1
|
Khandelwal N, Das K, Sharma R, Ghosh A. Testing the waters: A pilot trial of acceptance and commitment therapy (ACT) for alcohol use disorder. Indian J Psychiatry 2024; 66:191-194. [PMID: 38523767 PMCID: PMC10956592 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_820_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 03/26/2024] Open
Abstract
Background Psychosocial interventions help maintain alcohol abstinence. Third-wave psychotherapies have emerged as an alternative to cognitive behavioral therapies for Alcohol Use Disorder (AUD) treatment. However, third-wave therapies have not been tested in non-western settings or via telehealth. Aim We assessed the acceptability and feasibility of Acceptance and Commitment Therapy (ACT) in moderate/severe AUD. Methods This was a pre- and post-study design. All those who met the eligibility (n = 40) criteria consented to participate. A trained nurse delivered four sessions of ACT, either in-person or via video-conferencing, per participants' preference. Alcohol use, craving, relapse signs, and psychological flexibility were assessed three months post-intervention. Results Twenty-eight participants (70%) attended all four sessions. There was a significant increase in abstinence and a decrease in alcohol use, frequency of drinking/heavy drinking, craving, relapse signs, and improved psychological flexibility. Outcomes were positive for either mode of delivery. Conclusion ACT is feasible, acceptable, and probably effective in AUD.
Collapse
Affiliation(s)
- Nisha Khandelwal
- Department of Nursing, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Karobi Das
- Department of National Institute of Nursing Education, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Renu Sharma
- Department of National Institute of Nursing Education, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Abhishek Ghosh
- Department of Psychiatry and Drug De-addiction and Treatment Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
2
|
Stüben N, Franke AG, Soyka M. Evaluation of a Primary E-Health Intervention for People with Alcohol Use Disorder: Clinical Characteristics of Users and Efficacy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6514. [PMID: 37569054 PMCID: PMC10418680 DOI: 10.3390/ijerph20156514] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/12/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023]
Abstract
In Germany, only about 10% of patients with alcohol use disorder (AUD) are treated by the professional help system. "The First 30 Days without Alcohol", an interactive e-health intervention, was developed to support people with "alcohol problems" to abstain from alcohol. The aim of this study was to examine the feasibility of the approach, the program's target group, if and why it is effective. In March 2022 an email was sent to all users who had completed the program. A link to a web-based survey regarding the target group's characteristics, its alcohol-use patterns, former attempts to change the problematic drinking behavior and experience with the program was introduced. The Alcohol Use Disorders Identification Test (AUDIT) was used prior and post intervention. A total of 718 participants completed the questionnaire. Of these, 99.2% suffered from AUD; 81.6% of participants were females, and about one third reported some form of psychiatric comorbidity; 46.6% did not use any additional help or assistance apart from the program; 78.3% reported to be abstinent after participation in the 30-day program, and the data show a significant AUDIT score reduction. Primary e-health interventions may contribute to the established addiction-help system. The intervention seems to reach predominantly highly educated and high-functioning females because of their characteristics.
Collapse
Affiliation(s)
- Nathalie Stüben
- Department of Psychiatry and Psychotherapy, University Hospital Munich, Ludwig Maximilian University of Munich, Nußbaumstr. 7, 80336 Munich, Germany;
| | - Andreas Guenter Franke
- University of Applied Labour Studies, Seckenheimer Landstr. 16, 68163 Mannheim, Germany;
| | - Michael Soyka
- Department of Psychiatry and Psychotherapy, University Hospital Munich, Ludwig Maximilian University of Munich, Nußbaumstr. 7, 80336 Munich, Germany;
| |
Collapse
|
3
|
Woolf-King SE, Firkey M, Foley JD, Bricker J, Hahn JA, Asiago-Reddy E, Wikier J, Moskal D, Sheinfil AZ, Ramos J, Maisto SA. Development of a Telephone-Delivered Acceptance and Commitment Therapy Intervention for People Living with HIV who are Hazardous Drinkers. AIDS Behav 2022; 26:3029-3044. [PMID: 35303190 PMCID: PMC8931450 DOI: 10.1007/s10461-022-03649-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2022] [Indexed: 11/16/2022]
Abstract
Alcohol use among people living with HIV (PWH) has been increasingly recognized as an important component of HIV care. Transdiagnostic treatments, such as Acceptance and Commitment Therapy (ACT), that target core processes common to multiple mental health and substance-related problems, may be ideal in HIV treatment settings where psychological and behavioral health comorbidities are high. In advance of a randomized clinical trial (RCT), the overall objective of this study was to systematically adapt an ACT-based intervention originally developed for smoking cessation, into an ACT intervention for PWH who drink at hazardous levels. Consistent with the ADAPT-ITT model, the adaptation progressed systematically in several phases, which included structured team meetings, three focus group discussions with PWH (N = 13), and in-depth interviews with HIV providers (N = 10), and development of standardized operating procedures for interventionist training, supervision, and eventual RCT implementation. The procedures described here offer a template for transparent reporting on early phase behavioral RCTs.
