Cognitive Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach by J. Russell Ramsay

Author:J. Russell Ramsay
Language: eng
Format: mobi
ISBN: 9780415955003
Publisher: Routledge
Published: 2007-07-24T21:00:00+00:00

Research Evidence for CBT and Medications for ADHD

101

appetite suppression, gastrointestiral

nsomnia, nervousness,

and slight increases in heart rate and blood pressure. Less common but

critically important adverse events include irritability, mood instability,

dysphoria, tics (involuntary movements), and potentially harmful cardio-

vascular effects such as hypertension or cardiac arrhythmias. The onset

of these symptoms may warrant discontinuation of the medication.

Nonstimulant Medications

Atomoxetine is a norepinephrine reuptake inhibitor that is FDA approved

for ADHD in adults (see Michelson, Adler, & Spencer, 2003; Reimherr

et al., 2005; Simpson & Plosker, 2004). By reducing the presynaptic

reuptake of norepinephrine from the synapse, both NE and DA neuro-

transmission in the prefrontal cortex is increased, leading to the positive

effects reported on attention span and impulse control. Atomoxetine has

a long duration of action (longer than 12 hours) but works with gradual

onset (4 to 6 weeks), so that positive effects emerge over a longer time

period than with stimulants. The response rate to atomoxetine is 60%

and the effect size of 0.4 is considered moderate.

Atomoxetine is most helpful for patients who do not tolerate stimu-

lants, who are highly anxious, and/or who express a preference for a

medication that works “around the clock.” The most common side effects

from atomoxetine are nausea, GI upset, headache, sedation, fatigue,

reduced sexual drive, and difficulty with urination. Mild increases in

heart rate and blood pressure have also been reported, but rarely are

these significant enough to require discontinuation.

Bupropion, a dopamine reuptake inhibitor with slight norepineph-

rine reuptake activity, is a widely used antidepressant that has been

shown to have beneficial effects on ADHD symptoms in adult patients.

Its efficacy in smoking cessation provides an added value for ADHD

adults who are dependent on nicotine. While it is not FDA approved for

ADHD, two controlled studies by Wilens et al. (2005) and Wilens, Spen-

cer, and Biederman (2001) found response rates of slightly over 50%

and a treatment effect size of 0.6 (significant). Common side effects of

bupropion include headache, dry mouth, insomnia, nausea, dizziness,

irritability and constipation. Seizures can occur in 0.4% of patients on

the short-acting form of the medication but lower rates occur with the

extended-release preparations.

Tricyclic antidepressants, especially desipramine and nortripty-

line, have been shown to be highly effective for adults with ADHD (see

Wilens et al., 1995; Wilens et al., 1996) with response rates reported

in the range of 65 to 68%. These medications work by inhibiting the

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Cognitive Behavioral Therapy for Adult ADHD

reuptake of NE, DA, and serotonin to varying degrees, which results

in improved attention span and impulse control over periods of 2 to 6

weeks. A major drawback of the tricyclics is their side effects profile.

Of greatest concern is the potential for cardiac arrhythmias, necessitat-

ing cl

Other problems include

somnolence, constipation, urinary retention, dry mouth, and headache.

Moreover, they are not FDA approved for the treatment of ADHD.

Modafanil, a wakefulness agent approved for treatment of narco-

lepsy, was reported to be effective for ADHD in adults in two studies

(Taylor & Ru

however, a more recent

double-blind, placebo-controlled study of 113 adults found that it had

no advantage over placebo for ADHD symptoms (Cephalon Inc., 2006).

While modafanil is well tolerated and has fewer side effects compared to

stimulant medications, its usefulness as monotherapy for ADHD is still

questionable.

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