Benzodiazepine maintenance for alcohol dependence: A case series

Alcohol addiction is a chronic relapsing syndrome. Benzodiazepines remain as the mainstay for detoxification, taking care of the acute withdrawal syndrome. There is fear of dependence and abuse of benzodiazepines on prolonged use. Here, we selectively interviewed ten cases who were on longer duration of benzodiazepines to elicit their potential perceived benefits, attitudes, and any adverse effect. Three patients experienced adverse effects. None of them had features of benzodiazepine dependence. We opine that in select cases, benzodiazepine use should persist beyond detox period, and its benefits continue beyond the acute withdrawal phase while monitoring their safety/adverse effects.

PPARγ agonism attenuates cocaine cue reactivity

Cocaine use disorder is a chronic relapsing condition characterized by compulsive drug seeking and taking even after prolonged abstinence periods. Subsequent exposure to drug-associated cues can promote intense craving and lead to relapse in abstinent humans and rodent models. The responsiveness to these cocaine-related cues, or 'cue reactivity', can trigger relapse and cocaine-seeking behaviors; cue reactivity is measurable in cocaine-dependent humans as well as rodent models. Cue reactivity is thought to be predictive of cocaine craving and relapse. Here we report that PPARγ agonism during abstinence from cocaine self-administration reduced previously active lever pressing in Sprague Dawley rats during cue-reactivity tests, while administration of the PPARγ antagonist, GW9662, reversed this effect. PPARγ agonism also normalized nuclear ERK activity in the medial prefrontal cortex and hippocampus which was reversed with GW9662. Our results support the utility of PPARγ agonism as a relapse prevention strategy to maintain abstinence in the presence of cocaine-associated cues.

Randomised controlled trial of the clinical and cost-effectiveness of a peer-delivered self-management intervention to prevent relapse in crisis resolution team users: study protocol

INTRODUCTION

Crisis resolution teams (CRTs) provide assessment and intensive home treatment in a crisis, aiming to offer an alternative for people who would otherwise require a psychiatric inpatient admission. They are available in most areas in England. Despite some evidence for their clinical and cost-effectiveness, recurrent concerns are expressed regarding discontinuity with other services and lack of focus on preventing future relapse and readmission to acute care. Currently evidence on how to prevent readmissions to acute care is limited. Self-management interventions, involving supporting service users in recognising and managing signs of their own illness and in actively planning their recovery, have some supporting evidence, but have not been tested as a means of preventing readmission to acute care in people leaving community crisis care. We thus proposed the current study to test the effectiveness of such an intervention. We selected peer support workers as the preferred staff to deliver such an intervention, as they are well-placed to model and encourage active and autonomous recovery from mental health problems.

METHODS AND ANALYSIS

The CORE (CRT Optimisation and Relapse Prevention) self-management trial compares the effectiveness of a peer-provided self-management intervention for people leaving CRT care, with treatment as usual supplemented by a booklet on self-management. The planned sample is 440 participants, including 40 participants in an internal pilot. The primary outcome measure is whether participants are readmitted to acute care over 1 year of follow-up following entry to the trial. Secondary outcomes include self-rated recovery at 4 and at 18 months following trial entry, measured using the Questionnaire on the Process of Recovery. Analysis will follow an intention to treatment principle. Random effects logistic regression modelling with adjustment for clustering by peer support worker will be used to test the primary hypothesis.

ETHICS AND DISSEMINATION

The CORE self-management trial was approved by the London Camden and Islington Research Ethics Committee (REC ref: 12/LO/0988). A Trial Steering Committee and Data Monitoring Committee oversee the progress of the study. We will report on the results of the clinical trial, as well as on the characteristics of the participants and their associations with relapse.

TRIAL REGISTRATION NUMBER

ISRCTN 01027104;pre-results stage.

Use of a Smartphone Recovery Tool for Latinos with Co-Occurring Alcohol and Other Drug Disorders and Mental Disorders

OBJECTIVE

Addressing alcohol and other drug disorders and other mental disorders among adult Hispanics/Latinos is of critical concern, as they are one of the fastest-growing ethnic groups with a disproportionate rate of disease, mental disorders, and poverty. Although improvement in outcomes is associated with sustained participation in ongoing treatment for co-occurring alcohol and other drug disorders/mental disorders, continuing care is rare for these chronic conditions, especially for Latinos with more limited access to culturally and linguistically competent services.

METHODS

The evidence-based smartphone recovery application Addiction-Comprehensive Health Enhancement Support System (A-CHESS) was translated and adapted for Spanish-speaking Latinos with alcohol and other drug disorders/mental disorders, thus developing CASA-CHESS to address a high level of need for services, high rates of relapse, and lack of existing culturally competent services for Latinos.

RESULTS

Of the 79 Latino clients who completed residential treatment and received a smartphone equipped with CASA-CHESS, 26.6% discontinued using CASA-CHESS and 73.4% remained active for four or more months. CASA-CHESS usage was sustained over the four months across all three tenets of self-determination theory (competence, relatedness, and autonomy), with the most commonly utilized services being relevant to relatedness (e.g., messaging, discussion boards). CASA-CHESS clients demonstrated a similar pattern of usage to A-CHESS clients.

CONCLUSIONS

Findings illustrate that Spanish-speaking Latinos with alcohol and other drug disorders/mental disorders will use a smartphone application to assist with their recovery, continuing their access to resources, case management, and quality information after leaving residential treatment. Consistent with previous findings, our results also emphasize the importance of social support during the four months post-discharge. Such evidence-based, theory-driven digital interventions may extend access to culturally and linguistically competent services.

Hypnosis for Smoking Relapse Prevention: A Randomized Trial

The purpose of this study was to determine whether hypnosis would be more effective than standard behavioral counseling in helping smokers to remain abstinent. A total of 140 current smokers were enrolled in a randomized controlled smoking cessation trial at an urban Veterans Affairs medical center. Participants (n = 102) who were able to quit for at least 3 days received either a hypnosis or behavioral relapse prevention intervention. Both relapse prevention interventions consisted of two 60 min face-to-face sessions and four 20 min follow-up phone calls (two phone calls per week). At 26 weeks, the validate\d point-prevalence quit rate was 35% for the hypnosis group and 42% for the behavioral counseling group (relative risk = 0.85; 95% confidence interval: 0.52-1.40). At 52 weeks, the validated quit rate was 29% for the hypnosis group and 28% for the behavioral group (relative risk  = 1.03; 95% confidence interval: 0.56-1.91). It was concluded that hypnosis warrants further investigation as an intervention for facilitating maintenance of quitting.

Stimuli previously associated with reinforcement mitigate resurgence

Resurgence refers to the recurrence of an extinguished target behavior following subsequent suspension of alternative reinforcement. Delivery of reinforcers during extinction of alternative behavior has been shown to mitigate resurgence. The present experiment aimed to determine whether delivering stimuli associated with reinforcers during resurgence testing similarly mitigates resurgence. Three groups of rats pressed target levers for food according to variable-interval 15-s schedules during Phase 1. In Phase 2, lever pressing was extinguished, and an alternative nose-poke response produced alternative reinforcement according to a variable-interval 15-s schedule. Food reinforcement was always associated with illumination of the food aperture and an audible click from the pellet dispenser during Phases 1 and 2. Phase 3 treatments differed between groups. For one group, nose poking continued to produce food and food-correlated stimuli. Both of these consequences were suspended for a second group. Finally, nose poking produced food-correlated stimuli but not food for a third group. Target-lever pressing resurged in the group that received no consequences and in the group that received only food-correlated stimuli for nose poking. Resurgence, however, was smaller for the group that received food-correlated stimuli than for the group that received no consequences for nose poking. Target-lever pressing did not increase between phases in the group that continued to receive food and associated stimuli. Thus, delivery of stimuli associated with food reinforcement after suspension of food reduced but did not eliminate resurgence of extinguished lever pressing. These findings contribute to potential methodologies for preventing relapse of extinguished problem behavior in clinical settings.

Providing Antismoking Socialization to Children After Quitting Smoking: Does It Help Parents Stay Quit?

PURPOSE

To test whether an antismoking parenting program provided to parents who had quit smoking for ≥24 hours increased parents' likelihood of remaining abstinent 2 and 3 years postbaseline.

DESIGN

Two-group randomized controlled trial with 3-year follow-up.

SETTING

Eleven states (Colorado, Indiana, Michigan, Minnesota, Montana, New York, Ohio, Pennsylvania, South Dakota, Utah, and Vermont).

PARTICIPANTS

Five hundred seventy-seven adults (286 treatment and 291 control) who had smoked ≥10 cigarettes daily at baseline, had quit smoking for ≥24 hours after calling a Quitline, and were parents of an 8- to 10-year-old child; 358 (62%) completed the 2-year follow-up interview, and 304 (53%) completed the 3-year follow-up interview.

INTERVENTION

Theory-driven, home-based, self-help parenting program.

MEASURES

Sociodemographic, smoking history, and 30-day point prevalence.

ANALYSIS

Multivariable regression analyses tested for group differences in 30-day abstinence. Attriters were coded as having relapsed.

