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Thorpy MJ, Krahn L, Ruoff C, Foldvary-Schaefer N. Clinical considerations in the treatment of idiopathic hypersomnia. Sleep Med 2024; 119:488-498. [PMID: 38796978 DOI: 10.1016/j.sleep.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/22/2024] [Accepted: 05/04/2024] [Indexed: 05/29/2024]
Abstract
Idiopathic hypersomnia typically is a chronic and potentially debilitating neurologic sleep disorder, and is characterized by excessive daytime sleepiness. In addition to excessive daytime sleepiness, idiopathic hypersomnia symptoms can include severe sleep inertia; long, unrefreshing naps; long sleep time; and cognitive dysfunction. Patients with idiopathic hypersomnia may experience a significant impact on their quality of life, work or school performance, earnings, employment, and overall health. Given the complex range of symptoms associated with idiopathic hypersomnia and the array of treatments available, there is a need to provide guidance on the treatment of idiopathic hypersomnia and the clinically relevant recommendations that enhance effective disease management. Identifying appropriate treatment options for idiopathic hypersomnia requires timely and accurate diagnosis, consideration of individual patient factors, and frequent reassessment of symptom severity. In 2021, low-sodium oxybate was the first treatment to receive approval by the US Food and Drug Administration for the treatment of idiopathic hypersomnia in adults. However, many off-label treatments continue to be used. Adjunct nonpharmacologic therapies, including good sleep hygiene, patient education and counseling, and use of support groups, should be recognized and recommended when appropriate. This narrative review describes optimal treatment strategies that take into account patient-specific factors, as well as the unique characteristics of each medication and the evolution of a patient's response to treatment. Perspectives on appropriate symptom measurement and management, and potential future therapies, are also offered.
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López-Pinar C, Selaskowski B, Braun N, Fornés-Ferrer V, Euscher R, Matthies S, Jans T, van Elst LT, Jacob C, Huss M, Sobanski E, Retz W, Roesler M, Retz-Junginger P, Alm B, Kis B, Abdel-Hamid M, Colla M, Berger M, Lux S, Philipsen A. Exploring the efficacy of dialectical behaviour therapy and methylphenidate on emotional comorbid symptoms in adults with attention Deficit/Hyperactivity disorder: Results of the COMPAS multicentre randomised controlled trial. Psychiatry Res 2023; 330:115610. [PMID: 37992514 DOI: 10.1016/j.psychres.2023.115610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/12/2023] [Indexed: 11/24/2023]
Abstract
This study evaluated the efficacy of dialectical behaviour group therapy (GPT) vs. individual clinical management (CM) and methylphenidate (MPH) vs. placebo (PLB) on emotional symptoms in adults with ADHD. This longitudinal multicentre RCT compared four groups (GPT+MPH, GPT+PLB, CM+MPH, and CM+PLB) over five assessment periods, from baseline to week 130. Emotional symptomatology was assessed using SCL-90-R subscales. Of the 433 randomised participants, 371 remained for final analysis. At week 13, the GPT+MPH group showed smaller reductions in anxiety symptoms than the CM groups, but the differences disappeared at subsequent assessments. Improvements in emotional symptom were significantly predicted by reductions in core ADHD symptoms in all groups except the GPT+MPH group. The unexpected lack of between-group differences may be explained by a "floor effect", different intervention settings (group vs. individual), and psychotherapy type. Multiple regression analyses suggest a more specific effect of combined interventions (GPT+MPH). Implications for clinical practice are discussed. Clinical trial registration: ISRCTN54096201 (Current Controlled Trials).
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Affiliation(s)
- Carlos López-Pinar
- Department of Psychobiology and Basic Psychology, University of Valencia, Valencia, Spain; Department of Psychology, European University of Valencia, Valencia, Spain.
| | | | - Niclas Braun
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
| | | | - Rebekka Euscher
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
| | - Swantje Matthies
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, Germany
| | - Thomas Jans
- Centre of Mental Health, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Hospital of Würzburg, Würzburg, Germany
| | - Ludger Tebartz van Elst
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, Germany
| | - Christian Jacob
- Department of Psychiatry and Psychotherapy, Medius Hospital of Kirchheim, Kirchheim unter Teck, Germany
| | - Michael Huss
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Centre Mainz, Mainz, Germany
| | - Esther Sobanski
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Centre Mainz, Mainz, Germany; Institute for Forensic Psychology and Psychiatry, Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Wolfgang Retz
- Institute for Forensic Psychology and Psychiatry, Saarland University Faculty of Medicine, Homburg/Saar, Germany; Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Mainz, Germany
| | - Michael Roesler
- Institute for Forensic Psychology and Psychiatry, Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Petra Retz-Junginger
- Institute for Forensic Psychology and Psychiatry, Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Barbara Alm
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty of Mannheim, University of Heidelberg, Mannheim, Germany
| | - Bernhard Kis
- Department of Psychiatry and Psychotherapy, University Medical Centre Göttingen, Göttingen, Germany; Department of Psychiatry, Psychotherapy and Psychosomatics, St. Elisabeth Hospital Niederwenigern, Contilia Group, Hattingen, Germany; LVR-Hospital Essen, Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Mona Abdel-Hamid
- Department of Psychiatry and Psychotherapy, University Medical Centre Göttingen, Göttingen, Germany; LVR-Hospital Essen, Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Michael Colla
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, Switzerland
| | - Mathias Berger
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, Germany
| | - Silke Lux
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
| | - Alexandra Philipsen
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
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Storebø OJ, Storm MRO, Pereira Ribeiro J, Skoog M, Groth C, Callesen HE, Schaug JP, Darling Rasmussen P, Huus CML, Zwi M, Kirubakaran R, Simonsen E, Gluud C. Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD). Cochrane Database Syst Rev 2023; 3:CD009885. [PMID: 36971690 PMCID: PMC10042435 DOI: 10.1002/14651858.cd009885.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children and adolescents with ADHD find it difficult to pay attention and they are hyperactive and impulsive. Methylphenidate is the psychostimulant most often prescribed, but the evidence on benefits and harms is uncertain. This is an update of our comprehensive systematic review on benefits and harms published in 2015. OBJECTIVES To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to March 2022. In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate. SELECTION CRITERIA We included all randomised clinical trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. The search was not limited by publication year or language, but trial inclusion required that 75% or more of participants had a normal intellectual quotient (IQ > 70). We assessed two primary outcomes, ADHD symptoms and serious adverse events, and three secondary outcomes, adverse events considered non-serious, general behaviour, and quality of life. DATA COLLECTION AND ANALYSIS Two review authors independently conducted data extraction and risk of bias assessment for each trial. Six review authors including two review authors from the original publication participated in the update in 2022. We used standard Cochrane methodological procedures. Data from parallel-group trials and first-period data from cross-over trials formed the basis of our primary analyses. We undertook separate analyses using end-of-last period data from cross-over trials. We used Trial Sequential Analyses (TSA) to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the GRADE approach. MAIN RESULTS We included 212 trials (16,302 participants randomised); 55 parallel-group trials (8104 participants randomised), and 156 cross-over trials (8033 participants randomised) as well as one trial with a parallel phase (114 participants randomised) and a cross-over phase (165 participants randomised). The mean age of participants was 9.8 years ranging from 3 to 18 years (two trials from 3 to 21 years). The male-female ratio was 3:1. Most trials were carried out in high-income countries, and 86/212 included trials (41%) were funded or partly funded by the pharmaceutical industry. Methylphenidate treatment duration ranged from 1 to 425 days, with a mean duration of 28.8 days. Trials compared methylphenidate with placebo (200 trials) and with no intervention (12 trials). Only 165/212 trials included usable data on one or more outcomes from 14,271 participants. Of the 212 trials, we assessed 191 at high risk of bias and 21 at low risk of bias. If, however, deblinding of methylphenidate due to typical adverse events is considered, then all 212 trials were at high risk of bias. PRIMARY OUTCOMES methylphenidate versus placebo or no intervention may improve teacher-rated ADHD symptoms (standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -0.88 to -0.61; I² = 38%; 21 trials; 1728 participants; very low-certainty evidence). This corresponds to a mean difference (MD) of -10.58 (95% CI -12.58 to -8.72) on the ADHD Rating Scale (ADHD-RS; range 0 to 72 points). The minimal clinically relevant difference is considered to be a change of 6.6 points on the ADHD-RS. Methylphenidate may not affect serious adverse events (risk ratio (RR) 0.80, 95% CI 0.39 to 1.67; I² = 0%; 26 trials, 3673 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 0.91 (CI 0.31 to 2.68). SECONDARY OUTCOMES methylphenidate may cause more adverse events considered non-serious versus placebo or no intervention (RR 1.23, 95% CI 1.11 to 1.37; I² = 72%; 35 trials 5342 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 1.22 (CI 1.08 to 1.43). Methylphenidate may improve teacher-rated general behaviour versus placebo (SMD -0.62, 95% CI -0.91 to -0.33; I² = 68%; 7 trials 792 participants; very low-certainty evidence), but may not affect quality of life (SMD 0.40, 95% CI -0.03 to 0.83; I² = 81%; 4 trials, 608 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS The majority of our conclusions from the 2015 version of this review still apply. Our updated meta-analyses suggest that methylphenidate versus placebo or no-intervention may improve teacher-rated ADHD symptoms and general behaviour in children and adolescents with ADHD. There may be no effects on serious adverse events and quality of life. Methylphenidate may be associated with an increased risk of adverse events considered non-serious, such as sleep problems and decreased appetite. However, the certainty of the evidence for all outcomes is very low and therefore the true magnitude of effects remain unclear. Due to the frequency of non-serious adverse events associated with methylphenidate, the blinding of participants and outcome assessors is particularly challenging. To accommodate this challenge, an active placebo should be sought and utilised. It may be difficult to find such a drug, but identifying a substance that could mimic the easily recognised adverse effects of methylphenidate would avert the unblinding that detrimentally affects current randomised trials. Future systematic reviews should investigate the subgroups of patients with ADHD that may benefit most and least from methylphenidate. This could be done with individual participant data to investigate predictors and modifiers like age, comorbidity, and ADHD subtypes.
