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Article
Psychiatric Times
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Combining cognitive behavioral therapy with medication enhances ADHD treatment in adults, showing significant benefits within 3 months.
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TRANSLATING RESEARCH INTO PRACTICE
Rajesh R. Tampi, MD, MS, DFAPA, DFAAGP, Column Editor
A monthly column dedicated to reviewing the literature and sharing clinical implications.
Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that is characterized by patterns of inattention, hyperactivity, and impulsivity that interfere with functioning or development. Although traditionally considered a childhood disorder, ADHD frequently persists into adulthood, affecting approximately 2.5% of adults globally. Adult ADHD is associated with significant impairments in occupational, academic, and social domains, and it often coexists with other psychiatric conditions such as anxiety, depression, and substance use disorders. Pharmacotherapy remains the cornerstone of treatment for adult ADHD, with stimulant medications such as amphetamines and methylphenidate being first-line options due to their efficacy. Nonstimulant medications such as atomoxetine and viloxazine are alternatives for patients who cannot tolerate stimulants or have comorbid conditions. Psychotherapy is often recommended to address functional impairments and comorbidities but is not always considered a first-line recommendation for ADHD.
The Study
Li Y, Zhang L. Efficacy of cognitive behavioral therapy combined with pharmacotherapy versus pharmacotherapy alone in adult ADHD: a systematic review and meta-analysis. J Atten Disord. 2024;28(3):279-292.
Study Funding
None listed.
Study Objectives
To compare the efficacy of cognitive behavioral therapy (CBT) plus pharmacotherapy with pharmacotherapy alone for the treatment of adults with ADHD.
Methodology
1. There was an adequate number of participants in both groups (208 in the intervention group and 208 in the control group).
2. The investigators reported the effects of treatment based on the country of origin of the study and its socioeconomic status, which can prove beneficial in future studies.
3. There was sufficient analysis for discrete posttreatment follow-up periods, which informed the sustainability of the treatment effects.
1. Some control groups did not receive any nonpharmacological intervention (no sham), which may have affected blinding and introduced a selection bias.
2. There was no ADHD subtyping, limiting the generalizability of the conclusions.
3. The study did not differentiate between the various medications that were used in these studies.
4. Each study had a different follow-up timeline.
5. There was no reporting on the dosages of medications or dosage equivalency of the various pharmacotherapeutic agents.
This study was a systematic review and meta-analysis that included 6 randomized clinical trials (RCTs) comparing the treatment of adult ADHD using a combination treatment of CBT and psychopharmacotherapy (CBT + M) with M alone. The systematic review followed the PRISMA guidelines, and investigators searched 4 databases (PubMed, Embase, Cochrane, and Web of Science) and ClinicalTrials.gov up to July 29, 2023, for relevant studies. The studies included in the systematic review and meta-analysis were RCTs that had participants 18 years or older who were diagnosed with ADHD and who had received pharmacological treatment for ADHD. The treatment arm of all included studies was the combination of CBT + M, whereas the control arm for all included studies was M alone.
The primary outcomes in the reviewed studies involved data from any of the following rating scales: the Conners Adult ADHD Rating Scale, the Adult ADHD Self-Report Scale, the RATE-S Scale, and the Kiddie Schedule for Affective Disorders and Schizophrenia. Secondary outcomes included scores on rating scales such as the Beck Anxiety Inventory, Beck Depression Inventory, Hamilton Anxiety Scale, Hamilton Depression Rating Scale, Clinical Global Impression Scale, and Barkley ADHD Current Symptoms Scale for measures of depression, anxiety, inattention, hyperactivity-impulsivity, social functioning, antisocial symptoms, and clinical global impression.
Study Results
The systematic screening of studies yielded a total of 6 RCTs. They were conducted in Iceland, China, Switzerland, and the United States. A total of 416 participants were included, with 208 in the intervention group and 208 in the control group. Regarding primary outcomes, the authors compared results at the end of the treatment, 3 months post treatment, 6 months post treatment, and 9 months post treatment. At the end of treatment, individuals in the CBT + M group showed significant improvements in ADHD symptoms when compared with the individuals in the M alone group (standardized mean difference [SMD], –0.43; 95% CI, –0.60 to –0.27; P < .00001). At follow-up, only 5 studies were included, as 1 study did not assess follow-up outcomes after the end of allocated treatment. At the end of the follow-up period, CBT + M was more effective in improving ADHD symptoms when compared with M alone (SMD, –0.45; 95% CI, –0.70 to –0.19; P < .0005). Individuals in the CBT + M group did not show any significant improvements in the hyperactivity-impulsivity symptoms at any time when compared with the individuals in the M alone group (SMD, −0.12/−0.34; 95% CI, −0.38 to 0.14/−0.69 to 0.02; P = .38/.06).
The subgroup analysis of different time points post treatment revealed that CBT + M showed significant improvement in ADHD symptoms when compared with M alone at 3 months follow-up (SMD, −0.89; 95% CI, −1.17 to −0.60; P < .00001). At 6 months and 9 months follow-up, the difference was not significant between the 2 groups (6-month SMD, −0.23; 95% CI, −0.52 to 0.06; P = .12; 9-month SMD, −0.05; 95% CI, −0.32 to 0.22; P = .73). Further subgroup analysis revealed significant improvements in ADHD symptoms with CBT + M when compared with M alone in developed countries (United States, Switzerland, Iceland; SMD, −0.58; 95% CI, −0.79 to −0.37; P < .00001), but this effect was not significant in developing countries (China; SMD, −0.15; 95% CI, −0.44 to 0.14; P = .32).
Conclusions
This systematic review and meta-analysis supports the use of CBT + M over M alone among adults with ADHD for at least 3 months. However, the superiority of combination treatment appears to wane after the 3-month period. This indicates the possible need to intensify CBT treatment when there is a requirement for longer-term combined treatment among adults with ADHD.
Practical Applications
The combination of CBT + M appears to be superior to M alone among adults with ADHD at the end of treatment and during the 3-month follow-up period.
Bottom Line
Among adults with ADHD, CBT + M appears to be more beneficial than M alone at the end of treatment and during the 3-month follow-up period. When longer-term combination treatments are needed, the CBT treatments probably need to be intensified to maintain superiority of combined treatment over M alone.
Dr Al-Khalila is a first-year psychiatry resident at Creighton University in Omaha, Nebraska. Dr Essa is a second-year psychiatry resident at Creighton University. Dr Schuster is a fourth-year psychiatry resident at Creighton University. Dr Mullen is an assistant professor of psychiatry at Saint Louis University School of Medicine in Missouri. Dr Tampi is professor and chair of the Department of Psychiatry at Creighton University School of Medicine and Catholic Health Initiatives Health Behavioral Health Services. He is also an adjunct professor of psychiatry at Yale School of Medicine in New Haven, Connecticut, and a member of the Psychiatric Times editorial board.
Reference
1. Li Y, Zhang L. Efficacy of cognitive behavioral therapy combined with pharmacotherapy versus pharmacotherapy alone in adult ADHD: a systematic review and meta-analysis. J Atten Disord. 2024;28(3):279-292.
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