Adult ADHD is a common and impairing condition [1
]. Even though medications are very useful in treating symptoms of ADHD, there are a number of reasons why psychological treatment may also be required. Clinical trials of new medications for ADHD have demonstrated that up to one-quarter of patients will either not respond or not tolerate the medication, or if they do respond will improve but not achieve full remission [2
]. Even when medication is effective, training in the acquisition of adaptive life skills may offer additional benefit, especially when looking at functioning in addition to symptom outcomes. ADHD throughout the life span is associated with self-perception of inadequacy and incompetence, and even if ADHD symptoms improve in adults, poor self esteem may remain embedded in the patient's self-concept [4
Psychological treatments of ADHD in childhood in combination with medication shows a small margin of additional benefit over medication alone, especially in children with anxiety or other comorbid disorders [5
]. There are however, several reasons to suspect that adults may be more responsive to psychological interventions than children. Children may be placed in therapy at the parents request, where adults are self-referred. By adulthood, many patients have obtained greater insight into their difficulties with ADHD and are receptive to learning better ways of coping. Children on medication are in school where they are exposed to demands and training in attention, where an adult on medication is unlikely to receive instruction in executive function or other skills.
Previous empirical research in psychological treatment in ADHD has consistently demonstrated that skills based therapies are effective for ADHD symptoms and functioning, despite differences in the details of the therapy offered. This is not true for insight oriented therapy which, in one study, had deleterious effects [6
]. This is true for individual CBT [7
] group psychoeducation and organization training [11
], group cognitive remediation as used with brain injury patients [12
] and dialectical behavior therapy (DBT) [13
]. Bramham et al. reported on a group intervention for adults with ADHD resulted in greater improvement on measures of knowledge about ADHD, self-efficacy and self-esteem than the control group [14
]. Rostain et al. reported robust effects for individual therapy combined with medication [15
All of these treatments were brief, structured, skills based and included a component where the patient practiced learned skills in real life situations. While the effect size on ADHD was large in all studies, depression, anxiety, anger, and self esteem did not always improve. The early pilot studies had various methodological limitations including small sample size, with open without blinded raters, and/or did not control for comorbidity or medication.
There are now four manuals for psychological treatment of adults with ADHD, which enable replication and use of these interventions by clinicians [16
]. The last year has seen the publication of three randomized controlled trials of CBT that are methodologically rigorous in diagnosis, use of objective outcomes, blinded raters and comparison with a non-specific form of treatment [17
]. Solanto did not find that stratification by medication status changed her findings [21
]. These studies demonstrated definitively that both individual and group administered CBT treatment for adults with ADHD is highly effective.
At the present time a seven site study in Germany is specifically addressing the issue of the relative benefits of medication alone, psychological treatment alone or combination therapy [22
]. The therapy used in Philipsen's study is an extension of the pilot work of Hesslinger using DBT.
It remains unclear from previous studies which included either medicated or a mixed sample of medicated and unmedicated patients, whether therapy vs. medication target different outcomes., There is some evidence that therapy adds significantly to the functional and/or symptom outcome of medication alone. Wilens found that the addition of CBT improved outcomes in patients who had a partial response to medication [10
]. Safren has examined whether the addition of therapy augments the improvement obtained with medication alone [8
] and found that combination therapy was superior to medication alone. Emilsson found that CBT and medication was superior to treatment as usual and medication [20
None of these research studies ask the opposite question: does medication add significantly to the functional and/or symptom outcome of therapy alone? To answer this question it is necessary to compare the outcome of patients who receive therapy and medication to patients who receive therapy and placebo, since there is going to be a strong halo effect of knowing you are on a medication to treat ADHD.
All of the trials cited above demonstrated that CBT is effective, and can augment the effect of medication alone. However, none of these studies controls for the effect of medication on therapy outcome. We do not know whether symptom remission with medication is a prerequisite for the ability to acquire skills in therapy. Nor do we know if medication and therapy target symptoms and functioning respectively, or if both modalities have a comparable effect on either outcome. The objective of the study reported here is to determine whether CBT psychotherapy in combination with medication is superior to CBT psychotherapy and placebo in mitigating core symptoms of ADHD and functioning.