RESULTS

Between-group differences in abstinence rates were 5.6% and 5.9% at 2 and 3 years, respectively. Treatment group parents had greater odds of abstinence, an effect that was significant only at the latter time point (odds ratio [OR] = 1.49, P = .075 at 2 years; OR = 1.70, P = .026 at 3 years).

CONCLUSIONS

This study obtained preliminary evidence that engaging parents who recently quit smoking as agents of antismoking socialization of children has the potential to reduce the long-term odds of relapse.

Evaluation of a community-based integrated heroin addiction treatment model in Chinese patients

In this study, we analyzed the efficacy and feasibility of a community-based integrated heroin addiction treatment model in Chinese patients. The 210 heroin addicts belonging to six Chinese communities received an integrated biopsychosocial intervention that included pharmacological treatment, counseling and social assistance. High proportions of study participants were retained at the 12-month (91.9%; 193/210) and 24-month (88.1%; 185/210) follow-up visits. The number of morphine-positive subjects declined from 61.4% at baseline to 36.2% and 30.5% (Q=52.01; P<0.001) after 12 and 24 months, respectively. The crime rate decreased from 32.4% at baseline to 2.2% and 1.6% (Q=7.84; P<0.001) after 12 and 24 months, respectively. The number of patients that were employed increased from 24.3% at baseline to 37.8% and 50.8% after 12 and 24 months, respectively (Q=41.68; P<0.001). Addiction-related issues and mental health status improved according to Addiction Severity Index (ASI) and Symptom Checklist-90 (SCL-90). We therefore conclude that this community-based, integrated heroin addiction treatment model is highly feasible with high treatment retention, reduced drug use, a lower crime rate, improved health and increased employment.

An mHealth App for Supporting Quitters to Manage Cigarette Cravings With Short Bouts of Physical Activity: A Randomized Pilot Feasibility and Acceptability Study

Background

While gains in reducing smoking rates in Finland have been made, prevalence rates are still substantial. Relapse rates among smokers engaged in quit-smoking programs are high. Physical activity has been proposed as one means to help smokers manage cravings. Software and apps on mobile phone and handheld devices offer an opportunity to communicate messages on how to use physical activity to manage cravings as part of quit-smoking programs.

Objective

We aimed to test the feasibility, acceptability, usability, and preliminary efficacy of an mHealth mobile phone app, Physical activity over Smoking (PhoS), to assist smokers in quitting smoking in a randomized controlled trial. The app was designed to prompt smokers to engage in physical activities to manage their smoking cravings.

Methods

Regular smokers (n=44) attended a group-based behavioral counselling program aimed at promoting physical activity as an additional aid to quit. After quit day, participants were randomly allocated to an intervention (n=25) or to a comparison (n=19) group. Participants in the intervention group were provided with the PhoS app and training on how to use it to assist with relapse prevention. Participants in the comparison condition were provided with generalized relapse prevention training.

Results

Some participants reported that the PhoS app was useful in assisting them to successfully manage their cigarette cravings, although compliance across the sample was modest and participants reported low levels of usability. Participants receiving the PhoS app did not report greater abstinence than those who did not receive the app. However, participants receiving the app were more likely to report greater abstinence if they did not use pharmacological support, while those who did not receive the app reported greater abstinence when using pharmacological support. Participants receiving the app reported greater levels of physical activity than those who did not. Results revealed that the app resulted in better retention.

Conclusions

The PhoS app showed some potential to reduce abstinence among participants not using pharmacological therapy and to increase physical activity. However, problems with usability and lack of effects on abstinence raise questions over the app’s long-term effectiveness. Future research should prioritize further development of the app to maximize usability and test effects of the intervention independent of quit-smoking programs.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 55259451; http://www.controlled-trials.com/ISRCTN55259451 (Archived by WebCite at http://www.webcitation.org/6cKF2mzEI)

Effectiveness of Mobile Apps for Smoking Cessation: A Review

INTRODUCTION

Smartphone-based smoking cessation interventions are increasingly used around the world. However, the effects of smartphone applications on applicability and efficacy on cessation rate and prevention of relapses are not often evaluated. Therefore, this review aims to assess the evidence on effectiveness of smartphone applications as an intervention tool for smoking cessation support.

METHODS

We conducted the search using Ovid Medline/PubMed, CENTRAL and Scopus databases dated (January 2007-June 2016). Inclusion criteria include randomized control trials or intervention studies with mobile applications that offer smoking cessation support. Two assessors independently extracted and evaluated the data from each included study.

RESULTS

The review of eight selected studies illustrate the use of smartphone applications in increasing quit rates among smokers, however adherence to app features influences quit rates. Audiovisual features followed by a quit plan, tracking progress and sharing features are most accepted and utilised app features. However, inconsistency was observed in their association with abstinence or quit rate. App engagement features increase the statistical significance in the quit rate. Development of smartphone applications was supported by behavior change theories in all studies nevertheless; heterogeneous forms of intervention were adopted within studies. Similarly, reduction in relapse attributed to enhanced discussion among quitters using social media applications was observed.

CONCLUSIONS

Quality evidence is warranted with large sample size to measure effect size of the intervention. Future research on effectiveness and efficacy of smartphone alone and comparisons with other mHealth interventions, such as text messaging would be useful.

The Role of Self-Efficacy, Adaptive Coping, and Smoking Urges in Long-Term Cessation Outcomes

OBJECTIVE

Smoking cessation self-efficacy and adaptive coping are posited as two important treatment targets in smoking cessation interventions, especially in the context of handling strong urges to smoke. Yet, less is known about whether intervention-related changes in these constructs predict long-term smoking outcomes. The current study aimed to examine changes in smoking urges, smoking cessation self-efficacy, and adaptive coping following a health-focused and cognitive-behavioral telephone-delivered smoking cessation treatment, and the association to smoking reduction during long-term, 12-month follow-up.

METHODS

Participants (n = 61) were daily smokers enrolled in a 12-week pilot trial that tested the efficacy of two different health-focused interventions with an adjunct of traditional telephone-delivered cessation counseling. Smoking urges, smoking cessation self-efficacy, and adaptive coping were assessed as baseline and immediately post-treatment. Average of seven-day cigarettes use per day were assessed at post-treatment, and 6- and 12-months post-baseline follow-up timepoints.

RESULTS

Smoking urges were significantly lower post-treatment, and smoking cessation self-efficacy and adaptive coping were significantly higher post-treatment, relative to baseline. After adjusting for baseline values, post-treatment smoking urges were significantly positively associated with cigarette use at post-treatment and 6-month follow-up. Post-treatment smoking cessation self-efficacy, but not adaptive coping, was significantly negatively predictive of cigarette use at post-treatment and 6- and 12-month follow-up timepoints. Post-treatment smoking cessation self-efficacy emerged as significant indirect predictor of the association between post-treatment smoking urges and post-treatment cigarette use.

CONCLUSIONS

Interventions that target smoking cessation self-efficacy may facilitate long-term reductions in smoking among daily smokers undergoing a quit attempt.

Helping Sex Offenders to Desist Offending: The Gains and Drains for CoSA Volunteers-A Review of the Literature

In Circles of Support and Accountability (CoSA), a group of trained volunteers support sex offenders in their desistance process by engaging in a long-lasting empathic relationship. Is it safe to employ volunteers in this way? This literature review provides an overview of both theoretical explanations and empirical evidence of the possible impact of this type of volunteerism on the volunteers themselves. Fifty original research articles and reviews met the selection criteria of a systematic search. Results on effects of volunteering in general, effects of volunteer work with offenders, and effects of working with sex offenders on professionals are summarized and integrated. Generally, volunteering supports and improves physical health and mental well-being, personal growth, and citizenship. However, working with sex offenders in an empathic relationship generates both positive and negative effects on psychological and social function. Personal characteristics, task characteristics, and organizational characteristics moderate and mediate the impact.

Implementation of a Substance Use Recovery Support Mobile Phone App in Community Settings: Qualitative Study of Clinician and Staff Perspectives of Facilitators and Barriers

BACKGROUND

Research supports the effectiveness of technology-based treatment approaches for substance use disorders. These approaches have the potential to broaden the reach of evidence-based care. Yet, there is limited understanding of factors associated with implementation of technology-based care approaches in different service settings.

OBJECTIVES

In this study, we explored provider and staff perceptions of facilitators and barriers to implementation of a mobile phone substance use recovery support app with clients in 4 service settings.

METHODS

Interviews were conducted with leadership and provider stakeholders (N=12) from 4 agencies in the first year of an implementation trial of the mobile phone app. We used the Consolidated Framework for Implementation Research as the conceptual foundation for identifying facilitators and barriers to implementation.

RESULTS

Implementation process facilitators included careful planning of all aspects of implementation before launch, engaging a dedicated team to implement and foster motivation, working collaboratively with the app development team to address technical barriers and adapt the app to meet client and agency needs, and consistently reviewing app usage data to inform progress. Implementation support strategies included training all staff to promote organization awareness about the recovery support app and emphasize its priority as a clinical care tool, encouraging clients to try the technology before committing to use, scaling rollout to clients, setting clear expectations with clients about use of the app, and using peer coaches and consistent client-centered messaging to promote engagement. Perceived compatibility of the mobile phone app with agency and client needs and readiness to implement emerged as salient agency-level implementation facilitators. Facilitating characteristics of the recovery support app itself included evidence of its impact for recovery support, perceived relative advantage of the app over usual care, the ability to adapt the app to improve client use, and its ease of use. The mobile phone itself was a strong motivation for clients to opt in to use the app in settings that provided phones. App access was limited in settings that did not provide phones owing to lack of mobile phone ownership or incompatibility of the app with clients' mobile phones. Individual differences in technology literacy and provider beliefs about substance use care either facilitated or challenged implementation. Awareness of patient needs and resources facilitated implementation, whereas external policies and regulations regarding technology use introduced barriers to implementation.