Collapse
|
4
|
Shepherd K, Pritty B, Tickle A, Moghaddam N. "I don't want to take buprenorphine for the rest of my life": Acceptance and Commitment Therapy for a Client Struggling to Reduce Low-Dose Buprenorphine (a Hermeneutic Single-Case Efficacy Design). Int J Ment Health Addict 2021; 21:1-24. [PMID: 34955695 PMCID: PMC8686789 DOI: 10.1007/s11469-021-00729-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 02/03/2023] Open
Abstract
The misuse of substances is often maintained by both physical and psychological factors. Opioid-substitution medications manage physical aspects of addiction; however, difficulties with emotional regulation and avoidance perpetuate continued substance misuse. In the UK, individuals who misuse substances are often excluded from mental health services, meaning these underlying difficulties are not addressed. Acceptance and Commitment Therapy (ACT) seeks to reduce emotional avoidance. A hermeneutic single-case efficacy design was used to evaluate the effects of ACT within drugs and alcohol service. Quantitative and qualitative data was critically analysed to understand factors involved in identified changes. Analysis recognised the client progressed towards two of three of their goals, related to motivation and anxiety. Their psychological flexibility also increased. ACT processes played a key role in this; however, the therapeutic relationship and psychopharmacological factors were also noted. Study limitations and clinical and research implications are discussed.
Collapse
Affiliation(s)
- Kate Shepherd
- Trent Doctorate in Clinical Psychology, School of Psychology, University of Lincoln, Lincoln, UK
| | - Beth Pritty
- Trent Doctorate in Clinical Psychology, Division of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK
- Nottinghamshire Healthcare NHS Trust, Nottingham, UK
| | - Anna Tickle
- Trent Doctorate in Clinical Psychology, Division of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK
- Framework; Opportunity Nottingham; and Trent Doctorate in Clinical Psychology, University of Nottingham, B Floor, Yang Fujia, Jubilee Campus, Wollaton Road, Nottingham, NG8 1BB UK
| | - Nima Moghaddam
- Trent Doctorate in Clinical Psychology, School of Psychology, University of Lincoln, Lincoln, UK
| |
Collapse
|
5
|
Albal E, Buzlu S. The effect of maladaptive schemas and psychological flexibility approaches on the addiction severity of drug addicts. Arch Psychiatr Nurs 2021; 35:617-624. [PMID: 34861954 DOI: 10.1016/j.apnu.2021.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 07/15/2021] [Accepted: 09/24/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE This study tested a model of the effect of maladaptive schemas on addiction severity and the mediating role of psychological flexibility between the two. METHODS The descriptive and methodological study was conducted with 661 opioid users. Data were collected using the questionnaire, including sociodemographic Characteristics, Addiction Profile Index, Young Schema Questionnaire 3 Short Form, Freiburg Mindfulness Inventory, Acceptance and Action Questionnaire-II and Cognitive Fusion Questionnaire. Data were analyzed using descriptive and correlational analysis and structural equation model. RESULTS The mean age was 27.43 ± 7.04 years. Of participants, 52.3% had a secondary school degree, 76.7% had no children, 90.8% were men, 69.3% single, 71.9% unemployed, and 71.4% lived with their parents. Relationship between schemas and addiction severity was 0.36 (p < 0.05), which was reduced to 0.10 by psychological flexibility (p < 0.05). Psychological flexibility affects addiction severity directly, but maladaptive schemas affect addiction severity through psychological flexibility. CONCLUSIONS Maladaptive schemas and psychological flexibility are constructs that need to be addressed in substance use treatment.
Collapse
Affiliation(s)
- Esra Albal
- Istanbul University - Cerrahpasa, Institute of Graduate Studies, Department of Mental Health and Psychiatric Nursing, Istanbul, Turkey.
| | - Sevim Buzlu
- Istanbul University - Cerrahpasa, Florence Nightingale Faculty of Nursing, Department of Mental Health and Psychiatric Nursing, Istanbul, Turkey
| |
Collapse
|
6
|
Berman BM, Kurlancheek K. The Choice Point Model of Acceptance and Commitment Therapy With Inpatient Substance Use and Co-occurring Populations: A Pilot Study. Front Psychol 2021; 12:758356. [PMID: 34777161 PMCID: PMC8581629 DOI: 10.3389/fpsyg.2021.758356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 09/30/2021] [Indexed: 11/23/2022] Open
Abstract
Objectives: Acceptance and Commitment Therapy (ACT) is an empirically supported treatment which aims to enhance self-acceptance and a commitment to core values. The present study examined the effectiveness of the Choice Point model of ACT in a residential substance use disorder (SUD) setting. Choice Point is a contemporary approach to ACT and targets transdiagnostic processes. Methods: This uncontrolled quasi-experimental design assessed 47 participants taking part in Choice Point for Substances (CHOPS) in order to investigate its influence on psychological inflexibility, values-based action, and self-compassion over time. The study additionally assessed for sleeper effects and associations between transdiagnostic processes and warning signs of relapse. Results: Findings demonstrated a decrease in psychological inflexibility and increases in values-based action and self-compassion over time. Gains were maintained at follow-up, and sleeper effects were observed for psychological inflexibility and mindfulness. Correlational analysis suggested that all transdiagnostic processes were related to warning signs of relapse at follow-up. Conclusion: These results provide preliminary evidence for the feasibility, acceptability, and effectiveness of CHOPS for SUD. Observed sleeper effects in psychological inflexibility and mindfulness indicate that CHOPS may provide longer-term benefits critical to a population where relapse is common. While encouraging, these findings should be interpreted with caution. Future research should utilize comparison groups when investigating CHOPS.
