Patients with traumatic brain injury (TBI) showed improvement in attention, memory, and executive functioning when treated with a combination of metacognitive rehabilitation and pharmaceuticals, according to a new study. Metacognitive approaches emphasize improving behaviors involved in higher-order thinking.

Treatments for TBI typically consist of either cognitive rehabilitation or pharmaceuticals. But the results of a new study, published in the journal Neuropsychopharmacology, suggest that combined treatment, using a form of cognitive rehabilitation called Memory and Attention Adaptation Training (MAAT) and the drug methylphenidate (a stimulant, sold under the brand names Ritalin and Concerta, among others) is more effective than either therapy or medication alone.

Adults with persistent cognitive problems stemming from TBI were treated in this research. The team, led by Thomas W. McAllister, M.D., of Indiana University School of Medicine, included first author Brenna C. McDonald, Psy.D., of Indiana University School of Medicine, Laura Flashman, Ph.D., 1996 Young Investigator grantee at the Geisel School of Medicine at Dartmouth College, and 1999 Independent Investigator grantee Andrew Saykin, Psy.D., at the Indiana University School of Medicine.

Each patient in the study received one of two forms of cognitive rehabilitation, either MAAT or Attention Builders Training (ABT). Some participants in each group received methylphenidate in addition to the cognitive rehabilitation, while others in each group received a placebo.

Methylphenidate acts by affecting two systems in the brain, one which uses the neurotransmitter dopamine as a signal, and another which uses the neurotransmitters adrenaline and norepinephrine as signals. Evidence from previous research suggests that methylphenidate improves performance on a variety of cognitive tests, including those for attention, memory, and verbal fluency.

A key difference between MAAT and ABT—the two forms of cognitive rehabilitation tested—is that MAAT takes a metacognitive approach. Noting dopamine’s role in multiple aspects of cognition, the researchers suggest that methylphenidate’s effects on the dopamine system may explain the relatively greater improvements of patients receiving both MAAT and methylphenidate. In other words, MAAT and methylphenidate may work synergistically on aspects of the brain’s dopamine system.

The researchers see this combined treatment strategy as “promising,” as the areas in which patients showed improvement are among the most common problems seen after TBI. They call for future studies to further explore how cognitive rehabilitation and pharmaceuticals may work together to improve persistent cognitive problems after TBI.