Behavioral therapies for co-occurring substance use and mood disorders

Computer-based training for cognitive behavioral therapy for Spanish-speaking substance users: adaptation and satisfaction

There are few available culturally and linguistically adapted behavioral health interventions for substance use among Spanish-speaking adults. The authors describe the cultural adaptation of an innovative computer-based training for cognitive behavioral therapy program (CBT4CBT). Based in cognitive-behavioral skills training, CBT4CBT utilizes a telenovela to teach monolingual Spanish-speaking adults who have migrated to the United States to recognize triggers; avoid these situations; and cope more effectively with the consequences of substance use. Participants endorsed high levels of satisfaction with the program content and found the material to be easy to understand and relevant to their life experiences.

Anxiety and depression in lung cancer: effect of psychological interventions - network meta-analysis

BACKGROUND

The prevalence of depression and anxiety is high in patients with lung cancer, while multiple psychological interventions have revealed a positive impact on patients' negative emotions. However, it remains scarce which psychological intervention is the best choice for patients.This study was conducted to compare and rank the efficacy of psychological interventions on anxiety and depression in patients with lung cancer using a network meta-analysis.

METHODS

The Chinese academic database (CNKI, Wan Fang and Vip) and English academic database (The Cochrane Library, PubMed, PsycINFO and Web of Science) were searched from their inception to March 2022. Randomised controlled studies of psychological interventions on depression and anxiety in patients with lung cancer were included. Study selection and evaluation were conducted independently by two researchers. Included studies were performed a network meta-analysis to compare and rank the psychological interventions for negative emotions of patients with lung cancer. The clustered ranking of psychotherapies in the network was based on surface under the cumulative probability ranking curve values.

RESULTS

23 studies (2221 participants) with 13 psychological interventions were retrieved. The random-effects model showed a significantly large effect size of supportive therapy for anxiety (mean difference, MD 14.38, 95% CI 2.42 to 26.21) and depression (MD 14.29, 95% CI 2.74 to 25.70). The supportive therapy, sandplay therapy and music therapy were top three rankings of interventions for anxiety, while supportive therapy, dignity therapy and sandplay therapy were the top three interventions for depression.

CONCLUSIONS

Supportive therapy would be a more appropriate option for alleviating negative emotions in patients with lung cancer. Other psychological intervention techniques may be used as alternatives, such as sandplay therapy and music therapy for anxiety, dignity therapy and sandplay therapy for depression.

PROSPERO REGISTRATION NUMBER

CRD42022320188.

Cognitive-Behavioral Interventions Targeting Alcohol or Other Drug Use and Co-Occurring Mental Health Disorders: A Meta-Analysis

AIMS

This meta-analysis reviewed 15 clinical trials (18 study sites/arms), examining the efficacy of an integrated cognitive-behavioral intervention (CBI) delivered to individuals with an alcohol or other drug use disorder and a co-occurring mental health disorder (AOD/MHD). Outcomes were alcohol or other drug use and mental health symptoms at post-treatment through follow-up.

METHODS

The inverse-variance weighted effect size was calculated for each study and pooled under random effects assumptions.

RESULTS

Integrated CBI showed a small effect size for AOD (g = 0.188, P = 0.061; I2 = 86%, τ2 = 0.126, k = 18) and MHD (g = 0.169, P = 0.024; I2 = 58%, τ2 = 0.052, k = 18) outcomes, although only MHD outcomes were statistically significant. Analysis by subgroup suggested that effect magnitude varied by type of contrast condition (integrated CBI + usual care vs. usual care only; integrated CBI vs. a single-disorder intervention), follow-up time point (post-treatment vs. 3-6 months) and primary AOD/MHD diagnosis, although these sub-groups often contained significant residual heterogeneity. In a series of mixed effects, meta-regression models, demographic factors were non-significant predictors of between-study heterogeneity. For AOD outcomes, greater effects were observed in higher quality studies, but study quality was not related to effect size variability for MHD outcomes.

CONCLUSIONS

The current meta-analysis shows a small and variable effect for integrated CBI with the most promising effect sizes observed for integrated CBI compared with a single disorder intervention (typically an AOD-only intervention) for follow-up outcomes, and for interventions targeting alcohol use and/or post-traumatic stress disorder. Given the clinical and methodological variability within the sample, results should be considered a preliminary, but important step forward in our understanding of treatment for co-occurring AOD/MHD.