CONCLUSIONS

The conceptually grounded facilitators and barriers identified in this study can guide systematic targeting of strategies to improve implementation of mobile phone interventions in community treatment settings. Results also inform the design of technology-based therapeutic tools. This study highlights directions for research with regard to implementation of technology-based behavioral health care approaches.

A Cognitive Behavioral Therapy-Based Text Messaging Intervention Versus Medical Management for HIV-Infected Substance Users: Study Protocol for a Pilot Randomized Trial

Background

Evidence-based psychosocial interventions for addictions and related conditions such as cognitive behavioral therapy (CBT) are underutilized. Obstacles to implementation of CBT in clinical settings include limited availability of quality training, supervision, and certification in CBT for clinicians; high rates of clinician turnover and high caseloads; and limited qualifications of the workforce to facilitate CBT expertise.

Objective

Mobile phone–based delivery of CBT, if demonstrated to be feasible and effective, could be transformative in broadening its application and improving the quality of addiction treatment. No experimental interventions that deliver CBT targeting both drug use and medication adherence using text messaging have been previously reported; as such, the objective of this study is to develop and test an SMS-based treatment program for HIV-positive adults with comorbid substance use disorders.

Methods

With user input, we developed a 12-week CBT-based text messaging intervention (TXT-CBT) targeting antiretroviral (ART) adherence, risk behaviors, and drug use in a population of HIV-infected substance users.

Results

The intervention has been developed and is presently being tested in a pilot randomized clinical trial. Results will be reported later this year.

Conclusions

This investigation will yield valuable knowledge about the utility of a cost-effective, readily deployable text messaging behavioral intervention for HIV-infected drug users.

A Preliminary Exploration of Former Smokers Enrolled in an Internet Smoking Cessation Program

BACKGROUND

Internet interventions may have an important role to play in helping self-quitters maintain an initial period of abstinence. Little is known about the characteristics and utilization patterns of former smokers who use Internet cessation programs.

OBJECTIVE

The overarching aim of this preliminary study was to establish the feasibility of a subsequent randomized trial of the effectiveness of Internet interventions in preventing relapse. Specifically, this study sought to determine the number of former smokers that register on a smoking cessation website, the characteristics of former smokers and their website utilization patterns, and potential predictors of sustained abstinence.

METHODS

Participants were self-identified former smokers who registered on a free smoking cessation website. Recruitment occurred immediately following site registration. Participants completed Web-based baseline and 1-month follow-up assessments. Website utilization metrics were extracted at 1 month. Descriptive statistics were used to characterize the full sample. Baseline differences were examined between recent quitters (≤7 days of abstinence at enrollment) and more established quitters (8+ days of abstinence at enrollment) using chi-square tests and t tests. Univariate logistic regression examined demographic, smoking, psychosocial characteristics, and website utilization metrics as predictors of 1-month abstinence.

RESULTS

During the 10-month study period, 1141 former smokers were recruited to participate: 494 accepted the invitation, 395 were eligible, 377 provided informed consent, and 221 completed the baseline and fully enrolled (56% of those eligible). At 1 month, 55.7% (123/221) of participants completed the follow-up survey. Mean age was 44.25 years (SD 12.78) and the sample was primarily female (174/221, 78.7%), white (196/221, 88.7%), and had at least some college education (177/221, 80.1%). Slightly more than half of participants (123/221, 55.7%) reported quitting more than a week prior to website registration and 43.9% (97/221) had quit within 7 days of registration. The website features most likely to be used were an interactive Quit Date tool (166/221, 75.1%) and the Community (134/221, 60.6%). Univariate regression models showed that recent quitters, those with higher motivation to remain abstinent, and those who used cessation medication in the past year were more likely to use the Community. Older age, longer duration of abstinence at registration, better health status, and health care provider advice to quit were associated with 1-month abstinence. Website utilization metrics did not predict abstinence, though odds ratios suggested higher utilization was associated with greater odds of abstinence.

CONCLUSIONS

This exploratory study demonstrated the feasibility of recruiting former smokers to a research study and documented the uptake of an Internet cessation intervention among this group of self-quitters. Results also showed higher levels of website utilization and greater likelihood of community use among smokers early in their quit attempt compared to those with a longer period of abstinence at enrollment. Important areas for future research include identifying former smokers who may be more susceptible to relapse and determining which components of an Internet intervention are most helpful to prevent relapse in the early and later stages of a quit attempt.

Novel oral transforming growth factor-β signaling inhibitor EW-7197 eradicates CML-initiating cells

Recent strategies for treating CML patients have focused on investigating new combinations of tyrosine kinase inhibitors (TKIs) as well as identifying novel translational research agents that can eradicate CML leukemia‐initiating cells (CML‐LICs). However, little is known about the therapeutic benefits such CML‐LIC targeting therapies might bring to CML patients. In this study, we investigated the therapeutic potential of EW‐7197, an orally bioavailable transforming growth factor‐β signaling inhibitor which has recently been approved as an Investigational New Drug (NIH, USA), to suppress CML‐LICs in vivo. Compared to TKI treatment alone, administration of TKI plus EW‐7197 to CML‐affected mice significantly delayed disease relapse and prolonged survival. Notably, combined treatment with EW‐7197 plus TKI was effective in eliminating CML‐LICs even if they expressed the TKI‐resistant T315I mutant BCR‐ABL1 oncogene. Collectively, these results indicate that EW‐7197 may be a promising candidate for a new therapeutic that can greatly benefit CML patients by working in combination with TKIs to eradicate CML‐LICs.

Web-Based Cognitive Behavioral Relapse Prevention Program With Tailored Feedback for People With Methamphetamine and Other Drug Use Problems: Development and Usability Study

BACKGROUND

Although drug abuse has been a serious public health concern, there have been problems with implementation of treatment for drug users in Japan because of poor accessibility to treatment, concerns about stigma and confidentiality, and costs. Therapeutic interventions using the Internet and computer technologies could improve this situation and provide more feasible and acceptable approaches.

OBJECTIVE

The objective of the study was to show how we developed a pilot version of a new Web-based cognitive behavioral relapse prevention program with tailored feedback to assist people with drug problems and assessed its acceptance and usability.

METHODS

We developed the pilot program based on existing face-to-face relapse prevention approaches using an open source Web application to build an e-learning website, including relapse prevention sessions with videos, exercises, a diary function, and self-monitoring. When users submitted exercise answers and their diary, researchers provided them with personalized feedback comments using motivational interviewing skills. People diagnosed with drug dependence were recruited in this pilot study from a psychiatric outpatient ward and nonprofit rehabilitation facilities and usability was evaluated using Internet questionnaires. Overall, website usability was assessed by the Web Usability Scale. The adequacy of procedures in the program, ease of use, helpfulness of content, and adverse effects, for example, drug craving, mental distress, were assessed by original structured questionnaires and descriptive form questions.

RESULTS

In total, 10 people participated in the study and completed the baseline assessment, 60% completed all relapse prevention sessions within the expected period. The time needed to complete one session was about 60 minutes and most of the participants took 2 days to complete the session. Overall website usability was good, with reasonable scores on subscales of the Web Usability Scale. The participants felt that the relapse prevention sessions were easy to use and helpful, but that the length of the videos was too long. The participant who until recently used drugs was satisfied with the self-monitoring, but others that had already maintained abstinence for more than a year felt this activity was unhelpful and were bored tracking and recording information on daily drug use. Feedback comments from researchers enhanced participants' motivation and further insight into the disease. Serious adverse effects caused by the intervention were not observed. Some possible improvements to the program were suggested.

CONCLUSIONS

The Web-based relapse prevention program was easy to use and acceptable to drug users in this study. This program will be helpful for drug users who do not receive behavioral therapy. After the pilot program is revised, further large-scale research is needed to assess its efficacy among drug users who have recently used drugs.

Mindfulness-based cognitive therapy for residual depressive symptoms and relapse prophylaxis

PURPOSE OF REVIEW

The article reviews the recent evidence for mindfulness-based cognitive therapy (MBCT) for patients with residual depressive symptoms or in remitted patients at increased risk for relapse.

RECENT FINDINGS

Randomized controlled trials have shifted focus from comparing MBCT with treatment-as-usual to comparing MBCT against interventions. These studies have provided evidence for the efficacy of MBCT on par with maintenance antidepressant pharmacotherapy and leading to a relative reduction of risk on the order of 30-40%. Perhaps fuelled by these data, recent efforts have focused on extending MBCT to novel populations, such as acutely depressed patients, those diagnosed with health anxiety, social anxiety, fibromyalgia, or multiple chemical sensitivities as well migrating MBCT to online platforms so that it is more widely available. Neuroimaging studies of patients in structured therapies which feature mindfulness meditation, have reported findings that parallel behavioral changes, such as increased activation in brain regions subsuming self-focus and emotion regulation (prefrontal cortex) and interoceptive awareness (insula).

