Comparative efficacy and acceptability of methylphenidate and atomoxetine in treatment of attention deficit hyperactivity disorder in children and adolescents: A meta-analysis

BMC Psychiatry, 11/15/2011

Hanwella R et al. – In general atomoxetine and methylphenidate have comparable efficacy and equal acceptability in treatment of ADHD in children and adolescents. OROS methylphenidate is more effective than atomoxetine and may be considered as first line treatment in treatment of ADHD in children and adolescents.


  • All published, randomized, open label or double blind trials, comparing efficacy of methylphenidate with atomoxetine, in treatment of ADHD in children, diagnosed using DSM-IVTM criteria were included
  • Outcome studied was ADHDRS-IVParent:Inv score
  • Standardized mean difference (SMD) was used as measure of effect size


  • 9 randomized trials comparing methylphenidate and atomoxetine, with a total of 2762 participants were included
  • Meta-analysis did not find significant difference in efficacy between methylphenidate and atomoxetine (SMD= 0.09, 95% CI -0.08-0.26) (Z=1.06, p=0.29)
  • Synthesis of data from eight trials found no significant difference in response rates (RR=0.93 95% CI 0.76-1.14, p=0.49)
  • Sub group analysis showed a significant standardized mean difference favouring OROS methylphenidate (SMD=0.32, 95% CI 0.12-0.53 (Z=3.05, p<0.002)
  • Immediate release methylphenidate was not superior to atomoxetine (SMD= -0.04, 95% CI -0.19-0.12) (Z=0.46, p=0.64)
  • Excluding open label trials did not significantly alter the effect size (SMD=0.08, 95% CI -0.04-0.21) (Z=1.27, p=0.20)
  • All-cause discontinuation was used as a measure of acceptability
  • No significant difference in all cause discontinuation between atomoxetine and methylphenidate (RR 1.22, 95% CI 0.87-1.71)
  • There was significant heterogeneity among the studies (p=0.002, I2=67%)
  • Subgroup analysis demonstrated heterogeneity to be due to open label trials (p=0.001, I2=81%)

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