Prevention, screening, and treatment for heavy drinking and alcohol use disorder

Heavy drinking and alcohol use disorder are major public health problems. Practitioners not specialising in alcohol treatment are often unaware of the guidelines for preventing, identifying, and treating heavy drinking and alcohol use disorder. However, a consensus exists that clinically useful and valuable tools are available to address these issues. Here, we review existing information and developments from the past 5 years in these areas. We also include information on heavy drinking and alcohol use disorder among individuals with co-occurring psychiatric disorders, including drug use disorders. Areas covered include prevention; screening, brief intervention, and referral for treatment; evidence-based behavioural interventions; medication-assisted treatment; technology-based interventions (eHealth and mHealth); and population-level interventions. We also discuss the key topics for future research.

Integrated Treatment of Adolescents with Co-occurring Depression and Substance Use Disorder

Substance use disorders (SUDs) are commonly co-occurring among adolescents with depression. Integrated treatment is important given treatment implications and increased rates of suicidality. All adolescents should be screened for SUD using Screening, Brief Intervention, and Referral to Treatment. Review of randomized controlled trials in adolescents reveals motivational enhancement therapy/cognitive behavioral therapy is an evidence-based intervention and should be considered first-line treatment. If depression does not improve, fluoxetine should be considered, as it is well-tolerated in substance-involved adolescents with depression. Adolescents who do not show improvement in SUD or who have severe SUD should be referred to evidence-based SUD treatment.

Integrating Treatment for Co-Occurring Mental Health Conditions

Given the high co-occurrence between alcohol use disorder (AUD) and mental health conditions (MHCs), and the increased morbidity associated with the presence of co-occurring disorders, it is important that co-occurring disorders be identified and both disorders addressed in integrated treatment. Tremendous heterogeneity exists among individuals with co-occurring conditions, and factors related to both AUD and MHCs, including symptom type and acuity, illness severity, the chronicity of symptoms, and recovery capital, should be considered when recommending treatment interventions. This article reviews the prevalence of co-occurring AUD and MHCs, screening tools to identify individuals with symptoms of AUD and MHCs, and subsequent assessment of co-occurring disorders. Types of integrated treatment and current challenges to integrate treatment for co-occurring disorders effectively are reviewed. Innovative uses of technology to improve education on co-occurring disorders and treatment delivery are also discussed. Systemic challenges exist to providing integrated treatment in all treatment settings, and continued research is needed to determine ways to improve access to treatment.

A double blind, placebo controlled trial of modafinil for the treatment of cocaine dependence without co-morbid alcohol dependence

BACKGROUND

Modafinil is a medication approved for narcolepsy and shift work sleep disorder. It has both dopaminergic and glutamatergic activity that could be useful for the treatment of cocaine dependence. Modafinil has reduced cocaine subjective effects and cocaine self-administration in human laboratory trials and has reduced cocaine use in cocaine dependent patients in some clinical trials.

METHODS

This was an 8-week, double blind, placebo controlled clinical trial involving 94 cocaine dependent subjects. Subjects received 300mg of modafinil or identical placebo daily along with weekly individual therapy. The primary outcome measure was cocaine use measured by self-report, and confirmed by twice weekly urine benzoylecgonine tests (UBT). Additional outcome measures included cocaine craving measured by the Brief Substance Craving Scale and global improvement measured by the Clinical Global Impression Scale (CGI).

RESULTS

The odds ratio (OR) in favor of abstinence for modafinil vs. placebo was 2.54 (p=. 03) and modafinil-treated subjects were significantly more likely than placebo-treated subjects to be abstinent from cocaine during the last 3 weeks of the trial, 23% vs. 9%, χ(2)=3.9, p<.05. Modafinil treated subjects were more likely to report very low levels of cocaine craving intensity and duration on the Brief Substance Craving Scale (OR=2.04, p=.03 and OR 1.06, p=.03 respectively). Modafinil-treated subjects were also more likely than placebo-treated subjects to rate themselves as "very much improved" on the CGI (OR=2.69, p=.03).

CONCLUSION

Modafinil may be an efficacious treatment for cocaine dependence.

The interaction of active substance use, depression, and antiretroviral adherence in methadone maintenance

BACKGROUND

Adherence to highly active antiretroviral therapy (HAART) remains crucial in successfully treating HIV. While active substance use and depression are both associated with each other and with HAART nonadherence, little is known about their interaction. An understanding of the interaction of substance use and depressive symptoms on HAART adherence can inform adherence-enhancing interventions as well as interventions that target substance use and depression.

PURPOSE

We tested an interaction between substance use and depression on HAART adherence among methadone maintenance patients.

METHOD

We assessed substance use, depressive symptoms, and HAART adherence among 100 HIV-infected individuals receiving methadone maintenance in The Bronx, New York. Regressions were performed on adherence using an interaction term comprised of substance use and depressive symptoms. MODPROBE was used to assess significant interactions.