Collapse
Affiliation(s)
- Brian M Berman
- Retreat Behavioral Health, Department of Psychology, Ephrata, PA, United States
| | - Kris Kurlancheek
- Retreat Behavioral Health, Clinical Department, Ephrata, PA, United States
| |
Collapse
|
7
|
Zamboni L, Centoni F, Fusina F, Mantovani E, Rubino F, Lugoboni F, Federico A. The Effectiveness of Cognitive Behavioral Therapy Techniques for the Treatment of Substance Use Disorders: A Narrative Review of Evidence. J Nerv Ment Dis 2021; 209:835-845. [PMID: 34698698 DOI: 10.1097/nmd.0000000000001381] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
ABSTRACT Substance use disorders (SUDs) are characterized by a recurrent and maladaptive use of drugs and/or alcohol. Cognitive behavioral therapies (CBTs) comprise different types of interventions: traditional CBT and the more recent "third wave" behavior therapies, such as acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), mindfulness-based cognitive therapy (MBCT), and schema therapy (ST). We searched English-language articles published between 2014 and present. This review includes randomized controlled trials (RCTs), quasi-RCTs, pilot studies, and reviews of CBTs for SUDs available on PubMed. Results seem to indicate that CBT and MBCT are effective interventions for SUDs; however, the studies showed a high degree of heterogeneity, so no exhaustive conclusions could be outlined at this time. ACT and DBT in SUD management are limited to few studies and results are therefore inconclusive.
Collapse
Affiliation(s)
| | - Francesco Centoni
- Department of Medicine, Addiction Medicine Unit, Verona University Hospital
| | | | - Elisa Mantovani
- Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona
| | - Francesca Rubino
- Department of Medicine, Addiction Medicine Unit, Verona University Hospital
| | - Fabio Lugoboni
- Department of Medicine, Addiction Medicine Unit, Verona University Hospital
| | | |
Collapse
|
8
|
McInerney K, Garip G, Benson T. “We all need Purpose and Reason to be here.”: A Qualitative Investigation of howmembers of Alcoholics Anonymous with Long-term Recovery Experience Aging. ALCOHOLISM TREATMENT QUARTERLY 2021. [DOI: 10.1080/07347324.2021.1947165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Gulcan Garip
- School of Psychology, University of Derby, Derby, UK
| | - Tony Benson
- School of Psychology, University of Derby, Derby, UK
| |
Collapse
|
9
|
Is behavioral activation an effective and acceptable treatment for co-occurring depression and substance use disorders? A meta-analysis of randomized controlled trials. J Subst Abuse Treat 2021; 132:108478. [PMID: 34146994 DOI: 10.1016/j.jsat.2021.108478] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/28/2020] [Accepted: 05/11/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Depression often co-occurs with substance use problems and is associated with poor treatment outcomes. While the efficacy of behavioral activation (BA) has been tested in clinical trials with substance users, outcomes have not yet been quantitatively synthesized. METHODS The study team performed a random effects meta-analysis of the randomized clinical trial evidence base. We compared outcomes for individual or group BA against passive or active controls. We also compared attendance and dropout rates. The meta-analysis used a grading of recommendations assessment, development, and evaluation (GRADE) approach to assess the quality of each meta-analytic comparison. RESULTS We included five trials in the meta-analysis (N = 195). The analysis found no significant differences between BA and controls with regard to depression (Post-treatment: k = 5; N = 195; SMD: 0.19, CI -0.10 to 0.49; p = 0.20; GRADE = Low; Follow-up: k = 5; N = 195; SMD: -0.10, CI -0.51 to -0.30; p = 0.62; GRADE = Low) or substance use (post-treatment: k = 4; N = 151; SMD: 0.14, CI -0.33 to -0.6; p = 0.57, GRADE = Low; Follow-up: k = 4; N = 151; SMD: 0.17, CI -0.34 to 0.69; p = 0.51, GRADE = Low) and there was little evidence of publication bias. The average session attendance rate for BA was 72%. An average dropout rate of 35% was reported for both BA and comparator conditions. CONCLUSION BA does not emerge as a differentially efficacious treatment for comorbid depression and substance use disorders, although it does appear to be an acceptable treatment option. Our confidence in the results are limited by the number and quality of the original studies and the possibility of the effect of small study bias. We make suggestions for improving the methodological quality and direction of future BA trials.
Collapse
|
10
|
The Infinity Formulation: how transdiagnostic behaviours and endeavours for behavioural change serve to maintain co-morbid mental health presentations. COGNITIVE BEHAVIOUR THERAPIST 2021. [DOI: 10.1017/s1754470x21000118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Abstract
Treatment recommendations for mental health are often founded on diagnosis-specific models; however, there are high rates of co-morbidity of mental health presentations and growing recognition of the presence of ‘transdiagnostic processes’ (cognitive, emotional or behavioural features) seen across a range of mental health presentations. This model proposes a novel conceptualisation of how transdiagnostic behaviours may maintain co-morbid mental health presentations by acting as a trigger event for the cognitive biases specific to each presentation. Drawing on existing evidence, psychological theory and the author’s clinical experience, the model organises complex presentations in a theory-driven yet accessible manner for use in clinical practice. The model offers both theoretical and clinical implications for the treatment of mental health presentations using cognitive behavioural approaches, positing that transdiagnostic behaviours be the primary treatment target in co-morbid presentations.
Key learning aims
(1)
To understand the strengths and limitations of existing transdiagnostic CBT formulation models.
(2)
To learn about a novel, transdiagnostic and behaviourally focused formulation for use in clinical practice.
(3)
To understand how to use the tool in clinical practice and future research.