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Affiliation(s)
- Ole Jakob Storebø
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Child and Adolescent Psychiatric Department, Region Zealand, Roskilde, Denmark
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | | | | | - Maria Skoog
- Clinical Study Support, Clinical Studies Sweden - Forum South, Lund, Sweden
| | - Camilla Groth
- Pediatric Department, Herlev University Hospital, Herlev, Denmark
| | | | | | | | | | - Morris Zwi
- Islington Child and Adolescent Mental Health Service, Whittington Health, London, UK
| | - Richard Kirubakaran
- Cochrane India-CMC Vellore Affiliate, Prof. BV Moses Centre for Evidence Informed Healthcare and Health Policy, Christian Medical College, Vellore, India
| | - Erik Simonsen
- Research Unit, Mental Health services, Region Zealand Psychiatry, Roskilde, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Boesen K, Paludan-Müller AS, Gøtzsche PC, Jørgensen KJ. Extended-release methylphenidate for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database Syst Rev 2022; 2:CD012857. [PMID: 35201607 PMCID: PMC8869321 DOI: 10.1002/14651858.cd012857.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is a psychiatric diagnosis increasingly used in adults. The recommended first-line pharmacological treatment is central nervous system (CNS) stimulants, such as methylphenidate, but uncertainty remains about its benefits and harms. OBJECTIVES To assess the beneficial and harmful effects of extended-release formulations of methylphenidate in adults diagnosed with ADHD. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, nine other databases and four clinical trial registries up to February 2021. We searched 12 drug regulatory databases for clinical trial data up to 13 May 2020. In addition, we cross-referenced all available trial identifiers, handsearched reference lists, searched pharmaceutical company databases, and contacted trial authors. SELECTION CRITERIA Randomised, double-blind, parallel-group trials comparing extended-release methylphenidate formulations at any dose versus placebo and other ADHD medications in adults diagnosed with ADHD. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. We assessed dichotomous outcomes as risk ratios (RRs), and rating scales and continuous outcomes as mean differences (MDs) or standardised mean differences (SMDs). We used the Cochrane risk of bias tool to assess risks of bias, and GRADE to assess the certainty of the evidence. We meta-analysed the data using a random-effects model. We assessed three design characteristics that may impair the trial results' 'generalisability'; exclusion of participants with psychiatric comorbidity; responder selection based on previous experience with CNS stimulants; and risk of withdrawal effects. Our prespecified primary outcomes were functional outcomes, self-rated ADHD symptoms, and serious adverse events. Our secondary outcomes included quality of life, ADHD symptoms rated by investigators and by peers such as family members, cardiovascular variables, severe psychiatric adverse events, and other adverse events. MAIN RESULTS We included 24 trials (5066 participants), of which 21 reported outcome data for this review. We also identified one ongoing study. We included documents from six drug regulatory agencies covering eight trials. Twenty-one trials had an outpatient setting and three were conducted in prisons. They were primarily conducted in North America and Europe. The median participant age was 36 years. Twelve trials (76% of participants) were industry-sponsored, four (14% of participants) were publicly funded with industry involvement, seven (10% of participants) were publicly funded, and one had unclear funding. The median trial duration was eight weeks. One trial was rated at overall unclear risk of bias and 20 trials were rated at overall high risk of bias, primarily due to unclear blinding of participants and investigators, attrition bias, and selective outcome reporting. All trials were impaired in at least one of the three design characteristics related to 'generalisability'; for example, they excluded participants with psychiatric comorbidity such as depression or anxiety, or included participants only with a previous positive response to methylphenidate, or similar drugs. This may limit the trials' usefulness for clinical practice, as they may overestimate the benefits and underestimate the harms. Extended-release methylphenidate versus placebo (up to 26 weeks) For the primary outcomes, we found very low-certainty evidence that methylphenidate had no effect on 'days missed at work' at 13-week follow-up (mean difference (MD) -0.15 days, 95% confidence interval (CI) -2.11 to 1.81; 1 trial, 409 participants) or serious adverse events (risk ratio (RR) 1.43, CI 95% CI 0.85 to 2.43; 14 trials, 4078 participants), whereas methylphenidate improved self-rated ADHD symptoms (small-to-moderate effect; SMD -0.37, 95% CI -0.43 to -0.30; 16 trials, 3799 participants). For secondary outcomes, we found very low-certainty evidence that methylphenidate improved self-rated quality of life (small effect; SMD -0.15, 95% CI -0.25 to -0.05; 6 trials, 1888 participants), investigator-rated ADHD symptoms (small-to-moderate effect; SMD -0.42, 95% CI -0.49 to -0.36; 18 trials, 4183 participants), ADHD symptoms rated by peers such as family members (small-to-moderate effect; SMD -0.31, 95% CI -0.48 to -0.14; 3 trials, 1005 participants), and increased the risk of experiencing any adverse event (RR 1.27, 95% CI 1.19 to 1.37; 14 trials, 4214 participants). We rated the certainty of the evidence as 'very low' for all outcomes, primarily due to high risk of bias and 'indirectness of the evidence'. One trial (419 participants) had follow-up at 52 weeks and two trials (314 participants) included active comparators, hence long-term and comparative evidence is limited. AUTHORS' CONCLUSIONS We found very low-certainty evidence that extended-release methylphenidate compared to placebo improved ADHD symptoms (small-to-moderate effects) measured on rating scales reported by participants, investigators, and peers such as family members. Methylphenidate had no effect on 'days missed at work' or serious adverse events, the effect on quality of life was small, and it increased the risk of several adverse effects. We rated the certainty of the evidence as 'very low' for all outcomes, due to high risk of bias, short trial durations, and limitations to the generalisability of the results. The benefits and harms of extended-release methylphenidate therefore remain uncertain.
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Affiliation(s)
- Kim Boesen
- Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health at Charité, QUEST Center for Responsible Research, Berlin, Germany
- Nordic Cochrane Centre, Rigshospitalet Dept 7811, Copenhagen, Denmark
| | - Asger Sand Paludan-Müller
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
| | | | - Karsten Juhl Jørgensen
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
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Guo C, Assumpcao L, Hu Z. Efficacy of Non-pharmacological Treatments on Emotional Symptoms of Children and Adults with Attention-Deficit/Hyperactivity Disorder: A Meta-Analysis. J Atten Disord 2022; 26:508-524. [PMID: 33759605 DOI: 10.1177/10870547211001953] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The present meta-analysis aimed to evaluate the efficacy of various non-pharmacological interventions on comorbid emotional symptoms such as depression, anxiety, and emotional dysregulation (ED) in children and adults with ADHD. METHOD Forty-four randomized controlled trials (23 studies with ADHD children and 21 studies with ADHD adults) were included. Risk of bias, heterogeneity assessment, and subgroup analyses were conducted. RESULTS We found that therapies targeting the relationship between children and others (i.e., parent-training [on ED and depression] and social skills training [on ED]) were efficacious in the treatment of emotional symptoms in children with ADHD at post-intervention. As for adults with ADHD, cognitive behavioral therapy was found to be effective for the improvement of emotional symptoms at both post-intervention and follow-up. CONCLUSION Our findings demonstrate that the efficacy of non-pharmacological interventions varies substantially across children and adults with ADHD. These results provide important implications for the selection of non-pharmacological interventions for children with ADHD.
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Affiliation(s)
- Chao Guo
- The Affiliated Hospital of Hangzhou Normal University, Hangzhou, P.R. China.,Institute of Psychological Science, Hangzhou Normal University, P.R. China.,Zhejiang Key Laboratory for Research in Assessment of Cognitive Impairments, Hangzhou, P.R. China
| | - Leonardo Assumpcao
- The Affiliated Hospital of Hangzhou Normal University, Hangzhou, P.R. China.,Institute of Psychological Science, Hangzhou Normal University, P.R. China.,Zhejiang Key Laboratory for Research in Assessment of Cognitive Impairments, Hangzhou, P.R. China
| | - Zhiguo Hu
- The Affiliated Hospital of Hangzhou Normal University, Hangzhou, P.R. China.,Institute of Psychological Science, Hangzhou Normal University, P.R. China.,Zhejiang Key Laboratory for Research in Assessment of Cognitive Impairments, Hangzhou, P.R. China
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Abstract
Attention-Deficit Hyperactivity Disorder (ADHD) is a prevalent neurodevelopmental condition associated with impaired function and increased risk of poor outcomes in children, young people and adults with the condition. Currently approved pharmacological treatments for ADHD include a range of stimulant (methylphenidate, amphetamine) and nonstimulant (atomoxetine, guanfacine, clonidine) medications. All have been shown to be effective in treating the symptoms of ADHD and improving other functional outcomes including quality of life, academic performance, rates of accidents and injuries, and do not appear to be associated with significant adverse outcomes or side effects. In this chapter, we review medications for ADHD by summarising the mechanisms of action of each of the two main classes of compounds (stimulants and nonstimulants), the formulations of the most commonly prescribed medications within each class, their efficacy in treating ADHD symptoms and other outcomes, and other factors that influence treatment decisions including side effects and tolerability, comorbidities and medical history. We conclude with a summary of the treatment decisions made by clinicians and suggest some next steps for research. Further research is needed to understand the mechanisms of action of these medications and how exactly they improve symptoms, and to examine their effects on commonly occurring comorbidities.
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Affiliation(s)
- Madeleine J Groom
- Academic Unit of Mental Health and Clinical Neurosciences, School of Medicine, Institute of Mental Health, University of Nottingham, Nottingham, UK.
| | - Samuele Cortese
- Faculty of Environmental and Life Sciences, Center for Innovation in Mental Health, School of Psychology, University of Southampton, Southampton, UK
- Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK
- Solent NHS Trust, Southampton, UK
- Hassenfeld Children's Hospital at NYU Langone, New York University Child Study Center, New York, NY, USA
- Centre for ADHD and Neurodevelopmental Disorders Across the Lifespan, Institute of Mental Health, University of Nottingham, Nottingham, UK
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Tully J. Management of ADHD in Prisoners-Evidence Gaps and Reasons for Caution. Front Psychiatry 2022; 13:771525. [PMID: 35370827 PMCID: PMC8973692 DOI: 10.3389/fpsyt.2022.771525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 02/04/2022] [Indexed: 12/03/2022] Open
Affiliation(s)
- John Tully
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
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Higgins GA, Silenieks LB. The Effects of Drug Treatments for ADHD in Measures of Cognitive Performance. Curr Top Behav Neurosci 2022; 57:321-362. [PMID: 35606638 DOI: 10.1007/7854_2022_341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Based on core symptoms of inattention and deficient impulse control, and the identification of effective pharmacotherapies such as amphetamine (AMP; Adderall®), methylphenidate (MPH; Ritalin®), and atomoxetine (ATX; Strattera®), ADHD is a clinical condition which provides opportunity for translational research. Neuropsychological tests such as the 5-Choice and Continuous Performance Tasks, which measure aspects of attention and impulse control in animals and humans, provide scope for both forward (animal to human) and reverse (human to animal) translation. Rodent studies support pro-attentive effects of AMP and MPH and effectiveness in controlling some forms of impulsive behavior. In contrast, any pro-attentive effects of ATX appear to be less consistent, the most reliable effects of ATX are recorded in tests of impulsivity. These differences may account for AMP and MPH being recognized as first-line treatments for ADHD with a higher efficacy relative to ATX. DSM-5 classifies three "presentations" of ADHD: predominantly inattentive type (ADHD-I), predominantly hyperactive/impulsive type (ADHD-HI), or combined (ADHD-C). Presently, it is unclear whether AMP, MPH, or ATX has differential levels of efficacy across these presentation types. Nonetheless, these studies encourage confidence for the forward translation of NCEs in efforts to identify newer pharmacotherapies for ADHD.
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Affiliation(s)
- Guy A Higgins
- Intervivo Solutions, Toronto, ON, Canada.
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.
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Boesen K, Jørgensen KJ, Gøtzsche PC. Clinical trials were missing from regulatory documents of extended-release methylphenidate for ADHD in adults: a case study of public documents. Cochrane Database Syst Rev 2021. [PMID: 34752938 DOI: 10.1002/14651858.cd012857] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To assess whether drug regulatory agencies decided on applications for extended-release methylphenidate for use in adult ADHD based on select samples of trials. STUDY DESIGN AND SETTING Case series of publicly available regulatory documents. We matched an index of extended-release methylphenidate trials for adult ADHD with trials appearing in regulatory documents of extended-release methylphenidate applications. Trials and regulatory documents were identified as part of this systematic review (https://doi.org/10.1002/14651858.CD012857). We sought to identify missing trials in the regulatory documents and to clarify regulatory submission requirements. RESULTS We indexed 18 trials and matched those with 13 drug applications (11 approved, 2 rejected) published by 7 agencies. There were trials missing in 7 (54%) of 13 applications, median 4 trials (range 1-6). The median proportion of missing trial participants was 45% (range 23% - 72%). Regulators seemingly require that all trials must be included in new drug applications, but wording is ambiguous. CONCLUSION In this sample of extended-release methylphenidate drug applications for adult ADHD, 7 of 13 regulatory decisions were missing entire trials according to public documents, even though regulatory requirements seem to stipulate that all available trials should be included in drug applications.
