A Novel Text Message Intervention to Improve Adherence to Stimulants in Adults With Attention Deficit/Hyperactivity Disorder

Phase-specific strategies and interventions to enhance medication adherence across different phases in ADHD: a systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis assessed the characteristics, types, and impact of interventions to improve adherence to attention-deficit hyperactivity disorder (ADHD) medications within the context of the three phases of adherence, namely, initiation, implementation, and discontinuation.

METHODS

PubMed, Psychological Information Database, Embase, International Pharmaceutical Abstracts, and Google Scholar were systematically searched for relevant trials using appropriate search terms. Interventions were classified as educational, behavioural, affective, and multifaceted. Data was pooled using odds ratios and proportions.

RESULTS

Seventeen studies were included in this review. In a pooled analysis of four RCTs, interventions did not significantly improve medication adherence (OR = 2.32; 95%-Confidence Interval=CI = 0.91-5.90; p = 0.08). In seven non-randomized trials, a pooled proportion of people who adhered to ADHD medication was considerably higher in the intervention group (85%, 95%CI = 78%-91%) than in the control group (47%, 95%CI = 33%-61%). Interventions varied in terms of study design, methods and their impact on different phases of adherence.

CONCLUSIONS

Despite some promising results, the lack of consideration of phase-specific adherence factors may limit the effectiveness and sustainability of interventions to improve adherence in clinical practice. Future interventions should be phase-specific, guided by factors which are pertinent to each phase. Meanwhile, clinicians should choose or tailor interventions based on individual needs and preferences.

In Memoriam: Professor Joseph Biederman's Contributions to Child and Adolescent Psychiatry

OBJECTIVE

To provide an overview of Joe Biederman's contributions to child and adolescent psychiatry.

METHOD

Nine colleagues described his contributions to: psychopharmacology, comorbidity and genetics, pediatric bipolar disorder, autism spectrum disorders, Tourette's and tic disorders, clinical and neuro biomarkers for pediatric mood disorders, executive functioning, and adult ADHD.

RESULTS

Joe Biederman left us with many concrete indicators of his contributions to child and adolescent psychiatry. He set up the world's first pediatric psychopharmacology clinic and clinical research program in child adolescent psychiatry. As a young faculty member he began a research program that led to many awards and eventual promotion to full professor at Harvard Medical School. He was for many years the most highly cited researcher in ADHD. He achieved this while maintaining a full clinical load and was widely respected for his clinical acumen.

CONCLUSION

The world is a better place because Joe Biederman was here.

A Blended Intervention Targeting Emotion Dysregulation in Adults With Attention-Deficit/Hyperactivity Disorder: Development and Feasibility Study

BACKGROUND

Many adults with attention-deficit/hyperactivity disorder (ADHD) experience difficulties related to emotion regulation. Such difficulties are known to substantially impact quality of life and overall functioning. Yet, there is a lack of treatment interventions specifically designed to address these challenges.

OBJECTIVE

This study aimed to describe the development and assess the feasibility, along with the initial clinical outcomes, of a novel blended intervention for adults with ADHD. The blended intervention combines both face-to-face and digital components and is specifically designed to address emotion dysregulation in ADHD.

METHODS

This intervention was an 8-week blended intervention combining weekly face-to-face group sessions with a supplementary digital companion app. The intervention is based on elements from dialectic behavioral therapy skills training and positive psychology. To evaluate its feasibility, we performed a 10-week feasibility study with an uncontrolled pre-post study design, including 16 adults with ADHD and co-occurring emotion dysregulation. The feasibility measures encompassed adherence, satisfaction, and perceived credibility of the intervention. Clinical outcomes were evaluated by self-reported symptoms of emotion dysregulation, inattention, hyperactivity-impulsivity, executive function, depression, anxiety, and a measure of quality of life. Paired sample 2-tailed t tests were used to analyze clinical outcomes with a Bonferroni-corrected significance level.

RESULTS

Both treatment credibility and treatment satisfaction were rated favorably by the majority of the participants. In particular, the participants emphasized meeting others with ADHD as beneficial. In terms of adherence, 3 participants withdrew before initiating the intervention, while another 4 participants did not complete the intervention. On average, the participants who enrolled in the intervention attended 6.2 of the 8 group sessions and completed 6.7 of the 8 skills training modules in the companion app. In terms of clinical outcomes, there was a reduction in symptoms of emotion dysregulation from before to after the intervention (d=2.0). Significant improvements were also observed in measures of inattention (d=1.1) and hyperactivity-impulsivity (d=0.9). However, no significant improvements were found in the domains of depression, anxiety, quality of life, and executive functioning.