Collapse
|
11
|
Mallik D, Kaplan J, Somohano V, Bergman A, Bowen S. Examining the Role of Craving, Mindfulness, and Psychological Flexibility in a Sample of Individuals with Substance Use Disorder. Subst Use Misuse 2021; 56:782-786. [PMID: 33769196 DOI: 10.1080/10826084.2021.1899220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Substance Use Disorder (SUD) continues to represent a significant public health crisis in the United States. Purpose: Novel and effective treatments are needed, and third wave behavioral approaches focused on increasing mindfulness and psychological flexibility appear promising. However, the unique and shared impact of mindfulness and psychological flexibility on substance craving is not well understood. Methods: The current study explores how mindfulness and psychological flexibility predict substance craving while controlling for severity of substance dependence in a sample (N = 284) of treatment-seeking adults with SUD. Results and Discussion: Results suggest that mindfulness and psychological flexibility each account for unique variance in substance craving over and above the other. Implications and limitations are discussed.
Collapse
Affiliation(s)
- Debesh Mallik
- Pacific University, School of Graduate Psychology, Hillsboro, Oregon, USA
| | - Josh Kaplan
- Oregon Health and Science University, Portland, Oregon, USA
| | - Vanessa Somohano
- Veterans Administration Portland Health Care System, Portland, Oregon, USA
| | - Aaron Bergman
- Pacific University, School of Graduate Psychology, Hillsboro, Oregon, USA
| | - Sarah Bowen
- Pacific University, School of Graduate Psychology, Hillsboro, Oregon, USA
| |
Collapse
|
12
|
Outcome of First-admission Depression Treated in a Specialized Mood Disorders Service. J Psychiatr Pract 2020; 26:461-471. [PMID: 33275383 DOI: 10.1097/pra.0000000000000509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Few studies have described the treatment or outcome of depression in specialized mood disorders units (MDUs). Previous studies have focused on cohorts of patients with highly treatment-resistant illness who are likely to have a poor prognosis even with intensive treatment. This study describes the treatment and medium-term outcomes of a cohort of first-admission depressed patients with less treatment-resistant illness treated in a specialized MDU. METHODS A cohort of 137 consecutive first-admission depressed patients, referred to an MDU over 2 years, were interviewed using standardized schedules and followed up prospectively from admission for ∼18 months to describe baseline characteristics, treatment, outcome, and predictors of outcome. Times to recovery and recurrence were evaluated using survival analyses and predictors of outcome were examined using bivariate and multivariate regression analyses. RESULTS On admission, 75% of the 137 patients had depression that had been found to be resistant to pharmacological treatment, and 34% had been chronically depressed (>2 y). Over half of the patients had likely maladaptive personality traits and one third had at least 1 comorbid psychiatric disorder. By discharge, a significantly higher proportion of the patients were being prescribed very high (P<0.01) or high doses (P<0.05) of antidepressants, augmentation therapy (P<0.001), or a combination of antidepressants (P<0.001) or were engaged in individual psychotherapy (P<0.001), compared with baseline. With intensive treatment, 62% of the patients recovered by 6 months and 76% by 12 months, with 83% overall recovering and patients found to be asymptomatic during almost 60% of the follow-up period. However, 48% suffered a recurrence over the course of the follow-up. Chronicity of mood episodes (P<0.01) and the presence of psychiatric comorbidity (P<0.05) predicted recurrence. CONCLUSIONS This prospective, naturalistic, medium-term study describes better outcomes, in terms of recovery and symptomatology over time, in a cohort of first-admission depressed patients than previous first-admission studies after continuous, intensive treatment, although the proportion of patients who experienced recurrences remained high.
Collapse
|
13
|
Stapleton A, O’Connor M, Feerick E, Kerr J, McHugh L. Testing the relationship between health values consistent living and health-related behavior. JOURNAL OF CONTEXTUAL BEHAVIORAL SCIENCE 2020. [DOI: 10.1016/j.jcbs.2020.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
|
14
|
Swan JE, Votaw VR, Stein ER, Witkiewitz K. The Role of Affect in Psychosocial Treatments for Substance Use Disorders. CURRENT ADDICTION REPORTS 2020; 7:108-116. [PMID: 34327114 PMCID: PMC8317473 DOI: 10.1007/s40429-020-00304-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW This paper provides a narrative review of studies published over the past five years that have examined the role of affect, including both affective symptoms and affective disorders, in psychosocial treatments for substance use disorder. RECENT FINDINGS A growing body of literature suggests that affective symptoms and affective disorders may moderate substance use disorder treatment efficacy, mediate the effects of treatment on substance use outcomes, and may be directly changed by substance use disorder treatment. SUMMARY Substance use disorders and affective disorders commonly co-occur, and both affect and affective disorders are associated with substance use disorder treatment outcomes. Future research should continue to examine affect as a moderator, mediator, and outcome of substance use disorder treatments. In particular, new studies that are designed to test precision medicine hypotheses would greatly expand our understanding of the role of affective symptoms and disorders in substance use disorder treatment.