RESULTS

Any use of illicit substances was associated with HAART nonadherence (p = 0.043). Cannabis was the single substance of abuse most strongly associated with nonadherence (p = 0.003). Depressive symptoms approached significance in bivariate analysis (p = 0.066). In regression analysis, a significant interaction was found between illicit substance use and depressive symptoms [OR (95% CI) 1.23 (1.06-1.44), p = 0.007], where illicit substance use was associated with nonadherence in individuals with lower depressive symptoms, but not among those with depressive symptoms at higher levels. No individual substances interacted with depressive symptoms on adherence.

CONCLUSION

Though substance use and depressive symptoms interacted on HAART adherence, they did not have a synergistic effect. Continued substance use (51% of the sample) suggests an unmet need for treatment, even in methadone maintenance. Further examinations of the interplay of substance use and depression on HAART adherence are warranted.

Attempted suicide in people with co-occurring bipolar and substance use disorders: systematic review and meta-analysis

BACKGROUND

Both individuals with bipolar (BD) and those with alcohol (AUD) and other substance (SUD) use disorders are likely to attempt suicide. Comorbidity of BD and AUD/SUD may increase the likelihood of suicide attempts. We conducted a meta-analysis to estimate the association of comorbid AUD/SUD and suicide attempts in subjects with BD in the literature to date.

METHODS

Electronic databases through January 2013 were searched. Studies reporting rates of suicide attempts in people with co-occurring BD and AUD/SUD were retrieved. Comorbid AUD and SUD and suicide attempts rates as well as demographic, clinical, and methodological variables were extracted from each publication or obtained directly from its authors.

RESULTS

Twenty-nine of 222 studies assessed for eligibility met the inclusion criteria, comprising a total of 31,294 individuals with BD, of whom 6308 (20.1%) had documented suicide attempts. There were consistent findings across the studies included. As compared to controls, subjects with BD and comorbid AUD/SUD were more likely to attempt suicide. The cross-sectional association estimates showed random-effects pooled crude ORs of 1.96 (95% CI=1.56-2.47; p<0.01), 1.72 (95% CI=1.52-1.95; p<0.01), and 1.77 (95% CI=1.49-2.10; p<0.01), for combined AUD/SUD, AUD, and SUD. There was no publication bias and sensitivity analyses based on the highest quality studies confirmed core results.

LIMITATIONS

The effects of the number and the type of suicide attempts could not be investigated due to insufficient information.

CONCLUSIONS

Comorbid AUD and SUD in individuals with BD are significantly associated with suicide attempts. Individuals with this comorbidity should be targeted for intensive suicide prevention efforts.

Patient's experience with comorbidity management in primary care: a qualitative study of comorbid pain and obesity

AIM

The aim of this research is to examine perceptions of those with comorbid chronic pain and obesity regarding their experience of comorbidity management in primary care settings.

BACKGROUND

Chronic pain and obesity are common comorbidities frequently managed in primary care settings. Evidence suggests individuals with this comorbidity may be at risk for suboptimal clinical interactions; however, treatment experiences and preferences of those with comorbid chronic pain and obesity have received little attention.

METHODS

Semi-structured interviews conducted with 30 primary care patients with mean body mass index=36.8 and comorbid persistent pain. The constant comparative method was used to analyze data.

FINDINGS

Participants discussed frustration with a perceived lack of information tailored to their needs and a desire for a personalized treatment experience. Participants found available medical approaches unsatisfying and sought a more holistic approach to management. Discussions also focused around the need for providers to initiate efforts at education and motivation enhancement and to show concern for and understanding of the unique difficulties associated with comorbidity. Findings suggest providers should engage in integrated communication regarding weight and pain, targeting this multimorbidity using methods aligned with priorities discussed by patients.

Treatment development and feasibility study of family-focused treatment for adolescents with bipolar disorder and comorbid substance use disorders

BACKGROUND

Comorbid substance use disorders (SUD) are associated with increased illness severity and functional impairment among adolescents with bipolar disorder (BD). Previous psychosocial treatment studies have excluded adolescents with both BD and SUD. Studies suggest that integrated interventions are optimal for adults with BD and SUD.

METHODS

We modified family-focused treatment for adolescents with BD (FFT-A) in order to explicitly target comorbid SUD (FFT-SUD). Ten adolescents with BD who had both SUD and an exacerbation of manic, depressed, or mixed symptoms within the last 3 months were enrolled. FFT-SUD was offered as an adjunct to pharmacotherapy, with a target of 21 sessions over 12 months of treatment. The FFT- SUD manual was iteratively modified to integrate a concurrent focus on SUD.

