Treating Hoarding Disorder in a real-world setting: Results from the Mental Health Association of San Francisco

Hoarding Disorder (HD) is associated with substantial distress, impairment, and individual and societal costs. Cognitive-behavioral therapy (CBT) tailored to HD is the best-studied form of treatment and can be led by mental health professionals or by non-professionals (peers) with specific training. No previous study has directly compared outcomes for therapist-led and peer-led groups, and none have examined the effectiveness of these groups in a real-world setting. We used retrospective data to compare psychologist-led CBT groups (G-CBT) to groups led by peer facilitators using the Buried in Treasures workbooks (G-BiT) in individuals who sought treatment for HD from the Mental Health Association of San Francisco. The primary outcome was change in Hoarding Severity Scale scores. Approximate costs per participant were also examined. Both G-CBT and G-BiT showed improvement consistent with previous reports (22% improvement overall). After controlling for baseline group characteristics, there were no significant differences in outcomes between G-CBT and G-BiT. For G-CBT, where additional outcome data were available, functional impairment and severity of hoarding symptoms improved to a similar degree as compared to previous G-CBT studies, while hoarding-related cognition improved to a lesser degree (also consistent with previous studies). G-BiT cost approximately $100 less per participant than did G-CBT.

PATTERNS OF CLINICALLY SIGNIFICANT COGNITIVE IMPAIRMENT IN HOARDING DISORDER

OBJECTIVES

The cognitive characteristics of individuals with hoarding disorder (HD) are not well understood. Existing studies are relatively few and somewhat inconsistent but suggest that individuals with HD may have specific dysfunction in the cognitive domains of categorization, speed of information processing, and decision making. However, there have been no studies evaluating the degree to which cognitive dysfunction in these domains reflects clinically significant cognitive impairment (CI).

METHODS

Participants included 78 individuals who met DSM-V criteria for HD and 70 age- and education-matched controls. Cognitive performance on measures of memory, attention, information processing speed, abstract reasoning, visuospatial processing, decision making, and categorization ability was evaluated for each participant. Rates of clinical impairment for each measure were compared, as were age- and education-corrected raw scores for each cognitive test.

RESULTS

HD participants showed greater incidence of CI on measures of visual memory, visual detection, and visual categorization relative to controls. Raw-score comparisons between groups showed similar results with HD participants showing lower raw-score performance on each of these measures. In addition, in raw-score comparisons HD participants also demonstrated relative strengths compared to control participants on measures of verbal and visual abstract reasoning.

CONCLUSIONS

These results suggest that HD is associated with a pattern of clinically significant CI in some visually mediated neurocognitive processes including visual memory, visual detection, and visual categorization. Additionally, these results suggest HD individuals may also exhibit relative strengths, perhaps compensatory, in abstract reasoning in both verbal and visual domains.

Treating Tobacco Dependence at the Intersection of Diversity, Poverty, and Mental Illness: A Randomized Feasibility and Replication Trial

INTRODUCTION

In an ethnically-diverse, uninsured psychiatric sample with co-occurring drug/alcohol addiction, we evaluated the feasibility and reproducibility of a tobacco treatment intervention. The intervention previously demonstrated efficacy in insured psychiatric and nonpsychiatric samples with 20.0%-25.0% abstinence at 18 months.

METHODS

Daily smokers, recruited in 2009-2010 from psychiatric units at an urban public hospital, were randomized to usual care (on-unit nicotine replacement plus quit advice) or intervention, which added a Transtheoretical-model tailored, computer-assisted intervention, stage-matched manual, brief counseling, and 10-week post-hospitalization nicotine replacement.

RESULTS

The sample (N = 100, 69% recruitment rate, age M = 40) was 56% racial/ethnic minority, 65% male, 79% unemployed, and 48% unstably housed, diagnosed with unipolar (54%) and bipolar (14%) depression and psychotic disorders (46%); 77% reported past-month illicit drug use. Prior to hospitalization, participants averaged 19 (SD = 11) cigarettes/day for 23 (SD = 13) years; 80% smoked within 30 minutes of awakening; 25% were preparing to quit. Encouraging and comparable to effects in the general population, 7-day point prevalence abstinence for intervention versus control was 12.5% versus 7.3% at 3 months, 17.5% versus 8.5% at 6 months, and 26.2% versus 16.7% at 12 months. Retention exceeded 80% over 12 months. The odds of abstinence increased over time, predicted by higher self-efficacy, greater perceived social status, and diagnosis of psychotic disorder compared to unipolar depression.

CONCLUSIONS

Findings indicate uninsured smokers with serious mental illness can engage in tobacco treatment research with quit rates comparable to the general population. A larger investigation is warranted. Inclusion of diverse smokers with mental illness in clinical trials is supported and encouraged.

Interpersonal psychotherapy for depression and posttraumatic stress disorder among HIV-positive women in Kisumu, Kenya: study protocol for a randomized controlled trial

BACKGROUND

Mental disorders are the leading global cause of years lived with disability; the majority of this burden exists in low and middle income countries (LMICs). Over half of mental illness is attributable to depression and anxiety disorders, both of which have known treatments. While the scarcity of mental health care providers is recognized as a major contributor to the magnitude of untreated disorders in LMICs, studies in LMICs find that evidence-based treatments for depression and anxiety disorders, such as brief, structured psychotherapies, are feasible, acceptable and have strong efficacy when delivered by local non-specialist personnel. However, most mental health treatment studies using non-specialist providers in LMICs deploy traditional efficacy designs (T1) without the benefit of integrated mental health treatment models shown to succeed over vertical interventions or methods derived from new implementation science to speed policy change. Here, we describe an effectiveness-implementation hybrid study that evaluates non-specialist delivery of mental health treatment within an HIV clinic for HIV-positive (HIV+) women affected by gender- based violence (GBV) (HIV+ GBV+) in the Nyanza region of Kenya.

METHODS/DESIGN

In this effectiveness-implementation hybrid type I design, 200 HIV+ women with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) who are receiving care at a Family AIDS Care Education and Services (FACES)-supported clinic in Kisumu, Kenya will be randomized to: (1) interpersonal psychotherapy (IPT) + treatment as usual (TAU) or (2) TAU, both delivered within the HIV clinic. IPT will consist of 12 weekly 60-minute individual IPT sessions, delivered by non-specialists trained to provide IPT. Primary effectiveness outcomes will include MDD and PTSD diagnosis on the Mini International Diagnostic Interview (MINI). Primary implementation outcomes will include treatment cost-benefit, acceptability, appropriateness, feasibility and fidelity of the IPT delivery within an HIV clinic.

DISCUSSION

This trial leverages newly defined effectiveness-implementation hybrid designs to gather data on mental health treatment implementation within an HIV care clinic, while testing the effectiveness of an evidence-based treatment for use with a large underserved population (HIV+ GBV+ women) in Kenya.

TRIAL REGISTRATION

CLINICAL TRIALS IDENTIFIER

NCT02320799, registered on 9 September 2014.

Moderators and mediators of the relationship between receiving versus being denied a pregnancy termination and subsequent binge drinking

BACKGROUND

Women who terminate pregnancies drink more subsequent to the pregnancy than women who give birth, including women who give birth after seeking to terminate a pregnancy.

METHODS

Data are from the Turnaway Study, a prospective, longitudinal study of 956 women who sought to terminate pregnancies at 30 U.S. facilities. This paper focuses on the 452 women who received terminations just below facility gestational limits and 231 who were denied terminations because they presented just beyond facility gestational limits. This study examined whether baseline characteristics moderate the relationship between termination and subsequent binge drinking and whether stress, feelings about the pregnancy, and number of social roles mediate the relationship.

RESULTS

Only having had a previous live birth modified the termination-binge drinking relationship. Among women with previous live births, binge drinking was reduced among women carrying to term compared to terminating the pregnancy. Among women who had not had a previous live birth, however, the reduction in binge drinking among those denied termination was not sustained over time, and binge drinking of those who had and had not had terminations converged by 2.5 years. Neither stress, negative emotions, nor social roles mediated effects on binge drinking. Positive emotions at one week mediated effects on binge drinking at six months, although positive emotions at two years did not mediate effects on binge drinking at 2.5 years.

CONCLUSIONS

Higher levels of binge drinking among those who terminate pregnancies do not appear due to stress or to negative emotions. Only parous women - and not nulliparous women - denied terminations experienced sustained reductions in binge drinking over time.

A Randomized Controlled Trial of Mindfulness-Based Cognitive Therapy for Treatment-Resistant Depression

BACKGROUND

Due to the clinical challenges of treatment-resistant depression (TRD), we evaluated the efficacy of mindfulness-based cognitive therapy (MBCT) relative to a structurally equivalent active comparison condition as adjuncts to treatment-as-usual (TAU) pharmacotherapy in TRD.