Collapse
Affiliation(s)
- Julia E Swan
- Department of Psychology, University of New Mexico
| | | | | | | |
Collapse
|
15
|
Byrne SP, Haber P, Baillie A, Costa DSJ, Fogliati V, Morley K. Systematic Reviews of Mindfulness and Acceptance and Commitment Therapy for Alcohol Use Disorder: Should we be using Third Wave Therapies? Alcohol Alcohol 2019; 54:159-166. [DOI: 10.1093/alcalc/agy089] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 11/28/2018] [Accepted: 12/04/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Simon P Byrne
- Discipline of Addiction Medicine, National Health and Medical Research Council Centre for Excellence in Mental Health and Substance Use, University of Sydney, NSW, Australia
| | - Paul Haber
- Discipline of Addiction Medicine, National Health and Medical Research Council Centre for Excellence in Mental Health and Substance Use, University of Sydney, NSW, Australia
- Drug Health Services, Royal Prince Alfred Hospital, Level 6 King George V Building, Camperdown, NSW, Australia
| | - Andrew Baillie
- Faculty of Health Sciences, National Health and Medical Research Council, Centre for Excellence in Mental Health and Substance Use, University of Sydney, NSW, Australia
| | - Daniel S J Costa
- Pain Management Research Institute, University of Sydney, Royal North Shore Hospital, Douglas Building, St Leonards, NSW, Australia
| | | | - Kirsten Morley
- Discipline of Addiction Medicine, National Health and Medical Research Council Centre for Excellence in Mental Health and Substance Use, University of Sydney, NSW, Australia
| |
Collapse
|
16
|
Woolf-King SE, Sheinfil AZ, Babowich JD, Siedle-Khan B, Loitsch A, Maisto SA. Acceptance and Commitment Therapy (ACT) for HIV-infected Hazardous Drinkers: A Qualitative Study of Acceptability. ALCOHOLISM TREATMENT QUARTERLY 2018; 37:342-358. [PMID: 31564766 PMCID: PMC6764523 DOI: 10.1080/07347324.2018.1539630] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Alcohol use is a significant problem in HIV care, and clinical trials of alcohol interventions for people living with HIV infection (PLWH) have produced mixed results. The purpose of this qualitative study was to collect preliminary data on the practical feasibility and acceptability of Acceptance and Commitment Therapy (ACT) as a treatment for PLWH who are hazardous drinkers. A total of 25 PLWH participated in individual interviews. Four major themes emerged from the thematic analysis: (I) Perceived Appropriateness for PLWH and People who use Alcohol and/or other Substances, (II) General Satisfaction and Dissatisfaction, (III) Positive and Negative Effects on Participants and (IV) Facilitators and Barriers to Implementing ACT Intervention Strategies.
Collapse
Affiliation(s)
- Sarah E. Woolf-King
- Syracuse University, Department of Psychology, Syracuse, New York
- University of California, San Francisco, Department of Medicine, Center for AIDS Prevention Studies, San Francisco, California
| | - Alan Z Sheinfil
- Syracuse University, Department of Psychology, Syracuse, New York
| | | | - Bob Siedle-Khan
- University of California, San Francisco, Department of Medicine, Center for AIDS Prevention Studies, San Francisco, California
| | - Amanda Loitsch
- Syracuse University, Department of Psychology, Syracuse, New York
| | | |
Collapse
|
17
|
Meyer EC, Walser R, Hermann B, La Bash H, DeBeer BB, Morissette SB, Kimbrel NA, Kwok OM, Batten SV, Schnurr PP. Acceptance and Commitment Therapy for Co-Occurring Posttraumatic Stress Disorder and Alcohol Use Disorders in Veterans: Pilot Treatment Outcomes. J Trauma Stress 2018; 31:781-789. [PMID: 30338561 DOI: 10.1002/jts.22322] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 05/10/2018] [Accepted: 05/21/2018] [Indexed: 12/11/2022]
Abstract
Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur and are associated with worse outcomes together than either disorder alone. A lack of consensus regarding recommendations for treating PTSD-AUD exists, and treatment dropout is a persistent problem. Acceptance and Commitment Therapy (ACT), a transdiagnostic, mindfulness- and acceptance-based form of behavior therapy, has potential as a treatment option for PTSD-AUD. In this uncontrolled pilot study, we examined ACT for PTSD-AUD in 43 veterans; 29 (67%) completed the outpatient individual therapy protocol (i.e., ≥ 10 of 12 sessions). Clinician-assessed and self-reported PTSD symptoms were reduced at posttreatment, ds = 0.79 and 0.96, respectively. Self-reported symptoms of PTSD remained lower at 3-month follow-up, d = 0.88. There were reductions on all alcohol-related outcomes (clinician-assessed and self-reported symptoms, total drinks, and heavy drinking days) at posttreatment and 3-month follow-up, dmean = 0.91 (d range: 0.65-1.30). Quality of life increased at posttreatment and follow-up, ds = 0.55-0.56. Functional disability improved marginally at posttreatment, d = 0.35; this effect became significant by follow-up, d = 0.52. Fewer depressive symptoms were reported at posttreatment, d = 0.50, and follow-up, d = 0.44. Individuals experiencing suicidal ideation reported significant reductions by follow-up. Consistent with the ACT theoretical model, these improvements were associated with more between-session mindfulness practice and reductions in experiential avoidance and psychological inflexibility. Recommendations for adapting ACT to address PTSD-AUD include assigning frequent between-session mindfulness practice and initiating values clarification work and values-based behavior assignments early in treatment.
