The most telling findings from this study are that for adults diagnosed with ADHD, the medications usually used (stimulants and atomoxetine):

• have somewhere between very low to moderate impact on symptoms in the short term
• have no positive impact on outcomes at one year follow up
• are not shown to improve quality of life, a more important measure than symptomatic improvement.

The authors rightly point out the quality of evidence is poor, there are harms from medication, and more research is needed about meaningful benefits beyond symptomatic improvement of questionable significance.

The study reinforces the need for clinicians to go beyond oversimplified symptomatic diagnosis to seek understanding of why each individual is experiencing some combination of inattentiveness, overactivity and impulsivity, since merely diagnosing and treating ADHD will have dubious benefit.

The study by Ostinelli and colleagues reviewed randomised controlled trials on treatments for adult ADHD (≥18 years). While stimulants are the only intervention consistently reducing self-reported and clinician-reported ADHD symptoms in the short term, they fail to improve broader outcomes like quality of life. Adults with ADHD face challenges that extend beyond core symptoms, highlighting the need for treatments and trials that address functional and emotional well-being.

Non-stimulant options, such as atomoxetine, showed some symptom reduction but were less tolerable due to side effects and slower onset of efficacy. Non-pharmacological treatments demonstrated inconsistent effects, likely due to variability in intervention types, frequency, and duration, as well as limited high-quality trials. Notably, of the included trials only 38 examined non-pharmacological approaches vs 113 of pharmacological treatments.

Ultimately a tailored multimodal treatment approach that considers functional and emotional well-being as well as core symptom reduction should be adopted (an approach supported by the Australian ADHD Guideline). Finally the study also highlights a significant gap in evidence for the long-term effects of ADHD treatments. Given that ADHD is a lifelong condition for many individuals, it is essential that sustained, effective interventions are available to adults with ADHD. As such research needs to move beyond short-term symptom control and focus on long-term outcomes that truly improve daily life for those with ADHD.

ADHD is a very prevalent psychiatric disorder in adults, affecting about 2.5-6% of adults. It is frequently undiagnosed and untreated. Less is known about adult ADHD than childhood ADHD, and whether both conditions respond to treatment with the same types of treatment. This massive work surveys all clinical trial evidence to conclude that psychostimulants (methylphenidate- and dexamfetamine-based drugs) stand out as the only clear winner in treating Adult ADHD, although their use comes at the price of side effects.

This study could not endorse an improvement in the quality of life associated with treatment with these drugs. The meaning of this, and whether this is a technical issue in patient self-reports, could explain that puzzling finding. The non-stimulant drugs for Adult ADHD were unimpressive - guanfacine was not effective for treating core symptoms and atomoxetine caused more side effects than placebo, although it did help the core symptoms.

Non-drug interventions (e.g. psychological treatments, neurostimulation) were also unimpressive in helping the core symptoms and emotional dysregulation of ADHD. But it is important to note that, in clinical practice, we treat more than the core symptoms - ADHD is complicated by several psychiatric disorders such as anxiety and depression. It makes sense that these complications would not respond to psychostimulants as robustly. These findings reinforce the importance of treatment with psychostimulants for ADHD, with impact within 12 weeks. It does not rule out non-pharmacological interventions as being of value to the complications of this prevalent disorder.

This study systematically reviewed and meta-analysed over a hundred clinical trials of attention-deficit/hyperactivity disorder (ADHD) treatments, which collectively involved almost 15,000 adult participants (all over the age of 18 years; studies in children were excluded). The study identifies specific treatments for ADHD which were effective in reducing core symptoms of this complex and heterogeneous brain disorder.

Some treatments were found to be effective (in the combined ‘network meta-analysis’) on both clinician-reported and self-reported measures, whereas others were only effective on self-reported measures. However, even those treatments that were effective for core symptoms did not show significant benefits in ‘quality of life’ measures.

As David Coghill noted in his associated Lancet Psychiatry commentary article, it is extremely challenging for clinicians to know ‘how best to balance the merits of pharmacological and non-pharmacological approaches’ and that different types of clinical trials differ in ways that make them very difficult to compare directly (in such a meta-analysis).

So the key message for mental health clinicians and researchers is that some existing treatments are effective, but we could do much better in making them more effective, with fewer side effects. The ideal we are striving for in ongoing research is ‘precision psychiatry’ (as part of ‘precision medicine’) where treatment is tailored to the individual based not only on their symptoms but also biological ‘markers’. This requires much more research to understand the causes of ADHD and identify new approaches for novel therapies.