METHODS

This single-site, randomized controlled trial compared 8-week courses of MBCT and the Health Enhancement Program (HEP), comprising physical fitness, music therapy and nutritional education, as adjuncts to TAU pharmacotherapy for outpatient adults with TRD. The primary outcome was change in depression severity, measured by percent reduction in the total score on the 17-item Hamilton Depression Rating Scale (HAM-D17), with secondary depression indicators of treatment response and remission.

RESULTS

We enrolled 173 adults; mean length of a current depressive episode was 6.8 years (SD = 8.9). At the end of 8 weeks of treatment, a multivariate analysis showed that relative to the HEP condition, the MBCT condition was associated with a significantly greater mean percent reduction in the HAM-D17 (36.6 vs. 25.3%; p = 0.01) and a significantly higher rate of treatment responders (30.3 vs. 15.3%; p = 0.03). Although numerically superior for MBCT than for HEP, the rates of remission did not significantly differ between treatments (22.4 vs. 13.9%; p = 0.15). In these models, state anxiety, perceived stress and the presence of personality disorder had adverse effects on outcomes.

CONCLUSIONS

MBCT significantly decreased depression severity and improved treatment response rates at 8 weeks but not remission rates. MBCT appears to be a viable adjunct in the management of TRD.

Feasibility and Quit Rates of the Tobacco Status Project: A Facebook Smoking Cessation Intervention for Young Adults

Background

Young adult smokers are a challenging group to engage in smoking cessation interventions. With wide reach and engagement among users, Facebook offers opportunity to engage young people in socially supportive communities for quitting smoking and sustaining abstinence.

Objective

We developed and tested initial efficacy, engagement, and acceptability of the Tobacco Status Project, a smoking cessation intervention for young adults delivered within Facebook.

Methods

The intervention was based on the US Public Health Service Clinical Practice Guidelines and the Transtheoretical Model and enrolled participants into study-run 3-month secret Facebook groups matched on readiness to quit smoking. Cigarette smokers (N=79) aged 18-25, who used Facebook on most days, were recruited via Facebook. All participants received the intervention and were randomized to one of three monetary incentive groups tied to engagement (commenting in groups). Assessments were completed at baseline, 3-, 6-, and 12-months follow-up. Analyses examined retention, smoking outcomes over 12 months (7-day point prevalence abstinence, ≥50% reduction in cigarettes smoked, quit attempts and strategies used, readiness to quit), engagement, and satisfaction with the intervention.

Results

Retention was 82% (65/79) at 6 months and 72% (57/79) at 12 months. From baseline to 12-months follow-up, there was a significant increase in the proportion prepared to quit (10/79, 13%; 36/79, 46%, P<.001). Over a third (28/79, 35%) reduced their cigarette consumption by 50% or greater, and 66% (52/79) made at least one 24-hour quit attempt during the study. In an intent-to-treat analysis, 13% (10/79) self-reported 7-day abstinence (6/79, 8% verified biochemically) at 12-months follow-up. In their quit attempts, 11% (9/79) used a nicotine replacement therapy approved by the Food and Drug Administration, while 18% (14/79) used an electronic nicotine delivery system to quit (eg, electronic cigarette). A majority (48/79, 61%) commented on at least one Facebook post, with more commenting among those with biochemically verified abstinence at 3 months (P=.036) and those randomized to receive a personal monetary incentive (P=.015). Over a third of participants (28/79, 35%) reported reading most or all of the Facebook posts. Highest acceptability ratings of the intervention were for post ease (57/79, 72%) and thinking about what they read (52/79, 66%); 71% (56/79) recommended the program to others. Only 5 participants attended the optional cognitive-behavioral counseling sessions, though their attendance was high (6/7 sessions overall) and the sessions were rated as easy to understand, useful, and helpful (all 90-100% agreed).

Conclusions

A Facebook quit smoking intervention is attractive and feasible to deliver, and early efficacy data are encouraging. However, the 1.5-fold greater use of electronic cigarettes over nicotine replacement products for quitting is concerning.

Modeling the role of negative symptoms in determining social functioning in individuals at clinical high risk of psychosis

A priority for improving outcome in individuals at clinical high risk (CHR) is enhancing our understanding of predictors of psychosis as well as psychosocial functioning. Social functioning, in particular, is a unique indicator of risk as well as an important outcome in itself. Negative symptoms are a significant determinant of social functioning in CHR individuals; yet, it is unclear which specific negative symptoms drive functional outcome and how these symptoms function relative to other predictors, such as neurocognition and mood/anxiety symptoms. In a sample of 85 CHR individuals, we examined whether a two-factor negative symptom structure that is found in schizophrenia (experiential vs expressive symptoms) would be replicated in a CHR sample; and tested the degree to which specific negative symptoms predict social functioning, relative to neurocognition and mood/anxiety symptoms, which are known to predict functioning. The two-factor negative symptom solution was replicated in this CHR sample. Negative symptom severity was found to be uniquely predictive of social functioning, above and beyond depression/anxiety and neurocognition. Experiential symptoms were more strongly associated with social functioning, relative to expression symptoms. In addition, experiential symptoms mediated the relationship between expressive negative symptoms and social functioning. These results suggest that experiences of motivational impairment are more important in determining social functioning, relative to affective flattening and alogia, in CHR individuals, thereby informing the development of more precise therapeutic targets. Developing novel interventions that stimulate goal-directed behavior and reinforce rewarding experiences in social contexts are recommended.

Substance use history in behavioral-variant frontotemporal dementia versus primary progressive aphasia

As older adults are prone to cognitive disorders, the interaction of the fields of substance use and misuse and cognitive neuroscience is an emerging area of research. Substance use has been reported in some subtypes of frontotemporal dementia, such as behavioral variant frontotemporal dementia. However, characterization of substance use in other subtypes of frontotemporal dementia, such as primary progressive aphasia, is unknown. The objective of this baseline analysis was to explore whether any measures of substance use history differed significantly among behavioral variant frontotemporal dementia (n = 842) and primary progressive aphasia (n = 526) in a large national dataset. The National Alzheimer's Coordinating Center's Uniform Data Set study is a national dataset that collects data on patients with various cognitive disorders and includes some questions on substance use. Each substance use variable was used as the outcome and the frontotemporal dementia subtype as the predictor. Total years smoked cigarettes, age when last smoked cigarettes, average number of packs/day smoked when participants smoked, and any recent, remote, or combined recent/remote history of alcohol abuse or drug abuse did not significantly differ between the behavioral variant frontotemporal dementia and primary progressive aphasia subtypes (all p-values > .001). A significantly greater percentage of participants smoked in the last 30 days in the behavioral variant frontotemporal dementia subtype (10.4%, n = 834) compared to the primary progressive aphasia subtype (3.3%, n = 517; p < .001). Clinical providers in both the dementia and substance use fields are encouraged to screen for and monitor substance use in all frontotemporal dementia subtypes.

The Tobacco Status Project (TSP): Study protocol for a randomized controlled trial of a Facebook smoking cessation intervention for young adults

BACKGROUND

Tobacco use remains the leading cause of premature morbidity and mortality in the United States. Young adults are less successful at quitting, use cessation treatment less often than smokers of other ages, and can be a challenge to retain in treatment. Social media, integrated into the lives of many young adults, represents a promising strategy to deliver evidence-based smoking cessation treatment to a large, diverse audience. The goal of this trial is to test the efficacy of a stage-based smoking cessation intervention on Facebook for young adults age 18 to 25 on smoking abstinence, reduction in cigarettes smoked, and thoughts about smoking abstinence.

METHODS/DESIGN

This is a randomized controlled trial. Young adult smokers throughout the United States are recruited online and randomized to either the 3 month Tobacco Status Project intervention on Facebook or a referral to a smoking cessation website. The intervention consists of assignment to a secret Facebook group tailored to readiness to quit smoking (precontemplation, contemplation, preparation), daily Facebook contacts tailored to readiness to quit smoking, weekly live counseling sessions, and for those in preparation, weekly Cognitive Behavioral Therapy counseling sessions on Facebook. Primary outcome measure is biochemically-verified 7-day point prevalence abstinence from smoking at posttreatment (3 months), 6, and 12 months. Secondary outcome measures are reduction of 50 % or more in cigarettes smoked, 24 h quit attempts, and commitment to abstinence at each time point. A secondary aim is to test, within the TSP condition, the effect of a monetary incentive at increasing engagement in the intervention.

DISCUSSION

This randomized controlled trial is testing a novel Facebook intervention for treating young adults' tobacco use. If efficacious, the social media intervention could be disseminated widely and expanded to address additional health risks.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02207036 , May 13, 2014.

Viral hepatitis among drug users in methadone maintenance: associated factors, vaccination outcomes, and interventions

Drug users are at high risk of viral Hepatitis A, B, and C. The prevalence of Hepatitis A, Hepatitis B, and Hepatitis C, associated factors, and vaccine seroconversion among drug treatment program participants in a randomized controlled trial of hepatitis care coordination were examined. Of 489 participants, 44 and 47% required Hepatitis A/Hepatitis B vaccinations, respectively; 59% were Hepatitis C positive requiring linkage to care. Factors associated with serologic statuses, and vaccine seroconversion are reported; implications for strategies in drug treatment settings are discussed. Results suggest generalizable strategies for drug treatment programs to expand viral hepatitis screening, prevention, vaccination, and linkage to care.