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Affiliation(s)
- Kim Boesen
- Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health at Charité, QUEST Center for Responsible Research, Germany; Nordic Cochrane Centre, Rigshospitalet, Copenhagen, Denmark.
| | - Karsten Juhl Jørgensen
- Nordic Cochrane Centre, Rigshospitalet, Copenhagen, Denmark; Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
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Mintzer J, Lanctôt KL, Scherer RW, Rosenberg PB, Herrmann N, van Dyck CH, Padala PR, Brawman-Mintzer O, Porsteinsson AP, Lerner AJ, Craft S, Levey AI, Burke W, Perin J, Shade D. Effect of Methylphenidate on Apathy in Patients With Alzheimer Disease: The ADMET 2 Randomized Clinical Trial. JAMA Neurol 2021; 78:1324-1332. [PMID: 34570180 PMCID: PMC8477302 DOI: 10.1001/jamaneurol.2021.3356] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Apathy, characterized by diminished will or initiative and one of the most prevalent neuropsychiatric symptoms in individuals with Alzheimer disease, is associated with significant caregiver burden, excess disability, increased medical costs, and mortality. Objective To measure whether methylphenidate compared with placebo decreases the severity of apathy in individuals with Alzheimer disease. Design, Setting, and participants This multicenter randomized placebo-controlled clinical trial was conducted from August 2016 to July 2020 in 9 US clinics and 1 Canadian clinic specializing in dementia care. A total of 307 potential participants were screened. Of those, 52 did not pass screening and 55 were not eligible. Participants with Alzheimer disease, mild to moderate cognitive impairment, and frequent and/or severe apathy as measured by the Neuropsychiatric Inventory (NPI) were included. Interventions Ten milligrams of methylphenidate, twice daily, vs matching placebo. Main Outcomes and Measures The coprimary outcomes included (1) change from baseline to 6 months in the NPI apathy subscale or (2) improved rating on the Alzheimer's Disease Cooperative Study Clinical Global Impression of Change. Other outcomes include safety, change in cognition, and quality of life. Results Of 200 participants, 99 were assigned to methylphenidate and 101 to placebo. The median (interquartile range) age of study participants was 76 (71-81) years; 68 (34%) were female and 131 (66%) were male. A larger decrease was found from baseline to 6 months in the NPI apathy score in those receiving methylphenidate compared with placebo (mean difference, -1.25; 95% CI, -2.03 to -0.47; P = .002). The largest decrease in the NPI apathy score was observed in the first 100 days, with a significant hazard ratio for the proportion of participants with no apathy symptoms receiving methylphenidate compared with placebo (hazard ratio, 2.16; 95% CI, 1.19-3.91; P = .01). At 6 months, the odds ratio of having an improved rating on the Alzheimer's Disease Cooperative Study Clinical Global Impression of Change for methylphenidate compared with placebo was 1.90 (95% CI, 0.95-3.84; P = .07). The difference in mean change from baseline to 6 months estimated using a longitudinal model was 1.43 (95% CI, 1.00-2.04; P = .048). Cognitive measures and quality of life were not significantly different between groups. Of the 17 serious adverse events that occurred during the study, none were related to the study drug. No significant differences in the safety profile were noted between treatment groups. Conclusions and Relevance This study found methylphenidate to be a safe and efficacious medication to use in the treatment of apathy in Alzheimer disease. Trial Registration ClinicalTrials.gov Identifier: NCT02346201.
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Affiliation(s)
- Jacobo Mintzer
- Ralph H. Johnson VA Medical Center, Medical University of South Carolina, Charleston
| | - Krista L. Lanctôt
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Roberta W. Scherer
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Nathan Herrmann
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | | | - Prasad R. Padala
- Central Arkansas Veterans Healthcare System, University of Arkansas for Medical Sciences, Little Rock
| | - Olga Brawman-Mintzer
- Ralph H. Johnson VA Medical Center, Medical University of South Carolina, Charleston
| | | | - Alan J. Lerner
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Suzanne Craft
- Wake Forest University, Winston-Salem, North Carolina
| | - Allan I. Levey
- Emory Goizueta Alzheimer’s Disease Research Center, Atlanta, Georgia
| | | | - Jamie Perin
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - David Shade
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
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Jaeschke RR, Sujkowska E, Sowa-Kućma M. Methylphenidate for attention-deficit/hyperactivity disorder in adults: a narrative review. Psychopharmacology (Berl) 2021; 238:2667-2691. [PMID: 34436651 PMCID: PMC8455398 DOI: 10.1007/s00213-021-05946-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/31/2021] [Indexed: 12/12/2022]
Abstract
RATIONALE Psychostimulants, including methylphenidate (MPH), are the mainstay of pharmacotherapy for attention-deficit/hyperactivity disorder (ADHD) in adults. Even though MPH is the most commonly used medication for ADHD these days, there are relatively few resources available that provide comprehensive insight into the pharmacological and clinical features of the compound. OBJECTIVE The aim of this paper is to provide an up-to-date outline of the pharmacology and clinical utility of MPH for ADHD in adult patients. METHODS While conducting the narrative review, we applied structured search strategies covering the two major online databases (MEDLINE and Cochrane Central Register of Controlled Trials). In addition, we performed handsearching of reference lists of relevant papers. RESULTS Methylphenidate exhibits multimodal mechanism of action, working primarily as a dopamine and noradrenaline reuptake inhibitor. It also protects the dopaminergic system against the ongoing 'wearing off' (by securing a substantial reserve pool of the neurotransmitter, stored in the presynaptic vesicles). In placebo-controlled trials, MPH was shown to be moderately effective both against the core ADHD symptoms (standardized mean difference [SMD], 0.49; 95% confidence interval [CI], 0.35-0.64), and the accompanying emotion regulation deficits (SMD, 0.34; 95% CI, 0.23-0.45). The most common adverse events related to long-term treatment with MPH are decreased appetite (~ 20%), dry mouth (15%), heart palpitations (13%), gastrointestinal infections (~ 10%), and agitation/feeling restless (~ 10%). CONCLUSIONS There is substantial body of evidence to suggest that MPH is an effective and safe treatment option for adults with ADHD.
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Affiliation(s)
- Rafał R Jaeschke
- Section of Affective Disorders, Department of Psychiatry, Jagiellonian University Medical College, ul. Kopernika 21a, 31-501, Kraków, Poland.
| | - Ewelina Sujkowska
- Department of Human Physiology, Institute of Medical Sciences, Medical College of Rzeszów University, ul. Kopisto 2a, 35-315, Rzeszów, Poland
| | - Magdalena Sowa-Kućma
- Department of Human Physiology, Institute of Medical Sciences, Medical College of Rzeszów University, ul. Kopisto 2a, 35-315, Rzeszów, Poland
- Centre for Innovative Research in Medical and Natural Sciences, Medical College of Rzeszów University, ul. Warzywna 1a, 35-310, Rzeszów, Poland
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12
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Higgins GA, Silenieks LB, MacMillan C, Thevarkunnel S, Parachikova AI, Mombereau C, Lindgren H, Bastlund JF. Characterization of Amphetamine, Methylphenidate, Nicotine, and Atomoxetine on Measures of Attention, Impulsive Action, and Motivation in the Rat: Implications for Translational Research. Front Pharmacol 2020; 11:427. [PMID: 32390829 PMCID: PMC7193984 DOI: 10.3389/fphar.2020.00427] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/19/2020] [Indexed: 12/18/2022] Open
Abstract
Amphetamine (AMP), methylphenidate (MPH), and atomoxetine (ATX) are approved treatments for ADHD, and together with nicotine (NIC), represent pharmacological agents widely studied on cognitive domains including attention and impulsive action in humans. These agents thus represent opportunities for clinical observation to be reinvestigated in the preclinical setting, i.e., reverse translation. The present study investigated each drug in male, Long Evans rats trained to perform either (1) the five-choice serial reaction time task (5-CSRTT), (2) Go/NoGo task, or (3) a progressive ratio (PR) task, for the purpose of studying each drug on attention, impulsive action and motivation. Specific challenges were adopted in the 5-CSRTT designed to tax attention and impulsivity, i.e., high frequency of stimulus presentation (sITI), variable reduction in stimulus duration (sSD), and extended delay to stimulus presentation (10-s ITI). Initially, performance of a large (> 80) cohort of rats in each task variant was conducted to examine performance stability over repeated challenge sessions, and to identify subgroups of "high" and "low" attentive rats (sITI and sSD schedules), and "high" and "low" impulsives (10-s ITI). Using an adaptive sequential study design, the effects of AMP, MPH, ATX, and NIC were examined and contrasting profiles noted across the tests. Both AMP (0.03-0.3 mg/kg) and MPH (1-6 mg/kg) improved attentional performance in the sITI but not sSD or 10-s ITI condition, NIC (0.05-0.2 mg/kg) improved accuracy across all conditions. ATX (0.1-1 mg/kg) detrimentally affected performance in the sITI and sSD condition, notably in "high" performers. In tests of impulsive action, ATX reduced premature responses notably in the 10-s ITI condition, and also reduced false alarms in Go/NoGo. Both AMP and NIC increased premature responses in all task variants, although AMP reduced false alarms highlighting differences between these two measures of impulsive action. The effect of MPH was mixed and appeared baseline dependent. ATX reduced break point for food reinforcement suggesting a detrimental effect on motivation for primary reward. Taken together these studies highlight differences between AMP, MPH, and ATX which may translate to their clinical profiles. NIC had the most reliable effect on attentional accuracy, whereas ATX was reliably effective against all tests of impulsive action.
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Affiliation(s)
- Guy A Higgins
- Intervivo Solutions, Toronto, ON, Canada.,Department of Pharmacology & Toxicology, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | - Hanna Lindgren
- Discovery Research, H. Lundbeck A/S, Copenhagen, Denmark
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13
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López-Pinar C, Martínez-Sanchís S, Carbonell-Vayá E, Sánchez-Meca J, Fenollar-Cortés J. Efficacy of Nonpharmacological Treatments on Comorbid Internalizing Symptoms of Adults With Attention-Deficit/Hyperactivity Disorder: A Meta-Analytic Review. J Atten Disord 2020; 24:456-478. [PMID: 31189374 DOI: 10.1177/1087054719855685] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Attention-deficit/hyperactivity disorder (ADHD) is highly comorbid in adulthood. This meta-analysis was aimed at ascertaining the efficacy of different psychotherapies in improving comorbid internalizing symptoms in adults with ADHD. Method: Twenty randomized controlled trials and 12 uncontrolled pretest-posttest studies were included and combined using the inverse variance method. Risk of bias and heterogeneity assessment and moderator analyses were performed. Results: Cognitive-behavioral therapy (CBT) improved quality of life (QoL), emotional dysregulation (ED), depression, and anxiety symptoms, particularly at follow-up, which was predicted by core symptoms reduction. A significant between-group effect was obtained only on QoL, ED, and self-esteem for dialectical behavior therapy (DBT), mindfulness-based therapies (MBTs), and neurofeedback, respectively. Conclusion: Results support CBT efficacy for treating comorbid internalizing symptoms. More research is needed to determine the effectiveness of DBT, MBT, and neurofeedback. The small number of studies evaluating some therapies and the high risk of bias observed might limit these results.
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14
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Bahn GH, Lee YS, Yoo HK, Kim EJ, Park S, Han DH, Hong M, Kim B, Lee SI, Bhang SY, Lee SY, Hong JP, Joung YS. Development of the Korean Practice Parameter for Adult Attention-Deficit/Hyperactivity Disorder. Soa Chongsonyon Chongsin Uihak 2020; 31:5-25. [PMID: 32612409 PMCID: PMC7324844 DOI: 10.5765/jkacap.190030] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Adult attention-deficit/hyperactivity disorder (ADHD) is an important mental health problem that needs resolution, especially considering the high rates of ADHD continuation from childhood to adolescence/adulthood and the high prevalence of ADHD in adults. Adults with ADHD have lifelong negative impacts and require close monitoring with long-term follow-up. Hence, the establishment of a Korean practice parameter for adult ADHD is necessary to minimize discontinuation of treatment and enable information sharing among Korean mental health professionals. METHODS The Korean practice parameter was developed using an evidence-based approach consisting of expert consensus survey coupled with literature review. RESULTS According to the expert consensus survey, the most commonly used diagnostic methods were clinical psychiatric interview (20.66%) and self-report scales (19.25%) followed by attention (14.71%) and psychological tests (14.24%). Key evaluation instruments currently available in Korea are the World Health Organization Adult ADHD Self-Report Rating Scale, Korean Adult ADHD Rating Scale, Diagnostic Interview for ADHD in Adults, Barkley Deficits in Executive Functioning Scale for adults, Comprehensive Attention Test, Conners' Continuous Performance Test, and the subtests of Wechsler Adult Intelligence Scale, Digit Span and Letter-Number Sequencing. Although pharmacotherapy is recommended as the first-line of treatment for adult ADHD, we recommend that it be followed by a multimodal and multidisciplinary approach including psychoeducation, pharmacotherapy, cognitive behavior therapy and coaching. CONCLUSION The Korean practice parameter introduces not only general information for the diagnosis and treatment of adult ADHD on a global scale, but also the process of diagnosis and treatment options tailored to the Korean population.