RESULTS

Six subjects completed a mid-treatment 6-month assessment (after a mean of 16 sessions was completed). Of the 10 subjects, 3 dropped out early (after ≤1 session); in the case of each of these subjects, the participating parent had active SUD. No other subjects in the study had a parent with active SUD. Preliminary findings suggested significant reductions in manic symptoms and depressive symptoms and improved global functioning in the subjects who completed 6 months of treatment. Reduction in cannabis use was modest and did not reach significance. Limitations. Limitations included a small sample, open treatment, concurrent medications, and no control group.

CONCLUSIONS

These preliminary findings suggest that FFT-SUD is a feasible intervention, particularly for youth without parental SUD. FFT-SUD may be effective in treating mood symptoms, particularly depression, despite modest reductions in substance use. Integrating motivation enhancing strategies may augment the effect of this intervention on substance use. Additional strategies, such as targeting parental substance use, may prevent early attrition.

LONGER-TERM EFFECTIVENESS OF CBT IN TREATMENT OF COMORBID AUD/MDD ADOLESCENTS

Cognitive Behavioral Therapy (CBT) is a commonly used therapy among persons with major depressive disorder (MDD) and also among those with alcohol use disorders (AUD). However, less is known regarding the efficacy of CBT for treating persons with co-occurring disorders involving both MDD and an AUD. Studies assessing the efficacy of CBT in adolescent populations with co-occurring disorders are particularly sparse, especially studies designed to assess the potential longer-term efficacy of an acute phase trial of CBT therapy in that youthful comorbid population. We recently conducted a first acute phase treatment study involving comorbid AUD/MDD adolescents, which involved the medication fluoxetine as well as manualized CBT therapy. The results of that acute phase study suggested efficacy for CBT therapy but not for fluoxetine for treating the depressive symptoms and the excessive alcohol use of study subjects (Cornelius et al., 2009). The current chapter provides an assessment of the long-term efficacy of CBT for treating comorbid AUD/MDD adolescents, based on results from our own long-term (four-year) follow-up study, which was conducted following the completion of our recent acute phase treatment study. The results of the study suggest long-term efficacy for acute phase CBT/MET therapy for treating both the depressive symptoms and the excessive alcohol use of comorbid AUD/MDD adolescents, but demonstrate no evidence of long-term efficacy for fluoxetine for treating either the depressive symptoms or the excessive alcohol use of that population.

Effects of independent and substance-induced major depressive disorder on remission and relapse of alcohol, cocaine and heroin dependence

AIMS

Little is known about the differential effects of independent and substance-induced major depression on the longitudinal course of alcohol, cocaine and heroin disorders when studied prospectively.

DESIGN

Consecutively admitted in-patients, evaluated at baseline, 6-, 12- and 18-month follow-ups.

SETTING

Baseline evaluations in a short-stay in-patient urban community psychiatric hospital unit.

PARTICIPANTS

Adults (n = 250) with current DSM-IV cocaine, heroin and/or alcohol dependence at baseline.

MEASUREMENTS

The Psychiatric Research Interview for Substance and Mental Disorders (PRISM), used to evaluate independent and substance-induced major depression, alcohol, cocaine and heroin dependence, and other psychiatric disorders. Outcomes for each substance: (i) time (weeks) from hospital discharge to first use; (ii) time from discharge to onset of sustained (≥26 weeks) remission from dependence; (iii) time from onset of sustained remission to relapse.

FINDINGS

Substance-induced major depression significantly predicted post-discharge use of alcohol, cocaine and heroin (hazard ratios 4.7, 5.3 and 6.5, respectively). Among patients achieving stable remissions from dependence, independent major depression predicted relapse to alcohol and cocaine dependence (hazard ratios 2.3 and 2.7, respectively).

CONCLUSIONS

Substance-induced and independent major depressions were both related to post-discharge use of alcohol, cocaine and heroin. The findings suggest the importance of clinical attention to both types of depression in substance abusing patients.

Comorbidades psiquiátricas em dependentes químicos em abstinência em ambiente protegido

O objetivo desta pesquisa foi verificar a frequência de comorbidades psiquiátricas, utilizando Mini International Neuropsychiatric Interview, em diferentes grupos de dependentes químicos em abstinência, em ambiente protegido, classificados de acordo com o tipo de droga utilizada: (1) grupo controle (n = 37); (2) dependentes em abstinência de álcool (n = 8); (3) dependentes em abstinência de álcool, maconha e crack/cocaína (n = 24); e (4) dependentes em abstinência de múltiplas substâncias psicoativas (n=25), ou seja, indivíduos que faziam uso de vários tipos de drogas sem apresentar uma droga de escolha. Participaram 94 homens, com idade média de 30,41 anos (DP = 9,88). O período de abstinência variou entre 30 e 240 dias. A maioria dos participantes tinha baixa escolaridade e era solteira. Os resultados apontaram maior ocorrência de psicopatologias e risco de suicídio nos grupos formados por pacientes com histórico de consumo múltiplo de substâncias, sugerindo a importância da avaliação de outros transtornos associados à dependência química.