Prospective study of violence risk reduction by a mental health court

OBJECTIVE

Although many mental health courts (MHCs) have been established to reduce criminal justice involvement of persons with mental disorders, research has not kept pace with the widespread implementation of these courts. Whereas early MHCs were restricted to persons charged with nonviolent misdemeanors, many MHCs now accept persons with more serious charges for whom ameliorating risk of violence is a greater concern. This study evaluated the relationship between MHC participation and risk of violence by using a prospective design. It was hypothesized that MHC participation would decrease the risk of violence during a one year follow-up compared with a matched comparison group.

METHODS

The sample included 169 jail detainees with a mental disorder who either entered an MHC (N=88) or received treatment as usual (N=81). Seventy-two percent had been charged with felonies. Participants were interviewed at baseline and during a one-year follow up, and their arrest records were reviewed. Propensity-adjusted logistic regression evaluated the relationship between MHC participation and risk of violence, controlling for potential confounders such as history of violence, demographic characteristics, baseline treatment motivation, and time at risk in the community.

RESULTS

MHC participation was associated with reduction in risk of violence (odds ratio=.39). During follow-up, 25% of the MHC group perpetrated violence, compared with 42% of the treatment-as-usual group.

CONCLUSIONS

MHC participation can reduce the risk of violence among justice-involved persons with mental disorders. The findings support the conclusion that the MHC model can be extended beyond persons charged with nonviolent misdemeanors in a way that enhances public safety.

Smoking Behaviors and Attitudes Among Clients and Staff at New York Addiction Treatment Programs Following a Smoking Ban: Findings After 5 Years

INTRODUCTION

Addiction treatment clients are more likely to die of tobacco-related diseases than of alcohol or illicit drug-related causes. We aimed to assess smoking behavior, and smoking-related attitudes and services, in New York addiction treatment programs before a statewide smoking ban in treatment facilities was implemented (2008), 1 year (2009) and 5 years after implementation (2013).

METHODS

We conducted surveys at each time point with clients (N = 329, 341, and 353, respectively) and staff (N = 202, 203, and 166, respectively) from five residential and two methadone maintenance programs in New York State. At each data collection wave, questionnaires measured smoking behavior as well as smoking-related knowledge, attitudes, and experiences with tobacco cessation services as part of addiction treatment.

RESULTS

Staff smoking prevalence decreased from 35.2% in 2008 to 21.8% in 2013 (P = .005) while client smoking prevalence over the same period was unchanged (68.1% vs. 66.0%, P = .564). Among clients who smoked, mean cigarettes per day decreased from 13.7 (SD = 8.38) to 10.2 (SD = 4.44; P < .001). There were significant time-by-treatment-type interactions for client tobacco-related attitudes and cessation services received; and for staff self-efficacy and cessation services provided. In residential programs, scores for most items decreased (became less positive) in 2009 followed by a partial rebound in 2013. Methadone program scores tended to rise (become more positive) throughout the study period.

CONCLUSIONS

Staff and clients may respond differentially to tobacco-free policies depending on type of treatment program, and this finding may help to inform the implementation of tobacco-free policies in other statewide addiction treatment systems.

Association of age at depression onset with cognitive functioning in individuals with late-life depression and executive dysfunction

OBJECTIVE

To compare patterns of cognitive performance in older adults with late-onset depression (LOD; ≥65 years of age) with that of older adults with early-onset depression (EOD; <65 years).

METHODS

Participants were 171 adults aged 60 years or older with major depression and executive dysfunction who were participating in a randomized psychotherapy trial. Participants included 72 LOD and 99 EOD individuals. Cognitive performance on measures of verbal learning, memory, and executive functioning were evaluated. Demographic and clinical characteristics, severity of cerebrovascular risk factors, and disability ratings were also compared between groups.

RESULTS

The LOD group was older and had fewer previous episodes of depression and lower severity of depression compared with EOD participants. The LOD group demonstrated poorer performance on measures of verbal learning (F(1,161) = 4.28, p = 0.04) and memory (F(1,160) = 4.65, p = 0.03) than the EOD group. Linear regression analysis demonstrated that LOD and fewer years of education were significant predictors of poorer verbal learning (F(7,114) = 6.25, p <0.001) and memory (F(7,113)=7.24, p <0.001). Performance on measures of executive functioning, severity of vascular risk factors, and disability ratings did not differ between the two groups.

CONCLUSION

In older adults with depression and executive dysfunction, LOD was associated with poorer performance on measures of verbal learning and memory. Aging-related brain changes associated with LOD may play a more important role, leading to dysfunction in these cognitive domains than a history of recurrent depressive episodes in older adults with a dysexecutive syndrome.

Prevalence and Correlates of Social Smoking in Young Adults: Comparisons of Behavioral and Self-Identified Definitions

INTRODUCTION

Social smoking is an increasingly common pattern among emerging adults. Although distinct patterns have emerged between social smokers and non-social smokers, there is discrepancy about how to define the construct, with inconsistencies between self-identified social smoking and behavioral social smoking. We report prevalence and correlates of young adult smokers who self-identify and behave as social smokers (SELF + BEH), self-identified non-behavioral social smokers (SELF-ONLY), and non-social smokers (NON-SOCIAL).

METHODS

Young adults age 18-25 years who have smoked at least 1 cigarette in the past 30 days (N = 1,811) were recruited through Facebook for a national anonymous, online survey of tobacco and other substance use. Three social smoking items were used to categorize respondents into 1 of 3 smoking groups. Groups were examined for prevalence and differences on demographics, substance use, motivation to quit smoking and thoughts about tobacco abstinence.

RESULTS

SELF-ONLY (46%) was the largest group, followed by SELF + BEH (27%) and NON-SOCIAL (27%). SELF + BEH smoke less frequently, smoke fewer cigarettes per day, are less addicted to cigarettes, have a higher desire to quit, and perceive a lower quitting difficulty compared with SELF-ONLY. SELF + BEH and SELF-ONLY were more likely to be male, be marijuana users, and be addicted to marijuana than NON-SOCIAL. SELF + BEH exhibited a lower frequency of smoking, less cigarettes per day, were less addicted, and had more days co-using alcohol and cigarettes than NON-SOCIAL.

CONCLUSION

Identifying social smokers based on self-identification in addition to behavioral components appears to be important for designing smoking cessation interventions for emerging adults.

Alcohol use before and during unwanted pregnancy

BACKGROUND

There is little information about pregnancy-related changes in alcohol use and factors contributing to changes among women with unwanted pregnancies. This study describes changes in alcohol use from before pregnancy recognition to during pregnancy and identifies important predictors of alcohol use severity among women with unwanted pregnancies.

METHODS

Data are from the Turnaway Study of 956 women seeking pregnancy termination at 30 U.S. facilities between 2008 and 2010, some of whom were denied care because they were past the gestational limit of the facility where they were recruited and were still pregnant at the baseline interview, 1 week after termination seeking. Predictors of alcohol use severity (a latent variable) were identified.

RESULTS

About 56% of the total sample reported any alcohol use the month before pregnancy recognition, with 23% reporting 6 or more drinks on an occasion. Among the total sample, 35% of those drinking before pregnancy recognition had quit and 20% had reduced 1 week after termination seeking. Among those denied terminations and still pregnant, 71% had quit and 14% had reduced. In a multivariate model predicting alcohol severity, younger age, still pregnant, 1 or more previous births, later gestation, childhood physical abuse, and marijuana and other drug use were associated with lower severity; having completed college, tobacco use, and recent physical violence were associated with higher severity.

CONCLUSIONS

The proportion of the total sample drinking before pregnancy recognition is similar to national samples of women of childbearing age, while the proportion binge drinking appears higher. Of women denied terminations, who were still pregnant, the proportion having quit is similar to other populations of pregnant women. More research is needed to examine whether pregnant women may be substituting alcohol for marijuana and other drugs. Interventions focusing on alcohol use severity during pregnancy may need to also focus on tobacco.

Interpersonal psychotherapy versus treatment as usual for PTSD and depression among Sichuan earthquake survivors: a randomized clinical trial

Background

Without effective treatment, PTSD and depression can cause persistent disability in disaster-affected populations.

