Authors' objectives

To determine whether antidepressants are as effective as stimulants in the treatment of adults with attention-deficit hyperactivity disorder (ADHD).

Searching

MEDLINE was searched for English language articles (years and search terms not listed). Reference lists of other pertinent studies were scanned.

Study selection

Assessment of study quality

The author does not state that they assessed validity.

Data extraction

The author does not state how many of the reviewers extracted the data or how any disagreements were resolved. Data were extracted on blinding, whether the trial was a crossover trial, number of participants, medication given in the active group and number of responders.

Methods of synthesis

Results of the review

Nine studies on stimulant medication (n=280) and eleven studies on antidepressant medication (n=216).

Stimulants: The range of positive responders was 25% to 100% and results in the placebo-controlled studies were inconclusive. Childhood history of ADHD was associated with response in one study but not in another.

Antidepressants: The range of positive responders was 0% to 75%. Desipramine, bupropion, venlafaxine and tomoxetine appeared to be equally effective and fluoxetine and sertraline produced no response. The results of the indirect comparison from two trials showed that groups treated with 1.0mg/kg/day MPH and 200mg/day desipramine had similar responses as measured by the ADHD scale.

Authors' conclusions

Antidepressants and stimulants seem to be equally effective for adults with attention-deficit hyperactivity disorder (ADHD). Recent controlled studies suggest that desipramine (an antidepressant) may be as effective as methylphenidate (a stimulant) for improving symptoms of adult ADHD. Although few good controlled studies exist, the available research suggests that certain antidepressants and stimulants are equally effective for adults with ADHD. Antidepressants may offer a safe first-line treatment for adults with ADHD.

CRD commentary

There are many details missing from this review. The research question is clear but the literature search is poor - searching only one electronic database is likely to lead to publications being missed, as is restricting the search to English language articles. No effort was made to search for unpublished material and the literature search was poorly reported. Few details are given of inclusion criteria and there is no attempt to assess study validity, although more weight is given in the narrative to the results of placebo-controlled trials. It is unclear from the data presented which studies were placebo-controlled and which studies were uncontrolled, or how 'response' was measured, so the results are difficult to interpret. An indirect comparison is presented however there is no discussion of whether participant characteristics and population event rates were similar in the two trials compared and the results are therefore difficult to interpret.

The author's conclusions should be treated with caution given the above methodological limitations.

Implications of the review for practice and research

Practice: The author suggests that physicians treat patients with antidepressants rather than stimulants due to safety concerns. The author states that a good approach is to start with an agent from one class, either noradrenergic agents (desipramine, venlafaxine and tomoxetine) or dopaminergic agents (bupropion) and switch to an agent from another class if the patient fails to respond or has intolerable side effects. It is important to use an adequate dose of an antidepressant (a dose similar to that used to treat depression) before switching to another agent.

Research: The author states that future research should focus on treatment options for adults who have some symptoms of ADHD but fail to meet the full criteria. In particular, would antidepressants help problems with concentration and attention in patients who have a subthreshold ADHD? Future research needs to be conducted in primary care settings.

Bibliographic details

Higgins E S. A comparative analysis of antidepressants and stimulants for the treatment of adults with attention-deficit hyperactivity disorder. Journal of Family Practice 1999; 48(1): 15-20. [PubMed: 9934377]

Indexing Status

Subject indexing assigned by NLM

MeSH

Adult; Antidepressive Agents, Tricyclic /therapeutic use; Attention Deficit Disorder with Hyperactivity /drug therapy; Central Nervous System Stimulants /therapeutic use; Clinical Trials as Topic; Desipramine /therapeutic use; Evidence-Based Medicine; Humans; Methylphenidate /therapeutic use

AccessionNumber

11999000302

Database entry date

30/09/2000

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.