Table 3

Principal findings retrieved from six clinically relevant questions

Clinically relevant questionsPrincipal findings (each line reports the findings of individual systematic reviews)
What is the evidence base for the efficacy of pharmacological treatments of ADHD in adults?
  • All pharmacological treatments are more efficacious than placebo14

  • Methylphenidate is more efficacious than placebo15

  • Immediate-release and sustained-release methylphenidate are more efficacious than placebo15 21

  • Methylphenidate is more efficacious than placebo in reducing executive dysfunctions17

  • Dextroamphetamine, amphetamine salts and lisdexamfetamine are more efficacious than placebo18 20

  • Atomoxetine is more efficacious than placebo21–23

  • No difference between atomoxetine and sustained-release methylphenidate was found in efficacy16

  • Only preliminary results on efficacy are available for bupropion,25 buspirone,26 aripiprazole,27 magnesium,28 and reboxetine29

What is the evidence base for the acceptability and tolerability of pharmacological treatments of ADHD in adults?
  • All pharmacological treatments are less accepted and tolerated than placebo14

  • Mean adherence rate for all pharmacological treatments is from 52% to 87%30

  • Higher discontinuation in the longer term in adults than in children31

  • Methylphenidate is equally acceptable but less tolerable than placebo32

  • OROS methylphenidate is less acceptable than placebo16

  • Dexamphetamine and lisdexamfetamine are equally acceptable than placebo18

  • Mixed amphetamine salts are more acceptable than placebo18

  • The tolerability is lower for any amphetamine derivative versus placebo18

  • All psychostimulants can increase heart rate and systolic blood pressure, but have a low rate of significant cardiovascular events,33 probably increase the risk for transient ischaemic attack and sudden death/ventricular arrhythmia,34 decrease appetite and provoke insomnia31 35

  • Atomoxetine is less acceptable than placebo,16 21 but equally acceptable as OROS methylphenidate16

  • Atomoxetine has more sexual and genitourinary side effects than placebo36

  • Atomoxetine does not have an increased risk of suicidality versus placebo37

Is there an evidence-based recommended hierarchy in the choice of medications for ADHD in adults?
  • To date, there are no published meta-analytically based hierarchies on the efficacy and acceptability of all available ADHD drugs in adults

  • Effect sizes on efficacy versus placebo seem higher for amphetamines than for methylphenidate or atomoxetine

What is the evidence base for the efficacy of non-pharmacological treatments of ADHD in adults?
  • To date, current evidence is mixed and inconclusive

  • Preliminary positive results are available for mindfulness,43 dialectical behaviour therapy,44 45 CBT44 46

  • Behavioural interventions can improve driving performances48

What is the evidence base for the efficacy of multimodal treatments of ADHD in adults?
  • To date, there is no evidence from systematic reviews/meta-analyses on the efficacy of multimodal treatment in adults

How should adults with ADHD and co-occurring substance abuse be treated?
  • All ADHD pharmacological treatments are efficacious in treating ADHD symptoms in this clinical population, but not drug abstinence53

  • To date, there is no evidence of serious side effects of all pharmacological treatments if combined with alcohol and drugs of abuse54

  • High rate of misuse of prescription stimulants (17%) in college students with ADHD55 56

  • ADHD, attention deficit/hyperactivity disorder; CBT, cognitive–behavioural therapy; OROS, osmotic-controlled release oral delivery system.