SUMMARY

The current evidence base for MBCT is strongest for its application as a prophylactic intervention or for residual depressive symptoms, with early data suggesting additional indications outside the mood disorders. Future work will need to address dose-effect relationships between mindfulness practice and clinical benefits, as well as establishing the rates of uptake for online MBCT so that its benefits can be compared to in-person groups. Additionally, validating current or novel neural markers of MBCT treatment response will allow for patient matching and optimization of treatment response.

A double-blind, placebo-controlled, randomized withdrawal study of lurasidone for the maintenance of efficacy in patients with schizophrenia

OBJECTIVE

To evaluate the effectiveness of lurasidone as maintenance treatment for schizophrenia.

METHOD

Adults experiencing an acute exacerbation of schizophrenia initially received 12-24 weeks of open-label treatment with lurasidone (40-80 mg/d, flexibly dosed). Patients who maintained clinical stability for ⩾12 weeks were randomized in double-blind fashion to placebo or lurasidone (40-80 mg/d, flexibly dosed) for an additional 28-week treatment period. The primary efficacy endpoint was time to relapse (based on Kaplan-Meier survival analysis).

RESULTS

A total of 676 patients enrolled in the open-label phase; 285 met protocol-specified stabilization criteria and were randomized to lurasidone (N=144) or placebo (N=141). During the open-label phase, mean Positive and Negative Syndrome Scale total score decreased from 90.1 to 54.4 in patients who met clinical stability criteria and were randomized. In the double-blind phase, lurasidone significantly delayed time to relapse compared with placebo (log-rank test, p=0.039), reflecting a 33.7% reduction in risk of relapse (Cox hazard ratio (95% confidence interval), 0.663 (0.447-0.983); p=0.041). Probability of relapse at the double-blind week 28 endpoint (based on Kaplan-Meier analysis) was 42.2% in the lurasidone group and 51.2% in the placebo group. Minimal changes in weight, lipid, glucose, and prolactin were observed throughout the study.

CONCLUSIONS

This multicenter, placebo-controlled, randomized withdrawal study demonstrated the efficacy of lurasidone for the maintenance treatment of patients with schizophrenia.

Comparative effectiveness of intervention components for producing long-term abstinence from smoking: a factorial screening experiment

AIMS

To identify promising intervention components that help smokers attain and maintain abstinence during a quit attempt.

DESIGN

A 2 × 2 × 2 × 2 × 2 randomized factorial experiment.

SETTING

Eleven primary care clinics in Wisconsin, USA.

PARTICIPANTS

A total of 544 smokers (59% women, 86% white) recruited during primary care visits and motivated to quit.

INTERVENTIONS

Five intervention components designed to help smokers attain and maintain abstinence: (1) extended medication (26 versus 8 weeks of nicotine patch + nicotine gum); (2) maintenance (phone) counseling versus none; (3) medication adherence counseling versus none; (4) automated (medication) adherence calls versus none; and (5) electronic medication monitoring with feedback and counseling versus electronic medication monitoring alone.

MEASUREMENTS

The primary outcome was 7-day self-reported point-prevalence abstinence 1 year after the target quit day.

FINDINGS

Only extended medication produced a main effect. Twenty-six versus 8 weeks of medication improved point-prevalence abstinence rates (43 versus 34% at 6 months; 34 versus 27% at 1 year; P = 0.01 for both). There were four interaction effects at 1 year, showing that an intervention component's effectiveness depended upon the components with which it was combined.

CONCLUSIONS

Twenty-six weeks of nicotine patch + nicotine gum (versus 8 weeks) and maintenance counseling provided by phone are promising intervention components for the cessation and maintenance phases of smoking treatment.

Psychiatrist's adherence: a new factor in relapse prevention of schizophrenia. A randomized controlled study on relapse control through telemedicine system

ACCESSIBLE SUMMARY

Exposure to psychotic states has detrimental effects on the long-term outcome of schizophrenia and brain integrity. Therefore, improving relapse prevention is a key component of long-term management of schizophrenia. Previous studies using continuous monitoring of an individual's early signs of relapse and adopting preventative pharmacological interventions, when early signs are detected, showed promising clinical results in terms of relapse risk reduction. This 18-month multi-centre parallel randomized controlled, open label, trial with telemedicine relapse prevention programme ITAREPS failed to show superiority of maintenance plus prodrome-based targeted medication strategy over treatment as usual. The study, marked by low investigator's adherence, confirmed that absence of pharmacological intervention at early stage of prodrome, critically influenced the risk of relapse. This and previous randomized controlled trials with telemedicine programme ITAREPS suggested that substantial improvement in relapse prevention in schizophrenia is likely to be unattainable under current clinical settings. Future preventive strategies in schizophrenia would require rapid pharmacological intervention upon occurrence of subclinical prodromal symptoms that are undetectable under conventional outpatient practice. Studies with ITAREPS suggested that integration of telemedicine relapse prevention systems and visiting nurse service might together represent practical solution capable to address those requirements.

ABSTRACT

The Information Technology Aided Relapse Prevention Programme in Schizophrenia (ITAREPS) presents a telemedicine solution for weekly monitoring and management of schizophrenia. This study aims to evaluate the effectiveness of the programme in reducing the number of hospitalizations during the 18-month multi-centre parallel randomized controlled, open label, trial. Outpatients with schizophrenia or schizoaffective disorder were randomized to the active (n = 74) or control group (n = 72). In the active arm, investigators increased the antipsychotic dose upon occurrence of prodrome announced by the system. Intention-to-treat analysis showed no between-group difference in the hospitalization-free survival rate [Kaplan-Meier method; hazard ratio (HR) = 1.21, 95% confidence interval (CI): 0.56-2.61, P = 0.6). In a post hoc multivariate Cox proportional hazards model, out of 13 potential predictors, only ITAREPS-related variables (number of alerts without pharmacological intervention/HR = 1.38, P = 0.042/ and patient non-adherence with ITAREPS /HR = 1.08, P = 0.009/) increased the risk of hospitalization. In this trial ITAREPS was not effective. The results in context with previous ITAREPS studies suggest non-adherence of both psychiatrists and patients as the main reasons for the failure of this preventive strategy. Tertiary prevention in schizophrenia have to be regarded a major challenge, warranting the need for implementation of strategies with more active participation of both patient and treating psychiatrist.

Using WhatsApp and Facebook Online Social Groups for Smoking Relapse Prevention for Recent Quitters: A Pilot Pragmatic Cluster Randomized Controlled Trial

Background

Quit attempters often have episodes of smoking relapse before they eventually quit. Interactive text messaging through mobile phones has been shown to increase abstinence. This service can be potentially applied on the platform of a social networking service to help quitters maintain abstinence.

Objective

Our aim was to determine if the group discussion and reminders via the WhatsApp or Facebook social group were effective to prevent smoking relapse in quitters who had stopped smoking recently.

Methods

This was a single-blinded, parallel, 3-arm pilot cluster randomized controlled trial allocating recent quitters, who had completed an 8-week treatment and reported abstinence for at least 7 days, to WhatsApp (n=42), Facebook (n=40), and a control group (n=54). The 2 intervention groups participated in a 2-month online group discussion with either WhatsApp or Facebook moderated by a trained smoking cessation counselor and received a self-help booklet on smoking cessation. The control group only received the booklet. The primary outcome was the 2- and 6-month relapse rates, defined as the proportion of participants who smoked at least 5 cigarettes in 3 consecutive days.

Results

Fewer participants in the WhatsApp group (17%, 7/42) reported relapse than the control group (42.6%, 23/54) at 2-month (OR 0.27, 95% CI 0.10-0.71) and 6-month (40.5%, 17/42 vs 61.1%, 33/54; OR 0.43, 95% CI 0.19-0.99) follow-ups. The Facebook group (30.0%, 12/40) had an insignificantly lower relapse rate than the control group (42.6%, 23/54) at 2-month (OR 0.58, 95% CI 0.24-1.37) and 6-month (52.5%, 13/40 vs 61.1%, 33/54; OR 0.70, 95% CI 0.31-1.61) follow-ups. The WhatsApp social groups had more moderators’ posts (median 60, IQR 25 vs median 32, IQR 7; P=.05) and participants’ posts (median 35, IQR 50 vs median 6, IQR 9; P=.07) than their Facebook counterparts, but the difference was insignificant.

Conclusions

The intervention via the WhatsApp social group was effective in reducing relapse probably because of enhanced discussion and social support. Inactive discussion in the Facebook social group might have attributed to the lower effectiveness.

ClinicalTrial

Clinicaltrials.gov NCT02007369; https://clinicaltrials.gov/show/NCT02007369 (Archived by WebCite® at http://www.webcitation.org/6c3RbltQG)

Effectiveness of a Mobile Phone App for Adults That Uses Physical Activity as a Tool to Manage Cigarette Craving After Smoking Cessation: A Study Protocol for a Randomized Controlled Trial

Background

Results from studies on the effects of exercise on smoking-related variables have provided strong evidence that physical activity acutely reduces cigarette cravings. Mobile technology may provide some valuable tools to move from explanatory randomized controlled trials to pragmatic randomized controlled trials by testing the acute effectiveness of exercise on quitters under real-life conditions. An mHealth app was developed to be used as a support tool for quitters to manage their cigarette cravings.