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Affiliation(s)
- Geon Ho Bahn
- Department of Psychiatry, Kyung Hee University School of Medicine, Seoul, Korea
| | - Young Sik Lee
- Department of Psychiatry, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | | | - Eui-Jung Kim
- Department of Psychiatry, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Subin Park
- Department of Research Planning, Mental Health Research Institute, National Center for Mental Health, Seoul, Korea
| | - Doug Hyun Han
- Department of Psychiatry, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Minha Hong
- Department of Psychiatry, Myongji Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - Bongseog Kim
- Department of Psychiatry, Inje University College of Medicine, Seoul, Korea
| | - Soyoung Irene Lee
- Department of Psychiatry, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Buchun, Korea
| | - Soo Young Bhang
- Department of Psychiatry, Eulji University School of Medicine, Seoul, Korea
| | - Seung Yup Lee
- Department of Psychiatry, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jin Pyo Hong
- Department of Psychiatry, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoo-Sook Joung
- Department of Psychiatry, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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15
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Weibel S, Menard O, Ionita A, Boumendjel M, Cabelguen C, Kraemer C, Micoulaud-Franchi JA, Bioulac S, Perroud N, Sauvaget A, Carton L, Gachet M, Lopez R. Practical considerations for the evaluation and management of Attention Deficit Hyperactivity Disorder (ADHD) in adults. Encephale 2019; 46:30-40. [PMID: 31610922 DOI: 10.1016/j.encep.2019.06.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 05/27/2019] [Accepted: 06/07/2019] [Indexed: 12/12/2022]
Abstract
Attention deficit with or without hyperactivity disorder (ADHD) is one of the most frequent neuropsychiatric disorders, and affects 2-4% of adults. In contrast with many European countries, the identification and management of adult ADHD remains underdeveloped in France, and a subject of controversy. This review provides a practical update on current knowledge about ADHD in adults for French-speaking professionals who have to detect or manage adult patients with ADHD. ADHD is classified as a neurodevelopmental disorder in the recent update of the international diagnostic classification. While symptoms and impairment due to ADHD are frequently severe during childhood, they often evolve as children grow older, with frequent persistent disabilities in adulthood. In adulthood, the clinical presentation, as in childhood, involves the symptom triad of inattention, hyperactivity and impulsivity. However, differences are noted: hyperactivity is more often internalized, symptoms of inattention may be masked by anxiety symptoms or obsessive-like compensation strategies. ADHD is often diagnosed during childhood, but it is not rare for the diagnosis to be made later. Failure to recognise symptoms resulting in misdiagnosis, or alternatively well-developed compensation factors could be two underlying reasons for the long delay until diagnosis. Other symptoms, such as emotional deregulation or executive function-related symptoms are also usually observed in adults. In addition, in adults, ADHD is often associated with other psychiatric disorders (in 80% of cases); this makes the diagnosis even more difficult. These disorders encompass a broad spectrum, from mood disorders (unipolar or bipolar), to anxiety disorders, and other neurodevelopmental disorders and personality disorders, especially borderline and antisocial personality disorder. Substance-use disorders are very common, either as a consequence of impulsivity and emotional dysregulation or as an attempt at self-treatment. Sleep disorders, especially restless leg syndrome and hypersomnolence, could share common pathophysiological mechanisms with ADHD. ADHD and comorbidity-related symptoms are responsible for serious functional impairment, in various domains, leading to academic, social, vocational, and familial consequences. The impact on other psychiatric disorders as an aggravating factor should also be considered. The considerable disability and the poorer quality of life among adults with ADHD warrant optimal evaluation and management. The diagnostic procedure for ADHD among adults should be systematic. Once the positive diagnosis is made, the evaluation enables characterisation of the levels of severity and impairment at individual level. A full examination should also assess medical conditions associated with ADHD, to provide personalized care. In recent years, a growing number of assessment tools have been translated and validated in French providing a wide range of structured interviews and standardized self-report questionnaires for the evaluation of core and associated ADHD symptoms, comorbidities and functional impairment. The treatment of ADHD in adults is multimodal, and aims to relieve the symptoms, limit the burden of the disease, and manage comorbidities. The most relevant and validated psychological approaches are psycho-education, cognitive-behavioural therapy and "third wave therapies" with a specific focus on emotional regulation. Cognitive remediation and neurofeedback are promising strategies still under evaluation. Medications, especially psychostimulants, are effective for alleviating ADHD symptoms with a large effect size. Their safety and tolerance are satisfactory, although their long-term clinical benefit is still under discussion. In France, methylphenidate is the only stimulant available for the treatment of ADHD. Unfortunately, there is no authorization for its use among adults except in continuation after adolescence. Hence the prescription, which is subject to the regulations on narcotics, is off-label in France. This article aims to provide practical considerations for the management of ADHD and associated disorders in adults, in this particular French context.
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Affiliation(s)
- S Weibel
- Service de psychiatrie 2, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France; Inserm U1114, Strasbourg, France; Fédération de Médecine Translationnelle de Strasbourg (FMTS), 67000 Strasbourg, France.
| | - O Menard
- Service d'addictologie, Hôpital Fontan 2, CHRU de Lille, 59000 Lille, France
| | - A Ionita
- Clinique du château, Nightingale hospitals Paris, 92380 Garches, France
| | - M Boumendjel
- Équipe de liaison et de soins en addictologie (ELSA), service de psychiatrie et d'addictologie, centre de soin de prévention et d'accompagnement en addictologie (CSAPA), Hôpital André Mignot, 78000 Versailles, France
| | - C Cabelguen
- Unité de neuromodulation et de psychiatrie de liaison, centre ambulatoire pluridisciplinaire de psychiatrie et d'addictologie, Centre Hospitalier Universitaire de Nantes, 44000 Nantes, France
| | - C Kraemer
- Service de psychiatrie 2, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - J-A Micoulaud-Franchi
- Service d'explorations fonctionnelles du système nerveux, clinique du sommeil, CHU de Bordeaux, 33000 Bordeaux, France; CNRS, SANPSY, USR 3413, SANPSY, Université de Bordeaux, 33000 Bordeaux, France
| | - S Bioulac
- Service d'explorations fonctionnelles du système nerveux, clinique du sommeil, CHU de Bordeaux, 33000 Bordeaux, France; CNRS, SANPSY, USR 3413, SANPSY, Université de Bordeaux, 33000 Bordeaux, France
| | - N Perroud
- Service des spécialités psychiatrique, département de santé mentale et de psychiatrie, Hôpitaux Universitaires de Genève, 1201 Genève, Switzerland
| | - A Sauvaget
- Addictologie and psychiatrie de liaison, CHU de Nantes, 44000 Nantes, France; Laboratoire "mouvement, interactions, performance" (EA 4334), Faculté Sciences du sport, Université de Nantes, 44000 Nantes, France
| | - L Carton
- Inserm U1171 "Troubles cognitifs dégénératifs et vasculaires", Université de Lille, 59000 Lille, France; Département de pharmacologie médicale, CHRU de Lille, 59000 Lille, France
| | - M Gachet
- Service d'urgence et post-urgence psychiatrique, hôpital Lapeyronie, 34000 Montpellier, France
| | - R Lopez
- Consultation spécialisée TDAH adulte, centre national de référence narcolepsie hypersomnies rares, département de neurologie, Hôpital Gui-De-Chauliac, 34000 Montpellier, France; Inserm U1061, 34000 Montpellier, France.
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van Emmerik-van Oortmerssen K, Vedel E, Kramer FJ, Blankers M, Dekker JJM, van den Brink W, Schoevers RA. Integrated cognitive behavioral therapy for ADHD in adult substance use disorder patients: Results of a randomized clinical trial. Drug Alcohol Depend 2019; 197:28-36. [PMID: 30769263 DOI: 10.1016/j.drugalcdep.2018.12.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 12/21/2018] [Accepted: 12/27/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Attention Deficit Hyperactivity Disorder (ADHD) frequently co-occurs with Substance Use Disorders (SUDs). Standard ADHD pharmacotherapies are not effective in patients with this comorbidity and cognitive behavioral therapy (CBT) has not been tested in this population. This RCT aimed to compare the efficacy of Integrated CBT (CBT/Integrated) directed at adult ADHD and SUD with CBT directed at SUD only (CBT/SUD) in patients with SUD and ADHD (SUD + ADHD). METHODS Randomized clinical trial among 119 SUD + ADHD patients in a SUD treatment center. CBT/Integrated consisted of 15 individual sessions of motivational therapy, coping skills training and relapse prevention for SUD, and training of planning skills, problem-solving skills and dealing with emotions for ADHD. CBT/SUD consisted of 10 individual SUD treatment sessions only. Primary outcome was ADHD symptom severity according to the ADHD rating scale (ARS) at post-treatment. Secondary outcomes included ADHD symptom severity after two-month follow-up, and treatment response (≥30% ADHD symptom reduction), substance use, depressive or anxiety symptoms, and quality of life at post-treatment and follow-up. RESULTS CBT/Integrated was more effective than CBT/SUD in the reduction of ADHD symptoms post-treatment: ARS = 28.1 (SD 9.0) vs. 31.5 (SD 11.4) (F = 4.739, df = 1, 282, p = .030; d = 0.34). At follow-up, CBT/Integrated still resulted in lower ARS scores than CBT/SUD, but the difference was not significant at the 0.05 level. For other secondary outcomes, including substance use, no significant between-group differences were present. CONCLUSIONS Compared to regular SUD cognitive behavioral therapy, integrated cognitive behavioral therapy resulted in a significant extra improvement in ADHD symptoms in SUD + ADHD patients.
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Affiliation(s)
- Katelijne van Emmerik-van Oortmerssen
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Psychiatry, University of Amsterdam, Amsterdam Institute for Addiction Research, Academic Medical Center, Amsterdam, the Netherlands; Arkin Mental Health and Addiction Treatment Center, Amsterdam, the Netherlands; Jellinek Substance Abuse Treatment Center, Amsterdam, the Netherlands.
| | - Ellen Vedel
- Arkin Mental Health and Addiction Treatment Center, Amsterdam, the Netherlands; Jellinek Substance Abuse Treatment Center, Amsterdam, the Netherlands
| | - Floor J Kramer
- Arkin Mental Health and Addiction Treatment Center, Amsterdam, the Netherlands; Jellinek Substance Abuse Treatment Center, Amsterdam, the Netherlands
| | - Matthijs Blankers
- Arkin Mental Health and Addiction Treatment Center, Amsterdam, the Netherlands; Jellinek Substance Abuse Treatment Center, Amsterdam, the Netherlands
| | - Jack J M Dekker
- Arkin Mental Health and Addiction Treatment Center, Amsterdam, the Netherlands
| | - Wim van den Brink
- Department of Psychiatry, University of Amsterdam, Amsterdam Institute for Addiction Research, Academic Medical Center, Amsterdam, the Netherlands
| | - Robert A Schoevers
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Gazer-Snitovsky M, Brand-Gothelf A, Dubnov-Raz G, Weizman A, Gothelf D. High Familial Correlation in Methylphenidate Response and Side Effect Profile. J Atten Disord 2019; 23:135-139. [PMID: 25899797 DOI: 10.1177/1087054715580844] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine whether a familial tendency exists in clinical response to methylphenidate. METHOD Nineteen pairs of siblings or parent-child stimulant-naive individuals with ADHD were prescribed methylphenidate-immediate release, and were comprehensively evaluated at baseline, Week 2, and Week 4, using the ADHD Rating Scale IV, Clinical Global Impression Scale, and the Barkley Side Effects Rating Scale. RESULTS We found significant intraclass correlations in family member response to methylphenidate-immediate release and side effect profile, including emotional symptoms and loss of appetite and weight. CONCLUSION Family history of response to methylphenidate should be taken into account when treating ADHD.