CONCLUSIONS

The results are encouraging, both in terms of feasibility and the preliminary clinical results on emotion dysregulation. The blended format, combining digital and face-to-face elements, may also seem to offer some advantages: the group-based format was valued as it facilitated peer interaction, while a rather high completion of modules in the companion app highlights its potential to enhance skills training between the group sessions. Future randomized controlled trials are called for to further evaluate the clinical effectiveness of the intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05644028; https://clinicaltrials.gov/study/NCT05644028.

Transcranial Direct Current Stimulation vs Sham for the Treatment of Inattention in Adults With Attention-Deficit/Hyperactivity Disorder: The TUNED Randomized Clinical Trial

IMPORTANCE

Transcranial direct current stimulation (tDCS) may improve symptoms of inattention in adults with attention-deficit/hyperactivity disorder (ADHD). However, previous trials are characterized by small sample sizes, heterogeneous methodologies, and short treatment periods using clinic-based tDCS.

OBJECTIVE

To determine the efficacy and safety of home-based tDCS in treating inattention symptoms in adult patients with ADHD.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, double-blind, parallel, sham-controlled clinical trial (tDCS for the Treatment of Inattention Symptoms in Adult Patients With ADHD [TUNED]), conducted from July 2019 through July 2021 in a single-center outpatient academic setting. Of 277 potential participants screened by phone, 150 were assessed for eligibility on site, and 64 were included. Participants were adults with ADHD, inattentive or combined subtype. Exclusion criteria included current stimulant drug treatment, current moderate to severe symptoms of depression or anxiety, diagnosis of bipolar disorder with a manic or depressive episode in the last year, diagnosis of schizophrenia or another psychotic disorder, and diagnosis of autism spectrum disorder; 55 of participants completed follow-up after 4 weeks.

INTERVENTIONS

Thirty-minute daily sessions of home-based tDCS for 4 weeks, 2 mA anodal-right and cathodal-left prefrontal stimulation with 35-cm2 carbon electrodes.

MAIN OUTCOMES AND MEASURES

Inattentive scores in the clinician-administered version of the Adult ADHD Self-report Scale version 1.1 (CASRS-I).

RESULTS

Included in this trial were 64 participants with ADHD (31 [48%] inattentive presentation and 33 [52%] combined presentation), with a mean (SD) age of 38.3 (9.6) years. Thirty participants (47%) were women and 34 (53%) were men. Fifty-five finished the trial. At week 4, the mean (SD) inattention score, as measured with CASRS-I, was 18.88 (5.79) in the active tDCS group and 23.63 (3.97) in the sham tDCS group. Linear mixed-effects models revealed a statistically significant treatment by time interaction for CASRS-I (βinteraction = -3.18; 95% CI, -4.60 to -1.75; P < .001), showing decreased symptoms of inattention in the active tDCS group over the 3 assessments compared to the sham tDCS group. Mild adverse events were more frequent in the active tDCS group, particularly skin redness, headache, and scalp burn.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, daily treatment with a home-based tDCS device over 4 weeks improved attention in adult patients with ADHD who were not taking stimulant medication. Home-based tDCS could be a nonpharmacological alternative for patients with ADHD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04003740.

A systematic review of interventions to enhance adherence and persistence with ADHD pharmacotherapy

Although high rates of poor adherence/persistence have been documented in ADHD, there is limited research targeting the problem. This systematic review evaluated interventions to address poor adherence/persistence to ADHD pharmacotherapy, with the aim of guiding the development of future interventions. An extensive search was conducted from January 1980 until January 2021. Thirteen studies were identified involving interventions based on psychoeducation, behavioural therapy, combined psychoeducation/behavioural therapy, technology-based interventions, written informed consent and a nursing support line. All 13 studies (including five RCTs) reported improvement in adherence/persistence and five studies (including four RCTs) also reported improvement in ADHD symptomatology. Almost all studies involved interventions utilising some form of education. Three RCTs of psychoeducation alone were included, with two of the three studies reporting adherence benefits at three and 12 months respectively. The third RCT was terminated early due to poor recruitment. A behavioural intervention RCT reported improved adherence six months post intervention (but not at 12 months), although a substantial drop-out rate was observed. A final included RCT used a Smartphone Application and reported a short term increase in adherence. The authors of the studies in this review make salient attempts at improving adherence and provide insight for future intervention development. We believe future interventions should involve combinations of strategies, have a theoretical framework and target the most common reasons for non-adherence. Interventions should also be integratable into routine care and include patient input to maximise sustainability.

The Effect of SMS Reminders on Adherence in a Self-Guided Internet-Delivered Intervention for Adults With ADHD

Background

Self-guided Internet-delivered interventions may serve as an accessible and flexible non-pharmacological treatment supplement for adults with ADHD. However, these interventions are challenged by low adherence.

Objective

To examine whether weekly SMS reminders improve adherence to a self-guided Internet-delivered intervention for adults with ADHD.