Objective

The primary aim of this paper is to present the protocol of a study examining the effectiveness of the Physical over smoking app (Ph.o.S) by comparing the point prevalence abstinence rate of a group of users to a comparator group during a 6-month follow-up period.

Methods

After initial Web-based screening, eligible participants are recruited to attend a smoking cessation program for 3 weeks to set a quit smoking date. Fifty participants who succeed in quitting will be randomly allocated to the comparator and experimental groups. Both groups will separately have 1 more counseling session on how to manage cravings. In this fourth session, the only difference in treatment between the groups is that the experimental group will have an extra 10-15 minutes of guidance on how to use the fully automated Ph.o.S app to manage cravings during the follow-up period. Data will be collected at baseline, as well as before and after the quit day, and follow-up Web-based measures will be collected for a period of 6 months. The primary efficacy outcome is the 7-day point prevalence abstinence rate, and secondary efficacy outcomes are number of relapses and cravings, self-efficacy of being aware of craving experience, self-efficacy in managing cravings, and power of control in managing cravings.

Results

Recruitment for this project commenced in December 2014, and proceeded until May 2015. Follow-up data collection has commenced and will be completed by the end of December 2015.

Conclusions

If the Ph.o.S app is shown to be effective, the study will provide evidence for the use of the app as a support tool for people who are trying to manage cravings during smoking cessation programs. It is anticipated that the results of the study will provide knowledge of how physical activity affects cigarette craving in real-life situations and inform the development and delivery of relapse prevention in smoking cessation treatment.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): ISRCTN55259451; http://www.controlled-trials.com/ISRCTN55259451 (Archived by WebCite at http://www.webcitation.org/6cKF2mzEI)

Relapse Prevention and the Five Rules of Recovery

There are four main ideas in relapse prevention. First, relapse is a gradual process with distinct stages. The goal of treatment is to help individuals recognize the early stages, in which the chances of success are greatest. Second, recovery is a process of personal growth with developmental milestones. Each stage of recovery has its own risks of relapse. Third, the main tools of relapse prevention are cognitive therapy and mind-body relaxation, which are used to develop healthy coping skills. Fourth, most relapses can be explained in terms of a few basic rules. Educating clients in these rules can help them focus on what is important: 1) change your life (recovery involves creating a new life where it is easier to not use); 2) be completely honest; 3) ask for help; 4) practice self-care; and 5) don't bend the rules.

Acceptability and Cultural Appropriateness of Self-Help Booklets for Relapse Prevention in Puerto Rico

Cigarette smoking is associated with a range of cancers and is related to five of seven leading causes of death in Puerto Rico. Minimal self-help interventions have shown promising results in reaching participants and preventing relapse from smoking. Specifically, a collection of eight self-help booklets has demonstrated efficacy (Brandon et al., 2000; 2004). Those booklets have been transcreated into Spanish, with efforts to make them culturally appropriate across a range of Hispanic cultures. We conducted a pilot study in Ponce, Puerto Rico, to evaluate the Spanish version of our smoking relapse-prevention booklets. Qualitative, semi-structured interviews were conducted with 20 current and former smokers. Interviews were conducted to elicit feedback regarding the booklet's content, cultural appropriateness, dissemination, and perceived availability of smoking cessation resources in Puerto Rico. Interviews were audiotaped and transcribed verbatim. Transcripts were coded using content analysis, with a priori codes based on the interview guide. Emergent themes were examined. Overall, participants liked the booklets' content, perceived them to be culturally appropriate, easy to read and understand. Regarding dissemination, it was recommended that the booklets be disseminated by physicians and advertised through television. Most importantly, participants reported the best way to distribute and complement the booklets would be through support groups. Participants also reported having limited knowledge about resources provided in the community to aid smoking cessation. Overall, this pilot study was able to show the cultural acceptability of the booklets and highlights the need for the dissemination of these materials among current and former smokers in Puerto Rico.

A randomised controlled trial to prevent smoking relapse among recently quit smokers enrolled in employer and health plan sponsored quitlines

OBJECTIVE

To test adding an interactive voice response (IVR)-supported protocol to standard quitline treatment to prevent relapse among recently quit smokers.

DESIGN

Parallel randomised controlled trial with three arms: standard quitline, standard plus technology enhanced quitline with 10 risk assessments (TEQ-10), standard plus 20 TEQ assessments (TEQ-20).

SETTING

Quit For Life (QFL) programme.

PARTICIPANTS

1785 QFL enrolees through 19 employers or health plans who were 24+ h quit.

INTERVENTIONS

QFL is a 5-call telephone-based cessation programme including medications and web-based support. TEQ interventions included 10 or 20 IVR-delivered relapse risk assessments over 8 weeks with automated transfer to counselling for those at risk.

MAIN OUTCOME MEASURES

Self-reported 7-day and 30-day abstinence assessed at 6-month and 12-month post-enrolment (response rates: 61% and 59%, respectively). Missing data were imputed.

RESULTS

1785 were randomised (standard n=592, TEQ-10 n=602, TEQ-20 n=591). Multiple imputation-derived, intent-to-treat 30-day quit rates (95% CI) at 6 months were 59.4% (53.7% to 63.8%) for standard, 62.3% (57.7% to 66.9%) for TEQ-10, 59.4% (53.7% to 65.1%) for TEQ-20 and 30-day quit rates at 12 months were 61.2% (55.6% to 66.8%) for standard, 60.6% (56.0% to 65.2%) for TEQ-10, 54.9% (49.0% to 60.9%) for TEQ-20. There were no significant differences in quit rates. 73.3% of TEQ participants were identified as at-risk by IVR assessments; on average, participants completed 0.41 IVR-transferred counselling calls. Positive risk assessments identified participants less likely (OR=0.56, 95% CI 0.42 to 0.76) to be abstinent at 6 months.

CONCLUSIONS

Standard treatment was highly effective, with 61% remaining abstinent at 12 months using multiple imputation intent-to-treat (intent-to-treat missing=smoking quit rate: 38%). TEQ assessments identified quitters at risk for relapse. However, adding IVR-transferred counselling did not yield higher quit rates. Research is needed to determine if alternative designs can improve outcomes.

TRIAL REGISTRATION NUMBER

NCT00888992.

Internet-delivered cognitive control training as a preventive intervention for remitted depressed patients: Protocol for a randomized controlled trial

BACKGROUND

Preventing recurrence of depression forms an important challenge for current treatments. Cognitive control impairments often remain present during remission of depression, putting remitted depressed patients at heightened risk for new depressive episodes by disrupting emotion regulation processes. Importantly, research indicates that cognitive control training targeting working memory functioning shows potential in reducing maladaptive emotion regulation and depressive symptomatology in clinically depressed patients and at-risk student samples. The current study aims to test the effectiveness of cognitive control training as a preventive intervention in a remitted depressed sample, exploring effects of cognitive control training on rumination and depressive symptomatology, along with indicators of adaptive emotion regulation and functioning.

METHODS/DESIGN

We present a double blind randomized controlled design. Remitted depressed adults will complete 10 online sessions of a cognitive control training targeting working memory functioning or a low cognitive load training (active control condition) over a period of 14 days. Effects of training on primary outcome measures of rumination and depressive symptomatology will be assessed pre-post training and at three months follow-up, along with secondary outcome measure adaptive emotion regulation. Long-term effects of cognitive control training on broader indicators of functioning will be assessed at three months follow-up (secondary outcome measures).

DISCUSSION

This study will provide information about the effectiveness of cognitive control training for remitted depressed adults in reducing vulnerability for depression. Furthermore, this study will address key questions concerning the mechanisms underlying the effects of cognitive control training, will take into account the subjective experience of the patients (including a self-report measure for cognitive functioning), and explore whether these effects extend to broad measures of functioning such as Quality of Life and disability.

TRIAL REGISTRATION

This study is registered with ClinicalTrials.Gov, number NCT02407652 .

Opioid treatment at release from jail using extended-release naltrexone: a pilot proof-of-concept randomized effectiveness trial

BACKGROUND AND AIMS

Relapse to addiction following incarceration is common. We estimated the feasibility and effectiveness of extended-release naltrexone (XR-NTX) as relapse prevention among opioid-dependent male adults leaving a large urban jail.

DESIGN

Eight-week, proof-of-concept, open-label, non-blinded randomized effectiveness trial.

SETTING

New York City jails and Bellevue Hospital Center Adult Primary Care clinics, USA.

PARTICIPANTS

From January 2010 to July 2013, 34 opioid-dependent adult males with no stated interest in agonist treatments (methadone, buprenorphine) received a counseling and referral intervention and were randomized to XR-NTX (n = 17) versus no medication (n = 17) within one week prior to jail release.

INTERVENTION

XR-NTX (Vivitrol(®) ; Alkermes Inc.), a long-acting injectable mu opioid receptor antagonist.