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Affiliation(s)
| | | | - Gal Dubnov-Raz
- 1 Tel Aviv University, Israel.,2 The Edmond and Lily Safra Children's Hospital, Tel Hashomer, Israel
| | - Abraham Weizman
- 1 Tel Aviv University, Israel.,3 Geha Mental Health Center & Felsenstein Medical Research Center, Petah Tikva, Israel
| | - Doron Gothelf
- 1 Tel Aviv University, Israel.,2 The Edmond and Lily Safra Children's Hospital, Tel Hashomer, Israel
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18
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Updated European Consensus Statement on diagnosis and treatment of adult ADHD. Eur Psychiatry 2018; 56:14-34. [DOI: 10.1016/j.eurpsy.2018.11.001] [Citation(s) in RCA: 201] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/02/2018] [Accepted: 11/03/2018] [Indexed: 12/17/2022] Open
Abstract
AbstractBackground Attention-deficit/hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that often persists into adulthood and old age. Yet ADHD is currently underdiagnosed and undertreated in many European countries, leading to chronicity of symptoms and impairment, due to lack of, or ineffective treatment, and higher costs of illness.Methods The European Network Adult ADHD and the Section for Neurodevelopmental Disorders Across the Lifespan (NDAL) of the European Psychiatric Association (EPA), aim to increase awareness and knowledge of adult ADHD in and outside Europe. This Updated European Consensus Statement aims to support clinicians with research evidence and clinical experience from 63 experts of European and other countries in which ADHD in adults is recognized and treated.Results Besides reviewing the latest research on prevalence, persistence, genetics and neurobiology of ADHD, three major questions are addressed: (1) What is the clinical picture of ADHD in adults? (2) How should ADHD be properly diagnosed in adults? (3) How should adult ADHDbe effectively treated?Conclusions ADHD often presents as a lifelong impairing condition. The stigma surrounding ADHD, mainly due to lack of knowledge, increases the suffering of patients. Education on the lifespan perspective, diagnostic assessment, and treatment of ADHD must increase for students of general and mental health, and for psychiatry professionals. Instruments for screening and diagnosis of ADHD in adults are available, as are effective evidence-based treatments for ADHD and its negative outcomes. More research is needed on gender differences, and in older adults with ADHD.
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Franke B, Michelini G, Asherson P, Banaschewski T, Bilbow A, Buitelaar JK, Cormand B, Faraone SV, Ginsberg Y, Haavik J, Kuntsi J, Larsson H, Lesch KP, Ramos-Quiroga JA, Réthelyi JM, Ribases M, Reif A. Live fast, die young? A review on the developmental trajectories of ADHD across the lifespan. Eur Neuropsychopharmacol 2018; 28:1059-1088. [PMID: 30195575 PMCID: PMC6379245 DOI: 10.1016/j.euroneuro.2018.08.001] [Citation(s) in RCA: 320] [Impact Index Per Article: 53.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 06/25/2018] [Accepted: 08/07/2018] [Indexed: 02/07/2023]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is highly heritable and the most common neurodevelopmental disorder in childhood. In recent decades, it has been appreciated that in a substantial number of cases the disorder does not remit in puberty, but persists into adulthood. Both in childhood and adulthood, ADHD is characterised by substantial comorbidity including substance use, depression, anxiety, and accidents. However, course and symptoms of the disorder and the comorbidities may fluctuate and change over time, and even age of onset in childhood has recently been questioned. Available evidence to date is poor and largely inconsistent with regard to the predictors of persistence versus remittance. Likewise, the development of comorbid disorders cannot be foreseen early on, hampering preventive measures. These facts call for a lifespan perspective on ADHD from childhood to old age. In this selective review, we summarise current knowledge of the long-term course of ADHD, with an emphasis on clinical symptom and cognitive trajectories, treatment effects over the lifespan, and the development of comorbidities. Also, we summarise current knowledge and important unresolved issues on biological factors underlying different ADHD trajectories. We conclude that a severe lack of knowledge on lifespan aspects in ADHD still exists for nearly every aspect reviewed. We encourage large-scale research efforts to overcome those knowledge gaps through appropriately granular longitudinal studies.
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Affiliation(s)
- Barbara Franke
- Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Psychiatry, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Giorgia Michelini
- King's College London, Institute of Psychiatry, Psychology & Neuroscience, Social, Genetic & Developmental Psychiatry Centre, London, UK
| | - Philip Asherson
- King's College London, Institute of Psychiatry, Psychology & Neuroscience, Social, Genetic & Developmental Psychiatry Centre, London, UK
| | - Tobias Banaschewski
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Andrea Bilbow
- Attention Deficit Disorder Information and Support Service (ADDISS), Edgware, UK; ADHD-Europe, Brussels, Belgium
| | - Jan K Buitelaar
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Cognitive Neuroscience, Nijmegen, The Netherlands
| | - Bru Cormand
- Department of Genetics, Microbiology and Statistics, Faculty of Biology, Universitat de Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Spain; Institut de Biomedicina de la Universitat de Barcelona (IBUB), Barcelona, Catalonia, Spain; Institut de Recerca Sant Joan de Déu (IR-SJD), Esplugues de Llobregat, Catalonia, Spain
| | - Stephen V Faraone
- Departments of Psychiatry and of Neuroscience and Physiology, State University of New York Upstate Medical University, New York, USA; K.G. Jebsen Centre for Neuropsychiatric Disorders, Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Ylva Ginsberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
| | - Jan Haavik
- K.G. Jebsen Centre for Neuropsychiatric Disorders, Department of Biomedicine, University of Bergen, Bergen, Norway; Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Jonna Kuntsi
- King's College London, Institute of Psychiatry, Psychology & Neuroscience, Social, Genetic & Developmental Psychiatry Centre, London, UK
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
| | - Klaus-Peter Lesch
- Division of Molecular Psychiatry, Center of Mental Health, University of Würzburg, Würzburg, Germany; Laboratory of Psychiatric Neurobiology, Institute of Molecular Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia; Department of Translational Neuroscience, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - J Antoni Ramos-Quiroga
- Department of Psychiatry, Hospital Universitari Vall d'Hebron, Barcelona, Catalonia, Spain; Psychiatric Genetics Unit, Vall d'Hebron Research Institute (VHIR), Barcelona, Catalonia, Spain; Biomedical Network Research Centre on Mental Health (CIBERSAM), Barcelona, Catalonia, Spain; Department of Psychiatry and Legal Medicine, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - János M Réthelyi
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary; MTA-SE NAP-B Molecular Psychiatry Research Group, Hungarian Academy of Sciences, Budapest, Hungary
| | - Marta Ribases
- Department of Psychiatry, Hospital Universitari Vall d'Hebron, Barcelona, Catalonia, Spain; Psychiatric Genetics Unit, Vall d'Hebron Research Institute (VHIR), Barcelona, Catalonia, Spain; Biomedical Network Research Centre on Mental Health (CIBERSAM), Barcelona, Catalonia, Spain
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Frankfurt am Main, Germany
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Stuhec M, Lukić P, Locatelli I. 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. Ann Pharmacother 2018; 53:121-133. [DOI: 10.1177/1060028018795703] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: Psychostimulants are the first-line treatment in adults with attention-deficit hyperactivity disorder (ADHD). This meta-analysis aimed to evaluate the efficacy, acceptability, and tolerability of lisdexamfetamine (LDX), mixed amphetamine salts (MASs), modafinil (MDF), and methylphenidate (MPH) in comparison with placebo. Data Sources: We systematically searched PubMed/MEDLINE and Clinicaltrials.gov in May 2016, along with CENTRAL and EU Clinical Trials Register in February 2016, for the randomized, double-blind, placebo-controlled, parallel-group clinical trials conducted on adults diagnosed with ADHD. Study Selection and Data Extraction: Substantial comorbidity, substance abuse or dependence, and nonpharmacological interventions represented grounds for exclusion. Published reports were the sole source for data extraction. Improvement in ADHD symptoms was the primary outcome. Random-effects model meta-analysis was applied to calculate the standardized mean difference (SMD) with 95% CIs. Data Synthesis: The search retrieved 701 records, of which 20 studies were eligible for analysis. High effect size (expressed as SMD) in reducing ADHD symptoms was observed for LDX (−0.89; 95% CI = −1.09, −0.70), whereas MASs (−0.64; 95% CI = −0.83, −0.45) and MPH (−0.50; 95% CI = −0.58, −0.41) reduced symptoms moderately compared with placebo. No efficacy was shown for MDF (0.08; 95% CI; −0.18, 0.34). Relevance to Patient Care and Clinical Practice: In this meta-analysis, the efficacy, tolerability, and acceptability of psychostimulants were compared with that for placebo. Five of the included trials have not been evaluated in any of the previously published meta-analyses. Conclusions: The results suggest that LDX has the largest effect size and has a promising potential for treating adults with ADHD.
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Affiliation(s)
- Matej Stuhec
- Ormoz Psychiatric Hospital, Department of clinical pharmacy, Ormoz, Slovenia, European Union
- University of Ljubljana, Faculty of Pharmacy, Slovenia, European Union
| | - Petar Lukić
- University of Ljubljana, Faculty of Pharmacy, Slovenia, European Union
| | - Igor Locatelli
- University of Ljubljana, Faculty of Pharmacy, Slovenia, European Union
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Exocytosis-related genes and response to methylphenidate treatment in adults with ADHD. Mol Psychiatry 2018; 23:1446-1452. [PMID: 28461697 DOI: 10.1038/mp.2017.90] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 02/10/2017] [Accepted: 02/28/2017] [Indexed: 01/11/2023]
Abstract
Experimental studies have demonstrated that methylphenidate (MPH) modulates the synaptic vesicle trafficking and synaptotagmin-1 (SytI) mRNA levels. SytI is a regulatory protein of the SNARE complex, a neurotransmitter exocytosis mediator. Despite this evidence, most SNARE complex-related genes have never been evaluated in attention-deficit/hyperactivity disorder (ADHD) pharmacogenetics. This study evaluates, for we believe the first time, polymorphisms on the SNARE complex-related genes STX1A (rs2228607), VAMP2 (26bp Ins/Del) and SYT1 (rs1880867 and rs2251214) on the response to immediate-release methylphenidate (IR-MPH) in a naturalistic sample of adults with ADHD. The sample comprised 433 subjects, of which 272 (62.8%) have completed the short-term IR-MPH treatment (at least 30 days). The main outcome measure was the categorical variable of short-term response to IR-MPH based on the Swanson, Nolan and Pelham Rating Scale version 4 (SNAP-IV), and on the clinical global impression-improvement scale. Additional analyses evaluated the percentage of SNAP-IV symptom reduction for each dimension as well as short- and long- (7 years) term treatment persistence. SYT1-rs2251214 was associated with the categorical short-term response to IR-MPH (P=0.006, PFDR=0.028), and with the percentage of inattention and oppositional defiant disorder symptoms reduction (P=0.007, PFDR=0.028 and P=0.017, PFDR=0.048, respectively). SYT1-rs2251214 was also associated with short-term treatment persistence (P=0.018, PFDR=0.048), and with months of treatment (P=0.002, PFDR=0.016) in the long-term protocol. Our findings suggest that SYT1-rs2251214 presents a broad influence in IR-MPH response variability in adults with ADHD, being involved with both symptom response and treatment persistence. If such findings are replicated, SytI could represent a key element in MPH pharmacodynamics in adults with ADHD.
