Long-term Effects of Multimodal Treatment on Adult Attention-Deficit/Hyperactivity Disorder Symptoms
Authors: Alexandra P. Lam, Swantje Matthies, Erika Graf, Michael Colla, Christian Jacob, Esther Sobanski, Barbara Alm, Michael Rösler, Wolfgang Retz, Petra Retz-Junginger, Bernhard Kis, Mona Abdel-Hamid, Helge H. O. Müller, Caroline Lücke, Michael Huss, Thomas Jans, Mathias Berger, Ludger Tebartz van Elst, Alexandra Philipsen
Journal: JAMA Network Open (2019)

<h3>Importance</h3> Knowledge about the long-term effects of multimodal treatment in adult attention-deficit/hyperactivity disorder (ADHD) is much needed. <h3>Objective</h3> To evaluate the long-term efficacy of multimodal treatment for adult ADHD. <h3>Design, Setting, and Participants</h3> This observer-masked, 1.5-year follow-up of the Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study (COMPAS), a prospective, multicenter randomized clinical trial, compared cognitive behavioral group psychotherapy (GPT) with individual clinical management (CM) and methylphenidate (MPH) with placebo (2 × 2 factorial design). Recruitment started January 2007 and ended August 2010, and treatments were finalized in August 2011 with follow-up through March 2013. Overall, 433 adults with ADHD participated in the trial, and 256 (59.1%) participated in the follow-up assessment. Analysis began in November 2013 and was completed in February 2018. <h3>Interventions</h3> After 1-year treatment with GPT or CM and MPH or placebo, no further treatment restrictions were imposed. <h3>Main Outcomes and Measures</h3> The primary outcome was change in the observer-masked ADHD Index of Conners Adult ADHD Rating Scale score from baseline to follow-up. Secondary outcomes included further ADHD rating scale scores, observer-masked ratings of the Clinical Global Impression scale, and self-ratings of depression on the Beck Depression Inventory. <h3>Results</h3> At follow-up, 256 of 433 randomized patients (baseline measured in 419 individuals) participated. Of the 256 patients participating in follow-up, the observer-masked ADHD Index of Conners Adult ADHD Rating Scale score was assessed for 251; the mean (SD) baseline age was 36.3 (10.1) years; 125 patients (49.8%) were men; and the sample was well-balanced with respect to prior randomization (GPT and MPH: 64 of 107; GPT and placebo: 67 of 109; CM and MPH: 70 of 110; and CM and placebo: 55 of 107). At baseline, the all-group mean ADHD Index of Conners Adult ADHD Rating Scale score was 20.6, which improved to adjusted means of 14.2 for the GPT arm and 14.7 for the CM arm at follow-up with no significant difference between groups (difference, −0.5; 95% CI, −1.9 to 0.9;<i>P</i> = .48). The adjusted mean decreased to 13.8 for the MPH arm and 15.2 for the placebo arm (difference, −1.4; 95% CI, −2.8 to −0.1;<i>P</i> = .04). As in the core study, MPH was associated with a larger reduction in symptoms than placebo at follow-up. These results remained unchanged when accounting for MPH intake at follow-up. Compared with participants in the CM arm, patients who participated in group psychotherapy were associated with less severe symptoms as measured by the self-reported ADHD Symptoms Total Score according to the<i>Diagnostic and Statistical Manual of Mental Disorders</i>(Fourth Edition) (<i>DSM</i>-<i>IV</i>) of Conners Adult ADHD Rating Scale (AMD, −2.1; 95% CI, −4.2 to −0.1;<i>P</i> = .04) and in the subscale of reducing pure hyperactive symptoms, measured via the Diagnostic Checklist for the diagnosis of ADHD in adults (AMD, −1.3; 95% CI, −2.8 to 0.1;<i>P</i> = .08). Regarding the Clinical Global Impression scale assessment of effectiveness, the difference between GPT and CM remained significant at follow-up (odds ratio, 1.63; 95% CI, 1.03-2.59;<i>P</i> = .04). No differences were found for any comparison concerning depression as measured with the Beck Depression Inventory. <h3>Conclusions and Relevance</h3> Results from COMPAS demonstrate a maintained improvement in ADHD symptoms for adults 1.5 years after the end of a 52-week controlled multimodal treatment period. The results indicate that MPH treatment combined with GPT or CM provides a benefit lasting 1.5 years. Confirming the results of the core study, GPT was not associated with better results regarding the primary outcome compared with CM. <h3>Trial Registration</h3> isrctn.org Identifier:ISRCTN54096201