Methods

Our objective was to test the efficacy of Interpersonal Psychotherapy (IPT) delivered by trained local personnel compared with treatment as usual (TAU) for Posttraumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) among adults affected by the Sichuan 2008 earthquake. A small randomized controlled trial of IPT + TAU versus TAU alone was delivered by local mental health personnel in Shifang, China. Between July 2011 and January 2012, 49 adults ≥ 18 years with PTSD, MDD or both were enrolled and randomized to 12 weekly sessions of IPT + TAU (27) or TAU (22) alone x 12 weeks. IPT was then offered to the TAU group. Unblinded follow up assessments were conducted at three and six months. IPT was a 12 session, weekly one hour treatment delivered by local personnel who were trained and supervised in IPT. TAU was continuation of prescribed psychotropic medication (if applicable) and crisis counseling, as needed.

Main Outcome(s) and Measures (s): Clinician Administered PTSD Scale (CAPS) PTSD diagnosis; Structured Clinical Interview for DSM-IV (SCID) for MDD diagnosis. Secondary measures included PTSD/depression symptoms, interpersonal conflict/anger, social support, self-efficacy and functioning.

Results

Using an intent-to-treat analysis, 22 IPT + TAU and 19 TAU participants were compared at three months post-baseline. A significantly greater reduction of PTSD and MDD diagnoses was found in the IPT group (51.9%, 30.1%, respectively) versus the TAU group (3.4%, 3.4%, respectively). Despite the small sample, the estimates for time-by-condition analyses of target outcomes (2.37 for PTSD (p = .018) and 1.91 for MDD (p = .056)) indicate the improvement was better in the IPT + TAU condition versus the TAU group. Treatment gains were maintained at 6 months for the IPT group. A similar treatment response was observed in the TAU group upon receipt of IPT.

Conclusions

This initial study shows that IPT is a promising treatment for reducing PTSD and depression, the two major mental health disorders affecting populations surviving natural disaster, using a design that builds local mental health care capacity.

Trial Registration

ClinicalTrials.Gov number, NCT01624935.

Smoking cessation outcomes among sexual and gender minority and nonminority smokers in extended smoking treatments

INTRODUCTION

Sexual and gender minority individuals (i.e., lesbian, gay, bisexual, and transgender [LGBT]) have a higher smoking prevalence than nonminority individuals. There is limited evidence of smoking abstinence success in nontailored smoking treatments among LGBT smokers.

METHODS

This study is a secondary data analysis comparing the efficacy of extended, nontailored treatments among sexual and gender minority and nonminority smokers. Data from two clinical trials were combined to increase power and generalizability of the findings. Trials began with 12 weeks of counseling, nicotine replacement, and bupropion, after which participants were randomized to an extended treatment.

RESULTS

Follow-up occurred at weeks 12, 24, 52, 64, and 104. Of the sample (n = 777), 17% identified as sexual and gender minority and 83% as nonminority. The sample was 75% non-Hispanic White, with 86% completing at least some college, and 68% were employed. Sexual and gender minorities were younger and indicated a greater desire to quit smoking than nonminority smokers. No other differences emerged on demographic, smoking, or mood variables. The average Fagerström Test for Nicotine Dependence score was 4.8, and mean daily cigarettes was 19.8. The generalized estimating equations model revealed no significant differences in abstinence between sexual and gender minority smokers and nonminority smokers at all follow-up assessments.

CONCLUSIONS

Sexual and gender minority smokers appear as likely to quit or abstain as nonminority smokers in extended, nontailored interventions. However, these findings may not generalize to other geographic areas, where access to treatment is limited or a higher stigma of sexual orientation exists.

Design and implementation of the START (STem cells for ARDS Treatment) trial, a phase 1/2 trial of human mesenchymal stem/stromal cells for the treatment of moderate-severe acute respiratory distress syndrome

BACKGROUND

Despite advances in supportive care, moderate-severe acute respiratory distress syndrome (ARDS) is associated with high mortality rates, and novel therapies to treat this condition are needed. Compelling pre-clinical data from mouse, rat, sheep and ex vivo perfused human lung models support the use of human mesenchymal stem (stromal) cells (MSCs) as a novel intravenous therapy for the early treatment of ARDS.

METHODS

This article describes the study design and challenges encountered during the implementation and phase 1 component of the START (STem cells for ARDS Treatment) trial, a phase 1/2 trial of bone marrow-derived human MSCs for moderate-severe ARDS. A trial enrolling 69 subjects is planned (9 subjects in phase 1, 60 subjects in phase 2 treated with MSCs or placebo in a 2:1 ratio).

RESULTS

This report describes study design features that are unique to a phase 1 trial in critically ill subjects and the specific challenges of implementation of a cell-based therapy trial in the ICU.

CONCLUSIONS

Experience gained during the design and implementation of the START study will be useful to investigators planning future phase 1 clinical trials based in the ICU, as well as trials of cell-based therapy for other acute illnesses.

TRIAL REGISTRATION

CLINICAL TRIALS REGISTRATION

NCT01775774 and NCT02097641.

Alcohol use biomarkers predicting cognitive performance: a secondary analysis in veterans with alcohol dependence and posttraumatic stress disorder

OBJECTIVE

We conducted a secondary analysis of baseline data from a recently completed pharmacological pilot clinical trial among 30 veterans with alcohol dependence and posttraumatic stress disorder (PTSD). This trial included baseline measures of alcohol use biomarkers, both indirect (carbohydrate-deficient transferrin, GGT [γ-glutamyltransferase], mean corpuscular volume, AST [aspartate aminotransferase], alanine aminotransferase) and direct (ethyl glucuronide, ethyl sulfate), as well as neurocognitive measures (Trail Making Test parts A and B, Hopkins Verbal Learning Test-Revised, Balloon Analogue Risk Task, Delay Discounting Task).

METHODS

Two regression models were estimated and tested for each neurocognitive measure (dependent measure). The first model included the alcohol use biomarker alone as the predictor. The second model included the alcohol use biomarker along with the following 3 additional predictors: Beck Depression Inventory, Clinician-Administered PTSD Scale, and receiving medications.

RESULTS

In both models, the indirect biomarkers, such as GGT and AST, significantly predicted performance on the Hopkins Verbal Learning Test-Revised %Retention. GGT alone significantly predicted performance on the Trail Making Test part A.

CONCLUSIONS

Indirect alcohol use biomarkers may have a specific role in identifying those veterans with alcohol dependence and PTSD who have impaired cognitive performance. However, direct alcohol use biomarkers may not share such a role.

Smoking abstinence-related expectancies among American Indians, African Americans, and women: potential mechanisms of tobacco-related disparities

Research has documented tobacco-related health disparities by race and gender. Prior research, however, has not examined expectancies about the smoking cessation process (i.e., abstinence-related expectancies) as potential contributors to tobacco-related disparities in special populations. This cross-sectional study compared abstinence-related expectancies between American Indian (n = 87), African American (n = 151), and White (n = 185) smokers, and between women (n = 231) and men (n = 270) smokers. Abstinence-related expectancies also were examined as mediators of race and gender relationships with motivation to quit and abstinence self efficacy. Results indicated that American Indians and African Americans were less likely than Whites to expect withdrawal effects, and more likely to expect that quitting would be unproblematic. African Americans also were less likely than Whites to expect smoking cessation interventions to be effective. Compared with men, women were more likely to expect withdrawal effects and weight gain. These expectancy differences mediated race and gender relationships with motivation to quit and abstinence self-efficacy. Findings emphasize potential mechanisms underlying tobacco-related health disparities among American Indians, African Americans, and women and suggest a number of specific approaches for targeting tobacco dependence interventions to these populations.

Reciprocal effects of alcohol and nicotine in smoking cessation treatment studies

OBJECTIVE

Smoking and alcohol use are highly related; as such the present study investigated whether alcohol use is associated with failure in tobacco cessation attempts. We first examined the self-reported drinking behavior and smoking over the course of a year at a basic level. Next, we addressed two hypotheses to characterize this relationship at a deeper level: (Hypothesis 1) Alcohol use would be lower for those who attempted to quit smoking (quit for one or more days) during the year compared to those who never quit, and (Hypothesis 2) for those who relapsed to smoking after a quit increases in alcohol consumption would be positively associated with increases in smoking.

METHOD

Subjects were participants in two smoking cessation programs. One group of participants (N=139) was part of a smoking cessation study in alcohol dependent smokers in early recovery and the other group of participants (N=163) was drawn from a smoking cessation study for HIV positive smokers. H1 was tested using t-tests. For H2, a time series analysis examined relationships between smoking and alcohol use within person over a one year period. For H1 and for H2, the analyses utilized bivariate time series procedures. Timeline follow-back data allowed for detailed daily reports of both tobacco and alcohol use.

RESULTS

In the overall sample, there was no difference in alcohol use between those who stopped smoking and those who never stopped. However, when broken up by study, a difference was found in the alcohol dependent sample such that mean drinks were higher for those who stopped compared to those who never stopped smoking (H1). The results indicated a high number of positive significant cross-correlations between tobacco and alcohol use such that one substance predicted current, as well as past and future use of the alternate substance. Same-day cross-correlations were the most common, and dissipated with time (H2).

