Efficacy of Cognitive Behavioral Therapy Combined with Pharmacotherapy Versus Pharmacotherapy Alone in Adult ADHD: A Systematic Review and Meta-Analysis
Restricted accessResearch articleFirst published online February, 2024
Efficacy of Cognitive Behavioral Therapy Combined with Pharmacotherapy Versus Pharmacotherapy Alone in Adult ADHD: A Systematic Review and Meta-Analysis
ADHD diagnosis rates are rising; however, currently, no effective treatment method that has been identified. This study compared the efficacy of CBT + M with M for adult ADHD.
Methods:
PubMed, Embase, WOS, and Cochrane Library databases were searched up to July 29, 2023. Literature screening and data analysis were conducted.
Results:
The six randomized controlled studies included. Meta-analysis showed that CBT + M was more effective than M in improving ADHD symptoms. Subgroup analysis showed developed countries significant in ADHD symptoms improvement. At the 3-month, CBT + M was superior to M, but at the 6 and 9 months, no statistically significant differences were observed.
Conclusion:
CBT + M is more effective than M in improving adult ADHD symptoms and maintains an advantage for at least 3 months. It is recommended to intensifying CBT treatment after 3 months. Country and economy may influence results. Combined therapy for ADHD should be prioritized in developed countries.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association (DaolongZ., et al., Trans. Peking University Press, 2015).
2.
BanaschewskiT.CoghillD.SantoshP.ZuddasA.AshersonP.BuitelaarJ.DanckaertsM.DöpfnerM.FaraoneS. V.RothenbergerA.SergeantJ.SteinhausenH. C.Sonuga-BarkeE. J.TaylorE. (2006). Long-acting medications for the hyperkinetic disorders. A systematic review and European treatment guideline. European Child & Adolescent Psychiatry, 15, 476–495.
3.
Bolea-AlamañacB.NuttD. J.AdamouM.AshersonP.BazireS.CoghillD.HealD.MüllerU.NashJ.SantoshP.SayalK.Sonuga-BarkeE.YoungS. J. (2014). Evidence-based guidelines for the pharmacological management of attention deficit hyperactivity disorder: Update on recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 28, 179–203.
4.
BorzaL. (2017). Cognitive-behavioral therapy for generalized anxiety. Dialogues in Clinical Neuroscience, 19, 203–208.
5.
CayeA.SwansonJ. M.CoghillD.RohdeL. A. (2019). Treatment strategies for ADHD: An evidence-based guide to select optimal treatment. Molecular Psychiatry, 24, 390–408.
6.
CopelandJ.SwiftW.RoffmanR.StephensR. (2001). A randomized controlled trial of brief cognitive-behavioral interventions for cannabis use disorder. Journal of Substance Abuse Treatment, 21, 55–64; discussion 65-56.
7.
CorbisieroS.BittoH.NewarkP.Abt-MörstedtB.ElsässerM.Buchli-KammermannJ.KünneS.NybergE.Hofecker-FallahpourM.StieglitzR. D. (2018). A comparison of cognitive-behavioral therapy and pharmacotherapy vs. pharmacotherapy alone in adults with Attention-Deficit/Hyperactivity Disorder (ADHD)-A randomized controlled trial. Frontiers in Psychiatry, 9, 571.
8.
CorteseS.AdamoN.Del GiovaneC.Mohr-JensenC.HayesA. J.CarucciS.AtkinsonL. Z.TessariL.BanaschewskiT.CoghillD.HollisC.SimonoffE.ZuddasA.BarbuiC.PurgatoM.SteinhausenH. C.ShokranehF.XiaJ.CiprianiA. (2018). Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: A systematic review and network meta-analysis. The Lancet Psychiatry, 5, 727–738.
9.
DittnerA. J.HodsollJ.RimesK. A.RussellA. J.ChalderT. (2018). Cognitive-behavioural therapy for adult attention-deficit hyperactivity disorder: A proof of concept randomised controlled trial. Acta Psychiatrica Scandinavica, 137, 125–137.
10.
