Friday, 30 October 2015

Cognitive Therapy and ADHD - An Alternative or Adjutant to Drugs ?

From our own adult ADHD group we know that the majority have been prescribed psycho-active drugs, and despite many positive experiences, compliance, side effects and 'toleration' requiring hirer dosing are all reported by those who did not want to continue. No one in our group was directed to pyschological therapeutic regimes, such as cognitive behavioural therapy  (CBT) , relaxation-meditation, hypnosis, music therapy, working memory training, neurofeedback or diet-lifestyle-career councelling.

Low Actual Referral from Physicians to Psychological Therapy

Although some those general practitioners who had referred our participants further to psychological /psychiatric services had mentioned that they believed non drug based regimes would be available, the actual outpatient based handling was limited to gathering the personal history, confirming diagnosis and then going right onto prescribing 'Ritalin'. No alternative was offered and when two of our group had asked senior psychiatrists during such final consultations about alternative non pharma regimes, they were told that nothing was available or that no such route could be funded.

This may not be a surprise because most western physicians now believe that the disease is well managed in both children and adults at the end of one penned line of ink - Rx. There is a magic bullet, They will be cured. Efficacy can be debated in terms of both percent responders and those who do not 're-present' with symptoms. However the patients who are directed down this route may feel that this is an all or nothing because it is culturally accepted that Ritalin and other preparations, "cure" adhd.

Efficacy and the Lost Large Minority of Poorly Managed Patients on Drug Regimes

As the director of the then Glaxo-Smithkline Beecham said " I know that our drugs do not work on up to half of the patients treated, and I want to know which half they do work in" when the science of pharmacogenetics  promised to reveal the genetic markers and biomechanisms which explain 'resistance' , 'tolerance' (re. the specific interpreation of these terms in light of pharmaceuticals) and fast metabolism. Hence patients could be screened for these and hence their low probability for a successful treatment by a particular drug. However so far genetic testing  or biomarker assesment in relation to prescribed pharmaceuticals is limited to 'higher value' and higher risk regimes due to cost constraints and it could be argued an antipathy from Big Pharma who want their drugs prescribed as often as possible and is safe within the patent pending period.

Perhaps our group is quite representative of the adult experience with ADHD Medication in that around 3 in 10 report that drugs did not work, while a further 3 more in each ten (of 20 participants) reported leaving the prescribed regime due to the factors above (side effects, 'tolerance', disturbed compliance, price of medication all played a part for us) . Another 2 participants reported coming off the drugs and having a significant, lasting improvement in concentration and mood.

This last point highlights what we believe should be debated within clinical and social support services. That ADHD is one of those mental diseases which can be 'learned out of'. In the case of the minority who had come off the drug, but felt that they had this lasting benefit, could it be that the drug helped the brain learn new tricks ? Once again, it would not be in the interests of Big Pharma nor general practitioners to have patients leave what is prescribed as chronic and indefinite therapy, and a single piece of paper, single consultation, single referall "cure" from the general practitioners standpoint..

Few Clinical Trials on Alternatives to Medication

There are very few clinical trials of psychological treatments and the author is at this time still trying to consider the value of the results (many are multi-modal and part pharm and not comparitive to the exclusion of pharma)  and to find any reference to trials of CBT on adult adhd, where it may be most appropriate and effective.

Cognitive BehaviouralTherapies (CBT) Engaged by Patients By Accident or Self 'Prescribing'.

Cognitive based therapies have evolved in the post war era as highly effective for those participants who are diligent and receptive. ( Here in lies the compliance issue when compared to simply popping a daily pill when considering clinical trials) They are steadily replacing freudian derived pyschotherapeutic therapies in areas like angst, depression and most of all in stress management, and are seen as an alternative to medication by many psychologists if not so many physicians unfortunetly.

CBT is based on conscious methods and not obtuse routes to making the patient / participant understand the sub conscious nature of many feelings and how these produce often undesirable thought patterns (NAT - negative automatic thought for example). In essence awareness to this phenomena coupled to self 'arrest' of symptoms and situation / emotional analysis techniques are effective in a wide range of 'conditions' such as the above, but also they form the core of Anger Management offered by many services and charities.

It is via this route that several of our group had come into CBT, because their disruptive, impetuous and even violent behaviours lead them to be referred to self accept anger managment courses. The CBT based therapies are aimed at adults due to the quite high level of learning or maturity you might say, which is required in contrast to that which could be expected in children. However CBT is very much a part of many parental -strategy -therapies for ADHD too, and it is likely that an increasing body of work will arise in this area due to the quite widely held opinion that drugging children is always wrong for such ailments.

It would be interested to look at longditudinal studies or comparitive efficacy reviews where CBT was compared to both just ADHD medication and the combination, but the issue of compliance will still be there - how many complete the course which can be many hours over many weeks or months, followed by the accompanying need to really learn and practice the techniques and tools whcih are taught.

For our group we can report that participants had positive experiences with Anger Managment in particular and that CBT was something they were interested in terms of their wider set of symptoms and as an alternative to the drug regime and its inadvertent side effects and long term quiestion mark.

Further Reading

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