Major depression and treatment response in adolescents with ADHD and substance use disorder

BACKGROUND

Major depressive disorder (MDD) frequently co-occurs in adolescents with substance use disorders (SUDs) and attention deficit hyperactivity disorder (ADHD), but the impact of MDD on substance treatment and ADHD outcomes and implications for clinical practice are unclear.

METHODS

Adolescents (n=303; ages 13-18) meeting DSM-IV criteria for ADHD and SUD were randomized to osmotic release methylphenidate (OROS-MPH) or placebo and 16 weeks of cognitive behavioral therapy (CBT). Adolescents with (n=38) and without (n=265) MDD were compared on baseline demographic and clinical characteristics as well as non-nicotine substance use and ADHD treatment outcomes.

RESULTS

Adolescents with MDD reported more non-nicotine substance use days at baseline and continued using more throughout treatment compared to those without MDD (p<0.0001 based on timeline followback; p<0.001 based on urine drug screens). There was no difference between adolescents with and without MDD in retention or CBT sessions attended. ADHD symptom severity (based on DSM-IV ADHD rating scale) followed a slightly different course of improvement although with no difference between groups in baseline or 16-week symptom severity or 16-week symptom reduction. There was no difference in days of substance use or ADHD symptom outcomes over time in adolescents with MDD or those without MDD treated with OROS-MPH or placebo. Depressed adolescents were more often female, older, and not court ordered.

CONCLUSIONS

These preliminary findings suggest that compared to non-depressed adolescents with ADHD and SUD, those with co-occurring MDD have more severe substance use at baseline and throughout treatment. Such youth may require interventions targeting depression.

Evaluation of cognitive behavioral therapy/motivational enhancement therapy (CBT/MET) in a treatment trial of comorbid MDD/AUD adolescents

OBJECTIVE

Behavioral therapies developed specifically for co-occurring disorders remain sparse, and such therapies for comorbid adolescents are particularly rare. This was an evaluation of the long-term (2-year) efficacy of an acute phase trial of manualized cognitive behavioral therapy/motivation enhancement therapy (CBT/MET) vs. naturalistic treatment among adolescents who had signed consent for a treatment study involving the SSRI antidepressant medication fluoxetine and CBT/MET therapy for comorbid major depressive disorder (MDD) and an alcohol use disorder (AUD). We hypothesized that improvements in depressive symptoms and alcohol-related symptoms noted among the subjects who had received CBT/MET would exceed that of those in the naturalistic comparison group that had not received CBT/MET therapy.

METHODS

We evaluated levels of depressive symptoms and alcohol-related symptoms at a two-year follow-up evaluation among comorbid MDD/AUD adolescents who had received an acute phase trial of manual-based CBT/MET (in addition to the SSRI medication fluoxetine or placebo) compared to those who had received naturalistic care.

RESULTS

In repeated measures ANOVA, a significant time by enrollment status difference was noted for both depressive symptoms and alcohol-related symptoms across the two-year time period of this study, with those receiving CBT/MET demonstrating superior outcomes compared to those who had not received protocol CBT/MET therapy. No significant difference was noted between those receiving fluoxetine vs. those receiving placebo on any outcome at any time point.

CONCLUSIONS

These findings suggest long-term efficacy for an acute phase trial of manualized CBT/MET for treating comorbid MDD/AUD adolescents. Large multi-site studies are warranted to further clarify the efficacy of CBT/MET therapy among various adolescent and young adult comorbid populations.

Moderating effects of a craving intervention on the relation between negative mood and heavy drinking following treatment for alcohol dependence

OBJECTIVE

Negative affect is a significant predictor of alcohol relapse, and the relation between negative affect and drinking has been shown to be strongly mediated by alcohol craving. Thus, targeting craving during treatment could potentially attenuate the relation between negative affect and drinking.

METHOD

The current study is a secondary analysis of data from the COMBINE study, a randomized clinical trial that combined pharmacotherapy with behavioral intervention in the treatment of alcohol dependence. Our goal in the current study was to examine whether a treatment module that targeted craving would predict changes in negative mood during the 16-week combined behavioral intervention (n = 776) and the relation among changes in mood, craving, and changes in heavy drinking during treatment and 1 year posttreatment.

RESULTS

Changes in negative mood were significantly associated with changes in heavy drinking during treatment (f² = 0.78). Participants (n = 432) who received the craving module had significantly fewer heavy drinking days during treatment (d = 0.31), and receiving the module moderated the relation between negative mood and heavy drinking during treatment (f² = 0.92) and 1 year posttreatment (f² = 0.03). Moderating effects of the craving module were mediated by changes in craving during treatment. Within-subject analyses indicated significant pre- to postmodule reductions in negative mood. Additionally, postmodule craving significantly mediated the association between negative mood and heavy drinking during treatment and at posttreatment.

