Evidence surrounding use of pharmacological and non-pharmacological interventions in adults with ADHD is growing and clinicians need a reliable summary of all the best available information in order to better inform their daily practice. In order to assist with addressing clinically relevant questions, a meta-review focusing on recent meta-analyses and systematic reviews of the pharmacological and non‑pharmacological treatment of adults with ADHD was conducted.
MEDLINE, PubMed, PsycINFO and the Cochrane databases were searched using appropriate terms* for articles relating to treatment of adults (≥18 years of age) with ADHD published between 01 January 2010 and 31 May 2016. An initial review of the full article, followed by an independent review of a 20% randomised sample, provided publications eligible for review. Guidelines/recommendations of the past 10 years for adult ADHD were also searched.
Of the 635 publications initially sequestered, 40 publications were identified as eligible for review after being deemed pertinent or able to address one of six clinically relevant questions.† The results of this meta-review highlighted the following:
- Overall, compared with placebo, pharmacotherapeutic agents demonstrate efficacy in reducing symptoms in adults with ADHD (standardised mean difference 0.45, 95% confidence interval [CI] 0.37–0.52); however, they are shown to be less well tolerated (odds ratio [OR] 2.29, 95% CI 1.97–2.66) and accepted (OR 1.18, 95% CI 1.02–1.36) within adults with ADHD.
- To date, there are no published evidence-based treatment hierarchies; however, methylphenidate has the most solid evidence base and should be considered as the preferred first-line choice for pharmacological intervention by the National Institute for Health and Care Excellence (NICE). Other psychostimulants‡ and atomoxetine should be considered second choice.
- NICE guidelines recommend using pharmacological treatment as first-line choice, but that psychological treatment should be considered if it is preferred by the patient. However, evidence linking efficacy of non-pharmacological treatments and reduced symptoms in adults with ADHD is inconclusive and varied. Furthermore, studies concluding positive benefits through psychological intervention are not based on randomised evidence, which confers a limitation to the results.
- To date, there is no published evidence from systematic reviews on efficacy of multimodal treatment in adults, and there is limited evidence on the management of ADHD with comorbid substance abuse.
Overall, this study has shown that ADHD is not just a childhood disorder, and that pharmacological treatments were significantly more efficacious compared with placebo, albeit less well accepted and tolerated. While current studies support the efficacy and overall tolerability of pharmacological treatment of ADHD symptoms in the short term, additional studies are required to investigate their long-term effects, build a treatment hierarchy and advance our understanding of the advantages of combining pharmacological and non‑pharmacological treatments.
*PubMed syntax: (adhd OR ADHD OR attention-deficit/hyperactivity OR attention deficit) AND (meta-analy* OR metaanaly* OR systematic review*). Syntax was adapted as per electronic database
†These questions encompassed the evidence base for the following: efficacy, acceptability and tolerability of pharmacological treatments; recommended medication hierarchy; efficacy of non‑pharmacological treatments; efficacy of multimodal treatments; treatment of adults with ADHD and comorbid substance abuse
‡A Cochrane review found that, compared with placebo, the severity of ADHD symptoms could be significantly improved using any amfetamine derivative (standardised mean difference [SMD] -0.73, 95% CI -0.96 to -0.51), dextroamfetamine (SMD -0.6, 95% CI -1.0 to -0.2), mixed amfetamine salts (SMD -0.73, 95% CI -0.96 to -0.51) and lisdexamfetamine (SMD -0.8, 95% CI -1.07 to -0.53)
De Crescenzo F, Cortese S, Adamo N, et al. Pharmacological and non-pharmacological treatment of adults with ADHD: a meta-review. Evid Based Ment Health 2017; 20: 4-11.