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López-Pinar C, Martínez-Sanchís S, Carbonell-Vayá E, Fenollar-Cortés J, Sánchez-Meca J. Long-Term Efficacy of Psychosocial Treatments for Adults With Attention-Deficit/Hyperactivity Disorder: A Meta-Analytic Review. Front Psychol 2018; 9:638. [PMID: 29780342 PMCID: PMC5946687 DOI: 10.3389/fpsyg.2018.00638] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 04/16/2018] [Indexed: 01/23/2023] Open
Abstract
Background: Recent evidence suggests that psychosocial treatments, particularly cognitive-behavioral therapy (CBT), are effective interventions for adult attention deficit hyperactivity disorder (ADHD). The objective of this review was to determine the long-term efficacy of psychosocial interventions in improving clinically relevant variables, including ADHD core symptoms, clinical global impression (CGI), and global functioning. Methods: In total, nine randomized controlled trials and three uncontrolled single-group pretest-posttest studies were included. The data from these studies were combined using the inverse variance method. Heterogeneity and risk of bias were assessed. Subgroup analyses and meta-regressions were performed, to determine the influence of different potential moderator variables (risk of bias, medication status, follow-up length, therapy type and setting, and control group type) on effect size (ES) estimates. Results: Up to 680 of a total of 1,073 participants assessed pre-treatment were retained at follow-up. Treatment groups showed greater improvement than control groups in self-reported total ADHD symptoms, inattention, and hyperactivity/impulsivity, in addition to CGI and global functioning. Blind assessors also reported a large ES in within-subject outcomes. Studies using dialectical behavioral therapy (DBT) in a group setting, with active control matching, and that were rated as having an unclear risk of bias, achieved significantly lower ES estimates for most outcomes. Treatment effectiveness, according to the CGI measure, and global functioning were significantly increased when the percentage of medicated participants was greater. Conclusions: Our results indicate that the post-treatment gains reported in previous reviews are sustained for at least 12 months. Nevertheless, these results must be interpreted with caution, because of a high level of heterogeneity among studies and the risk of bias observed in the majority of outcomes. Thus, these findings indicate that psychological interventions are a highly valuable and stable clinical tool for the treatment of core symptoms and global functioning in adults with ADHD.
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Affiliation(s)
| | | | | | | | - Julio Sánchez-Meca
- Department of Basic Psychology and Methodology, University of Murcia, Murcia, Spain
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Scherer RW, Drye L, Mintzer J, Lanctôt K, Rosenberg P, Herrmann N, Padala P, Brawman-Mintzer O, Burke W, Craft S, Lerner AJ, Levey A, Porsteinsson A, van Dyck CH. The Apathy in Dementia Methylphenidate Trial 2 (ADMET 2): study protocol for a randomized controlled trial. Trials 2018; 19:46. [PMID: 29347996 PMCID: PMC5774109 DOI: 10.1186/s13063-017-2406-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 12/07/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Alzheimer's disease (AD) is characterized not only by cognitive and functional decline, but also often by the presence of neuropsychiatric symptoms. Apathy, which can be defined as a lack of motivation, is one of the most prevalent neuropsychiatric symptoms in AD and typically leads to a worse quality of life and greater burden for caregivers. Treatment options for apathy in AD are limited, but studies have examined the use of the amphetamine, methylphenidate. The Apathy in Dementia Methylphenidate Trial (ADMET) found that treatment of apathy in AD with methylphenidate was associated with significant improvement in apathy in two of three outcome measures, some evidence of improvement in global cognition, and minimal adverse events. However, the trial only enrolled 60 participants who were followed for only 6 weeks. A larger, longer-lasting trial is required to confirm these promising findings. METHODS The Apathy in Dementia Methylphenidate Trial 2 (ADMET 2) is a phase III, placebo-controlled, masked, 6-month, multi-center, randomized clinical trial targeted to enroll 200 participants with AD and apathy. Participants are randomly assigned 1:1 to 20 mg methylphenidate per day prepared as four over-encapsulated tablets or to matching placebo. The primary outcomes include (1) the mean difference in the Neuropsychiatric Inventory Apathy subscale scores measured as change from baseline to 6 months, and (2) the odds of having a given rating or better on the modified AD Cooperative Study Clinical Global Impression of Change ratings at month 6 compared with the baseline rating. Other outcomes include change in cognition, safety, and cost-effectiveness measured at monthly follow-up visits up to 6 months. DISCUSSION Given the prevalence of apathy in AD and its impact on both patients and caregivers, an intervention to alleviate apathy would be of great benefit to society. ADMET 2 follows on the promising results from the original ADMET to evaluate the efficacy of methylphenidate as a treatment for apathy in AD. With a larger sample size and longer follow up, ADMET 2 is poised to confirm or refute the original ADMET findings. TRIAL REGISTRATION ClinicalTrials.gov, NCT02346201 . Registered on 26 January 2015.
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Affiliation(s)
- Roberta W. Scherer
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD USA
| | - Lea Drye
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD USA
| | - Jacobo Mintzer
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC USA
| | | | - Paul Rosenberg
- Johns Hopkins University School of Medicine, Baltimore, MD USA
| | | | - Prasad Padala
- University of Arkansas for Medical Science, Central Arkansas Veterans Healthcare System, Little Rock, AR USA
| | - Olga Brawman-Mintzer
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC USA
| | | | - Suzanne Craft
- Wake Forest University School of Medicine, Winston-Salem, NC USA
| | - Alan J. Lerner
- University Hospitals – Case Western Reserve University, Cleveland, OH USA
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Boesen K, Saiz LC, Erviti J, Storebø OJ, Gluud C, Gøtzsche PC, Jørgensen KJ. The Cochrane Collaboration withdraws a review on methylphenidate for adults with attention deficit hyperactivity disorder. ACTA ACUST UNITED AC 2017; 22:143-147. [PMID: 28705922 PMCID: PMC5537554 DOI: 10.1136/ebmed-2017-110716] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2017] [Indexed: 12/11/2022]
Abstract
A Cochrane systematic review on immediate-release methylphenidate for adults with attention deficit hyperactivity disorder (ADHD) was withdrawn from the Cochrane Library on 26 May 2016 after substantial criticism of its methods and flawed conclusions. Retraction of scientific papers on this basis is unusual but can be necessary. We provide a summary of the criticism that led to the withdrawal. We detail the methodological flaws of the withdrawn Cochrane systematic review and general issues of bias and shortcomings of the included ADHD trials: cross-over designs compared with parallel-group designs, exclusion of participants with psychiatric comorbidity, absence of 'functional outcomes' and use of clinical outcomes with limited relevance, short trial duration and small trial populations, broken blinding caused by easily recognisable side effects, combining outcome assessments by trial investigators and participants, outcome reporting bias, poor evaluation of cardiovascular and psychiatric harms and conflicts of interest of trialists and systematic reviewers. The withdrawal of the Cochrane systematic review signals recognition of previous unreliable clinical ADHD research. We conclude that clinical trials of immediate-release methylphenidate in adults with ADHD are of very low quality. We urgently need well-conducted long-term trials free of bias to assess the benefits and harms of central stimulant treatment in adult ADHD.
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Affiliation(s)
- Kim Boesen
- Nordic Cochrane Centre, Rigshospitalet, Copenhagen, Denmark
| | - Luis Carlos Saiz
- Drug Prescribing Unit, Navarre Regional Health Service, Pamplona, Spain
| | - Juan Erviti
- Drug Prescribing Unit, Navarre Regional Health Service, Pamplona, Spain
| | - Ole Jakob Storebø
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen, Denmark
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Impaired oral absorption of methylphenidate after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2017; 13:1245-1247. [DOI: 10.1016/j.soard.2017.03.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 03/02/2017] [Accepted: 03/06/2017] [Indexed: 11/20/2022]
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Abstract
LEARNING OBJECTIVES After participating in this activity, learners should be better able to:• Evaluate pharmacologic treatment of attention deficit/hyperactivity disorder (ADHD) in patients with substance use disorder (SUD) • Assess the causes of the diminished efficacy of ADHD medication in patients with comorbid SUD OBJECTIVE: Substance use disorder (SUD) and attention-deficit/hyperactivity disorder (ADHD) frequently co-occur, and the presence of ADHD complicates the treatment of the addiction. Pharmacotherapy is a potent intervention in childhood and adult ADHD, but findings have been mixed in adolescent and adult ADHD patients with SUDs. This review focuses on several contributing factors and possible explanations, with implications both for future research and for clinical practice. METHOD This systematic review examined all randomized, placebo-controlled trials of pharmacotherapy for ADHD in adult and adolescent SUD patients. RESULTS The number of studies is limited, and several studies are hampered by qualitative flaws. The results, in general, are inconclusive for most medications studied, but more recent trials using psychostimulants in robust dosing have demonstrated significantly positive results. CONCLUSION In reviewing these trials, possible explanations relating to the particular characteristics and problems of this complex patient group are discussed. Several factors, including ADHD symptom severity, psychiatric comorbidity, persistent drug use, choice of medication, and concomitant psychosocial intervention, influence study results. Taking these factors into account may improve the likelihood of detecting significant effects in future research, as the recent positive trials have indicated, and may help in the appropriate selection of pharmacotherapy in clinical practice.
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Hutchison SL, Ghuman JK, Ghuman HS, Karpov I, Schuster JM. Efficacy of atomoxetine in the treatment of attention-deficit hyperactivity disorder in patients with common comorbidities in children, adolescents and adults: a review. Ther Adv Psychopharmacol 2016; 6:317-334. [PMID: 27721971 PMCID: PMC5036135 DOI: 10.1177/2045125316647686] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Attention-deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed mental health disorders and is associated with higher incidence of comorbid oppositional or conduct, mood, anxiety, pervasive developmental, and substance-use disorders. Comorbid mental health conditions may alter the presence of symptoms and treatment of ADHD. Atomoxetine (ATX), a nonstimulant medication for the treatment of ADHD, may be prescribed for individuals with ADHD and comorbid conditions despite some risk for certain undesirable side effects and lower effectiveness for the treatment of ADHD than stimulants. In this paper, we review studies utilizing randomized, placebo-controlled trials (RCTs) as well as within-subject designs to determine the effectiveness of ATX in the treatment of children and adults with ADHD and comorbid conditions. The current review uses an expanded methodology beyond systematic review of randomized controlled trials in order to improve generalizability of results to real-world practice. A total of 24 articles published from 2007 to 2015 were reviewed, including 14 RCTs: n = 1348 ATX, and n = 832 placebo. The majority of studies show that ATX is effective in the treatment of ADHD symptoms for individuals with ADHD and comorbid disorders. Cohen's d effect sizes (ES) for improvement in ADHD symptoms and behaviors range from 0.47 to 2.21. The effectiveness of ATX to improve symptoms specific to comorbidity varied by type but appeared to be most effective for diminishing the presence of symptoms for those with comorbid anxiety, ES range of 0.40 to 1.51, and oppositional defiant disorder, ES range of 0.52 to 1.10. There are mixed or limited results for individuals with ADHD and comorbid substance-use disorders, autism spectrum disorders, dyslexia or reading disorder, depression, bipolar disorder, and Tourette syndrome. Results from this review suggest that ATX is effective in the treatment of some youth and adults with ADHD and comorbid disorders, and may be a treatment option in these patients.
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Affiliation(s)
- Shari L. Hutchison
- Community Care Behavioral Health, UPMC Insurance Services Division, 339 Sixth Avenue, Suite 1300, Pittsburgh, PA 15222, USA
| | - Jaswinder K. Ghuman
- Community Care Behavioral Health, UPMC Insurance Services Division, Pittsburgh, PA, USA
| | | | - Irina Karpov
- Community Care Behavioral Health, UPMC Insurance Services Division, Pittsburgh, PA, USA
| | - James M. Schuster
- Community Care Behavioral Health, UPMC Insurance Services Division, Pittsburgh, PA, USA
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Baumeister TB, Wickenbrock I, Perings CA. STEMI Secondary to Coronary Vasospasm: Possible Adverse Event of Methylphenidate in a 21-Year-Old Man with ADHD. DRUG SAFETY - CASE REPORTS 2016; 3:10. [PMID: 27747690 PMCID: PMC5033796 DOI: 10.1007/s40800-016-0035-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Methylphenidate (Ritalin®) is an increasingly used medication in the treatment of attention-deficit hyperactivity disorder (ADHD). Cardiovascular adverse effects like vasospasm or myocardial infarction are described as very rare adverse effects. We present the case of a 21-year-old man diagnosed with ADHD who recently started therapy with Ritalin® Adult 20 mg for at least 3 days. Afterwards he presented with chest pain, elevated troponin and creatine kinase, and posterolateral ST elevations. A myocarditis was initially supposed. In the coronary angiography, signs of coronary artery spasm could be found. The echocardiography showed mild left ventricular dysfunction; no acute myocarditis could be found in the cardiac MRI and myocardial biopsy. The medication with methylphenidate was stopped, and after 12 days the asymptomatic patient was discharged from hospital.