CONCLUSIONS

The craving module of the combined behavioral intervention may weaken the relation between negative affect and heavy drinking by fostering greater decreases in craving during treatment.

What's new in the treatment of cocaine addiction?

Cocaine dependence continues to be a significant public health problem in the United States. The number of regular cocaine users has not declined significantly in the United States since 1992. Although counseling remains the treatment of choice for cocaine dependence, many cocaine-dependent patients do not respond completely to standard drug counseling. Therefore, the development of new and more effective treatments for cocaine dependence is a research priority. Progress in the understanding of the neurobiology of cocaine dependence has led to the discovery of several promising medications that have already shown encouraging results in controlled clinical trials. Other promising compounds are just becoming available for clinical trials. The use of novel psychosocial techniques such as contingency management seems to increase the efficacy of several medications used to treat cocaine dependence. New medications and new psychosocial techniques are leading to significant improvements in the treatment of cocaine dependence.

Mindfulness-based treatments for co-occurring depression and substance use disorders: what can we learn from the brain?

Both depression and substance use disorders represent major global public health concerns and are often co-occurring. Although there are ongoing discoveries regarding the pathophysiology and treatment of each condition, common mechanisms and effective treatments for co-occurring depression and substance abuse remain elusive. Mindfulness training has been shown recently to benefit both depression and substance use disorders, suggesting that this approach may target common behavioral and neurobiological processes. However, it remains unclear whether these pathways constitute specific shared neurobiological mechanisms or more extensive components universal to the broader human experience of psychological distress or suffering.We offer a theoretical, clinical and neurobiological perspective of the overlaps between these disorders, highlight common neural pathways that play a role in depression and substance use disorders and discuss how these commonalities may frame our conceptualization and treatment of co-occurring disorders. Finally, we discuss how advances in our understanding of potential mechanisms of mindfulness training may offer not only unique effects on depression and substance use, but also offer promise for treatment of co-occurring disorders.

[Cannabis and mood]

OBJECTIVE

Evaluate the relationship between acute and chronic use of cannabis and mood changes.

METHOD

Articles were selected by electronic search in PubMed. Chapters in books and reference lists of selected articles were also reviewed. As the research did not involve humans, there was no evaluation by a Research Ethics Committee.

RESULTS

High rates of comorbidity between use/abuse/dependence of cannabis and affective disorders in longitudinal studies and in clinical samples were observed. Longitudinal studies indicate that, in long-term, the higher use of cannabis is associated with an increased risk of developing bipolar disorder, and probably, major depression in subjects initially without affective disorder, but was not found increased risk of cannabis use among those initially only with mania or depression. Another important observation is that substance abuse in bipolar patients may be associated with a number of negative characteristics, such as difficulty in recovering the affective symptoms, more hospitalizations, poor compliance with treatment, increased risk of suicide, aggression and a poor response to lithium. Psychosocial and pharmacological treatments are indicated for the management of comorbidity between cannabis and affective disorders.

CONCLUSION

The relationship between cannabis use and mood changes are observed both in the epidemiological research and in the clinical settings.

Computer-based psychological treatment for comorbid depression and problematic alcohol and/or cannabis use: a randomized controlled trial of clinical efficacy

AIMS

To evaluate computer- versus therapist-delivered psychological treatment for people with comorbid depression and alcohol/cannabis use problems.

DESIGN

Randomized controlled trial.

SETTING

Community-based participants in the Hunter Region of New South Wales, Australia.

PARTICIPANTS

Ninety-seven people with comorbid major depression and alcohol/cannabis misuse.

INTERVENTION

All participants received a brief intervention (BI) for depressive symptoms and substance misuse, followed by random assignment to: no further treatment (BI alone); or nine sessions of motivational interviewing and cognitive behaviour therapy (intensive MI/CBT). Participants allocated to the intensive MI/CBT condition were selected at random to receive their treatment 'live' (i.e. delivered by a psychologist) or via a computer-based program (with brief weekly input from a psychologist).

MEASUREMENTS

Depression, alcohol/cannabis use and hazardous substance use index scores measured at baseline, and 3, 6 and 12 months post-baseline assessment.

FINDINGS

(i) Depression responded better to intensive MI/CBT compared to BI alone, with 'live' treatment demonstrating a strong short-term beneficial effect which was matched by computer-based treatment at 12-month follow-up; (ii) problematic alcohol use responded well to BI alone and even better to the intensive MI/CBT intervention; (iii) intensive MI/CBT was significantly better than BI alone in reducing cannabis use and hazardous substance use, with computer-based therapy showing the largest treatment effect.