EmilssonB.GudjonssonG.SigurdssonJ. F.BaldurssonG.EinarssonE.OlafsdottirH.YoungS. (2011). Cognitive behaviour therapy in medication-treated adults with ADHD and persistent symptoms: A randomized controlled trial. BMC Psychiatry, 11, 116.
11.
FayyadJ.SampsonN. A.HwangI.AdamowskiT.Aguilar-GaxiolaS.Al-HamzawiA.AndradeL. H.BorgesG.de GirolamoG.FlorescuS.GurejeO.HaroJ. M.HuC.KaramE. G.LeeS.Navarro-MateuF.O’NeillS.PennellB.E.PiazzaM.. . .KesslerR. C. (2017). The descriptive epidemiology of DSM-IV Adult ADHD in the World Health Organization World Mental Health Surveys. Attention Deficit and Hyperactivity Disorders, 9, 47–65.
12.
GouldK. L.PorterM.LynehamH. J.HudsonJ. L. (2018). Cognitive-behavioral therapy for children with anxiety and comorbid attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 57, 481–490.e482.
13.
HalmøyA.RingA. E.GjestadR.MøllerM.UbostadB.LienT.MunkhaugenE. K.FredriksenM. (2022). Dialectical behavioral therapy-based group treatment versus treatment as usual for adults with attention-deficit hyperactivity disorder: A multicenter randomized controlled trial. BMC Psychiatry, 22, 738.
14.
HeparkS.JanssenL.de VriesA.SchoenbergP. L. A.DondersR.KanC. C.SpeckensA. E. M. (2019). The efficacy of adapted MBCT on core symptoms and executive functioning in adults with ADHD: A preliminary randomized controlled trial. Journal of Attention Disorders, 23, 351–362.
15.
HigginsJ. P.AltmanD. G.GøtzscheP. C.JüniP.MoherD.OxmanA. D.SavovicJ.SchulzK. F.WeeksL.SterneJ. A. (2011). The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ, 343, d5928.
16.
HigginsJ. P.ThompsonS. G. (2002). Quantifying heterogeneity in a meta-analysis. Statistics in Medicine, 21, 1539–1558.
17.
HofmannS. G.SawyerA. T.FangA. (2010). The empirical status of the “new wave” of cognitive behavioral therapy. The Psychiatric Clinics of North America, 33, 701–710.
18.
JensenC. M.AmdisenB. L.JørgensenK. J.ArnfredS. M. (2016). Cognitive behavioural therapy for ADHD in adults: Systematic review and meta-analyses. Attention Deficit and Hyperactivity Disorders, 8, 3–11.
19.
MongiaM.HechtmanL. (2012). Cognitive behavior therapy for adults with attention-deficit/hyperactivity disorder: A review of recent randomized controlled trials. Current Psychiatry Reports, 14, 561–567.
20.
NakagawaA.MitsudaD.SadoM.AbeT.FujisawaD.KikuchiT.IwashitaS.MimuraM.OnoY. (2017). Effectiveness of supplementary cognitive-behavioral therapy for pharmacotherapy-resistant depression: A randomized controlled trial. The Journal of Clinical Psychiatry, 78, 1126–1135.
21.
NICE. (2019). National Institute for Health and Care Excellence: Guidelines, Attention deficit hyperactivity disorder: Diagnosis and management. National Institute for Health and Care Excellence (NICE).
22.
Nimmo-SmithV.MerwoodA.HankD.BrandlingJ.GreenwoodR.SkinnerL.LawS.PatelV.RaiD. (2020). Non-pharmacological interventions for adult ADHD: A systematic review. Psychological Medicine, 50, 529–541.
23.
PageM. J.McKenzieJ. E.BossuytP. M.BoutronI.HoffmannT. C.MulrowC. D.ShamseerL.TetzlaffJ. M.AklE. A.BrennanS. E.ChouR.GlanvilleJ.GrimshawJ. M.HróbjartssonA.LaluM. M.LiT.LoderE. W.Mayo-WilsonE.McDonaldS.. . .MoherD. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, n71.
