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Attention deficit hyperactivity disorder, or ADHD, was long thought to be a disorder that only affected children. But it has now been clearly established that the symptoms can last into adulthood – and a major new study has identified which treatments may be most effective at alleviating them.
Stimulant drugs and atomoxetine (a type of antidepressant) were more effective than placebos at reducing core symptoms of ADHD over a 12-week period, the study published Tuesday in the journal Lancet Psychiatry found. Core symptoms of the neurodevelopmental disorder include inattention, hyperactivity and impulsivity, said study author Dr. Samuele Cortese, professor of child and adolescent psychiatry at the University of Southampton in England, during a press conference organized by the Science Media Center on Tuesday.
Before conducting this study, Cortese and several other study authors had various ties — such as consulting or research — with pharmaceutical companies, some of which produce ADHD drugs. But the investigation said the tapes did not influence any aspect of the investigation.
Cortese said about 5% to 7% of children and 2.5% of adults worldwide have ADHD, which results from underdeveloped or impaired executive functions and self-regulation skills, according to Harvard University’s Center on the Developing Child. These skills help people plan, focus attention, remember instructions, multitask, and more. The symptoms of inattention, hyperactivity and impulsivity mean that people with ADHD may have difficulty staying organised, concentrating, managing time or controlling impulses, which can affect all areas of life.
A health care provider makes a diagnosis by assessing whether symptoms are persistent, profound, and inappropriate depending on a person’s stage of development, and whether they interfere with a patient’s daily life. The disorder can also be associated with several additional challenges, such as mental or physical conditions, social problems and a higher risk of premature death.
“It is a serious condition. It is not a trivial subject,” says Cortese, who is also chairman of the European ADHD Guidelines Group.
“If you look at the current guidelines for treating ADHD in Britain,” Cortese said, “they recommend medication as the first choice. They also mention non-pharmacological treatment if medication is ineffective or not well tolerated, but they do not specify which type of non-pharmacological treatment. They also mention the possible combination.”
There are still uncertainties about the best treatment for adults with ADHD, Cortese said — so he and the other authors sought “to provide an updated synthesis of all available evidence from studies of the pharmacological and nonpharmacological interventions.” The research was done in collaboration with people with lived experience of ADHD, the authors said.
The study is a systematic review and meta-analysis of 113 published and unpublished randomized controlled trials that compared different types of interventions with placebos or other controls for the symptoms of a total of nearly 14,900 adult participants who had been formally diagnosed with ADHD.
In a short period of twelve weeks, according to ratings of symptom improvement by both doctors and patients, only stimulants, such as lisdexamfetamine and methylphenidate, and atomoxetine produced better results than a placebo.
When it came to the effectiveness of non-pharmacological treatments versus a placebo, there was a discrepancy between the opinions of doctors and those of the patients themselves. Cognitive behavioral therapy, cognitive remediation, mindfulness, psychoeducation, and transcranial direct current stimulation were also more effective than a placebo at reducing patients’ symptoms, but this outcome was only reported by physicians.
Transcranial direct current stimulation is a non-invasive, painless brain stimulation technique that uses low-intensity electrical currents to stimulate specific parts of the brain.
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The authors found several other outcomes, including that medications were more likely to be discontinued due to side effects than placebos. For emotional dysregulation, which Cortese said many people with ADHD experience, atomoxetine and stimulants were more helpful than a placebo. But for executive function and quality of life, none of the treatments performed differently than a placebo.
“There are several take-home points from this study, which used a very clever approach to pool and contrast different types of ADHD treatments,” said Dr. Philip Shaw, professor at the Institute of Psychiatry, Psychology & Neuroscience at King’s College London, said in a statement to the Science Media Centre.
“First, the research shows that there are effective interventions for adults with ADHD who are looking for ways to reduce the unwanted consequences of symptoms,” said Shaw, who was not involved in the study. “The disadvantage was that some medications had difficult side effects, while this was not the case with psychostimulants, the most commonly used medications.”
The study also highlights “major gaps in our knowledge,” he said.
The study’s limitations are due to shortcomings in the literature analyzed for the review, as well as the lack of research on certain factors, said clinical psychologist Dr. Margaret Sibley, professor of psychiatry and behavioral sciences at the University of Washington School of Medicine. . Sibley was not involved in the investigation.
Because most treatment trials included in the review lasted less than three months, it’s difficult to be sure how long the benefits might last, Shaw said. The authors also looked at results at 26 and 52 weeks, but these were limited due to an insufficient amount of data, said study author Dr. Edoardo G. Ostinelli, senior researcher and deputy head at the Oxford Precision Psychiatry Lab at the University of Oxford, in the Science Media Center briefing.
“However, non-pharmacological treatments such as (cognitive behavioral therapy) are not intended to reduce the core symptoms of ADHD, although they sometimes do so indirectly,” Sibley said via email. “They are intended to teach coping skills to reduce the impact of symptoms on a person’s life. So if the primary outcome of this study had been disability or ADHD coping skills, or psychological variables such as self-esteem, self-efficacy, or sense of autonomy, you might have seen different findings.”
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It’s also likely that differences in treatment effectiveness simply come down to the fact that one size does not fit all, Ostinelli said.
Some people with ADHD are apprehensive about taking medications or have experienced side effects that make them uncomfortable, said Dr. Alessio Bellato, a lecturer in child and adolescent mental health at the University of Southampton, who was not involved in the study.
“The review also highlights an ongoing challenge in conducting ADHD research in adults,” Sibley added. “The self-perception of ADHD symptoms is fallible in all people. They are somewhat subjective symptoms. However, there are no “objective” tests that can accurately measure ADHD symptoms. In fact, the best practice is to use informant reports (i.e. reports from loved ones) in combination with self-report when assessing ADHD in adults.”
These reports are sometimes integrated with physician reports to definitively determine whether a symptom is present, but most treatment studies do not use this strategy, which can lead to inconclusive findings in research studies, she added.
All told, because people with ADHD usually seek treatment in hopes of improving more than just core symptoms, best practice in treating ADHD in adults typically involves both pharmacological and nonpharmacological care, Sibley said — a combination that requires the study had no data. but one that “can help people manage their ADHD and learn to write their own owner’s manual, while building a life that works for them.”
The study reflects the need for more long-term studies of different types of treatments and combinations thereof, especially among adults, experts said.
