Combining Stimulant With CBT May Reduce TBI-Related Cognitive Problems
Abstract
The positive outcomes seen in patients in the Memory and Attention Adaptation Training and methylphenidate groups may be due to the therapies’ acting on multiple domains of cognitive function—executive function and attention, respectively.
Cognitive difficulties immediately following a traumatic brain injury (TBI) are common, but for some people, these problems persist for months or even years after the injury.
To reduce these symptoms, clinicians often recommend that patients take stimulants and/or undergo cognitive rehabilitation, which can include brain-training exercises or teaching skills to compensate for deficits. However, few studies have examined whether a combination of medication and rehabilitation is more effective than either approach alone. A study published in Neuropsychopharmacology in November found that patients who received a combination of stimulants and a skills-focused cognitive-behavioral therapy (CBT) experienced greater cognitive improvements than patients who received only the cognitive training.
Adults with a history of TBI followed by at least four months of cognitive deficits were randomly assigned to Memory and Attention Adaptation Training (MAAT)—which aims to enhance skills for self-managing cognitive difficulties in daily life—or Attention Builders Training (ABT)—a repetitive practice intervention with no active cognitive-behavioral component. All participants were also assigned to either twice daily methylphenidate (MPH, up to 60 mg daily) or placebo.
As a skills-based approach, Memory and Attention Adaptation Training might be more generalizable to real-world situations encountered by people with cognitive deficits, says study co-author Thomas McAllister, M.D.
“MAAT is designed as skills-based approach, which can generalize to a person’s life,” study co-author Thomas McAllister, M.D., the Albert E. Sterne Professor and chair of psychiatry at the Indiana University School of Medicine, told Psychiatric News. Unlike the repetitive drilling of cognitive tasks demonstrated in brain-training programs, MAAT combines CBT techniques such as being more self-aware of potential problems with compensatory strategies to manage daily skills. The program uses a standardized manual and was designed as a one-month intervention.
For the study, a total of 76 adults with a history of cognitive problems following a TBI were administered a battery of neuropsychological tests at the start and end of the study. These tests measured memory, executive function, and processing speed—three cognitive areas in which patients with TBI tend to experience the greatest challenges.
The researchers found that MAAT/MPH was superior to ABT/MPH in the Paced Auditory Serial Addition Test Trial 3, which measures divided attention and working memory. MAAT/MPH was also superior to both ABT/MPH and MAAT/placebo on the Brown Location Test, which measures episodic memory. Interestingly, the MAAT/placebo group outperformed both ABT groups in another episodic memory test, the California Verbal Learning Test-II. There were no significant differences in any other tests.
Brenna McDonald, Psy.D., M.B.A., believes that methylphenidate can synergize with MAAT since it augments attention, which is a key component of higher order executive function.
Brenna McDonald, Psy.D., M.B.A., an associate professor of radiology and neurology at Indiana University School of Medicine and a study co-author, said she believes that the small study size (each of the four groups had 17 to 19 people) may have limited the ability to detect other differences between the cognitive performance of participants in the different groups. She noted that the MAAT/MPH group did appear to perform better in some other tests, but these improvements did not reach a statistical difference.
Robert Schloesser, M.D., executive director of the Sheppard Pratt-Lieber Research Institute Inc. in Baltimore, noted that the small size of the trial reflects the ongoing challenge that researchers face when attempting to recruit patients for TBI intervention trials. According to Schloesser, who was not directly involved with the study, researchers spent close to six years recruiting participants for this study.
“It is difficult to recruit study participants from the TBI population due to a lack of specialized treatment centers, especially in more rural areas,” he said.
Despite these limitations, Schloesser said he found the results of the trial to be encouraging. “Combining modalities is an idea that has been around psychiatry for a while, but it doesn’t always produce better results.”
McDonald said that the success of the MAAT and MPH combination may be due to the fact the therapies act on multiple domains of cognitive function—executive function and attention, respectively. Using MPH to boost attention may help augment the benefits of MAAT but also improve other areas of thinking, she explained.
While additional studies are needed, McDonald said that she thinks the MAAT/MPH combination is a strategy worth pursuing with TBI patients who experience long-term cognitive challenges.
“From a practical perspective, TBI patients don’t typically receive a thorough neuropsychological evaluation, so a clinician may not know exactly which cognitive domains are affected,” she said. Since MAAT and MPH together can potentially improve a wider range of cognitive deficits, using both may improve the chance of success, she continued.
McDonald noted that the study also suggests the benefits of combining MAAT with stimulants for patients who might go untreated for some time.
“While it’s always better to seek help as soon as possible, it is encouraging that we can make improvements even in chronic cases,” she said.
This study was funded by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. ■
