Comprehensive study compares stimulants, atomoxetine and non-pharmacological therapies

Stimulants and atomoxetine are the only interventions effective in reducing short-term symptoms of ADHD in adults, but show limited evidence of long-term outcomes and improved quality of life, according to a study from the Department of Psychiatry, University of Oxford, Warneford Hospital.

According to the CDC, about 2 to 5 percent of adults experience symptoms of attention-deficit/hyperactivity disorder (ADHD) such as inattention, hyperactivity, and impulsivity. The wide range of their estimates reflects limited, if any, tracking data on ADHD at the national level.

Ongoing debates focus on whether pharmacological and non-pharmacological interventions can effectively manage long-term outcomes. Existing guidelines focus on medications but suggest nonpharmacologic support if medications are not well tolerated or compliance is difficult.

Although pharmacological treatments such as stimulants and non-stimulants like atomoxetine constitute the cornerstone of treatment in adults, concerns about tolerability and side effects have led to increased interest in non-pharmacological therapies.

Cognitive behavioral therapy (CBT), mindfulness and neurostimulation are among the main non-pharmacological treatments. These alternatives lack solid comparative data, particularly regarding their effectiveness compared to established pharmacological treatments.

In the article titled “Comparative effectiveness and acceptability of pharmacological, psychological, and neurostimulatory interventions for ADHD in adults: a systematic review and component network meta-analysis,” published in Lancet psychiatryResearchers evaluated the results of pharmacological, psychological and neurostimulatory interventions.

The investigators searched multiple databases and included 113 randomized controlled trials involving a total of 14,887 participants, lasting at least one week for medications and multiple sessions of psychological therapies. Pharmacologic therapies included stimulants, atomoxetine, bupropion, clonidine, guanfacine, modafinil, and viloxazine.

Non-pharmacological strategies included psychological therapies such as CBT and mindfulness, as well as neurostimulatory approaches such as transcranial direct current stimulation.

Standardized mean differences were calculated for the severity of core ADHD symptoms, both self-rated and clinician-rated. Results were sorted by time periods up to 52 weeks and reviewed for acceptability, measured by all-cause treatment discontinuation. Secondary outcomes included emotional dysregulation, executive dysfunction, and quality of life.

Stimulants and atomoxetine demonstrated the greatest effectiveness in reducing ADHD symptoms at 12 weeks, confirmed by self-reported (-0.39) and clinician-reported (-0.61) scales. Atomoxetine also performed well, although slightly less than stimulants (-0.38 and -0.51) on all scales.

Interventions such as CBT and mindfulness have revealed a fascinating disconnect between clinicians and patients. On clinician-reported scales, both treatments were more effective than placebo, but not on self-reported measures.

Non-pharmacological therapies used in the studies could not be completely ignored, which could introduce bias leading to discordance in the reported results. Although it is unclear which, if not both, introduced bias, the contrast with the agreement observed in the blinded versions is an excellent example of why eliminating bias is such a crucial aspect research whenever possible.

Most interventions were comparable to placebo for all causes of discontinuation (including lack of effectiveness, side effects, personal preference, or any other factor), with the exception of atomoxetine (OR 1.43 ) and guanfacine (OR 3.70), which were considered less acceptable due to a higher dropout rate. prices. Atomoxetine, guanfacine, and modafinil had higher discontinuation rates than placebo, specifically due to adverse effects.

Evidence beyond 12 weeks was scant, with only five trials providing data at 52 weeks. CBT, neurofeedback, and relaxation therapy have shown some effectiveness in reducing long-term symptoms, although small sample sizes have limited confidence in the results.

Stimulants were the only intervention showing small to moderate benefits in emotional dysregulation at 12 and 52 weeks. No interventions have demonstrated effectiveness for executive dysfunction, and none have significantly improved quality of life.

This review offers the most comprehensive investigation to date of interventions for ADHD in adults and, unfortunately, it suggests that there is still a huge unmet need waiting to be addressed.

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