CONCLUSIONS

Computer-based treatment, targeting both depression and substance use simultaneously, results in at least equivalent 12-month outcomes relative to a 'live' intervention. For clinicians treating people with comorbid depression and alcohol problems, BIs addressing both issues appear to be an appropriate and efficacious treatment option. Primary care of those with comorbid depression and cannabis use problems could involve computer-based integrated interventions for depression and cannabis use, with brief regular contact with the clinician to check on progress.

Dual diagnosis and psychosocial interventions--introduction and commentary

Treatment of patients with concurrent mental illness and substance abuse represents a challenge to the traditional treatment systems. This article gives: 1) an introduction of the concept and frequency of dual diagnosis (DD), 2) a presentation and discussion of the latest guidelines on DD treatment, 3) status on the current situation in the DD field in Denmark, and 4) potentials for future research. The article is based on systematic examination of evidence-based research and popularized latest guidelines on DD treatment. Methodologically, both treatment and research is challenged by the diversity in DD combinations. Although integrated treatment with the inclusion of cognitive-behavioural therapy, motivational interviewing and family intervention in DD treatment show promising results, it remains to establish which treatment programme is the most qualified in improving mental health and reducing substance use. A future priority is the development of DD treatment that targets specific co-morbid combinations and treatment needs.

Pilot study of interpersonal psychotherapy versus supportive psychotherapy for dysthymic patients with secondary alcohol abuse or dependence

Interpersonal psychotherapy (IPT) has demonstrated efficacy for depression but yielded negative results for substance disorders. Alcohol abuse frequently complicates mood disorders. This pilot study compared IPT with brief supportive psychotherapy (BSP) for dysthymic disorder and alcohol abuse. We hypothesized that effect sizes would suggest greater IPT efficacy for both diagnoses, despite limited statistical power. Subjects with primary DSM-IV dysthymic disorder and secondary alcohol abuse/dependence were randomly assigned 16 weeks of IPT (N = 14) or BSP (N = 12). Patients in both treatments reported improved depressive symptoms and alcohol abstinence. IPT had a large and BSP a moderate effect size in depression, whereas BSP had a moderate and IPT a small effect size in percentage of days abstinent. This pilot study offers initial data on IPT and BSP for comorbid chronic depression and alcohol abuse/dependence. Results suggest IPT may have specific antidepressant benefits for dysthymic alcoholic patients but not in treating alcoholism.

Treatment response of bipolar and unipolar alcoholics to an inpatient dual diagnosis program

BACKGROUND

Depressed and bipolar alcoholics represent a significant affective subgroup that has a poorer prognosis than either diagnosis alone. To date few systematic treatment programs have been developed to treat dual diagnosis.

METHODS

An inpatient treatment program was developed at St Patrick's Hospital Dublin to treat dual diagnosis clients with alcohol dependence and either unipolar or bipolar affective disorder. Clients (N=232) were assessed for depression, anxiety, elation, cravings, drink and drug intake on admission, discharge, 3 and 6 months post-discharge from the program.

RESULTS

In the overall group there was a reduction in number of drinking days and units per drinking day over the study (p<.01). There was a 71.8% complete abstinent rate at 3 months and 55.8% at 6 months in the depression group, non-significantly greater than for the bipolar group at 64.7% and 54.1% respectively. Gamma GT, MCV and craving scores were significantly reduced over time (p<.01). Mania, depression and anxiety inventory scores fell over time in both groups (p<.01). 15-21-year olds were more severely anxious, had higher illicit drug use, and were more likely to relapse to drug use than older clients. Bipolar 1 clients were significantly more likely than bipolar 2 clients to be on mood stabilisers at all follow-up stages (p<.001).

LIMITATIONS

No control group was used.

CONCLUSIONS

There is evidence for efficacy of a specifically designed dual diagnosis inpatient treatment program as both depressed and bipolar alcoholics had significant reductions in all measurements of mood, craving, and alcohol/drug consumption by self report and biological markers, suggesting both diagnoses can be effectively treated together.

Substance abuse treatment and psychiatric comorbidity: do benefits spill over? Analysis of data from a prospective trial among cocaine-dependent homeless persons

Background

Comorbid psychiatric illness can undermine outcomes among homeless persons undergoing addiction treatment, and psychiatric specialty care is not always readily available. The prognosis for nonsubstance abuse psychiatric diagnoses among homeless persons receiving behaviorally-based addiction treatment, however, is little studied.