CONCLUSIONS

This analysis provided insights into the proximal influence of one substance on the other. Alcohol is related to relapse in smoking cessation attempts. It is important that smoking cessation efforts in alcohol using populations consider alcohol use in treatment.

Clinical significance of early smoking withdrawal effects and their relationships with nicotine metabolism: preliminary results from a pilot study

INTRODUCTION

Although the early time course of smoking withdrawal effects has been characterized, the clinical significance of early withdrawal symptoms and their predictors are unknown. This study evaluated the relationships of early smoking withdrawal effects with quit attempt outcomes and the rate of nicotine metabolism.

METHODS

Eleven treatment-seeking smokers abstained from smoking for 4 hr in the laboratory before a quit attempt. Withdrawal measures included heart rate, sustained attention, and self-report. Following baseline assessment, withdrawal measures were administered every 30 min. At the conclusion of the 4-hr early withdrawal session, participants received a brief smoking cessation intervention and then returned 1 week and 12 weeks later for outcome assessments that included biochemically confirmed smoking abstinence, cigarettes smoked in the past 24hr, and self-reported withdrawal symptoms. The rate of nicotine metabolism was estimated at intake with the nicotine metabolite ratio (trans-3'-hydroxycotinine/cotinine) measured in saliva.

RESULTS

Greater self-reported negative affect and concentration difficulty during early withdrawal, most notably anxiety, were related with poorer quit attempt outcomes. There was some indication that although a faster increase in craving and greater hunger during early withdrawal were associated with more favorable outcomes, a greater decrease in heart rate during this time was associated with poorer outcomes. Faster nicotine metabolism was related to a faster increase in anxiety but a slower increase in craving during early withdrawal.

CONCLUSIONS

These findings lend support to the clinical significance of early smoking withdrawal effects. The rate of nicotine metabolism may be a useful predictor of early withdrawal symptoms.

A randomized trial of a hepatitis care coordination model in methadone maintenance treatment

OBJECTIVES

We evaluated the efficacy of a hepatitis care coordination intervention to improve linkage to hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination and clinical evaluation of hepatitis C virus (HCV) infection among methadone maintenance patients.

METHODS

We conducted a randomized controlled trial of 489 participants from methadone maintenance treatment programs in San Francisco, California, and New York City from February 2008 through June 2011. We randomized participants to a control arm (n = 245) and an intervention arm (n = 244), which included on-site screening, motivational-enhanced education and counseling, on-site vaccination, and case management services.

RESULTS

Compared with the control group, intervention group participants were significantly more likely (odds ratio [OR] = 41.8; 95% confidence interval [CI] = 19.4, 90.0) to receive their first vaccine dose within 30 days and to receive an HCV evaluation within 6 months (OR = 4.10; 95% CI = 2.35, 7.17). A combined intervention adherence outcome that measured adherence to HAV-HBV vaccination, HCV evaluation, or both strongly favored the intervention group (OR = 8.70; 95% CI = 5.56, 13.61).

CONCLUSIONS

Hepatitis care coordination was efficacious in increasing adherence to HAV-HBV vaccination and HCV clinical evaluation among methadone patients.

Subjective social status and substance use severity in a young adult sample

Subjective social status (SSS), an individual's subjective view of standing in society, has been shown to better predict health outcomes compared to objective measures of socioeconomic status (SES), including educational attainment and income. This study examines the relationship between SSS and severity of tobacco, alcohol, and marijuana use after controlling for objective measures of SES. Young adults (N = 1,987) aged 18-25 who reported smoking at least one cigarette in the past 30 days were recruited and surveyed anonymously online. Three separate structural equation models examined whether SSS was associated with severity of tobacco, alcohol, and marijuana use, controlling for personal and household income, years of education, employment status, and parental education. Household income (b = .31), employment status (b = .07), years of education (b = .09), and parental education (b = .16) were positively associated with SSS (all p values < .001); personal income was not significantly associated with SSS (p = .11). All three models adequately fit the data. SSS was negatively associated with severity of tobacco (b = -.13, p < .001) and marijuana use (b = -36, p = .02), but not alcohol use severity (b = .01, p = .56). Among young adults, higher subjective social status is associated with less severe tobacco and marijuana use, whereas alcohol use severity appears to be similar across socioeconomic class.

Marijuana and tobacco co-use in young adults: patterns and thoughts about use

OBJECTIVE

We examined the frequency and intensity of tobacco use and thoughts about abstinence among young adults in the United States as a function of their use of marijuana. We hypothesized that heavier marijuana use would be associated with heavier tobacco use and fewer attempts to quit smoking, and we explored relationships between marijuana use and ratings of intentions and thoughts related to quitting tobacco.

METHOD

This was a cross-sectional survey consisting of online recruitment and anonymous self-report. Participants were English literate, were between the ages of 18 and 25 years, and reported past-month tobacco use. More than half (53%) had smoked marijuana in the past 30 days. Tobacco use (quantity/frequency, Heavy Smoking Index, past-year quit attempt), thoughts about tobacco use (outcome expectancies, desire, self-efficacy, difficulty of quitting, abstinence goal, pros and cons, stage of change), alcohol use, and other drug use were assessed.

RESULTS

Compared with those who smoked only tobacco, cousers were younger and had smoked for fewer years; had higher household income; were more likely to be male, multiethnic, and nondaily smokers; and reported greater alcohol and other drug use. The variable of days using marijuana in the past 30 days was associated with multiple measures of tobacco use intensity/frequency. Only one association was significant between marijuana use and tobacco-related cognitions: Cousers had a lower likelihood of planning to quit tobacco for good (odds ratio = 0.75, 95% CI [0.58, 0.98]).

CONCLUSIONS

Findings support the association between tobacco and marijuana use among young people but speak to the importance of addressing tobacco cognitions in young adult smokers regardless of level of marijuana use.

APOE e4 genotype and cigarette smoking in adults with normal cognition and mild cognitive impairment: a retrospective baseline analysis of a national dataset

BACKGROUND

APOE e4 genotype is known to be a risk factor for Alzheimer's disease and atherosclerosis. Recently, published evidence has shown that APOE e4 genotype may also be associated with the cessation of cigarette smoking.

OBJECTIVES

The aim of this retrospective analysis was to explore whether any past smoking outcomes differed based on APOE e4 genotype in a large national dataset.

METHODS

Data were extracted from the National Alzheimer's Coordinating Center's longitudinal Uniform Data Set study. We limited this retrospective baseline analysis to the normal cognition (n = 2995) and mild cognitive impairment (n = 1627) groups that had APOE genotype and smoking data. Because this was an exploratory retrospective analysis, we conducted descriptive analyses on all variables based on APOE e4 genotype. We controlled for demographic, clinical, medication and neurocognitive data in the analyses.

RESULTS

In both the normal cognition group and the mild cognitive impairment group, e4 carriers and e4 non-carriers did not significantly differ on total years smoked, age when last smoked and the average # of packs/day smoked during the years they smoked. In both groups, e4 carriers and e4 non-carriers differed on various neurocognitive measures.

CONCLUSION

These data do not support the recently published evidence of the association between APOE e4 genotype and smoking outcomes.

SCIENTIFIC SIGNIFICANCE

Larger prospective clinical trials are needed to further explore the relationship between APOE genotype and smoking outcomes.

Participation in Team Sports and Alcohol and Marijuana Use Initiation Trajectories

A parallel-process latent growth curve model was used to model alcohol and marijuana use (vs. nonuse). Participation in team sports and gender were considered to be time-invariant covariates. The sample consisted of 8,179 youth from the National Survey of Parents and Youth. Data were collected over four yearly rounds. Analysis revealed that being part of a competitive sports team was related to a lower probability of marijuana initiation, but to increased rates of alcohol use over time. Males had significantly higher levels of marijuana initiation and decreases in rates of alcohol use over time; females had significantly greater rate of increase in alcohol use over time. Analysis suggests that youth involved in sports are less likely to use marijuana over time. This information may help to uncover other predictors of use over time and to inform policy making as well design as effective prevention.

Moderators of outcome in late-life depression: a patient-level meta-analysis

OBJECTIVE

The authors sought to identify factors that moderate outcome in late-life major depression and that identify patients for whom antidepressants have clinically meaningful effects.

METHOD

A previous systematic review identified 10 placebo-controlled trials of second-generation antidepressants in outpatients with major depressive disorder who were age 60 or older. For the present study, the authors obtained from the sponsors of the 10 trials individual patient data, including age, sex, duration of illness (current age minus age at onset), course (single episode or recurrent depression), baseline depression severity, treatment assignment, and outcomes. Logistic regression models were estimated and tested to examine the association of potential moderator variables with treatment response and the treatment group-response interaction.

