Exploring the Relationship between Adherence to Therapy, Treatment Acceptability, and Clinical Outcomes in Adults with Attention-Deficit/Hyperactivity Disorder: Results from the COMPAS Multicenter Randomized Controlled Trial

Abstract

<b><i>Introduction:</i></b> Cognitive behavioral therapy and dialectical behavior therapy (DBT) can be effective in treating adults with ADHD, and patients generally consider these interventions useful. While adherence, as measured by attendance at sessions, is mostly sufficient, adherence to therapy skills has not been assessed. Furthermore, the relationship between patient evaluation of therapy effectiveness, treatment adherence, and clinical outcomes is understudied. <b><i>Objective:</i></b> This study aimed to examine treatment acceptability and adherence in relation to treatment outcomes in a large randomized controlled trial comparing a DBT-based intervention with a nonspecific active comparison, combined with methylphenidate or placebo. <b><i>Method:</i></b> A total of 433 adult patients with ADHD were randomized. Participants reported how effective they found the therapy, and adherence was measured by attendance at therapy sessions and by self-reports. Descriptive, between-groups, and linear mixed model analyses were conducted. <b><i>Results:</i></b> Participants rated psychotherapy as moderately effective, attended 78.40–94.37% of sessions, and used skills regularly. The best-accepted skills were sports and mindfulness. Groups receiving placebo and/or nonspecific clinical management rated their health condition and the medication effectiveness significantly worse than the psychotherapy and methylphenidate groups. Improvements in clinical outcomes were significantly associated with treatment acceptability. Subjective (self-reported) adherence to psychotherapy was significantly associated with improvements in ADHD symptoms, clinical global efficacy and response to treatment. <b><i>Discussion:</i></b> These results further support the acceptability of DBT for adult ADHD and suggest the need to address adherence to treatment to maximize clinical improvements. Results may be limited by the retrospective assessment of treatment acceptability and adherence using an ad hoc instrument.

Experience of CBT in adults with ADHD: a mixed methods study

“…Research shows that when CBT is adapted specifically for ADHD symptoms, it can provide concrete strategies for managing the core symptoms of inattention, hyperactivity and impulsivity, and the associated personal interpersonal, social and occupational concomitants of the condition ( 55 ). Additionally, adapted DBT group interventions have demonstrated high effectiveness and acceptability, in helping people manage ADHD related symptoms ( 38 – 43 ). Group delivery of therapy is not commonplace within NHSTTAD services for patients with higher levels of distress or complexity, with one to one CBT being the primary treatment option.…”

“…Additionally, there are a number of studies which have shown the efficacy and acceptability of adapted Dialectical Behaviour Therapy (DBT) for ADHD patients ( 38 – 43 ). DBT ( 44 ) is an empirically validated approach for working with distress tolerance and coping behaviours.…”

“…As applied to ADHD treatment, adapted DBT includes acceptance, mindfulness, functional behavioural analysis, psychoeducation and distress tolerance techniques ( 42 , 43 ). Many of the studies of adapted DBT for ADHD, have utilised group level interventions ( 38 – 43 ). The reliance on group interventions is at odds with the dominant model of one-to-one CBT used within NHSTTAD services.…”

Group cognitive behavioural therapy (CBT) for university students with attention-deficit/hyperactivity disorder (ADHD): a feasibility study

“…Studies on CBT have shown that participants who complete the homework assignments show greater improvement than participants who do little or no homework [29][30][31]. An app was developed to facilitate homework compliance, with the assumption that students would rather use an app to complete their homework assignments than to complete them on paper.…”