Results

Data from an addiction treatment trial for 95 cocaine-dependent homeless persons (1996–1998) were used to profile psychiatric diagnoses at baseline and 6 months, including mood-related disorders (e.g. depression) and anxiety-related disorders (e.g. post-traumatic stress disorder). Treatment interventions, including systematic reinforcement for goal attainment, were behavioral in orientation. There was a 32% reduction in the prevalence of comorbid non-addiction psychiatric disorder from baseline to 6 months, with similar reductions in the prevalence of mood (-32%) and anxiety-related disorders (-20%) (p = 0.12).

Conclusion

Among cocaine-dependent homeless persons with psychiatric comorbidity undergoing behavioral addiction treatment, a reduction in comorbid psychiatric disorder prevalence was observed over 6 months. Not all participants improved, suggesting that even evidence-based addiction treatment will prove insufficient for a meaningful proportion of the dually diagnosed homeless population.

Effects of motivational interviewing training on mental health therapist behavior

This study examined the effectiveness of training community mental health therapists in motivational interviewing (MI) adapted to treat clients with co-occurring disorders. Ten therapists with high caseloads of culturally diverse clients in two different community mental health settings fulfilled all study requirements. MI training consisted of a two-day didactic and experiential workshop followed by eight biweekly small group supervision (coaching) sessions. Using an interrupted time series design, 156 randomly selected therapy sessions involving 28 clients were coded for assessment of therapist fidelity to MI at multiple points in time, both pre- and post-training. Employing hierarchical linear modeling analysis, significant improvement in MI skill was observed after training on five of six key therapist ratings, and on the sole client rating (client change talk) that was examined. Importantly, the present study demonstrates training-related proficiency in motivational interviewing using: (a) a representative sample of mental health therapists from the community; (b) a protocol emphasizing adherence to a mental health treatment regimen as well as management of substance use behavior for clients with co-occurring disorders; (c) repeated random observations of therapy sessions; (d) measurement of training-related changes in clinician skills and self motivational statements by clients. Findings of this effectiveness study compared favorably with efficacy literature on MI training.

New medications for the treatment of cocaine dependence

Cocaine dependence continues to be a significant public health problem in the United States. Although some cocaine- dependent patients will respond well to drug counseling, for many, standard psychosocial treatment is inadequate. Therefore, the development of an effective medication for the treatment of cocaine dependence is a research priority. However, despite many years of research, no medication has emerged as consistently effective for the treatment of cocaine dependence. Progress in the understanding of the neurobiology of cocaine dependence has led to the discovery of several promising medications that have already shown encouraging results in controlled clinical trials. Among more severely addicted patients, propranolol may be helpful in promoting an initial period of stable abstinence. For the prevention of relapse, medications that block cocaine euphoria or reduce cocaine craving have shown promise. Potential relapse-prevention medications include GABAergic medications, such as baclofen, tiagabine, and topiramate, and the glutamatergic medication, modafinil. Surprisingly, an old treatment for alcohol dependence, disulfiram, may also have efficacy for cocaine relapse prevention. Finally, a vaccine capable of stimulating the production of cocaine specific antibodies has shown promise in preliminary studies for the prevention of relapse to cocaine use.

Medications development: Successes and challenges

The National Institute on Drug Abuse has funded a medications program that has concentrated on the development of medications for opiate and cocaine dependence. Levomethadyl acetate (LAAM) and buprenorphine and buprenorphine/naloxone sublingual tablets were developed in conjunction with pharmaceutical partners and approved by the Food and Drug Administration. The remaining challenges for medications development for opiate dependence involves Phase IV studies in special populations, for example, pregnant opiate-dependent patients, and to translate neuroscience-based findings into treatments. Several marketed medications have shown initial efficacy to reduce cocaine use in well-controlled clinical trials. Disulfiram has been shown to reduce cocaine use in several clinical trials, while baclofen, modafinil, naltrexone, ondansetron, tiagabine, and topiramate have shown preliminary efficacy in initial clinical studies. Confirmatory studies of many of these medications is underway. More recently, the NIDA medications program has evaluated medications for their ability to reduce methamphetamine use. To date, no medications tested have shown efficacy to reduce methamphetamine use. Both marketed medications and investigational agents will be tested. Finally, NIDA has begun to test medications for efficacy to reduce cannabis use. Initial studies are underway. Both agonist and antagonist approaches will be evaluated. Additionally, medications will be tested in cannabis-dependent patients for the management of insomnia, withdrawal, and concurrent depression.

Bipolar disorder and substance abuse

SUDs are common in people with BPD. The reasons for this association are not well understood and may be related to several factors. When present,SUDs in BPD patients seem to be associated with a poor prognosis. The treatment of patients with BPD and an SUD has been the subject of relatively little investigation, but medications that are effective mood stabilizers seem to decrease substance use in some reports.