Collapse
Affiliation(s)
- Eric C Meyer
- U.S. Department of Veterans Affairs Veterans Integrated Service Network 17 Center of Excellence for Research on Returning War Veterans at Central Texas Veterans Healthcare System, Waco, Texas, USA.,Texas A&M University Health Science Center, College of Medicine, College Station, Texas, USA
| | - Robyn Walser
- National Center for PTSD Training and Dissemination Division, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.,Department of Psychology, University of California, Berkeley, California, USA
| | | | - Heidi La Bash
- U.S. Department of Veterans Affairs Veterans Integrated Service Network 17 Center of Excellence for Research on Returning War Veterans at Central Texas Veterans Healthcare System, Waco, Texas, USA.,Texas A&M University Health Science Center, College of Medicine, College Station, Texas, USA
| | - Bryann B DeBeer
- U.S. Department of Veterans Affairs Veterans Integrated Service Network 17 Center of Excellence for Research on Returning War Veterans at Central Texas Veterans Healthcare System, Waco, Texas, USA.,Texas A&M University Health Science Center, College of Medicine, College Station, Texas, USA
| | | | - Nathan A Kimbrel
- Durham VA Medical Center, Durham, North Carolina, USA.,VA Mid-Atlantic Mental Illness Research Education and Clinical Center, Durham, North Carolina, USA.,School of Medicine, Duke University Health System, Durham, North Carolina, USA
| | - Oi-Man Kwok
- Texas A&M University, College Station, Texas, USA
| | - Sonja V Batten
- Mental Health Services, Department of Veterans Affairs, Washington, D.C., USA.,Booz Allen Hamilton, Washington, D.C., USA
| | - Paula P Schnurr
- National Center for PTSD, Executive Division, White River Junction, Vermont, USA.,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| |
Collapse
|
18
|
Mujcic A, Blankers M, Boon B, Engels R, van Laar M. Internet-based self-help smoking cessation and alcohol moderation interventions for cancer survivors: a study protocol of two RCTs. BMC Cancer 2018; 18:364. [PMID: 29609554 PMCID: PMC5879805 DOI: 10.1186/s12885-018-4206-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 03/09/2018] [Indexed: 01/21/2023] Open
Abstract
Background Brief interventions for smoking cessation and alcohol moderation may contribute considerably to the prevention of cancer among populations at risk, such as cancer survivors, in addition to improving their general wellbeing. There is accumulating evidence for the effectiveness of internet-based brief health behaviour interventions. The objective of this study is to assess the effectiveness, patient-level cost-effectiveness and cost-utility of two new online theory-based self-help interventions among adult cancer survivors in the Netherlands. One of the interventions focuses on alcohol moderation, the other on smoking cessation. Both interventions are tailored to cancer survivors. Methods Effectiveness will be assessed in two separate, nearly identical 2-armed RCTs: alcohol moderation (AM RCT) and smoking cessation (SC RCT). Participants are randomly allocated to either the intervention groups or the control groups. In the intervention groups, participants have access to one of the newly developed interventions. In the control groups, participants receive an online static information brochure on alcohol (AM RCT) or smoking (SC RCT). Main study outcome parameters are the number of drinks post-randomisation (AM RCT) and tobacco abstinence (SC RCT). In addition, cost-data and possible effect moderators and mediators will be assessed. Both treatments are internet-based minimally guided self-help interventions: MyCourse – Moderate Drinking (in Dutch: MijnKoers – Minderen met Drinken) and MyCourse – Quit Smoking (MijnKoers – Stoppen met Roken). They are based on cognitive behaviour therapy (CBT), motivational interviewing (MI) and acceptance and commitment therapy (ACT). Both interventions are optimized in collaboration with the target population of cancer survivors in focus groups and interviews, and in collaboration with several experts on eHealth, smoking cessation, alcohol misuse and cancer survivorship. Discussion The present study will add to scientific knowledge on the (cost-)effectiveness of internet-based self-help interventions to aid in smoking cessation or alcohol moderation, working mechanisms and impact on quality of life of cancer survivors. If found effective, these interventions can contribute to providing evidence-based psychosocial oncology care to a growing population of cancer survivors. Trial registration Trials are prospectively registered in The Netherlands Trial Register (NTR): NTR6011 (SC RCT), NTR6010 (AM RCT) on 1 September 2016.
Collapse
Affiliation(s)
- Ajla Mujcic
- Trimbos-institute, Netherlands Institute of Mental Health and Addiction, Da Costakade 45, 3521, VS, Utrecht, The Netherlands. .,Utrecht University, Domplein 29, 3512, JE, Utrecht, The Netherlands.
