investigating the efficacy of cognitive behavioral therapy in patients with substance use disorder and comorbid ADHD. A randomized controlled trial with cognitive behavioral therapy.

For references in this text: see reference list in research protocol.
Attention Deficit Hyperactivity Disorder (ADHD) is characterised by symptoms of
inattention, hyperactivity and impulsivity. The prevalence among children and
adolescents is approximately 5% (1). Recently there has been growing awareness
of the fact that ADHD can persist in adulthood. Moreover, it becomes clear that
ADHD is a highly comorbid disorder, with high rates of, for example, substance
use disorder (SUD). Biederman et al (2) found a significantly higher life time
risk for psychoactive substance use disorders in ADHD adults compared with non
ADHD controls (52% versus 27%). According to Wilens and colleagues (3), 17-45%
of adult ADHD patients have histories of alcohol abuse or dependency, and 9-30%
of ADHD patients have histories of drug abuse or dependency. Rasmussen et al
(4) also investigated the presence of alcohol- and drug abuse among untreated
ADHD patients, and found that 37% of the untreated men and 18% of untreated
women had problems of alcohol abuse; moreover, 45% of these men and 29% of
these women reported drug abuse. This combination of ADHD and SUD is a very
invalidating and interfering problem as the prognosis of addiction is
negatively influenced by ADHD. For example, Arias and collegues (5) showed that
patients with ADHD and SUD become addicted at earlier age, use more substances
and are admitted to inpatient clinics more often than addicted patients without
ADHD. ADHD is also associated with increased risk of relapse in substance use
(Carrol and Rounsaville, 6). It is estimated that 20% of the patients with SUD
have ADHD (7). However, diagnosing ADHD in this population is difficult because
of partly overlapping symptoms and because there is no validated instrument for
diagnosing ADHD in this patientgroup. Also, a validated screening instrument
for ADHD in substance-abusing patients is not available yet. To make an
accurate estimation of the prevalence of ADHD in SUD patients, a European
study, EASP, has been designed by ICASA. In this study, a screening instrument
will also be validated. Arkin participates in this European study with the
Jellinek addiction treatment centre. We expect to find a high number of SUD
patients with comorbid ADHD. This will raise new questions, as an adequate
treating program for this patientgroup is not available.
One of the treatment options for patients with ADHD en SUD is medication.
Numerous studies have demonstrated the effectiveness of medication (especially
stimulant medication) for adult patients with ADHD (8). The findings for
patients with ADHD and SUD however, are at best inconsistent (9-15), but
results of randomized trials are, almost without exception, disappointing.
Moreover, medication is contra-indicated in the case of continued or relapsing
substance use. In addiction, relapse is common.
Another treatment option for adults with ADHD is Cognitive Behavioral Therapy
(CBT). Although the experience is limited, there is beginning evidence for the
effect of cognitive behavioural therapy for adult patients with ADHD (16-30).
However, this therapy has not yet been investigated in patients with comorbid
substance use disorders.
The current proposal is designed to contribute to developing adequate treatment
options for patients with ADHD and SUD.

The objective of this study is to investigate the acceptance, feasibility and
efficacy of cognitive behavioral therapy in reducing ADHD symptoms for adult
patients with ADHD and SUD. We will also investigate how substance use and
craving are influenced by ADHD treatment with cognitive behavioral therapy. The
research questions are:
1. Does Cognitive Behavioral Therapy (CBT) reduce self-reported ADHD symptoms
in a population of treatment seeking adult patients with SUD and comorbid ADHD,
compared to Treatment As Usual (TAU)?
2. Does ADHD treatment with CBT lead to reduced substance use or increased
abstinence in adult patients with ADHD and SUD, compared to TAU?

The research questions will be investiged using a randomized controlled trial
design. Patients will be randomized for adding cognitive behavioral therapy to
standard addiction treatment. Allocation to either condition will be performed
in a blinded way, but treatment itself is of course not blinded to patients,
clinicians or investigators.

All patients receive addiction treatment. Moreover, patients are randomzed to 2
conditions: Treatment as Usual, or Treatment as Usual plus Cognitive Behavioral
Therapy (CBT). This CBT consists of 7 individual sessions for adult ADHD
patients, as desigend by Safren et al. Addiction treatment consists of 8
sessions, both in the CBT condition as in the TAU condition. In the TAU
condition, patients receive 1 session psycho-education on ADHD, and 1 session
with a theme of choice. Medication for ADHD is not provided during the trial.
Patients who use a stable dosage of medication for ADHD, and still experience
ADHD symptoms, are allowed to enter the trial and continue their medication.
ADHD symptoms and substance use will be monitored during the trial.

The burden for participants in this research project consists of:
- attending 5 extra one-hour-sessions of cognitive behavioral therapy for ADHD
(for 50% of the participants)
- completing questionnaires at three moments (for all participants).
There are no risks associated with this research project.