RESULTS

All moderator variables were collected and documented for seven of the 10 trials (N=2,283). Univariate and multivariate analyses were restricted to these seven trials. Illness duration was the only variable significantly associated with drug-placebo differences in the multivariate model. In patients with an illness duration >10 years, baseline depression severity was also significantly associated with drug-placebo differences. In those with an illness duration >10 years and a Hamilton Depression Rating Scale score ≥21, the drug-placebo difference in response rates was relatively robust (number needed to treat=4). In the remaining patients, the drug-placebo difference in response rates was small (46.3% compared with 41.5%).

CONCLUSIONS

Older patients with a long illness duration and moderate to severe depression appear to benefit from antidepressants as compared with placebo. Antidepressants do not appear to be effective for older patients with short illness duration.

A randomized clinical trial of smoking cessation treatments provided in HIV clinical care settings

INTRODUCTION

Identifying successful smoking treatment interventions and methods of delivery is critical given the smoking rates among HIV-positive populations and the medical implications of smoking in this population. This study compared the efficacy of 3 smoking cessation interventions provided in HIV clinical treatment settings.

METHODS

Following a baseline assessment, 209 HIV-positive smokers were randomly assigned to 1 of 3 conditions in a parallel group design. Treatment conditions were individual counseling plus nicotine replacement treatment (NRT), a computer-based Internet smoking treatment plus NRT, and self-help plus NRT. Smoking status was determined at follow-up assessments completed at 12, 24, 36, and 52 weeks following treatment initiation.

RESULTS

Cessation rates ranged from 15% to 29%; however, no statistically significant differences in abstinence were found among the treatment conditions over time. Those employed, those who reported a greater desire to quit, or those with lower mood disturbance scores were more likely to achieve abstinence (p < .01). The number of cigarettes participants reported smoking in the 24hr prior to each assessment significantly declined over time (p < .001).

CONCLUSIONS

Although we found no differences in abstinence rates across groups, the results indicate that integration of smoking cessation interventions is feasible in HIV clinical treatment settings, and cessation results are promising. The overall abstinence rates we report are comparable to those found in similar treatment studies across multiple populations. Further research is warranted.

Ten-year stability of remission in private alcohol and drug outpatient treatment: non-problem users versus abstainers

BACKGROUND

This study examined stability of remission in patients who were abstainers and non-problem users at 1-year after entering private, outpatient alcohol and drug treatment. We examined: (a) How does risk of relapse change over time? (b) What was the risk of relapse for non-problem users versus abstainers? (c) What individual, treatment, and extra-treatment characteristics predicted time to relapse, and did these differ by non-problem use versus abstinence?

METHODS

The sample consisted of 684 adults in remission (i.e., abstainers or non-problem users) 1 year following treatment intake. Participants were interviewed at intake, and 1, 5, 7, 9, and 11 years after intake. We used discrete-time survival analysis to examine when relapse is most likely to occur and predictors of relapse.

RESULTS

Relapse was most likely at 5-year, and least likely at 11-year follow-up. Non-problem users had twice the odds of relapse compared to abstainers. Younger individuals and those with fewer 12-step meetings and shorter index treatment had higher odds of relapse than others. We found no significant interactions between non-problem use and the other covariates suggesting that significant predictors of outcome did not differ for non-problem users.

CONCLUSIONS

Non-problem use is not an optimal 1-year outcome for those in an abstinence-oriented, heterogeneous substance use treatment program. Future research should examine whether these results are found in harm reduction treatment and self-help models, or in those with less severe problems. Results suggest treatment retention and 12-step participation are prognostic markers of long-term positive outcomes for those achieving remission at 1 year.

Menthol use among smokers with psychological distress: findings from the 2008 and 2009 National Survey on Drug Use and Health

OBJECTIVE

The Food and Drug Administration is considering regulation of menthol cigarettes. While persons with mental distress are known to smoke cigarettes at high rates, little is known about their use of menthol. The authors examined the association of psychological distress and menthol use in a national sample of adult smokers.

METHODS

Data were from the 2008 and 2009 National Survey on Drug Use and Health. Past month smokers (N=24,157) were categorised for menthol or non-menthol use. Psychological distress was categorised as none/mild, moderate or severe on the Kessler six-item scale.

RESULTS

The prevalence of menthol use was higher among individuals with severe psychological distress, women, young adults, African-Americans, Native Hawaiians/Pacific Islanders, persons with fewer years of education and lower income, and the unmarried and uninsured. In a multivariate model controlling for socio-demographic factors, smoking intensity and time to first cigarette, smokers with severe (adjusted OR (AOR) 1.23, 95% CI 1.04 to 1.46, p=0.02) but not moderate (AOR 1.03, 95% CI 0.92 to 1.15, p=0.58) psychological distress were significantly more likely to smoke menthols compared with smokers with none/mild distress.

CONCLUSION

An elevated prevalence of menthol use was found among persons with severe psychological distress, suggesting another group that could potentially benefit from the regulation of menthol cigarettes.

Remission from alcohol and other drug problem use in public and private treatment samples over seven years

BACKGROUND

The treatment of alcohol and other drugs is now more commonly framed in terms of a chronic condition which requires ongoing monitoring. A model which includes continuing access to health care may optimize outcomes. Most studies of chronic care models have not included health care and have only examined short term effects.

METHODS

The sample (n = 783) included consecutive admissions in ten public and private alcohol and other drug (AOD) treatment programs followed over seven years. The outcome was remission which was defined as alcohol and drug abstinence or non-problem use.

RESULTS

In the private sample, receiving health care services predicted remission across the seven years; however this did not occur in the public sample. More patients in the public treatment sample received AOD treatment readmissions each year, while more of those in the private sector received psychiatric and general health visits. Except for drug problem severity, there were no other clinical differences between the samples. There were no differences in the proportions of patients in the two sectors who received the full spectrum of chronic care services. In the final models, 12-step participation was markedly significant for both samples.

CONCLUSIONS

Models of chronic care for substance use need to consider differences between private and public treatment and should take into account that individuals may not always have access, or avail themselves of services that may optimize long-term outcomes.

Alcohol and marijuana use in the context of tobacco dependence treatment: impact on outcome and mediation of effect

INTRODUCTION

Alcohol and marijuana are among the most commonly used substances together with tobacco worldwide, but their relationship to smoking cessation is unclear. Although alcohol use decreases the likelihood of abstinence from tobacco, mechanisms of this effect have not been identified. Moreover, a small literature has yielded inconsistent findings regarding the effect of marijuana use on tobacco dependence treatment outcome. The aims of this study were to test increased positive-reinforcement smoking urge as a mediator of the relationship between alcohol and cigarette use and evaluate the impact of marijuana use on abstinence from tobacco.

METHODS

Participants were adult cigarette smokers (N = 739) from 3 randomized clinical trials of smoking cessation treatment. Alcohol consumption and marijuana use were assessed at pretreatment and postcessation. Biochemically verified, 7-day point prevalence smoking abstinence was determined at Weeks 12, 24, 36, and 52, as were urges to smoke as measured by the Questionnaire of Smoking Urges.

RESULTS

Increased positive-reinforcement urge mediated the effect of postcessation alcohol use on smoking abstinence. Although pretreatment alcohol use was associated with a decreased likelihood of abstinence from tobacco, increased positive-reinforcement urge did not account for this relationship. Marijuana use was not associated with abstinence from tobacco.

CONCLUSIONS

Smoking cessation treatments should provide those who drink during a quit attempt techniques designed to mitigate positive-reinforcement urge to smoke. Additional research is needed to determine how pretreatment alcohol consumption exerts its effect on cigarette use. Modifying the use of marijuana might not be critical to the success of tobacco interventions.

Error-related negativity in individuals with obsessive-compulsive symptoms: toward an understanding of hoarding behaviors

The error-related negativity (ERN), an event-related potential component elicited by error responses in cognitive tasks, has been shown to be abnormal in most, but not all, studies of obsessive-compulsive disorder or obsessive-compulsive symptoms (OCD/S); these inconsistencies may be due to task selection, symptom subtype, or both. We used meta-analysis to further characterize the ERN in OCD/S, and pooled data across studies to examine the ERN in OCD/S with hoarding. We found an enhanced ERN in OCD/S relative to controls, as well as heterogeneity across tasks. When stratified, OCD/S showed a significantly enhanced ERN only in response conflict tasks. However, OCD/S+hoarding showed a marginally larger ERN than OCD/S-hoarding, but only for probabilistic learning tasks. These results suggest that abnormal ERN in OCD/S is task-dependent, and that OCD/S+hoarding show different ERN activity from OCD/S-hoarding perhaps suggesting different pathophysiological mechanisms of error monitoring.

Following problem drinkers over eleven years: understanding changes in alcohol consumption

OBJECTIVE

Much of what we know about the course of alcohol consumption in problem and dependent drinkers comes from studies of in-treatment populations. Less is known about the natural course of alcohol consumption among such drinkers in the general population and what predicts how much they drink.

METHOD

This study examined alcohol consumption over the course of 11 years in a randomly selected sample of 672 problem and dependent drinkers from a single, heterogeneous U.S. county.