MEASURES

The primary intent-to-treat outcome was post-release opioid relapse at week 4, defined as ≥10 days of opioid misuse by self-report and urine toxicologies. Secondary outcomes were proportion of urine samples negative for opioids and rates of opioid abstinence, intravenous drug use (IVDU), cocaine use, community treatment participation, re-incarceration and overdose.

FINDINGS

Acceptance of XR-NTX was high; 15 of 17 initiated treatment. Rates of the primary outcome of week 4 opioid relapse were lower among XR-NTX participants: 38 versus 88% [P<0.004; odds ratio (OR) = 0.08, 95% confidence interval (CI) = 0.01-0.48]; more XR-NTX urine samples were negative for opioids, 59 versus 29% (P<0.009; OR = 3.5, 95% CI = 1.4-8.5). There were no significant differences in the remaining secondary outcomes, including rates of IVDU, cocaine use, re-incarceration and overdose.

CONCLUSION

Extended-release naltrexone is associated with significantly lower rates of opioid relapse among men in the United States following release from jail when compared with a no medication treatment-as-usual condition.

Psychoeducation for relapse prevention in bipolar disorder: a systematic review of efficacy in randomized controlled trials

OBJECTIVES

Previous reviews have concluded that interventions including psychoeducation are effective in preventing relapse in bipolar disorder, but the efficacy of psychoeducation itself has not been systematically reviewed. Our aim was to evaluate the efficacy of psychoeducation for bipolar disorder in preventing relapse and other outcomes, and to identify factors that relate to clinical outcomes.

METHODS

We employed the systematic review of randomized controlled trials of psychoeducation in participants with bipolar disorder not in an acute illness episode, compared with treatment-as-usual, and placebo or active interventions. Pooled odds ratios (ORs) for non-relapse into any episode, mania/hypomania, and depression were calculated using an intent-to-treat (ITT) analysis, assigning dropouts to relapse, with a sensitivity analysis in which dropouts were assigned to non-relapse (optimistic ITT).

RESULTS

Sixteen studies were included, eight of which provided data on relapse. Although heterogeneity in the data warrants caution, psychoeducation appeared to be effective in preventing any relapse [n = 7; OR: 1.98-2.75; number needed to treat (NNT): 5-7, depending on the method of analysis] and manic/hypomanic relapse (n = 8; OR: 1.68-2.52; NNT: 6-8), but not depressive relapse. Group, but not individually, delivered interventions were effective against both poles of relapse; the duration of follow-up and hours of therapy explained some of the heterogeneity. Psychoeducation improved medication adherence and short-term knowledge about medication. No consistent effects on mood symptoms, quality of life, or functioning were found.

CONCLUSIONS

Group psychoeducation appears to be effective in preventing relapse in bipolar disorder, with less evidence for individually delivered interventions. Better understanding of mediating mechanisms is needed to optimize efficacy and personalize treatment.

Comparison of SGA oral medications and a long-acting injectable SGA: the PROACTIVE study

Until relatively recently, long-acting injectable (LAI) formulations were only available for first-generation antipsychotics and their utilization decreased as use of oral second-generation antipsychotics (SGA) increased. Although registry-based naturalistic studies show LAIs reduce rehospitalization more than oral medications in clinical practice, this is not seen in recent randomized clinical trials. PROACTIVE (Preventing Relapse Oral Antipsychotics Compared to Injectables Evaluating Efficacy) relapse prevention study incorporated efficacy and effectiveness features. At 8 US academic centers, 305 patients with schizophrenia or schizoaffective disorder were randomly assigned to LAI risperidone (LAI-R) or physician's choice oral SGAs. Patients were evaluated during the 30-month study by masked, centralized assessors using 2-way video, and monitored biweekly by on-site clinicians and assessors who knew treatment assignment. Relapse was evaluated by a masked Relapse Monitoring Board. Differences between LAI-R and oral SGA treatment in time to first relapse and hospitalization were not significant. Psychotic symptoms and Brief Psychiatric Rating Scale total score improved more in the LAI-R group. In contrast, the LAI group had higher Scale for Assessment of Negative Symptoms Alogia scale scores. There were no other between-group differences in symptoms or functional improvement. Despite the advantage for psychotic symptoms, LAI-R did not confer an advantage over oral SGAs for relapse or rehospitalization. Biweekly monitoring, not focusing specifically on patients with demonstrated nonadherence to treatment and greater flexibility in changing medication in the oral treatment arm, may contribute to the inability to detect differences between LAI and oral SGA treatment in clinical trials.

Development and Pilot Evaluation of an Online Relapse-Prevention Program Based on Acceptance and Commitment Therapy for Chronic Pain Patients

Background

A significant number of chronic pain patients experience a decline in therapeutic effects after rehabilitation. As face-to-face contacts with health care professionals are not always feasible after treatment, new, innovative, fully automated relapse-prevention programs are highly needed.

Objective

In this study an online, automated relapse-prevention program based on acceptance and commitment therapy (ACT)—both as a website and as a mobile app—was developed and evaluated. At each step of the development, end users (ie, chronic pain patients) were consulted in order to fully address their needs.

Methods

In a step-by-step process, a contextual inquiry, requirement specification, and design were executed with chronic pain patients by conducting, respectively, a focus group (n=10), interviews with rapid prototyping (n=28), and a user- and expert-based usability evaluation (n=14). Furthermore, a pilot evaluation was conducted with 14 chronic pain or fatigue patients who had received the online relapse-prevention program following a multidisciplinary ACT treatment. They were interviewed about their usage and the usefulness of the program in supporting them to maintain changed behaviors and prevent relapses in avoidance and pain control behaviors.

Results

The three stages provided information about the expected needs of end users, comments about the usefulness of the proposed features, and feedback about the design and usability of the program. This resulted in a fully operational, online relapse-prevention program. Results from the pilot evaluation showed that 9 patients used the online program after treatment, 5 of whom indicated that the program supported them after treatment. Of all the patients, 4 of them indicated that the program did not support them because they wanted more social interaction with other users.

Conclusions

This study showed that an innovative, automated, online program that is user friendly can be developed by involving the end users in each step. The program was evaluated positively by some participants. The evaluation showed that the online relapse-prevention program has the potential to support chronic pain patients in maintaining their changed behaviors and preventing relapses in avoidance and pain control behaviors.

Trial Registration

Nederlands Trial Register (NTR) Number: NTR4177; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4177 (Archived by WebCite at http://www.webcitation.org/6Ur6EFD1D).

Mindfulness-based cognitive therapy for recurrent depression: A translational research study with 2-year follow-up

OBJECTIVE

While mindfulness-based cognitive therapy (MBCT) has demonstrated efficacy in reducing depressive relapse/recurrence over 12-18 months, questions remain around effectiveness, longer-term outcomes, and suitability in combination with medication. The aim of this study was to investigate within a pragmatic study design the effectiveness of MBCT on depressive relapse/recurrence over 2 years of follow-up.

METHOD

This was a prospective, multi-site, single-blind trial based in Melbourne and the regional city of Geelong, Australia. Non-depressed adults with a history of three or more episodes of depression were randomised to MBCT + depression relapse active monitoring (DRAM) (n=101) or control (DRAM alone) (n=102). Randomisation was stratified by medication (prescribed antidepressants and/or mood stabilisers: yes/no), site of usual care (primary or specialist), diagnosis (bipolar disorder: yes/no) and sex. Relapse/recurrence of major depression was assessed over 2 years using the Composite International Diagnostic Interview 2.1.

RESULTS

The average number of days with major depression was 65 for MBCT participants and 112 for controls, significant with repeated-measures ANOVA (F(1, 164)=4.56, p=0.03). Proportionally fewer MBCT participants relapsed in both year 1 and year 2 compared to controls (odds ratio 0.45, p<0.05). Kaplan-Meier survival analysis for time to first depressive episode was non-significant, although trends favouring the MBCT group were suggested. Subgroup analyses supported the effectiveness of MBCT for people receiving usual care in a specialist setting and for people taking antidepressant/mood stabiliser medication.

CONCLUSIONS

This work in a pragmatic design with an active control condition supports the effectiveness of MBCT in something closer to implementation in routine practice than has been studied hitherto. As expected in this translational research design, observed effects were less strong than in some previous efficacy studies but appreciable and significant differences in outcome were detected. MBCT is most clearly demonstrated as effective for people receiving specialist care and seems to work well combined with antidepressants.

The Use of New Communications Technologies to Evaluate and Intervene in Substance Use Disorders

The widespread availability of high speed, mobile cellular telephones and other advances in communication technology have the potential to change the way that interventions for substance use disorders (SUD) are delivered and how progress is monitored. This article reviews recent research on the use of new technology to monitor progress and deliver interventions for SUD. Several studies of telephone-based interventions show positive effects, but sometimes only in certain subgroups. However, other studies produced negative results. Studies support the use of interactive voice response (IVR) and personal digital assistants (PDAs) to conduct assessments, but there is little data on whether IVR- or PDA-based interventions improve outcomes. Text messaging has received comparatively little research, but appears promising as a means to conduct assessments and deliver automated interventions. Finally, smartphone technology provides the widest range of features and interventions and the greatest flexibility, but few intervention studies that use them have been conducted.