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Affiliation(s)
- Timo-Benjamin Baumeister
- Medizinische Klinik I, Abteilung für Kardiologie, Elektrophysiologie, Pneumologie und konservative Intensivmedizin, Klinikum Lünen, Altstadtstraße 23, 44534, Lünen, Germany.
| | - Ingo Wickenbrock
- Medizinische Klinik I, Abteilung für Kardiologie, Elektrophysiologie, Pneumologie und konservative Intensivmedizin, Klinikum Lünen, Altstadtstraße 23, 44534, Lünen, Germany
| | - Christian A Perings
- Medizinische Klinik I, Abteilung für Kardiologie, Elektrophysiologie, Pneumologie und konservative Intensivmedizin, Klinikum Lünen, Altstadtstraße 23, 44534, Lünen, Germany
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29
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Pillidge K, Porter AJ, Young JW, Stanford SC. Perseveration by NK1R-/- ('knockout') mice is blunted by doses of methylphenidate that affect neither other aspects of their cognitive performance nor the behaviour of wild-type mice in the 5-Choice Continuous Performance Test. J Psychopharmacol 2016; 30:837-47. [PMID: 27097734 PMCID: PMC4994704 DOI: 10.1177/0269881116642541] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The underlying cause(s) of abnormalities expressed by patients with attention deficit hyperactivity disorder (ADHD) have yet to be delineated. One factor that has been associated with increased vulnerability to ADHD is polymorphism(s) of TACR1, which is the human equivalent of the rodent NK1 (substance P-preferring) receptor gene (Nk1r). We have reported previously that genetically altered mice, lacking functional NK1R (NK1R-/-), express locomotor hyperactivity, which was blunted by the first-line treatment for ADHD, methylphenidate. Here, we compared the effects of this psychostimulant (3, 10 and 30 mg/kg, intraperitoneally) on the behaviour of NK1R-/- mice and their wild types in the 5-Choice Continuous Performance Test, which emulates procedures used to study attention and response control in ADHD patients. Methylphenidate increased total trials (a measure of 'productivity') completed by wild types, but not by NK1R-/- mice. Conversely, this drug reduced perseveration by NK1R-/- mice, but not by wild types. Other drug-induced changes in key behaviours were not genotype dependent, especially at the highest dose: for example, % omissions (an index of inattentiveness) was increased, whereas % false alarms and % premature responses (measures of impulsivity) declined in both genotypes, indicating reduced overall response. These findings are discussed in the context of the efficacy of methylphenidate in the treatment of ADHD. Moreover, they lead to several testable proposals. First, methylphenidate does not improve attention in a subgroup of ADHD patients with a functional deficit of TACR1. Second, these patients do not express excessive false alarms when compared with other groups of subjects, but they do express excessive perseveration, which would be ameliorated by methylphenidate.
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Affiliation(s)
- Katharine Pillidge
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, UK
| | - Ashley J Porter
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, UK
| | - Jared W Young
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA,Research Service, VA San Diego Healthcare System, San Diego, CA, USA
| | - S Clare Stanford
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, UK
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Hegvik TA, Jacobsen KK, Fredriksen M, Zayats T, Haavik J. A candidate gene investigation of methylphenidate response in adult attention-deficit/hyperactivity disorder patients: results from a naturalistic study. J Neural Transm (Vienna) 2016; 123:859-65. [PMID: 27091191 PMCID: PMC4969350 DOI: 10.1007/s00702-016-1540-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 03/20/2016] [Indexed: 12/28/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is a common childhood onset neuropsychiatric disorder with a complex and heterogeneous symptomatology. Persistence of ADHD symptoms into adulthood is common. Methylphenidate (MPH) is a widely prescribed stimulant compound that may be effective against ADHD symptoms in children and adults. However, MPH does not exert satisfactory effect in all patients. Several genetic variants have been proposed to predict either treatment response or adverse effects of stimulants. We conducted a literature search to identify previously reported variants associated with MPH response and additional variants that were biologically plausible candidates for MPH response. The response to MPH was assessed by the treating clinicians in 564 adult ADHD patients and 20 genetic variants were successfully genotyped. Logistic regression was used to test for association between these polymorphisms and treatment response. Nominal associations (p < 0.05) were meta-analysed with published data from previous comparable studies. In our analyses, rs1800544 in the ADRA2A gene was associated with MPH response at a nominal significance level (OR 0.560, 95 % CI 0.329–0.953, p = 0.033). However, this finding was not affirmed in the meta-analysis. No genetic variants revealed significant associations after correction for multiple testing (p < 0.00125). Our results suggest that none of the studied variants are strong predictors of MPH response in adult ADHD as judged by clinician ratings, potentially except for rs1800544. Consequently, pharmacogenetic testing in routine clinical care is not supported by our analyses. Further studies on the pharmacogenetics of adult ADHD are warranted.
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Affiliation(s)
- Tor-Arne Hegvik
- Department of Biomedicine, University of Bergen, 5009, Bergen, Norway. .,K.G. Jebsen Centre for Research on Neuropsychiatric Disorders, University of Bergen, 5009, Bergen, Norway.
| | - Kaya Kvarme Jacobsen
- Department of Biomedicine, University of Bergen, 5009, Bergen, Norway.,K.G. Jebsen Centre for Research on Neuropsychiatric Disorders, University of Bergen, 5009, Bergen, Norway.,Center for Medical Genetics and Molecular Medicine, Haukeland University Hospital, 5021, Bergen, Norway
| | - Mats Fredriksen
- Division of Mental Health and Addiction, Vestfold Hospital Trust, 3101, Tønsberg, Norway.,University of Oslo, 0318, Oslo, Norway
| | - Tetyana Zayats
- Department of Biomedicine, University of Bergen, 5009, Bergen, Norway.,K.G. Jebsen Centre for Research on Neuropsychiatric Disorders, University of Bergen, 5009, Bergen, Norway
| | - Jan Haavik
- Department of Biomedicine, University of Bergen, 5009, Bergen, Norway.,K.G. Jebsen Centre for Research on Neuropsychiatric Disorders, University of Bergen, 5009, Bergen, Norway.,Division of Psychiatry, Haukeland University Hospital, 5021, Bergen, Norway
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Bachmann K, Lam AP, Philipsen A. Mindfulness-Based Cognitive Therapy and the Adult ADHD Brain: A Neuropsychotherapeutic Perspective. Front Psychiatry 2016; 7:117. [PMID: 27445873 PMCID: PMC4921925 DOI: 10.3389/fpsyt.2016.00117] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 06/14/2016] [Indexed: 12/12/2022] Open
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is a recognized serious mental disorder that often persists into adulthood. The symptoms and impairments associated with ADHD often cause significant mental suffering in affected individuals. ADHD has been associated with abnormal neuronal activity in various neuronal circuits, such as the dorsofrontostriatal, orbitofrontostriatal, and frontocerebellar circuits. Psychopharmacological treatment with methylphenidate hydrochloride is recommended as the first-line treatment for ADHD. It is assumed that medication ameliorates ADHD symptoms by improving the functioning of the brain areas affected in the condition. However, side effects, contraindications, or non-response can limit the effectiveness of a psychopharmacological treatment for ADHD. It is therefore necessary to develop non-pharmacological interventions that target neuronal mechanisms associated with the condition in the same way as pharmacological treatment. We think that mindfulness meditation employed as a neuropsychotherapeutic intervention could help patients with ADHD to regulate impaired brain functioning and thereby reduce ADHD symptoms. In this paper, we highlight the mechanisms of such mindfulness meditation, and thus provide a rationale for further research and treatment development from a neuropsychotherapeutic perspective. We conclude that mindfulness meditation employed as a neuropsychotherapeutic intervention in therapy is a promising treatment approach in ADHD.
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Affiliation(s)
- Katharina Bachmann
- School of Medicine & Health Sciences, University of Oldenburg , Oldenburg , Germany
| | - Alexandra P Lam
- School of Medicine & Health Sciences, University of Oldenburg, Oldenburg, Germany; Psychiatry and Psychotherapy, University Hospital, Karl-Jaspers-Klinik, Bad Zwischenahn, Germany
| | - Alexandra Philipsen
- School of Medicine & Health Sciences, University of Oldenburg, Oldenburg, Germany; Psychiatry and Psychotherapy, University Hospital, Karl-Jaspers-Klinik, Bad Zwischenahn, Germany; Department of Psychiatry and Psychotherapy, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
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Storebø OJ, Krogh HB, Ramstad E, Moreira-Maia CR, Holmskov M, Skoog M, Nilausen TD, Magnusson FL, Zwi M, Gillies D, Rosendal S, Groth C, Rasmussen KB, Gauci D, Kirubakaran R, Forsbøl B, Simonsen E, Gluud C. Methylphenidate for attention-deficit/hyperactivity disorder in children and adolescents: Cochrane systematic review with meta-analyses and trial sequential analyses of randomised clinical trials. BMJ 2015; 351:h5203. [PMID: 26608309 PMCID: PMC4659414 DOI: 10.1136/bmj.h5203] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2015] [Indexed: 12/12/2022]
Abstract
STUDY QUESTION Is methylphenidate beneficial or harmful for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents? METHODS Electronic databases were searched up to February 2015 for parallel and crossover randomised clinical trials comparing methylphenidate with placebo or no intervention in children and adolescents with ADHD. Meta-analyses and trial sequential analyses (TSA) were conducted. Quality was assessed using GRADE. Teachers, parents, and observers rated ADHD symptoms and general behaviour. STUDY ANSWER AND LIMITATIONS The analyses included 38 parallel group trials (n=5111, median treatment duration 49 days) and 147 crossover trials (n=7134, 14 days). The average age across all studies was 9.7 years. The analysis suggested a beneficial effect of methylphenidate on teacher rated symptoms in 19 parallel group trials (standardised mean difference (SMD) -0.77, n=1698), corresponding to a mean difference of -9.6 points on the ADHD rating scale. There was no evidence that methylphenidate was associated with an increase in serious adverse events (risk ratio 0.98, nine trials, n=1532; TSA adjusted intervention effect RR 0.91). Methylphenidate was associated with an increased risk of non-serious adverse events (1.29, 21 trials, n=3132; TSA adjusted RR 1.29). Teacher rated general behaviour seemed to improve with methylphenidate (SMD -0.87, five trials, n=668) A change of 7 points on the child health questionnaire (CHQ) has been deemed a minimal clinically relevant difference. The change reported in a meta-analysis of three trials corresponds to a mean difference of 8.0 points on the CHQ (range 0-100 points), which suggests that methylphenidate may improve parent reported quality of life (SMD 0.61, three trials, n=514). 96.8% of trials were considered high risk of bias trials according to the Cochrane guidelines. All outcomes were assessed very low quality according to GRADE. WHAT THIS STUDY ADDS The results suggest that among children and adolescents with a diagnosis of ADHD, methylphenidate may improve teacher reported symptoms of ADHD and general behaviour and parent reported quality of life. However, given the risk of bias in the included studies, and the very low quality of outcomes, the magnitude of the effects is uncertain. Methylphenidate is associated with an increased risk of non-serious but not serious adverse events. FUNDING, COMPETING INTERESTS, DATA SHARING Region Zealand Research Foundation and Copenhagen Trial Unit. Competing interests are given in the full paper on bmj.com. Full data are available in the version of this review published in The Cochrane Library.
