Medication not psychotherapy intensity sways treatment outcome in adult ADHD

By Lucy Piper, Senior medwireNews Reporter

Psychological interventions for adult attention deficit/hyperactivity disorder (ADHD) are best combined with methylphenidate, show findings from the COMPAS trial.

The results also indicate that highly structured interventions, such as cognitive behavioural group psychotherapy (GPT), do not perform better than less specific treatments like clinical management (CM), which the researchers note is “much easier to implement in practical care.”

The trial (The Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study) involved 419 patients with ADHD aged 18 to 58 years. After 3 months of weekly intensive treatment with either GPT or CM and monthly treatment thereafter, both groups showed a similar improvement on the ADHD Index of the Conners Adult ADHD Rating Scale.

Scores at 13 weeks decreased from an all-group average of 20.6 at baseline to an adjusted mean of 17.6 for 109 patients randomly assigned to receive GPT plus placebo and to 16.5 for 107 patients randomly assigned to receive CM plus placebo. The difference in improvement was not significant.

The team, led by Alexandra Philipsen (University of Oldenburg, Germany), suggests that the CM control condition, which involved individual counselling and was chosen to simulate practice care in an optimal way, may have met the individual needs of the patients better than the group psychotherapy program, hindering its ability to outperform.

The performance of both therapies did improve with the addition of methylphenidate, however, as seen for 107 patients receiving GPT and 110 receiving CM. At 13 weeks, ADHD Index scores decreased to an adjusted mean of 16.2 with combined methylphenidate compared with 17.9 with placebo.

While psychotherapy treatment effects were generally stable over the remaining year, the researchers note in JAMA Psychiatry that any slight benefit of CM on the ADHD Index in the first 6 months was not maintained to the end of the year. By this time, treatment effects favoured GPT slightly, albeit not significantly.

Also, Clinical Global Impression (CGI) effectiveness scores, a secondary measure, were significantly better for GPT than CM at all timepoints, although the researchers caution that their data “could not show whether superior CGI ratings of GPT reflected otherwise hidden differences in patients’ daily functioning.”

They conclude: “The COMPAS trial sheds light on issues that, to our knowledge, have not yet been addressed. First it almost doubles the observation period of the longest randomized study conducted globally so far. Second it systematically addresses the effect of medication on the outcome of psychotherapy.”

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