Method

The study used a multiple randomized trial design where the participants who had not completed their weekly module within 2 days were randomized to either receive or not receive an SMS reminder. The primary outcome was adherence, defined as module completion, logins, time spent on intervention, and self-reported practice of coping strategies.

Results

A total of 109 adults with a self-reported ADHD diagnosis were included in the study. The results showed that SMS reminders were associated with an increased likelihood of login within 48 h during the second module of the intervention, but not for the remaining modules. Moreover, receiving an SMS reminder was associated spending more time on the modules and faster login time in module three and five, specifically. However, the overall results did not show an effect of SMS reminders on module completion, number of logins or practice of coping strategies.

Conclusion

The results showed that SMS reminders do not improve number of logins, module completion rates or practice of coping strategies, but they may lead to faster login time and more time spent on the modules. To utilize the potential of self-guided Internet-delivered intervention in making non-pharmacological accessible for adults with ADHD, new methods to facilitate meaningful engagement should be developed and tested.

Trial Registration

ClinicalTrials.gov NCT04511169.

The Association of Oral Stimulant Medication Adherence with Work Productivity among Adults with ADHD

OBJECTIVE

Examine associations between oral psychostimulant pharmacotherapy adherence, work productivity, and related indirect costs among US adults with ADHD.

METHODS

Medication adherence (Medication Adherence Reasons Scale [MAR-Scale]), work productivity and activity impairment (Work Productivity and Activity Impairment-General Health questionnaire), and ADHD symptom level (Adult ADHD Self-Report Scale version 1.1 Symptom Checklist) were assessed in this noninterventional online survey of adults who self-reported having an ADHD diagnosis and were currently receiving oral psychostimulant treatment for ≥3 months.

RESULTS

Of 602 respondents, 395 had low/medium adherence (LMA: MAR-Scale total score ≥1) and 207 had high adherence (HA: MAR-Scale total score 0). After adjusting for covariates, the LMA group had significantly greater levels of absenteeism, absenteeism-related indirect costs, and total indirect costs (all p < .01) than the HA group.

CONCLUSION

In adults with ADHD using oral psychostimulants, lower medication adherence was associated with greater absenteeism and indirect costs.

Trends, Limits, and Challenges of Computer Technologies in Attention Deficit Hyperactivity Disorder Diagnosis and Treatment

Attention deficit hyperactivity disorder (ADHD) is a neurobiological condition that appears during an individual's childhood and may follow her/him for life. The research objective was to understand better how and which computer technologies have been applied to support ADHD diagnosis and treatment. The research used the systematic literature review method: a rigorous, verifiable, and repeatable approach that follows well-defined steps. Six well-known academic data sources have been consulted, including search engines and bibliographic databases, from technology and health care areas. After a rigorous research protocol, 1,239 articles were analyzed. For the diagnosis, the use of machine learning techniques was verified in 61 percent of the articles. Neurofeedback was ranked second with 9.3 percent participation, followed by serious games and eye tracking with 5.6 percent each. For the treatment, neurofeedback was present in 50 percent of the articles, whereas some studies combined both approaches, accounting for 31 percent of the total. Nine percent of the articles reported remote assistance technology, whereas another 9 percent have used virtual reality. By highlighting the leading computer technologies used, their applications, results, and challenges, this literature review breaks ground for further investigations. Moreover, the study highlighted the lack of consensus on ADHD biomarkers. The approaches using machine learning call attention to the probable occurrence of overfitting in several studies, thus demonstrating limitations of this technology on small-sized bases. This research also presented the convergence of evidence from different studies on the persistence of long-term effects of using neurofeedback in treating ADHD.

Individualization of attention-deficit/hyperactivity disorder treatment: pharmacotherapy considerations by age and co-occurring conditions

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that manifests in childhood and can persist into adolescence and adulthood. Impairments associated with ADHD can impact quality of life, social interactions, and increase the risk of morbidity and mortality; however, for many patients, effective treatment can lessen these effects. Pharmacotherapy with stimulants or nonstimulants is recommended in conjunction with psychosocial therapy for most patients. Determining the optimal pharmacotherapy can be complex, and the clinician needs to consider many factors such as the patient's age, comorbidities, and lifestyle. Furthermore, the needs of the patient with ADHD will change over time, with specific challenges to consider at each stage of life. A variety of Food and Drug Administration (FDA)-approved stimulant and nonstimulant formulations are available with different modes of delivery and durations of effect. This armamentarium of ADHD medications can be used to individualize ADHD treatment for each patient's needs. This article combines current information from the literature and the first-hand experience of the authors to provide guidance on ADHD treatment options for patients of different ages and for some of the more common comorbidities.

Updates in technology-based interventions for attention deficit hyperactivity disorder

PURPOSE OF REVIEW

Technological advancement has led to the development of novel treatment approaches for attention deficit hyperactivity disorder (ADHD). This review aims to review recent studies which employ the use of technology to treat ADHD, with particular focus on studies published during a 1-year period from February 2019 to February 2020.

