1. Home>
2. Specialties>
3. Psychiatry>
4. Summary and Comment

Adult ADHD: When Medications Aren't Enough

Using cognitive-behavioral therapy to train attention in patients with attention deficit hyperactivity disorder adds to the benefit of medications.

Of the estimated 4.4% of U.S. adults with ADHD, many respond to medication but continue to have symptoms. This therapy add-on study involved 86 patients (mean age, 43) who had at least mildly and persistently symptomatic ADHD initially diagnosed in childhood, were on stable psychotropic medication regimens, and lacked major psychiatric comorbidities. Participants were randomized to 12 sessions of individual cognitive-behavioral therapy (CBT) or relaxation training plus education. CBT modules focused on psychoeducation regarding ADHD and training in organizing, planning, and problem solving; skills to reduce distractibility; and cognitive restructuring (thinking adaptively in distress-causing situations). Two sessions were boosters or focused on procrastination (n=40) or support from significant others (n=27). The control treatment consisted of one psychoeducation session, six on progressive muscle relaxation, four on applying relaxation to ADHD, and one wrap-up.

Although both groups improved, the CBT group showed more improvement posttreatment, with moderately better treatment-effect sizes. Depending on the scale, 53% to 67% of the CBT group responded, roughly double the response rates in the control group. In both groups, mean Clinical Global Impressions scale ratings declined from moderate severity at baseline (CBT, 4.74; relaxation and education, 4.63) to mild illness posttreatment (3.20 and 3.73). At 6- and 12-month follow-ups, gains by partial or full responders in both groups were generally maintained.

Comment: Given the distress and impairment associated with ADHD in adulthood, additional options for treatment are highly desirable. This excellent first-step study demonstrates the value of individually administered add-on therapy. CBT appeared to be moderately superior to relaxation and education. Recently, group metacognitive therapy was found to be superior to supportive psychotherapy in ameliorating ADHD symptoms (JW Psychiatry Apr 12 2010). Clinicians should consider various attention-focusing interventions for ADHD patients with insufficient response to medication. We now have several promising leads. To disseminate these approaches, researchers might develop computer-based interventions that engage, sustain, and train the ADHD patient's attention.

— Joel Yager, MD

Published in Journal Watch Psychiatry August 24, 2010

Citation(s):

Safren SA et al. Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: A randomized controlled trial. JAMA 2010 Aug 25; 304:875.

• Original article (Subscription may be required)
• Medline abstract (Free)

Reader Remarks:

Review and add to remarks on this article

• When drugs aren't enough
  angela a heithaus, Seattle Healing Arts Center, 4 Oct 2010 10:07 AM EST
  On going relaxation practices such as weekly restorative yoga sessions along with daily fitness and healthy nutrition vs a limited... [more]

2011 Year in Review