| | - Matthijs Blankers
- Trimbos-institute, Netherlands Institute of Mental Health and Addiction, Da Costakade 45, 3521, VS, Utrecht, The Netherlands.,Arkin Mental Health Care, Klaprozenweg 111, 1033, NN, Amsterdam, The Netherlands.,Academic Medical Center, Department of Psychiatry, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Brigitte Boon
- Academy het Dorp & Siza, Kemperbergerweg 139E, 6816, RP, Arnhem, The Netherlands
| | - Rutger Engels
- Trimbos-institute, Netherlands Institute of Mental Health and Addiction, Da Costakade 45, 3521, VS, Utrecht, The Netherlands.,Utrecht University, Domplein 29, 3512, JE, Utrecht, The Netherlands
| | - Margriet van Laar
- Trimbos-institute, Netherlands Institute of Mental Health and Addiction, Da Costakade 45, 3521, VS, Utrecht, The Netherlands
| |
Collapse
|
19
|
Beck AK, Baker A, Jones S, Lobban F, Kay-Lambkin F, Attia J, Banfield M. Exploring the feasibility and acceptability of a recovery-focused group therapy intervention for adults with bipolar disorder: trial protocol. BMJ Open 2018; 8:e019203. [PMID: 29391366 PMCID: PMC5829875 DOI: 10.1136/bmjopen-2017-019203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/08/2017] [Accepted: 11/07/2017] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Improving accessible, acceptable recovery-oriented service provision for people with bipolar disorder (BD) is an important priority. Mindfulness and acceptance-based cognitive and behavioural therapies (or 'third -wave' CBT) may prove fruitful due to the considerable overlap between these approaches and key features of personal recovery. Groups also confer therapeutic benefits consistent with personal recovery and may improve recovery-oriented service provision by adding another modality for accessing support. The primary objective of this trial is to explore the feasibility and acceptability of a new recovery-focused group therapy (RfGT) intervention for adults with BD. This is the first published feasibility assessment of a time-limited RfGTrecovery-focused group therapy intervention for BD. METHODS/ ANALYSIS This protocol describes an open feasibility study, utilising a pre-treatment design versus post- treatment design and nested qualitative evaluation. Participants will be recruited from the Central Coast region of New South Wales, Australia, from primary care providers, specialist mental health services, non-government organisations and via self-referral. The primary outcomes are feasibility and acceptability as indexed by recruitment, retention, intervention adherence, adverse events (if any) and detailed consumer feedback. Clinical outcomes and process measures will be assessed to inform future research. Primary outcome data will utiliseuse descriptive statistics (eg, summarizingsummarising recruitment, demographics, attendance, attrition and intervention adherence). Secondary outcomes will be assessed using repeated-measures analysis of covariance across all time points (including change, effect size and variability). ETHICS AND DISSEMINATION Ethical approval has been granted by the Northern Sydney Local Health District HREChuman research ethics committee (HREC) (HREC/16/HAWKE/69) and The University of Newcastle HREC (H-2016-0107). The Ffindings will be used to improve the intervention per user needs and preferences, and inform what amendments and/or information are required before a follow-on trial would be possible. This study contributes to a growing body of innovative, recovery-oriented innovations of psychological treatments for adults with BD. TRIAL REGISTRATION NUMBER ACTRN12616000887471; Pre-results.
Collapse
Affiliation(s)
- Alison K Beck
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- NHMRC Centre for Research Excellence in Mental Health and Substance Use, Sydney, Australia
| | - Amanda Baker
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- NHMRC Centre for Research Excellence in Mental Health and Substance Use, Sydney, Australia
| | - Steven Jones
- Spectrum Centre for Mental Health Research, Lancaster University, Lancaster, UK
| | - Fiona Lobban
- Spectrum Centre for Mental Health Research, Lancaster University, Lancaster, UK
| | - Frances Kay-Lambkin
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- NHMRC Centre for Research Excellence in Mental Health and Substance Use, Sydney, Australia
| | - John Attia
- Clinical Research Design, IT, and Statistical Support (CReDITSS) Unit, University of Newcastle, Newcastle, Australia
| | - Michelle Banfield
- Centre for Mental Health Research, Australian National University, Canberra, Australia
| |
Collapse
|
20
|
Guildford BJ, Daly-Eichenhardt A, Hill B, Sanderson K, McCracken LM. Analgesic reduction during an interdisciplinary pain management programme: treatment effects and processes of change. Br J Pain 2017; 12:72-86. [PMID: 29796259 DOI: 10.1177/2049463717734016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Long-term use of opioid medication is associated with a host of negative effects on health and quality of life. Guidelines state that people with chronic pain taking high doses of opioids without benefit should be supported to discontinue them. Little research has investigated psychological processes associated with analgesic use and tapering. This study investigated (1) analgesic use pre- and post-participation in an interdisciplinary pain management programme and its relationship to functioning and (2) psychological processes associated with analgesic use. Opioid use was associated with poorer functioning at baseline. Participating in an interdisciplinary pain management programme was associated with reductions in opioid dose and number of classes of analgesics used. Reductions in analgesic use were associated with improvements in functioning. Psychological inflexibility was associated with using higher doses of opioid medication and with using a greater number of classes of analgesics. Psychological flexibility appears relevant in explaining analgesic use. Future research could focus on targeting this process to improve tapering outcomes.