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Affiliation(s)
- Ole Jakob Storebø
- Psychiatric Research Unit, Region Zealand Psychiatry, Denmark Child and Adolescent Psychiatric Department, Region Zealand, Denmark Department of Psychology, Faculty of Health Science, University of Southern Denmark
| | - Helle B Krogh
- Psychiatric Research Unit, Region Zealand Psychiatry, Denmark Child and Adolescent Psychiatric Department, Region Zealand, Denmark
| | - Erica Ramstad
- Psychiatric Research Unit, Region Zealand Psychiatry, Denmark Child and Adolescent Psychiatric Department, Region Zealand, Denmark
| | - Carlos R Moreira-Maia
- Department of Psychiatry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Maria Skoog
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Morris Zwi
- Islington CAMHS, Whittington Health, London, UK
| | - Donna Gillies
- Western Sydney Local Health District; Mental Health, Parramatta, Australia
| | - Susanne Rosendal
- Psychiatric Centre North Zealand, The Capital Region of Denmark, Denmark
| | - Camilla Groth
- Pediatric Department, Herlev University Hospital, Herlev, Denmark
| | | | - Dorothy Gauci
- Directorate for Health Information and Research, Department of Health, G'Mangia, Malta
| | - Richard Kirubakaran
- South Asian Cochrane Network & Center, Prof BV Moses Center for Evidence-Informed Health Care and Health Policy, Christian Medical College, Vellore, India
| | - Bente Forsbøl
- Child and Adolescent Psychiatric Department, Region Zealand, Denmark
| | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Denmark Institute of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Storebø OJ, Ramstad E, Krogh HB, Nilausen TD, Skoog M, Holmskov M, Rosendal S, Groth C, Magnusson FL, Moreira‐Maia CR, Gillies D, Buch Rasmussen K, Gauci D, Zwi M, Kirubakaran R, Forsbøl B, Simonsen E, Gluud C. Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD). Cochrane Database Syst Rev 2015; 2015:CD009885. [PMID: 26599576 PMCID: PMC8763351 DOI: 10.1002/14651858.cd009885.pub2] [Citation(s) in RCA: 156] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children with ADHD find it difficult to pay attention, they are hyperactive and impulsive.Methylphenidate is the drug most often prescribed to treat children and adolescents with ADHD but, despite its widespread use, this is the first comprehensive systematic review of its benefits and harms. OBJECTIVES To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD. SEARCH METHODS In February 2015 we searched six databases (CENTRAL, Ovid MEDLINE, EMBASE, CINAHL, PsycINFO, Conference Proceedings Citations Index), and two trials registers. We checked for additional trials in the reference lists of relevant reviews and included trials. We contacted the pharmaceutical companies that manufacture methylphenidate to request published and unpublished data. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. At least 75% of participants needed to have an intellectual quotient of at least 70 (i.e. normal intellectual functioning). Outcomes assessed included ADHD symptoms, serious adverse events, non-serious adverse events, general behaviour and quality of life. DATA COLLECTION AND ANALYSIS Seventeen review authors participated in data extraction and risk of bias assessment, and two review authors independently performed all tasks. We used standard methodological procedures expected within Cochrane. Data from parallel-group trials and first period data from cross-over trials formed the basis of our primary analyses; separate analyses were undertaken using post-cross-over data from cross-over trials. We used Trial Sequential Analyses to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach for high risk of bias, imprecision, indirectness, heterogeneity and publication bias. MAIN RESULTS The studies.We included 38 parallel-group trials (5111 participants randomised) and 147 cross-over trials (7134 participants randomised). Participants included individuals of both sexes, at a boys-to-girls ratio of 5:1, and participants' ages ranged from 3 to 18 years across most studies (in two studies ages ranged from 3 to 21 years). The average age across all studies was 9.7 years. Most participants were from high-income countries.The duration of methylphenidate treatment ranged from 1 to 425 days, with an average duration of 75 days. Methylphenidate was compared to placebo (175 trials) or no intervention (10 trials). Risk of Bias.All 185 trials were assessed to be at high risk of bias. Primary outcomes. Methylphenidate may improve teacher-rated ADHD symptoms (standardised mean difference (SMD) -0.77, 95% confidence interval (CI) -0.90 to -0.64; 19 trials, 1698 participants; very low-quality evidence). This corresponds to a mean difference (MD) of -9.6 points (95% CI -13.75 to -6.38) on the ADHD Rating Scale (ADHD-RS; range 0 to 72 points; DuPaul 1991a). A change of 6.6 points on the ADHD-RS is considered clinically to represent the minimal relevant difference. There was no evidence that methylphenidate was associated with an increase in serious (e.g. life threatening) adverse events (risk ratio (RR) 0.98, 95% CI 0.44 to 2.22; 9 trials, 1532 participants; very low-quality evidence). The Trial Sequential Analysis-adjusted intervention effect was RR 0.91 (CI 0.02 to 33.2). SECONDARY OUTCOMES Among those prescribed methylphenidate, 526 per 1000 (range 448 to 615) experienced non-serious adverse events, compared with 408 per 1000 in the control group. This equates to a 29% increase in the overall risk of any non-serious adverse events (RR 1.29, 95% CI 1.10 to 1.51; 21 trials, 3132 participants; very low-quality evidence). The Trial Sequential Analysis-adjusted intervention effect was RR 1.29 (CI 1.06 to 1.56). The most common non-serious adverse events were sleep problems and decreased appetite. Children in the methylphenidate group were at 60% greater risk for trouble sleeping/sleep problems (RR 1.60, 95% CI 1.15 to 2.23; 13 trials, 2416 participants), and 266% greater risk for decreased appetite (RR 3.66, 95% CI 2.56 to 5.23; 16 trials, 2962 participants) than children in the control group.Teacher-rated general behaviour seemed to improve with methylphenidate (SMD -0.87, 95% CI -1.04 to -0.71; 5 trials, 668 participants; very low-quality evidence).A change of seven points on the Child Health Questionnaire (CHQ; range 0 to 100 points; Landgraf 1998) has been deemed a minimal clinically relevant difference. The change reported in a meta-analysis of three trials corresponds to a MD of 8.0 points (95% CI 5.49 to 10.46) on the CHQ, which suggests that methylphenidate may improve parent-reported quality of life (SMD 0.61, 95% CI 0.42 to 0.80; 3 trials, 514 participants; very low-quality evidence). AUTHORS' CONCLUSIONS The results of meta-analyses suggest that methylphenidate may improve teacher-reported ADHD symptoms, teacher-reported general behaviour, and parent-reported quality of life among children and adolescents diagnosed with ADHD. However, the low quality of the underpinning evidence means that we cannot be certain of the magnitude of the effects. Within the short follow-up periods typical of the included trials, there is some evidence that methylphenidate is associated with increased risk of non-serious adverse events, such as sleep problems and decreased appetite, but no evidence that it increases risk of serious adverse events.Better designed trials are needed to assess the benefits of methylphenidate. Given the frequency of non-serious adverse events associated with methylphenidate, the particular difficulties for blinding of participants and outcome assessors point to the advantage of large, 'nocebo tablet' controlled trials. These use a placebo-like substance that causes adverse events in the control arm that are comparable to those associated with methylphenidate. However, for ethical reasons, such trials should first be conducted with adults, who can give their informed consent.Future trials should publish depersonalised individual participant data and report all outcomes, including adverse events. This will enable researchers conducting systematic reviews to assess differences between intervention effects according to age, sex, comorbidity, type of ADHD and dose. Finally, the findings highlight the urgent need for large RCTs of non-pharmacological treatments.
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Affiliation(s)
- Ole Jakob Storebø
- Region ZealandChild and Adolescent Psychiatric DepartmentBirkevaenget 3RoskildeDenmark4300
- Region Zealand PsychiatryPsychiatric Research UnitSlagelseDenmark
- University of Southern DenmarkDepartment of Psychology, Faculty of Health ScienceCampusvej 55OdenseDenmark5230
| | - Erica Ramstad
- Region ZealandChild and Adolescent Psychiatric DepartmentBirkevaenget 3RoskildeDenmark4300
- Region Zealand PsychiatryPsychiatric Research UnitSlagelseDenmark
| | - Helle B. Krogh
- Region ZealandChild and Adolescent Psychiatric DepartmentBirkevaenget 3RoskildeDenmark4300
- Region Zealand PsychiatryPsychiatric Research UnitSlagelseDenmark
| | | | | | | | - Susanne Rosendal
- Psychiatric Centre North ZealandThe Capital Region of DenmarkDenmark
| | - Camilla Groth
- Herlev University HospitalPediatric DepartmentCapital RegionHerlevDenmark
| | | | - Carlos R Moreira‐Maia
- Federal University of Rio Grande do SulDepartment of PsychiatryRua Ramiro Barcelos, 2350‐2201APorto AlegreRSBrazil90035‐003
| | - Donna Gillies
- Western Sydney Local Health District ‐ Mental HealthCumberland HospitalLocked Bag 7118ParramattaNSWAustralia2124
| | | | - Dorothy Gauci
- Department of HealthDirectorate for Health Information and Research95 G'Mangia HillG'MangiaMaltaPTA 1313
| | - Morris Zwi
- Whittington HealthIslington Child and Adolescent Mental Health Service580 Holloway RoadLondonLondonUKN7 6LB
| | - Richard Kirubakaran
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Center for Evidence‐Informed Health Care and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - Bente Forsbøl
- Psychiatric Department, Region ZealandChild and Adolescent Psychiatric ClinicHolbaekDenmark
| | - Erik Simonsen
- Region Zealand PsychiatryPsychiatric Research UnitSlagelseDenmark
- Copenhagen UniversityInstitute of Clinical Medicine, Faculty of Health and Medical SciencesCopenhagenDenmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchCopenhagenDenmark
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Ho JH, Bailey GP, Archer JRH, Dargan PI, Wood DM. Ethylphenidate: availability, patterns of use, and acute effects of this novel psychoactive substance. Eur J Clin Pharmacol 2015. [DOI: 10.1007/s00228-015-1906-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Dürsteler KM, Berger EM, Strasser J, Caflisch C, Mutschler J, Herdener M, Vogel M. Clinical potential of methylphenidate in the treatment of cocaine addiction: a review of the current evidence. Subst Abuse Rehabil 2015; 6:61-74. [PMID: 26124696 PMCID: PMC4476488 DOI: 10.2147/sar.s50807] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Cocaine use continues to be a public health problem, yet there is no proven effective pharmacotherapy for cocaine dependence. A promising approach to treating cocaine dependence may be agonist-replacement therapy, which is already used effectively in the treatment of opioid and tobacco dependence. The replacement approach for cocaine dependence posits that administration of a long-acting stimulant medication should normalize the neurochemical and behavioral perturbations resulting from chronic cocaine use. One potential medication to be substituted for cocaine is methylphenidate (MPH), as this stimulant possesses pharmacobehavioral properties similar to those of cocaine. Aim To provide a qualitative review addressing the rationale for the use of MPH as a cocaine substitute and its clinical potential in the treatment of cocaine dependence. Methods We searched MEDLINE for clinical studies using MPH in patients with cocaine abuse/dependence and screened the bibliographies of the articles found for pertinent literature. Results MPH, like cocaine, increases synaptic dopamine by inhibiting dopamine reuptake. The discriminative properties, reinforcing potential, and subjective effects of MPH and cocaine are almost identical and, importantly, MPH has been found to substitute for cocaine in animals and human volunteers under laboratory conditions. When taken orally in therapeutic doses, its abuse liability, however, appears low, which is especially true for extended-release MPH preparations. Though there are promising data in the literature, mainly from case reports and open-label studies, the results of randomized controlled trials have been disappointing so far and do not corroborate the use of MPH as a substitute for cocaine dependence in patients without attention deficit hyperactivity disorder. Conclusion Clinical studies evaluating MPH substitution for cocaine dependence have provided inconsistent findings. However, the negative findings may be explained by specific study characteristics, among them dosing, duration of treatment, or sample size. This needs to be considered when discussing the potential of MPH as replacement therapy for cocaine dependence. Finally, based on the results, we suggest possible directions for future research.
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Affiliation(s)
- Kenneth M Dürsteler
- Center for Addictive Disorders, Psychiatric University Clinics Basel, Basel, Switzerland ; Center for Addictive Disorders, Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Eva-Maria Berger
- Center for Addictive Disorders, Psychiatric University Clinics Basel, Basel, Switzerland
| | - Johannes Strasser
- Center for Addictive Disorders, Psychiatric University Clinics Basel, Basel, Switzerland
| | - Carlo Caflisch
- Center for Addictive Disorders, Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Jochen Mutschler
- Center for Addictive Disorders, Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Marcus Herdener
- Center for Addictive Disorders, Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Marc Vogel
- Center for Addictive Disorders, Psychiatric University Clinics Basel, Basel, Switzerland
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