RESULTS

Alcohol consumption declined and leveled off over time but did not decrease to the average general U.S. population level. Several indicators of ongoing problems with drinking are associated with high levels of drinking over time: having a heavy-drinking network, receiving suggestions to do something about one's drinking, and going to treatment. Factors associated with less drinking include having contact with community agencies and going to Alcoholics Anonymous (AA).

CONCLUSIONS

Results suggest that problem and dependent drinkers continue to drink at an elevated level over the course of years. Gatekeepers, family members, and policymakers should encourage and facilitate contact with social service agencies and with AA for problem drinkers. Suggestions from others to do something about one's drinking and seeking specialty care occur more often in those with more severe problems and do not appear to be linked to less drinking over time.

Alcohol screening and changes in problem drinking behaviors in medical care settings: a longitudinal perspective

OBJECTIVE

Although the effect of alcohol assessment in medical settings has received attention, the longitudinal study of such efforts has been restricted to studying a single assessment/intervention dose. Such interventions can be recurrent and have effects on subsequent problem drinking.

METHOD

A sample of problem drinkers in the general population (n = 672) and with admissions to chemical-dependency programs (n = 926) was interviewed at baseline and 1, 3, 5, and 7 years later. At each wave, respondents were asked about their drinking, their medical visits, and the intensity of the medical contact (whether during the visit they were asked about their drinking and, if so, whether they received or were referred to alcohol treatment).

RESULTS

Rates of problem drinking declined over time, from 48% at the 1-year follow up to 38% at the 7-year follow-up. Problem drinkers were more likely at each wave to receive or be referred to treatment. Alcohol and drug severity increased with more intensive medical-contact types over time. Predicting subsequent problem drinking status from prior intensity of medical contact, odds of problem drinking at subsequent waves decreased with time, age, and prior drug severity while increasing with volume and alcohol severity. Odds of problem drinking were lower among prior problem drinkers receiving assessment and treatment/referral, compared with the assessed-only group. Examined separately, this effect was found only for those drinkers with lower volumes (average < 0.5 drinks/day).

CONCLUSIONS

Alcohol assessment may be effective in reducing problem drinking but may be most effective among the non-heaviest drinkers.

Measuring smoking knowledge, attitudes and services (S-KAS) among clients in addiction treatment

BACKGROUND

Addiction treatment programs are increasingly working to address prevalent and comorbid tobacco dependence in their service populations. However at present there are few published measurement tools, with known psychometric properties, that can be used to assess client-level constructs related to tobacco dependence in addiction treatment settings. Following on previous work that developed a staff-level survey instrument, this report describes the development and measurement characteristics of the smoking knowledge, attitudes and services (S-KAS) for use with clients in addiction treatment settings.

METHOD

250 clients enrolled in residential drug abuse treatment programs were surveyed. Summary statistics were used to characterize both the participants and their responses, and exploratory factor analysis (EFA) was used to examine the underlying factor structure.

RESULTS

Examination of the rotated factor pattern indicated that the latent structure was formed by one knowledge factor, one attitude factor, and two "service" factors reflecting program services and clinician services related to tobacco dependence. Standardized Cronbach's alpha coefficients for the four scales were, respectively, .57, .75, .82 and .82.

CONCLUSIONS

The proposed scales have reasonably good psychometric characteristics, although the knowledge scale leaves room for improvement, and will allow researchers to quantify client knowledge, attitudes and services regarding tobacco dependence treatment. Researchers, program administrators, and clinicians may find the S-KAS useful in changing organizational culture and clinical practices related to tobacco addiction, help in program evaluation studies, and in tracking and improving client motivation.

The Smoking Abstinence Questionnaire: measurement of smokers' abstinence-related expectancies

AIMS

To develop and validate a measure of smokers' expectancies for the abstinence process upon quitting smoking: the Smoking Abstinence Questionnaire (SAQ).

DESIGN

Principal component analysis and other psychometric analyses of self-report data.

SETTING

San Francisco, California.

PARTICIPANTS

A total of 507 adult smokers of at least 10 cigarettes per day diverse in gender, sexual orientation and ethnoracial status.

MEASUREMENTS

The primary measure was a draft version of the SAQ. Additional measures assessed a variety of other smoking-related constructs.

FINDINGS

Analyses yielded 10 scales of the SAQ: Withdrawal, Social Improvement/Non-smoker Identity, Adverse Outcomes, Treatment Effectiveness, Common Reasons, Barriers to Treatment, Social Support, Optimistic Outcomes, Coffee Use and Weight Gain. The SAQ scales demonstrated internal consistencies ranging from 0.62 to 0.85 and were associated with tobacco dependence, motivation to quit, abstinence self-efficacy, withdrawal symptoms, dietary restraint, shape and weight concern and tobacco use expectancies. The SAQ predicted smoking-related constructs above and beyond tobacco use expectancies, suggesting that abstinence-related expectancies and tobacco use expectancies are distinct from one another.

CONCLUSIONS

A newly developed questionnaire, the Smoking Abstinence Questionnaire, appears to capture reliably smokers' expectancies for abstinence (Withdrawal, Social Improvement/Non-smoker Identity, Adverse Outcomes, Common Reasons, Optimistic Outcomes, Coffee Use, and Weight Gain) and expectancies related to the success of a quit attempt (Treatment Effectiveness, Barriers to Treatment and Social Support). It remains to be seen how far any of these expectancies predict attempts to quit, withdrawal, treatment utilization and response and quitting success above and beyond existing measures.

Cognitive functioning in individuals with severe compulsive hoarding behaviors and late life depression

OBJECTIVES

The cognitive characteristics of individuals with severe compulsive hoarding behaviors (SCH) are not well understood and existing studies have largely focused on individuals with SCH and concurrent anxiety disorders. The present study was conducted to evaluate the frequency with which SCH co-occurs with LLD and to compare the cognitive characteristics of individuals with late life depression and concurrent SCH (LLD+SCH) to that of LLD individuals without SCH (LLD).

METHODS

Participants included 52 LLD individuals who received psychiatric and neuropsychological evaluations as part of a larger study. Cognitive performance on measures of memory, attention, language, information processing speed, and categorization/problem solving ability was evaluated for each participant using standard neuropsychological measures. Measures of depression and anxiety symptom severity were also obtained.

RESULTS

Seven (13%) of the 52 LLD participants reported significant SCH behaviors. The two groups (LLD+SCH; LLD) did not differ with respect to demographic characteristics or severity of depression or anxiety. Individuals with LLD+SCH demonstrated significantly poorer performance on two measures of categorization/problem solving ability relative to individuals with isolated LLD. Clinically significant impairments on measures of categorization ability, information processing speed, and verbal memory were more common for SCH+LLD than LLD participants.

CONCLUSIONS

Our preliminary results suggest that SCH behaviors in LLD are associated with specific aspects of executive dysfunction characterized by categorization deficits and to a lesser extent information processing speed and verbal memory deficits. Further study of cognitive functioning in older adults with LLD and SCH may clarify the underlying cognitive characteristics of the SCH syndrome.

Latent class analysis of the Yale-Brown Obsessive-Compulsive Scale symptoms in obsessive-compulsive disorder

OBJECTIVE

Obsessive-compulsive disorder (OCD) is phenomenologically heterogeneous, and findings of underlying structure classification based on symptom grouping have been ambiguous to date. Variable-centered approaches, primarily factor analysis, have been used to identify homogeneous groups of symptoms; but person-centered latent methods have seen little use. This study was designed to uncover sets of homogeneous groupings within 1611 individuals with OCD based on symptoms.

METHOD

Latent class analysis models using 61 obsessive-compulsive symptoms collected from the Yale-Brown Obsessive-Compulsive Scale were fit. Relationships between latent class membership and treatment response, sex, symptom severity, and comorbid tic disorders were tested for relationship to class membership.

RESULTS

Latent class analysis models of best fit yielded 3 classes. Classes differed only in frequency of symptom endorsement. Classes with higher symptom endorsement were associated with earlier age of onset, being male, higher Yale-Brown Obsessive-Compulsive Scale symptom severity scores, and comorbid tic disorders. There were no differences in treatment response between classes.

CONCLUSIONS

These results provide support for the validity of a single underlying latent OCD construct, in addition to the distinct symptom factors identified previously via factor analyses.

A population-based examination of cigarette smoking and mental illness in Black Americans

INTRODUCTION

This study examines the relation between tobacco use and cessation with lifetime and past year mental illness in a nationally representative sample of Blacks.

METHODS

This cross-sectional study analyzed nationally representative data from 3,411 adult Blacks participating in the 2001-2003 National Survey of American Life. Smoking prevalence and quit rates according to lifetime and past year Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition mental disorders were assessed by a modified version of the Composite International Diagnostic Interview.