A mobile app offering distractions and tips to cope with cigarette craving: a qualitative study

Background

Despite considerable effort, most smokers relapse within a few months after quitting due to cigarette craving. The widespread adoption of mobile phones presents new opportunities to provide support during attempts to quit.

Objective

To design and pilot a mobile app "DistractMe" to enable quitters to access and share distractions and tips to cope with cigarette cravings.

Methods

A qualitative study with 14 smokers who used DistractMe on their mobiles during the first weeks of their quit attempt. Based on interviews, diaries, and log data, we examined how the app supported quitting strategies.

Results

Three distinct techniques of coping when using DistractMe were identified: diversion, avoidance, and displacement. We further identified three forms of engagement with tips for coping: preparation, fortification, and confrontation. Overall, strategies to prevent cravings and their effects (avoidance, displacement, preparation, and fortification) were more common than immediate coping strategies (diversion and confrontation). Tips for coping were more commonly used than distractions to cope with cravings, because they helped to fortify the quit attempt and provided opportunities to connect with other users of the application. However, distractions were important to attract new users and to facilitate content sharing.

Conclusions

Based on the qualitative results, we recommend that mobile phone-based interventions focus on tips shared by peers and frequent content updates. Apps also require testing with larger groups of users to assess whether they can be self-sustaining.

Clinical efficacy of sertraline alone and augmented with gabapentin in recently abstinent cocaine-dependent patients with depressive symptoms

BACKGROUND

Cocaine dependence is a major public health problem with no available robustly effective pharmacotherapy. This study's aim was to determine if treatment with sertraline (SERT) or SERT plus gabapentin (GBP) improved treatment retention, depressive symptoms, and/or cocaine use.

METHODS

Depressed cocaine-dependent patients (N = 99) were enrolled in a 12-week, double-blind, randomized, placebo (PLA)-controlled, clinical trial and placed in research beds at a residential treatment facility (Recovery Centers of Arkansas). They were randomized by depressive symptom severity and inducted onto 1 of the following while residing at the Recovery Centers of Arkansas: SERT (200 mg/d), SERT (200 mg/d) plus GBP (1200 mg/d), or PLA. Participants transferred to outpatient treatment at the start of their third week, continued receiving study medications or PLA (weeks 3-12), and participated in weekly individual cognitive behavioral therapy. Compliance was facilitated through the use of contingency management procedures. Supervised urine samples were obtained thrice weekly and self-reported mood weekly. At the end of 12 weeks, participants were tapered off the study medication over 5 days and referred to a local treatment program.

RESULTS

Sertraline, but not SERT plus GBP, showed a significantly lower overall percentage of cocaine-positive urine samples compared with that of PLA. A significantly greater percentage of participants experienced relapse in the PLA group (88.9%) compared with that of the SERT group (65.2%). Hamilton depression ratings decreased significantly over time regardless of the treatment group. Retention in treatment did not differ significantly between the treatment groups.

CONCLUSIONS

Sertraline plus GBP may not be superior to SERT alone in delaying relapse among abstinent cocaine-dependent individuals undergoing cognitive behavioral therapy.

Mindfulness-based treatment to prevent addictive behavior relapse: theoretical models and hypothesized mechanisms of change

Mindfulness-based treatments are growing in popularity among addiction treatment providers, and several studies suggest the efficacy of incorporating mindfulness practices into the treatment of addiction, including the treatment of substance use disorders and behavioral addictions (i.e., gambling). The current paper provides a review of theoretical models of mindfulness in the treatment of addiction and several hypothesized mechanisms of change. We provide an overview of mindfulness-based relapse prevention (MBRP), including session content, treatment targets, and client feedback from participants who have received MBRP in the context of empirical studies. Future research directions regarding operationalization and measurement, identifying factors that moderate treatment effects, and protocol adaptations for specific populations are discussed.

Associations of attention-deficit hyperactivity disorder symptom dimensions with smoking deprivation effects in adult smokers

Identifying relations of attention deficit hyperactivity disorder (ADHD) symptom dimensions to individual facets of the tobacco withdrawal syndrome could elucidate the mechanisms linking ADHD and regular smoking. This study examined the unique relations of inattention (IN) and hyperactivity-impulsivity (HI) symptom dimensions of ADHD to a variety of tobacco withdrawal symptoms. One hundred thirty-two community-dwelling adult smokers recruited without regard to ADHD status completed a self-report measure of ADHD symptoms experienced over the past 6 months at a baseline visit. At two subsequent experimental sessions (one following overnight tobacco deprivation and one nondeprived; order counterbalanced), participants completed measures of tobacco withdrawal symptoms, mood, and desire to smoke. Preliminary analyses showed that higher levels of IN and HI symptoms were both associated with higher levels of negative affect and concentration difficulties during nondeprived ("baseline") states (ps < .01). Over and above nondeprived ratings, higher levels of HI symptoms were associated with larger deprivation-induced increases in negative affect, concentration problems, and desire to smoke, particularly for negative affect relief, during deprived states (ps < .01). ADHD symptoms, particularly HI symptoms, are associated with more severe exacerbations in abstinence-induced withdrawal symptoms, which could be an important mechanism of ADHD-smoking comorbidity. These findings suggest the need for clinical studies examining the role of these unique and potentially more severe withdrawal profiles experienced by smokers with high-levels of ADHD symptoms in smoking reinstatement and cessation outcomes.

Supportive housing: an evidence-based intervention for reducing relapse among low income adults in addiction recovery

Within the ranks of the homeless are individuals coping with substance addiction and/or chronic physical or mental disability. Their special needs often pose significant barriers to successfully re-integrate into society. For these individuals, simply securing a roof overhead may not be an adequate solution. Supportive housing combines housing with access to on-site social services to assist persons coping with disabling physical and behavioral health conditions. This study examined whether an association could be found between length of residency in supportive housing and subjective well-being. For the purposes of this study, subjective well-being was measured by length of sobriety, self-efficacy, and employment.

Long-term sobriety strategies for men with co-occurring disorders

OBJECTIVE

Roughly half of people with severe mental disorders also experience a co-occurring substance use disorder, and recovery from both is a critical objective for health care services. While understanding of abstinence initiation has grown, the strategies people with co-occurring disorders use to maintain sobriety are largely unknown. This article reports strategies for relapse prevention as described by men with co-occurring disorders who achieved one or more years of sobriety.

METHODS

We analyzed semi-structured interviews conducted with a sample of 12 men with co-occurring psychosis and substance use disorder who achieved and maintained sobriety for at least one year, supplemented with demographic and diagnostic clinical record data. These men were participating in residential or outpatient treatment at a private, nonprofit integrated treatment clinic.

RESULTS

The 12 men were primarily Caucasian (91.7%) and unmarried (100%), and their ages ranged from 23 to 42 years. The two most common psychiatric disorders were schizoaffective disorder (n = 4, 33.3%) and bipolar disorder (n = 4, 33.3%), while the two most commonly misused substances were alcohol and cannabis. Qualitative analyses showed that participants maintained sobriety for at least one year by building a supportive community, engaging in productive activities, and carefully monitoring their own attitudes toward substances, mental health, and responsibility. Alcoholics Anonymous might act as a catalyst for building skills.

CONCLUSIONS

People with co-occurring disorders who achieve sobriety use a variety of self-management strategies to prevent relapse-seeking support, activities, and a healthy mindset. The findings suggest a relapse prevention model that focuses on social networks, role functioning, and self-monitoring and conceptualizes self-care as critical to extending periods of wellness.

Use and effectiveness of lapse prevention strategies among pregnant smokers

Little is known about the use of lapse prevention strategies to help smokers manage situation-triggered urges to smoke. Pregnant smokers (N = 174) participating in an intervention trial reported use of cognitive-behavioural lapse prevention strategies and smoking abstinence (biochemically verified). Participants typically enacted few strategies. Distraction strategies were most commonly used. Total number of strategies used did not predict abstinence. However, using 'self-talk' (odds ratio (OR) = 3.44, 95% confidence interval = 1.14-10.40) or 'avoiding spending time with other smokers' (OR = 4.01, 95% confidence interval = 1.34-11.95) independently increased the odds of abstinence. The promotion of these and other under-utilised evidence-based strategies warrants further attention.

Postallogeneic monitoring with molecular markers detected by pretransplant next-generation or Sanger sequencing predicts clinical relapse in patients with myelodysplastic/myeloproliferative neoplasms

Relapse is the major cause of treatment failure after allogeneic stem-cell transplantation (AHSCT) for patients with myelodysplastic syndrome/myeloproliferative syndrome neoplasms (MDS/MPN). We evaluated the impact of molecular mutations on outcome and the value of molecular monitoring post-transplantation. We screened 45 patients with chronic myelomonocytic leukemia (n = 39 patients, including seven with transformed-acute myeloid leukemia), MDS/MPN unclassifiable (n = 5), and atypical BCR-ABL1-negative CML (n = 1) for mutations in ASXL1, CBL, NRAS, and TET2 genes by molecular genetics including a sensitive next-generation sequencing (NGS) technique. In 36 patients, sufficient DNA was available for molecular analyses. In particular, TET2 and CBL mutations were screened applying amplicon deep sequencing. In 89% of cases, at least one mutation could be detected: ASXL1: n = 18 (50%); CBL: n = 7 (19%); TET2: n = 15 (42%); and NRAS: n = 11 (32%). Survival after AHSCT at 5 yr was 46% (95% CI 28-64%) and was not influenced by any mutation. After a median of 6 months after AHSCT in 33% of the patients, one of the molecular markers was still detectable, resulting in a higher incidence of relapse than in patients with undetectable mutations (50% vs. 15%, P = 0.04). In conclusion, pretransplant molecular mutation analysis can help to detect biomarkers in patients with MPN/MDS, which may be subsequently used as minimal residual disease markers after AHSCT.

