ATLANTA — Combining stimulant medication and cognitive therapy is a promising approach for treating adult patients with attention-deficit hyperactivity disorder, reported Anthony L. Rostain, M.D.
In an open-label study involving 45 consecutive adults with ADHD in a university-based clinic, combination therapy was associated with a statistically significant improvement in both ADHD symptoms and overall functioning, Dr. Rostain said in a presentation at the annual meeting of the American Psychiatric Association.
The treatment also appeared to reduce symptoms of comorbid anxiety and depression, which occur frequently in adults with ADHD, he said.
Patients were recruited to the study based on the results of telephone screening assessments.
Approximately 78% of the participants were male and 72% had comorbid mental disorders. Average patient age was 31 years.
At baseline and at the end of treatment, all study participants completed the Structured Clinical Interview for DSM-IV Axis I Disorders and other rating scales to assess symptom prevalence and severity.
The combination treatment used in the study comprised an extended-release formulation of mixed amphetamine salts given at titrated doses based on patient response, and 16 sessions of cognitive therapy focused on patient goals and desired outcomes.
Specifically, the behavioral component was built around the cognitive model of ADHD, “which looks at the compensatory strategies for coping with the maladaptive schemas and beliefs in adults with the condition,” said Dr. Rostain of the University of Pennsylvania, Philadelphia.
These maladaptive schemas include self-mistrust and overwhelming feelings of failure and incompetence, accompanied by unproductive negative thoughts, such as “I am inadequate,” and “I can't rely on myself,” said Dr. Rostain.
Some of the compensatory strategies that adults adopt to deal with these negative processes include procrastination, overcritical judgment, and “pseudoefficiency,” whereby the individuals occupy themselves with busy work as a way to keep themselves from failing at real work, he noted.
Because these destructive thought processes and strategies impair personal, interpersonal, and professional efficacy and are thought to be the root of many of the struggles that adults with ADHD experience, cognitive therapeutic approaches, including the nonmanualized therapy used in the study, focus on eliminating unproductive thought and behavior patterns and developing productive coping patterns, said Dr. Rostain.
A comparison of pre- and posttreatment scores of clinical outcome measures, using a paired samples t-test, analyzed significant effect sizes for improvement in ADHD symptoms, depression, anxiety, hopelessness, and overall functioning.
Because of the small sample size of the combination therapy group, no conclusions can be drawn on the relative contribution of cognitive therapy with stimulant medication to patient improvement. However, “the findings let us know that we are in the ballpark,” by providing further evidence that this combination of therapies can address the problem of ADHD in adults, said Dr. Rostain.
J. Russell Ramsay, Ph.D., also of the University of Pennsylvania, was coinvestigator with Dr. Rostain in this study.