Collapse
Affiliation(s)
- Beth J Guildford
- INPUT Pain Management Unit, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,NIHR Maudsley Biomedical Research Centre, King's Health Partners, London, UK
| | - Aisling Daly-Eichenhardt
- INPUT Pain Management Unit, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Bethany Hill
- INPUT Pain Management Unit, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Karen Sanderson
- INPUT Pain Management Unit, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Lance M McCracken
- INPUT Pain Management Unit, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Health Psychology Section, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| |
Collapse
|
21
|
Atkins PWB, Ciarrochi J, Gaudiano BA, Bricker JB, Donald J, Rovner G, Smout M, Livheim F, Lundgren T, Hayes SC. Departing from the essential features of a high quality systematic review of psychotherapy: A response to Öst (2014) and recommendations for improvement. Behav Res Ther 2017; 97:259-272. [PMID: 28651775 DOI: 10.1016/j.brat.2017.05.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 02/12/2017] [Accepted: 05/24/2017] [Indexed: 11/24/2022]
Abstract
Öst's (2014) systematic review and meta-analysis of Acceptance and Commitment Therapy (ACT) has received wide attention. On the basis of his review, Öst argued that ACT research was not increasing in its quality and that, in contradiction to the views of Division 12 of the American Psychological Association (APA), ACT is "not yet well-established for any disorder" (2014, p. 105). We conducted a careful examination of the methods, approach, and data used in the meta-analysis. Based in part on examinations by the authors of the studies involved, which were then independently checked, 91 factual or interpretive errors were documented, touching upon 80% of the studies reviewed. Comparisons of Öst's quality ratings with independent teams rating the same studies with the same scale suggest that Ost's ratings were unreliable. In all of these areas (factual errors; interpretive errors; quality ratings) mistakes and differences were not random: Ost's data were dominantly more negative toward ACT. The seriousness, range, and distribution of errors, and a wider pattern of misinterpreting the purpose of studies and ignoring positive results, suggest that Öst's review should be set aside in future considerations of the evidence base for ACT. We argue that future published reviews and meta-analyses should rely upon diverse groups of scholars rather than a single individual; that resulting raw data should be made available for inspection and independent analysis; that well-crafted committees rather than individuals should design, apply and interpret quality criteria; that the intent of transdiagnostic studies need to be more seriously considered as the field shifts away from a purely syndromal approach; and that data that demonstrate theoretically consistent mediating processes should be given greater weight in evaluating specific interventions. Finally, in order to examine substantive progress since Öst's review, recent outcome and process evidence was briefly examined.
Collapse
Affiliation(s)
- Paul W B Atkins
- Institute for Positive Psychology and Education, Australian Catholic University, Strathfield 2135 NSW, Australia.
| | - Joseph Ciarrochi
- Institute for Positive Psychology and Education, Australian Catholic University, Strathfield 2135 NSW, Australia
| | - Brandon A Gaudiano
- Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University and Butler Hospital, 345 Blackstone Blvd, Providence, RI 02906, USA
| | - Jonathan B Bricker
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center & Department of Psychology, University of Washington, USA
| | - James Donald
- Institute for Positive Psychology and Education, Australian Catholic University, Strathfield 2135 NSW, Australia
| | - Graciela Rovner
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; ACT Institutet, Gothenburg, Sweden; Angered Hospital, Gothenburg, Sweden
| | - Matthew Smout
- School of Psychology, Social Work and Social Policy, University of South Australia, Australia
| | - Fredrik Livheim
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Tobias Lundgren
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Steven C Hayes
- Department of Psychology, University of Nevada, Reno, NV 89557-0062, USA
| |
Collapse
|
22
|
Vujanovic AA, Meyer TD, Heads AM, Stotts AL, Villarreal YR, Schmitz JM. Cognitive-behavioral therapies for depression and substance use disorders: An overview of traditional, third-wave, and transdiagnostic approaches. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2016; 43:402-415. [PMID: 27494547 DOI: 10.1080/00952990.2016.1199697] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The co-occurrence of depression and substance use disorders (SUD) is highly prevalent and associated with poor treatment outcomes for both disorders. As compared to individuals suffering from either disorder alone, individuals with both conditions are likely to endure a more severe and chronic clinical course with worse treatment outcomes. Thus, current practice guidelines recommend treating these co-occurring disorders simultaneously. OBJECTIVES The overarching aims of this narrative are two-fold: (1) to provide an updated review of the current empirical status of integrated psychotherapy approaches for SUD and depression comorbidity, based on models of traditional cognitive-behavioral therapy (CBT) and newer third-wave CBT approaches, including acceptance- and mindfulness-based interventions and behavioral activation (BA); and (2) to propose a novel theoretical framework for transdiagnostic CBT for SUD-depression, based upon empirically grounded psychological mechanisms underlying this highly prevalent comorbidity. RESULTS Traditional CBT approaches for the treatment of SUD-depression are well-studied. Despite advances in the development and evaluation of various third-wave psychotherapies, more work needs to be done to evaluate the efficacy of such approaches for SUD-depression. CONCLUSION Informed by this summary of the evidence, we propose a transdiagnostic therapy approach that aims to integrate treatment elements found in empirically supported CBT-based interventions for SUD and depression. By targeting shared cognitive-affective processes underlying SUD-depression, transdiagnostic treatment models have the potential to offer a novel clinical approach to treating this difficult-to-treat comorbidity and relevant, co-occurring psychiatric disturbances, such as posttraumatic stress.
Collapse
Affiliation(s)
- Anka A Vujanovic
- a Department of Psychology, University of Houston , Houston , TX , USA.,b Department of Psychiatry and Behavioral Sciences, McGovern Medical School , University of Texas Health Science Center at Houston , Houston , TX , USA
| | - Thomas D Meyer
- b Department of Psychiatry and Behavioral Sciences, McGovern Medical School , University of Texas Health Science Center at Houston , Houston , TX , USA
| | - Angela M Heads
- b Department of Psychiatry and Behavioral Sciences, McGovern Medical School , University of Texas Health Science Center at Houston , Houston , TX , USA
| | - Angela L Stotts
- b Department of Psychiatry and Behavioral Sciences, McGovern Medical School , University of Texas Health Science Center at Houston , Houston , TX , USA
| | - Yolanda R Villarreal
- b Department of Psychiatry and Behavioral Sciences, McGovern Medical School , University of Texas Health Science Center at Houston , Houston , TX , USA
| | - Joy M Schmitz
- b Department of Psychiatry and Behavioral Sciences, McGovern Medical School , University of Texas Health Science Center at Houston , Houston , TX , USA
| |
Collapse
|