For whom does it work? moderators of outcome on the effect of a transdiagnostic internet-based maintenance treatment after inpatient psychotherapy: randomized controlled trial

Background

Recent studies provide evidence for the effectiveness of Internet-based maintenance treatments for mental disorders. However, it is still unclear which participants might or might not profit from this particular kind of treatment delivery.

Objective

The study aimed to identify moderators of treatment outcome in a transdiagnostic Internet-based maintenance treatment (TIMT) offered to patients after inpatient psychotherapy for mental disorders in routine care.

Methods

Using data from a randomized controlled trial (N=400) designed to test the effectiveness of TIMT, we performed secondary analyses to identify factors moderating the effects of TIMT (intervention) when compared with those of a treatment-as-usual control condition. TIMT involved an online self-management module, asynchronous patient–therapist communication, a peer support group, and online-based progress monitoring. Participants in the control condition had unstructured access to outpatient psychotherapy, standardized outpatient face-to-face continuation treatment, and psychotropic management. Self-reports of psychopathological symptoms and potential moderators were assessed at the start of inpatient treatment (T1), at discharge from inpatient treatment/start of TIMT (T2), and at 3-month (T3) and 12-month follow-up (T4).

Results

Education level, positive outcome expectations, and diagnoses significantly moderated intervention versus control differences regarding changes in outcomes between T2 and T3. Only education level moderated change differences between T2 and T4. The effectiveness of the intervention (vs control) was more pronounced among participants with a low (vs high) education level (T2-T3: B=–0.32, SE 0.16, P=.049; T2-T4: B=–0.42, SE 0.21, P=.049), participants with high (vs low) positive outcome expectations (T2-T3: B=–0.12, SE 0.05, P=.02) and participants with anxiety disorder (vs mood disorder) (T2-T3: B=–0.43, SE 0.21, P=.04). Simple slope analyses revealed that despite some subgroups benefiting less from the intervention than others, all subgroups still benefited significantly.

Conclusions

This transdiagnostic Internet-based maintenance treatment might be suitable for a wide range of participants differing in various clinical, motivational, and demographic characteristics. The treatment is especially effective for participants with low education levels. These findings may generalize to other Internet-based maintenance treatments.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 28632626; http://www.controlled-trials.com/isrctn/pf/28632626 (Archived by WebCite at http://www.webcitation.org/6IqZjTLrx).

Assessing the generalization of relapse-prevention behaviors of sexual offenders diagnosed with an intellectual disability

The generalization of relapse-prevention skills of 10 males residing at a state facility for sexual offenders diagnosed with an intellectual disability was assessed in the community using three different experimental probes: (a) treatment staff (TS), (b) nontreatment staff (NTS), and (c) community adults (CAs). Results indicated a decrease in compliance from the TS to NTS and CAs, with the lowest levels of generalization displayed by offenders who were older and displayed a wider range of paraphilias. The degree of generalization also varied as a function of the contingencies for prevention-plan noncompliance, with higher rates of generalization occurring for violations that were more severely consequated. The implications of the findings for future research in promoting the generalization of relapse-prevention skills of sexual offenders, in general, and those who also exhibit intellectual disabilities, in particular, are discussed.

Neuromyelitis optica and pregnancy during therapeutic B cell depletion: infant exposure to anti-AQP4 antibody and prevention of rebound relapses with low-dose rituximab postpartum

Neuromyelitis optica (NMO) predominantly affects women, some in childbearing age, and requires early therapeutic intervention to prevent disabling relapses. We report an anti-AQP4 antibody-seropositive patient who became pregnant seven months after low-dose (100 mg) rituximab application. Pregnancy showed no complications, and low-dose rituximab restarted two days after delivery resulted in neurological stability for 24 months. Remarkably, her otherwise healthy newborn presented with anti-AQP4 antibody and reduced B lymphocyte counts in umbilical cord blood, which normalized three months later. Confirming and extending previous reports, our case suggests that low-dose rituximab might be compatible with pregnancy and prevent rebound NMO disease activity postpartum.

Two fully automated web-based interventions for risky alcohol use: randomized controlled trial

Background

Excessive alcohol use is a widespread problem in many countries, especially among young people. To reach more people engaging in high-risk drinking behaviors, a number of online programs have been developed in recent years. Change Your Drinking is a German, diary-based, fully automated alcohol intervention. In 2010, a revised version of the program was developed. It is more strongly oriented to concepts of relapse prevention than the previous version, includes more feedback, and offers more possibilities to interact with the program. Moreover, the program duration was extended from 10 to 14 days.

Objective

This paper examines whether the revised version of Change Your Drinking is more effective in reducing alcohol consumption than the original version.

Methods

The effectiveness of both program versions was compared in a Web-based, open, randomized controlled trial with follow-up surveys 6 weeks and 3 months after registration. Participants were recruited online and were randomly assigned to either the original or the revised version of Change Your Drinking. The following self-assessed outcomes were used: alcohol use days, alcohol intake in grams, the occurrence of binge drinking and risky drinking (all referring to the past 7 days prior to each survey), and the number of alcohol-related problems.

Results

A total of 595 participants were included in the trial. Follow-up rates were 58.0% after 6 weeks and 49.6% after 3 months. No significant group differences were found in any of the outcomes. However, the revised version was used by more participants (80.7%) than the original version (55.7%). A significant time effect was detected in all outcomes (alcohol use days: P=.002; alcohol intake in grams: P<.001; binge drinking: P<.001; alcohol-related problems: P=.004; risky drinking: P<.001).

Conclusions

The duration and complexity of the program played a minor role in reducing alcohol consumption. However, differences in program usage between the versions suggest the revised version was more attractive to participants.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 31586428; http://www.controlled-trials.com/ISRCTN31586428/ (Archived by WebCite at http://www.webcitation.org/6BFxApCUT)

A randomized controlled trial of relapse prevention therapy for first-episode psychosis patients: outcome at 30-month follow-up

The effectiveness of a novel 7-month psychosocial treatment designed to prevent the second episode of psychosis was evaluated in a randomized controlled trial at 2 specialist first-episode psychosis (FEP) programs. An individual and family cognitive behavior therapy for relapse prevention was compared with specialist FEP care. Forty-one FEP patients were randomized to the relapse prevention therapy (RPT) and 40 to specialist FEP care. Participants were assessed on an array of measures at baseline, 7- (end of therapy), 12-, 18-, 24-, and 30-month follow-up. At 12-month follow-up, the relapse rate was significantly lower in the therapy condition compared with specialized treatment alone (P = .039), and time to relapse was significantly delayed for those in the relapse therapy condition (P = .038); however, such differences were not maintained. Unexpectedly, psychosocial functioning deteriorated over time in the experimental but not in the control group; these differences were no longer statistically significant when between-group differences in medication adherence were included in the model. Further research is required to ascertain if the initial treatment effect of the RPT can be sustained. Further research is needed to investigate if medication adherence contributes to negative outcomes in functioning in FEP patients who have reached remission, or, alternatively, if a component of RPT is detrimental.

Medications for substance use disorders

In this article, the authors briefly review the pharmacotherapeutic agents that are currently available for the treatment of substance use disorders. Nicotine replacement therapies are most effective for tobacco cessation. Naltrexone, acamprosate, and disulfiram are effective for reducing alcohol use. The most effective pharmacotherapies for opiate use disorders are agonist therapies, including methadone and buprenorphine. The authors also examine recent advances in medication development for other substance use disorders such as stimulant addiction. The role of medication adherence and behavioral treatments and the integration of behavioral and pharmacotherapeutic interventions are also discussed.

Toward a Universal Maintenance Intervention: Integrating Cognitive-Behavioral Treatment With Motivational Interviewing for Maintenance of Behavior Change

Improvements in behavior following active interventions diminish over time across a broad spectrum of behaviors. Motivational interviewing (MI) has been found to increase intrinsic motivation for initial behavior change, but there has been little discussion on how to integrate MI and the cognitive-behavioral treatments (CBTs) commonly used to maintain change. A prominent CBT approach to relapse prevention that has been tested in multiple behavioral domains includes the following maintenance strategies: managing the goal violation effect, flexible goal setting, identifying triggers and developing coping skills, and increasing self-efficacy and social support. Using a model of integration where MI is the foundation for CBT delivery, the integration of specific relational and technical components of MI and CBT strategies for maintenance of change are described. A universal maintenance intervention that uses MI as an integrative framework to deliver CBT may address maintenance of behavior change across multiple behavioral domains. Further research is necessary to confirm whether delivering MI with fidelity adds to the effectiveness of CBT maintenance interventions.