Study: Cognitive Behavioral Therapy (CBT) + Medication outperforms CBT alone to treat ADHD symptoms among adults. At the same time…

Although med­ica­tion is the pri­ma­ry treat­ment for adults with ADHD, and has good empir­i­cal sup­port, many adults would rather not take it. For these adults with ADHD, it would be help­ful to know whether med­ica­tion is like­ly to pro­vide sig­nif­i­cant ben­e­fits above and beyond those they would gain from well-con­duct­ed ther­a­py, or whether they are like­ly to derive rough­ly equiv­a­lent ben­e­fits from ther­a­py alone.

This impor­tant ques­tion was addressed in a recent­ly pub­lished study titled ‘Effi­ca­cy of cog­ni­tive behav­ioral ther­a­py with and with­out med­ica­tion for adults with ADHD: A ran­dom­ized con­trolled tri­al’. The study was pub­lished online in 2016 in the Jour­nal of Atten­tion Dis­or­ders. From the abstract:

• Objec­tive: Recent tri­als have demon­strat­ed effi­ca­cy of cog­ni­tive behav­ioral ther­a­py (CBT) in med­icat­ed adults with ADHD. Effi­ca­cy of CBT in unmed­icat­ed ver­sus med­icat­ed adults remains most­ly unknown. We eval­u­at­ed the effects of group CBT alone ver­sus com­bined with med­ica­tion on ADHD symp­toms and func­tion­al out­comes in adult patients…Con­clu­sion: CBT + med­ica­tion out­per­formed CBT alone for ADHD symp­toms, orga­ni­za­tion­al skills, and self-esteem, although its supe­ri­or­i­ty tend­ed to decrease over follow-up.

The Study

Eighty-eight adults with care­ful­ly diag­nosed ADHD were ran­dom­ly assigned to receive 12 weeks of cog­ni­tive behav­ioral ther­a­py (CBT) alone, or CBT plus med­ica­tion. Over the 12 weeks, the fol­low­ing top­ics were addressed:

1. Basic edu­ca­tion about ADHD and how it impacts adults.
2. Goal set­ting and strate­gies for attain­ing goals.
3. Orga­ni­za­tion and time management.
4. Man­ag­ing stress.
5. Iden­ti­fy­ing and cor­rect­ing mal­adap­tive thoughts.
6. Anger man­age­ment.
7. Impulse con­trol and strate­gies for effec­tive self-regulation.
8. Build­ing self-esteem.
9. Under­stand­ing com­mon rela­tion­ship prob­lems in adults with ADHD and how to address them.

The pro­gram focused on the acqui­si­tion and prac­tice of adap­tive cog­ni­tive and behav­ioral skills to improve func­tion­ing in these areas. In addi­tion to didac­tic pre­sen­ta­tions on these top­ics, ses­sions were used to prac­tice new skills and iden­ti­fy ways to uti­lize new skills par­tic­i­pants’­dai­ly lives. Par­tic­i­pants received week­ly home­work focused on imple­ment­ing the new­ly learned skills — this was an impor­tant part of the program.

Each par­tic­i­pant was also assigned a coach that they worked with through­out the pro­gram. Coach­es held twice week­ly phone calls with par­tic­i­pants in addi­tion to a brief face-to-face ses­sion. Dur­ing these coach­ing ses­sions, par­tic­i­pants and their coach dis­cussed the practice/implementation of new skills and dis­cussed ways to address bar­ri­ers to their implementation.

Fol­low­ing the 12th ses­sion, there were 3 month­ly boost­er ses­sions ded­i­cat­ed to review­ing key con­cepts and trou­ble shoot­ing. Tele­phone coach­ing con­tin­ued dur­ing this time on a week­ly basis.

Med­ica­tion treat­ment — Adults assigned to the CBT + med­ica­tion group began on med­ica­tion pri­or to begin­ning CBT; they were start­ed on a low dose of stim­u­lant med­ica­tion that was grad­u­al­ly increased based on feed­back on effi­ca­cy and side effects. When fur­ther increas­es in dose did not enhance effi­ca­cy, or led to side effects, the pri­or dose was con­sid­ered opti­mal. They were main­tained on their opti­mal dose through­out the study and fol­low up peri­od. Adults who did not respond to the ini­tial stim­u­lant were tried on a dif­fer­ent stimulant.

Mea­sures — A broad array of out­come mea­sures were includ­ed so that treat­ment impact on core ADHD symp­toms and func­tion­ing in impor­tant life domains could be exam­ined. The domains assessed includ­ed orga­ni­za­tion­al skills, self-esteem, symp­toms of depres­sion and anx­i­ety, anger expres­sion, and glob­al func­tion­ing. These were all self-report mea­sures that were com­plet­ed by adults them­selves. Core ADHD symp­toms were also rat­ed by an infor­mant that each adult select­ed, e.g., a spouse, part­ner, close friend, co-work­er, etc.

The mea­sures sum­ma­rized above were col­lect­ed at mul­ti­ple time points — at base­line, imme­di­ate­ly fol­low­ing med­ica­tion opti­miza­tion and before CBT began, after 12 weeks of CBT, fol­low­ing the 3‑month boost­er peri­od, and a final time 3 months lat­er.

This data col­lec­tion sched­ule enabled the researchers to com­pare the 2 groups (CBT and CBT + meds) at mul­ti­ple time points to learn whether any ini­tial advan­tages found for either treat­ment were main­tained over time.