RESULTS

Compared with those without mental illness, respondents with a lifetime, past year, or past month mental illness had a higher smoking prevalence (20.6%, 35.6%, 36.0%, and 45.4%, respectively) and lower quit rate (40.5%, 31.2%, and 26.2%, respectively). The odds of being a current smoker among Blacks with mental illness in their lifetime, past year, and past month, after adjusting for age, gender, education, poverty, and marital status were 1.76 (95% CI = 1.39-2.22), 1.57 (95% CI = 1.22-2.03), and 2.20 (95% CI = 1.56-3.12), respectively. Mental illness also was associated with heavier smoking. Blacks with past year mental illness represented 18.1% of the sample, yet consumed 23.9% of cigarettes smoked by Black smokers. Past year (odds ratio [OR] = 0.72, 95% CI = 0.53-0.97) and past month (OR = 0.54, 95% CI = 0.29-0.98) mental illness were associated with a lower odds of quitting for at least 1 year.

CONCLUSIONS

Findings indicate that mental illness is significantly associated with tobacco use in Blacks. Tobacco cessation interventions that address mental illness as a barrier to cessation are needed.

Mechanisms of change in extended cognitive behavioral treatment for tobacco dependence

AIM

To evaluate potential mediators of an extended cognitive behavioral smoking cessation intervention.

DESIGN

Analysis of data from a randomized clinical trial of smoking cessation.

SETTING

The Habit Abatement Clinic, University of California, San Francisco.

PARTICIPANTS

Participants were older cigarette smokers (>/=50 years old). Those receiving Standard Treatment (N=100) were compared to those receiving extended cognitive behavioral treatment (N=99).

MEASUREMENTS

Negative affect was measured with the Profile of Mood States (POMS), the Medical Outcome Studies 36-item Short-Form Health Survey (SF-36), and the Perceived Stress Scale (PSS). Abstinence-specific social support was measured with the Partner Interaction Questionnaire (PIQ). Motivation to quit and abstinence self-efficacy were measured on 1-10 scales with the Thoughts about Abstinence Questionnaire. All were measured at the beginning of treatment and week 52.

RESULTS

Analyses revealed that extended CBT increased abstinence self-efficacy over the first 52 weeks postcessation. This effect, in turn, was positively associated with 7-day point prevalence abstinence at week 64 while controlling for treatment condition, and eliminated the independent effect of treatment condition on abstinence. The test of mediation indicated a significant effect, and abstinence self-efficacy accounted for 61% to 83% of the total effect of treatment condition on smoking abstinence. Results failed to support a mediational role of negative affect, abstinence-specific social support, or motivation to quit.

CONCLUSIONS

The results of the present study are consistent with theories of relapse and studies of more time-limited interventions, and underscore the importance of abstinence self-efficacy in achieving long-term abstinence from cigarettes.

Symptom dimensions in OCD: item-level factor analysis and heritability estimates

To reduce the phenotypic heterogeneity of obsessive-compulsive disorder (OCD) for genetic, clinical and translational studies, numerous factor analyses of the Yale-Brown Obsessive Compulsive Scale checklist (YBOCS-CL) have been conducted. Results of these analyses have been inconsistent, likely as a consequence of small sample sizes and variable methodologies. Furthermore, data concerning the heritability of the factors are limited. Item and category-level factor analyses of YBOCS-CL items from 1224 OCD subjects were followed by heritability analyses in 52 OCD-affected multigenerational families. Item-level analyses indicated that a five factor model: (1) taboo, (2) contamination/cleaning, (3) doubts, (4) superstitions/rituals, and (5) symmetry/hoarding provided the best fit, followed by a one-factor solution. All 5 factors as well as the one-factor solution were found to be heritable. Bivariate analyses indicated that the taboo and doubts factor, and the contamination and symmetry/hoarding factor share genetic influences. Contamination and symmetry/hoarding show shared genetic variance with symptom severity. Nearly all factors showed shared environmental variance with each other and with symptom severity. These results support the utility of both OCD diagnosis and symptom dimensions in genetic research and clinical contexts. Both shared and unique genetic influences underlie susceptibility to OCD and its symptom dimensions.

Transitioning into and out of problem drinking across seven years

OBJECTIVE

The extent to which problem drinkers transition into and out of problem drinking was examined using Markov modeling.

METHOD

Study participants (N = 1,350) were randomly sampled from one county's general population and from consecutive admissions to public and private alcohol treatment programs in the same county, and they were assessed at 1-, 3-, 5-, and 7-year follow-ups. At baseline, all met the criteria for problem drinking. Individuals were classified as "problem drinkers" if they reported at least two of three criteria (heavy episodic drinking, social consequences, dependence symptoms according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) during the prior 12 months.

RESULTS

Although all possible patterns were observed, a latent Markov model with heterogeneous transitions and five patterns fit the data. The sampling frame and baseline alcohol severity related to pattern.

CONCLUSIONS

The data indicate that, although they do change over time, problem drinkers on the whole are more likely either to remain problem drinkers or to cease to be problem drinkers than they are to move into and out of problem-drinking status. Once they transition out of problem drinking, they are more likely to remain nonproblem drinkers.

Drug treatment utilization before, during and after pregnancy

This study retrospectively explored drug treatment utilization before, during and after pregnancy for all identified substance-using women delivering at a county hospital over a 4-year period (n=431). Drug treatment data were linked to hospital data to analyse treatment utilization. Fifty-three per cent received treatment the year before, during, or within the year after delivery, with a significantly higher proportion receiving treatment during and after pregnancy. There were significant increases in methadone and residential treatment services during pregnancy. Women spent significantly more time in treatment after delivery compared with before or during pregnancy. However, 47% of these women did not receive drug treatment. These findings support current literature suggesting that pregnancy presents an opportunity to engage women in treatment. However, there is a need to decrease the institutional, legal, and funding barriers that exist between health care and drug treatment providers. Utilizing available data to track perinatal substance use and treatment utilization are important to plan for adequate availability of treatment services for this population.

Global reach of an Internet smoking cessation intervention among Spanish- and English-speaking smokers from 157 countries

This investigation is a secondary analysis of demographic, smoking, and depression information in a global sample of Spanish- and English-speaking smokers who participated in a series of randomized controlled smoking cessation trials conducted via the Internet. The final sample consisted of 17,579 smokers from 157 countries. Smoking profiles were similar across languages and world regions and consistent with characteristics of participants in traditional smoking cessation studies. Participants were predominantly Spanish-speakers, evenly divided between men and women and relatively few indicated using traditional smoking cessation methods (e.g., groups or medication). This study demonstrates that substantial numbers of smokers from numerous countries seek Web-based smoking cessation resources and adds to the growing support for Web-assisted tobacco interventions as an additional tool to address the need for global smoking cessation efforts.

Development of the Smoking Knowledge, Attitudes, and Practices (S-KAP) Instrument

This report describes the development and measurement characteristics of a new measure of smoking knowledge, attitudes, and practices (S-KAP) among treatment providers. Data are based on survey responses from 336 paid staff working in one of three drug abuse treatment or HIV care settings. Exploratory factor analysis, used to examine the factor structure, pointed towards five underlying factors: a single "knowledge" factor, three "attitude" factors ('treatment barriers,' 'counselor self-factor. The Knowledge scale had a standardized Cronbach's alpha coefficient of .85. The coefficients for Barriers, Self-Efficacy, and Attitudes were .81, .72, and .74, respectively. The Practice scale had a standardized Cronbach's alpha coefficient of .91. These results indicate that the proposed scales have reasonably good psychometric characteristics and will allow researchers to quantify staff knowledge, attitudes, and practices regarding smoking cessation treatments and issues.

Methadone patients in the therapeutic community: a test of equivalency

BACKGROUND

Residential therapeutic communities (TCs) have demonstrated effectiveness, yet for the most part they adhere to a drug-free ideology that is incompatible with the use of methadone. This study used equivalency testing to explore the consequences of admitting opioid-dependent clients currently on methadone maintenance treatment (MMT) into a TC.

METHODS

The study compared 24-month outcomes between 125 MMT patients and 106 opioid-dependent drug-free clients with similar psychiatric history, criminal justice pressure and expected length of stay who were all enrolled in a TC. Statistical equivalence was expected between groups on retention in the TC and illicit opioid use. Secondary hypotheses posited statistical equivalence in the use of stimulants, benzodiazepines, and alcohol, as well as in HIV risk behaviors.

RESULTS

Mean number of days in treatment was statistically equivalent for the two groups (166.5 for the MMT group and 180.2 for the comparison group). At each assessment, the proportion of the MMT group testing positive for illicit opioids was indistinguishable from the proportion in the comparison group. The equivalence found for illicit opioid use was also found for stimulant and alcohol use. The groups were statistically equivalent for benzodiazepine use at all assessments except at 24 months where 7% of the MMT group and none in the comparison group tested positive. Regarding injection- and sex-risk behaviors the groups were equivalent at all observation points.

CONCLUSIONS

Methadone patients fared as well as other opioid users in TC treatment. These findings provide additional evidence that TCs can be successfully modified to accommodate MMT patients.