RECENT FINDINGS

Most recent studies involved children aged 12 years and below. Interventions included cognitive training through games, neurofeedback and a combination of several approaches. More novel approaches included trigeminal nerve stimulation and brain-computer interface, and studies had utilized technology such as X-box Kinect and eye tracker. There was a shift towards delivering intervention at home and in school, enabled by technology. The study outcomes were variable and mainly included executive functioning measures and clinical ratings. These interventions were generally safe with few reported adverse events.

SUMMARY

Technology has enabled interventions to be delivered outside of the clinic setting and presented an opportunity for increased access to care and early intervention. Better quality studies are needed to inform on the efficacy of these interventions.

Digital Health Applications for Pharmacogenetic Clinical Trials

Digital health (DH) is the use of digital technologies and data analytics to understand health-related behaviors and enhance personalized clinical care. DH is increasingly being used in clinical trials, and an important field that could potentially benefit from incorporating DH into trial design is pharmacogenetics. Prospective pharmacogenetic trials typically compare a standard care arm to a pharmacogenetic-guided therapeutic arm. These trials often require large sample sizes, are challenging to recruit into, lack patient diversity, and can have complicated workflows to deliver therapeutic interventions to both investigators and patients. Importantly, the use of DH technologies could mitigate these challenges and improve pharmacogenetic trial design and operation. Some DH use cases include (1) automatic electronic health record-based patient screening and recruitment; (2) interactive websites for participant engagement; (3) home- and tele-health visits for patient convenience (e.g., samples for lab tests, physical exams, medication administration); (4) healthcare apps to collect patient-reported outcomes, adverse events and concomitant medications, and to deliver therapeutic information to patients; and (5) wearable devices to collect vital signs, electrocardiograms, sleep quality, and other discrete clinical variables. Given that pharmacogenetic trials are inherently challenging to conduct, future pharmacogenetic utility studies should consider implementing DH technologies and trial methodologies into their design and operation.

A novel digital health intervention to improve patient engagement to stimulants in adult ADHD in the primary care setting: Preliminary findings from an open label study

AIMS

We piloted the effectiveness and acceptability of a novel text messaging-based (SMS) digital health intervention aimed at addressing the previously documented poor rate of patient engagement in stimulant treatment in the primary care setting.

METHODS

117 adults ages 18-55 from primary care and psychiatric practices who were prescribed a stimulant medication for ADHD treatment received the SMS intervention. Comparators were age-, race-, and sex-matched patients from the same health care organization's electronic medical record who had been prescribed stimulant medications over a similar time period. Using documented prescription records, we determined whether patients had timely prescription refills.

RESULTS

Ninety-six percent (N = 112) of participants completed our a priori metric of patient engagement consisting of 37 days of the SMS program. Eighty-one percent of participants refilled their index prescriptions in a timely manner compared to only 36% of patients receiving treatment as usual (OR=7.54, 95% CI: 4.46, 12.77; p<0.001). We found no significant interaction between prescribing source (non-psychiatry vs. psychiatry) and intervention group (SMS vs. treatment as usual).

CONCLUSIONS

These data suggest that an ADHD-centric, digital health intervention using text messaging significantly improves patient engagement in stimulant treatment in adults with ADHD.

An innovative SMS intervention to improve adherence to stimulants in children with ADHD: Preliminary findings

BACKGROUND

Although large datasets document that stimulants decrease the risk for many adverse ADHD-associated outcomes, compliance with stimulants remains poor.

AIMS

This study examined the effectiveness of a novel ADHD-centric text messaging-based intervention aimed to improve adherence to stimulant medications in children with ADHD.

METHODS

Subjects were 87 children aged 6-12, who were prescribed a stimulant medication for ADHD treatment. Prescribers gave permission to contact their patients for participation in the study. Subjects were primarily from the primary care setting with a subsample of psychiatrically referred subjects for comparison. Age- and sex-matched comparators were identified (3:1) from the same pool of prescriber-approved subjects that did not participate. Timely prescription refills (within 37 days) were determined from prescription dates documented in patients' electronic medical record.

RESULTS

Eighty-five percent of SMS intervention patients refilled their prescriptions in a timely manner compared with 62% of patients receiving treatment as usual (OR = 3.46, 95% CI: 1.82, 6.58; p < 0.001). The number needed to treat statistic was computed as five, meaning for every five patients who receive the SMS intervention, we can keep one adherent to their stimulant treatment.

CONCLUSIONS

These preliminary findings support the potential utility of a readily accessible technology to improve the poor rate of adherence to stimulant treatment in children with ADHD. To the best of our knowledge, this study is the first digital health intervention aimed at improving adherence to stimulant medication for children with ADHD. These results support the need for further examination of this technology through more definitive randomized clinical trials.