Results

ADHD symp­toms — Adults in the CBT + med­ica­tion group report­ed sig­nif­i­cant­ly greater reduc­tion in core ADHD symp­toms than adults receiv­ing CBT alone; this was evi­dent after the 12-week CBT treat­ment, after the 3‑month boost­er end­ed, and at the final fol­low-up 3 months lat­er. Those who received CBT only also report­ed a sig­nif­i­cant reduc­tion in core symp­toms but this was less than for those who also received medication.

When observ­er rat­ings were exam­ined, adults receiv­ing meds were also report­ed to show greater improve­ment in core symp­toms than adults receiv­ing CBT alone; this was evi­dent imme­di­ate­ly after CBT end­ed as well as after the 3‑month boost­er. At the final assess­ment 3 months lat­er, how­ev­er, sig­nif­i­cant dif­fer­ences between the groups were no longer evident.

Orga­ni­za­tion­al skills and self-esteem — Those in the CBT + meds group report­ed greater improve­ment in orga­ni­za­tion­al skills fol­low­ing the CBT ses­sions as well as after the 3‑month boost­er; at the final assess­ment 3 months lat­er, how­ev­er, these dif­fer­ences were no longer sig­nif­i­cant. A sim­i­lar pat­tern was found for self-report­ed self-esteem. Thus, for these out­comes, those receiv­ing CBT + meds improved more quick­ly, but by the final mea­sure­ment point adults in the oth­er groups had ‘caught up’.

Depres­sion, anx­i­ety, anger expres­sion, and glob­al func­tion­ing — For these mea­sures, there was a trend towards improve­ment in both groups with no dif­fer­ences between them.

Summary and implications

Does med­ica­tion pro­vide sig­nif­i­cant addi­tion­al ben­e­fits to adults with ADHD above those pro­vid­ed by a good course of CBT alone? Results from this study indi­cate there is not a clear answer to this ques­tion as it depends on what out­comes are being con­sid­ered and the time frame in which they are being looked at.

For sev­er­al out­comes mea­sures — core ADHD symp­toms, orga­ni­za­tion, and self-esteem — those receiv­ing CBT + meds improved more quick­ly; that is not sur­pris­ing giv­en that the pos­i­tive effects of med­ica­tion are imme­di­ate while those result­ing from ther­a­py are like­ly to build over time. It was only for ADHD symp­toms, how­ev­er, that the incre­men­tal ben­e­fits of meds tend­ed to per­sist and this was only when con­sid­er­ing self-report and not observ­er ratings.

For the oth­er out­comes, i.e., depres­sion, anx­i­ety, anger expres­sion, and glob­al func­tion­ing, no addi­tion­al ben­e­fits from meds were evi­dent. The authors point out that this may have been because par­tic­i­pants were not clin­i­cal­ly ele­vat­ed on these mea­sures to begin with, so there was less room to show improvement.

What gen­er­al con­clu­sions can be drawn from this study? For adults whose dif­fi­cul­ties relat­ed to ADHD are acute, a tri­al of med­ica­tion seems very impor­tant. The impact on core symp­toms and on sev­er­al impor­tant func­tion­al domains is like­ly to be much quick­er; this can be espe­cial­ly impor­tant when some­one is real­ly strug­gling. Although those receiv­ing CBT only gen­er­al­ly caught up by the end of the study, this was more than a full year out (4 months CBT, 3 months of boost­er ses­sion, and final fol­low-up 3 months lat­er). For those whose ADHD is sig­nif­i­cant­ly impair­ing their day-to-day life, the time required for mean­ing­ful improve­ments with CBT alone may be too great.

For adults whose ADHD relat­ed dif­fi­cul­ties are less acute, and who do not wish to take meds, results indi­cat­ed that well-con­duct­ed CBT plus coach­ing is like­ly to pro­duce sig­nif­i­cant ben­e­fits in how they expe­ri­ence their lives; this will like­ly occur grad­u­al­ly over an extend­ed time peri­od. For many indi­vid­u­als, this more grad­ual reduc­tion in symp­toms and impair­ment may be fine.

Two impor­tant points qual­i­fy the above. First, except for observ­er rat­ings of core ADHD symp­toms, all out­comes were based on self-report and some would sug­gest that these are not objec­tive assess­ments. Thus, includ­ing more objec­tive assess­ments of dif­fer­ent out­comes when fea­si­ble would have strength­ened the study.

Sec­ond, it is impor­tant to note that the CBT pro­vid­ed was quite an exten­sive treat­ment — week­ly group ses­sions and mul­ti­ple week­ly coach­ing ses­sion for 4 month fol­lowed by month­ly boost­ers over anoth­er 3 months. To be can­did, it could be dif­fi­cult to pro­cure this treat­ment in many com­mu­ni­ties; med­ica­tion, of course, is avail­able pret­ty much everywhere.

Thus, chal­lenges to obtain­ing good non-med­ical treat­ment for ADHD is a real issue that must be addressed for indi­vid­u­als to more eas­i­ly real­ize the ben­e­fits that such treat­ment can provide.

– Dr. David Rabin­er is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. He pub­lishes the Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD, and helped pre­pare the self-paced, online course How to Nav­i­gate Con­ven­tion­al and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment.

Relat­ed reading:

• What are cog­ni­tive abil­i­ties and how to boost them?