Adults with attention-deficit/hyperactivity disorder (ADHD) who received medication and individual sessions of cognitive behavioral therapy (CBT) showed greater improvement in symptoms through 12 months compared to patients who did not receive CBT, according to a study in the August 25 issue of JAMA.
"Approximately 4.4 percent of adults in the United States have ADHD, which is a disorder characterized by impairing levels of inattention, hyperactivity, and impulsivity. Medications have been the primary treatment; however, many adults with ADHD cannot or will not take medications while others show a poor medication response. Furthermore, those considered responders to medications (i.e., 30 percent symptom reduction) may continue to experience significant and impairing symptoms. Thus, there is a need for alternative and next-step strategies," the authors write.
Steven A. Safren, Ph.D., A.B.P.P., of Massachusetts General Hospital, Boston, and colleagues tested cognitive behavioral therapy for ADHD in 86 adults treated with medication but who still had clinically significant symptoms. The study was conducted between November 2004 and June 2008 (with follow-up through July 2009). Of the 86 patients randomized, 79 completed treatment and 70 completed the follow-up assessments. Patients were randomized to 12 individual sessions of either cognitive behavioral therapy or relaxation with educational support.
Cognitive behavioral therapy included sessions that focused on psycho-education about ADHD and training in organizing and planning; learning skills to reduce distractibility; cognitive restructuring (learning to think more adaptively in situations that cause distress); and relapse prevention. ADHD symptoms were rated by an assessor using an ADHD rating scale and Clinical Global Impression scale at the beginning of the trial, at the end of treatment, and at 6- and 12-month follow-up.
The researchers found that after the treatment was completed, patients who received cognitive behavioral therapy had significantly better ADHD rating scale scores and Clinical Global Impression scale scores than those who were assigned to relaxation with educational support. Also, there was a greater proportion of responders in the cognitive behavioral therapy condition compared with the relaxation condition, using criteria from both the Clinical Global Impression scale (53 percent vs. 23 percent) and the ADHD rating scale (67 percent vs. 33 percent).
Throughout treatment, self-reported symptoms were also significantly more improved for cognitive behavioral therapy. Responders and partial responders in the cognitive behavioral therapy condition maintained their gains over 6 and 12 months.
The researchers add that further study is required to examine whether this cognitive behavioral therapy intervention may be useful for individuals who may be unwilling or unable, for medical reasons, to take medication for ADHD. "Additionally, because the only other tested treatment is a group intervention, further investigation is needed to examine whether different patients or settings may be more receptive or conducive to an individual vs. a group approach."
"This study suggests that cognitive behavioral therapy for ADHD in adults appears to be a useful and efficacious next step strategy for adults who show continued symptoms despite treatment with medication. Generally, the treatment was well tolerated, with very low drop-out rates, and had positive and sustained effects on ADHD symptoms. Clinical application of these strategies to patients in need is encouraged."
(JAMA. 2010;304[8]:875-880. Available pre-embargo to the media at www.jamamedia.org)
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