small and medium effect sizes, respectively. On the total BCS score the participants in the CBT/MED condition scored significantly lower than those in the TAU/MED condition at the end of treatment (F(1,32) = 10.45, p < .01) and at follow-up (F(1,29) = 17.36, p < .001) with medium and large effect sizes, respectively (see Figure 3).

Figure 3.

Self-reported changes in unadjusted means on the Barkley ADHD Current Symptom Scale.

After adjusting for baseline means no significant difference was found on anxiety scores on the BAI between the two conditions at end of treatment (p = .46). The participants in the CBT/MED condition showed however significant improvement at follow-up compared with those in the TAU/MED condition (F(1,29) = 4,61, p < .05) with a large effect size. On the BDI no significant difference was found at the end of treatment (p = .052) but the CBT/MED condition showed significant improvement compared with the TAU/MED condition at follow-up (F(1,29) = 5.86, p < .05) with a large effect size.

With respect to the RATE-S Scales, no significant difference was found between the two conditions at the end of treatment on the Total RATE-S score (p = .07) but the CBT/MED condition scored significantly lower than the TAU/MED condition at follow-up (F(1,28) = 14.77, p < .001) with a large effect size. The same effect was found for the ADHD, Emotional Control and Social Functioning Scales. No significant difference was found between the two conditions at the end of treatment on the ADHD Scale (p = .16) but the CBT/MED condition scored significantly lower than the TAU/MED condition at three month follow-up (F(1,28) = 11.83, p < .01) with a large effect size. No significant difference was found between the two conditions at the end of treatment on the Emotional Control Scale (p = .48) but at follow-up the CBT/MED condition showed significant improvement compared with the TAU/MED condition (F(1,28) = 6.35, p < .05) with a large effect size. On the Social Functioning Scale no significant difference was found between the two conditions at the end of treatment (p = .09) but the CBT/MED condition showed significant improvement compared with the TAU/MED condition at follow-up (F(1,28) = 10.88, p < .01) with a large effect size. On the Antisocial Scale, the CBT/MED condition showed significant improvement compared with the TAU/MED condition at the end of treatment (F(1,31) = 4.75, p < .05) with a large effect size. This difference was maintained at follow-up (F(1,29) = 7.28, p < .05) with a large effect size.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

processing....