24.
PanM. R.ZhangS. Y.QiuS. W.LiuL.LiH. M.ZhaoM. J.DongM.SiF. F.WangY. F.QianQ. J. (2022). Efficacy of cognitive behavioural therapy in medicated adults with attention-deficit/hyperactivity disorder in multiple dimensions: A randomised controlled trial. European Archives of Psychiatry and Clinical Neuroscience, 272, 235–255.
25.
PolanczykG. V.SalumG. A.SugayaL. S.CayeA.RohdeL. A. (2015). Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry, 56, 345–365.
26.
SafrenS. A.OttoM. W.SprichS.WinettC. L.WilensT. E.BiedermanJ. (2005). Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms. Behaviour Research and Therapy, 43, 831–842.
27.
SalariN.GhasemiH.AbdoliN.RahmaniA.ShiriM. H.HashemianA. H.AkbariH.MohammadiM. (2023). The global prevalence of ADHD in children and adolescents: A systematic review and meta-analysis. Italian Journal of Pediatrics, 49, 48.
28.
SimonV.CzoborP.BálintS.MészárosA.BitterI. (2009). Prevalence and correlates of adult attention-deficit hyperactivity disorder: Meta-analysis. The British Journal of Psychiatry: The Journal of Mental Science, 194, 204–211.
29.
SobanskiE.BrüggemannD.AlmB.KernS.PhilipsenA.SchmalzriedH.HesslingerB.WaschkowskiH.RietschelM. (2008). Subtype differences in adults with attention-deficit/hyperactivity disorder (ADHD) with regard to ADHD-symptoms, psychiatric comorbidity and psychosocial adjustment. European Psychiatry: The Journal of the Association of European Psychiatrists, 23, 142–149.
30.
SongP.ZhaM.YangQ.ZhangY.LiX.RudanI. (2021). The prevalence of adult attention-deficit hyperactivity disorder: A global systematic review and meta-analysis. Journal of Global Health, 11, 04009.
31.
StuhecM.LocatelliI. (2017). Age-related pharmacotherapy of attention deficit hyperactivity disorder in Slovenia in children and adolescents: A population-based study. European Psychiatry: The Journal of the Association of European Psychiatrists, 42, 129–133.
32.
StuhecM.LukićP.LocatelliI. (2019). Efficacy, acceptability, and tolerability of lisdexamfetamine, mixed amphetamine salts, methylphenidate, and modafinil in the treatment of attention-deficit hyperactivity disorder in adults: A systematic review and meta-analysis. Annals of Pharmacotherapy, 53, 121–133.
33.
ŠtuhecM.ŠvabV.LocatelliI. (2015). Prevalence and incidence of attention-deficit/hyperactivity disorder in Slovenian children and adolescents: A database study from a national perspective. Croatian Medical Journal, 56, 159–165.
34.
SwalesM. A. (2009). Dialectical behaviour therapy: Description, research and future directions. International Journal of Behavioral Consultation and Therapy, 5, 164–177.
35.
ThomaN.PileckiB.McKayD. (2015). Contemporary cognitive behavior therapy: A review of theory, history, and evidence. Psychodynamic Psychiatry, 43, 423–461.
36.
YoungS.EmilssonB.SigurdssonJ. F.KhondokerM.Philipp-WiegmannF.BaldurssonG.OlafsdottirH.GudjonssonG. (2017). A randomized controlled trial reporting functional outcomes of cognitive-behavioural therapy in medication-treated adults with ADHD and comorbid psychopathology. European Archives of Psychiatry and Clinical Neuroscience, 267, 267–276.
37.
YoungS.KhondokerM.EmilssonB.SigurdssonJ. F.Philipp-WiegmannF.BaldurssonG.OlafsdottirH.GudjonssonG. (2015). Cognitive-behavioural therapy in medication-treated adults with attention-deficit/hyperactivity disorder and co-morbid psychopathology: A randomized controlled trial using multi-level analysis. Psychological Medicine, 45, 2793–2804.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
