Who needs more than standard care? Treatment moderators in a randomized clinical trial comparing addiction treatment alone to addiction treatment plus anxiety disorder treatment for comorbid anxiety and substance use disorders

A Transdiagnostic group therapy for sleep and anxiety among adults with substance use disorders: Protocol and pilot investigation

Introduction

Treatment of substance use disorders (SUDs) is challenging with high rates of treatment dropout and relapse, particularly among individuals with comorbid psychiatric conditions. Anxiety and insomnia are prevalent among those with SUD and exacerbate poor treatment outcomes. Interventions that concurrently target anxiety and insomnia during the early stages of SUD treatment are lacking. To this end, we investigated the feasibility and preliminary effectiveness in a single-arm pilot trial of an empirically informed group transdiagnostic intervention, Transdiagnostic SUD Therapy, to concurrently reduce anxiety and improve sleep among adults receiving treatment for SUD. Specifically, we hypothesized that participants would evidence declines in anxiety and insomnia and improvements in sleep health, a holistic, multidimensional pattern of sleep-wakefulness that promotes wellbeing. A secondary aim was to describe the protocol for Transdiagnostic SUD Therapy and how it may be implemented into a real-world addiction treatment setting.

Method

Participants were 163 adults (M_age  = 43.23; 95.1% White; 39.93% female) participating in an intensive outpatient program for SUD who attended at least three of four Transdiagnostic SUD Therapy sessions. Participants had diverse SUDs (58.3% alcohol use disorder, 19.0% opioid use disorder) and nearly a third of the sample met criteria for two SUDs and comorbid mental health diagnoses (28.9% anxiety disorder, 24.6% major depressive disorder).

Results

As anticipated, anxiety and insomnia reduced significantly across the 4-week intervention period from clinical to subclinical severity, and sleep health significantly improved (ps < 0.001). These statistically significant improvements following Transdiagnostic SUD Therapy demonstrated medium to large effects (ds > 0.5).

Conclusion

Transdiagnostic SUD Therapy is designed to be flexibly administered in "real-world" clinical settings and, preliminarily, appears to be effective in improving emotional and behavioral factors that increase risk for return to substance use and poor SUD treatment outcomes. Additional work is needed to replicate these findings, determine the feasibility of widespread uptake of Transdiagnostic SUD Therapy, and examine whether the treatment effects translate to improvement in substance use outcomes.

Acceptability and Effectiveness of Artificial Intelligence Therapy for Anxiety and Depression (Youper): Longitudinal Observational Study

Background

Youper is a widely used, commercially available mobile app that uses artificial intelligence therapy for the treatment of anxiety and depression.

Objective

Our study examined the acceptability and effectiveness of Youper. Further, we tested the cumulative regulation hypothesis, which posits that cumulative emotion regulation successes with repeated intervention engagement will predict longer-term anxiety and depression symptom reduction.

Methods

We examined data from paying Youper users (N=4517) who allowed their data to be used for research. To characterize the acceptability of Youper, we asked users to rate the app on a 5-star scale and measured retention statistics for users’ first 4 weeks of subscription. To examine effectiveness, we examined longitudinal measures of anxiety and depression symptoms. To test the cumulative regulation hypothesis, we used the proportion of successful emotion regulation attempts to predict symptom reduction.

Results

Youper users rated the app highly (mean 4.36 stars, SD 0.84), and 42.66% (1927/4517) of users were retained by week 4. Symptoms decreased in the first 2 weeks of app use (anxiety: d=0.57; depression: d=0.46). Anxiety improvements were maintained in the subsequent 2 weeks, but depression symptoms increased slightly with a very small effect size (d=0.05). A higher proportion of successful emotion regulation attempts significantly predicted greater anxiety and depression symptom reduction.

Conclusions

Youper is a low-cost, completely self-guided treatment that is accessible to users who may not otherwise access mental health care. Our findings demonstrate the acceptability and effectiveness of Youper as a treatment for anxiety and depression symptoms and support continued study of Youper in a randomized clinical trial.

A Distinct Neurophenotype of Fearful Face Processing in Alcohol Use Disorder With and Without Comorbid Anxiety

BACKGROUND

Individuals with alcohol use disorder (AUD) can present with comorbid anxiety symptoms and often have deficits in emotional processing. Previous research suggests brain response is altered during facial affect recognition tasks, especially in limbic areas, due to either AUD or anxiety symptomology; however, the impact of both AUD and clinically significant anxiety symptoms during these tasks has not yet been examined.

METHODS

In this study, we investigated neural activation differences during an emotional face-matching task. Participants (N = 232) underwent fMRI scanning, as part of a larger study. Three groups were investigated: individuals with diagnosed AUD and elevated anxiety traits (AUD + ANX, n = 90), individuals with diagnosed AUD but non-clinically significant levels of anxiety (AUD-ANX, n = 39), and healthy controls (HC, n = 103).

RESULTS

Our results illustrate distinct neurophenotypes of AUD, where individuals with comorbid anxiety symptomology have blunted emotional face processing while those with singular AUD are hyperresponsive.

CONCLUSIONS

This suggests AUD with anxiety symptomology may have a unique neurobiological underpinning, and treatment and intervention should be tailored to individual constellations of symptoms.

Randomized Controlled Trial Testing Mobile-Based Attention-Bias Modification for Posttraumatic Stress Using Personalized Word Stimuli

Although behavioral therapies are effective for posttraumatic stress disorder (PTSD), access for patients is limited. Attention-bias modification (ABM), a cognitive-training intervention designed to reduce attention bias for threat, can be broadly disseminated using technology. We remotely tested an ABM mobile app for PTSD. Participants (N = 689) were randomly assigned to personalized ABM, nonpersonalized ABM, or placebo training. ABM was a modified dot-probe paradigm delivered daily for 12 sessions. Personalized ABM included words selected using a recommender algorithm. Placebo included only neutral words. Primary outcomes (PTSD and anxiety) and secondary outcomes (depression and PTSD clusters) were collected at baseline, after training, and at 5-week-follow-up. Mechanisms assessed during treatment were attention bias and self-reported threat sensitivity. No group differences emerged on outcomes or attention bias. Nonpersonalized ABM showed greater declines in self-reported threat sensitivity than placebo (p = .044). This study constitutes the largest mobile-based trial of ABM to date. Findings do not support the effectiveness of mobile ABM for PTSD.

The Role of Affect in Psychosocial Treatments for Substance Use Disorders

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.

Early Life Poly-Victimization and Differential Development of Anxiety as Risk Factors for the Continuity of Substance Dependence in Adulthood

Background: Abuse of psychoactive substances may lead to physical and/or physiological dependence on said substances. While a great deal of research has focused on risk factors predicting onset, there has been little research focused on risk factors influencing continued dependence on substances in adulthood following onset early in life. Purpose/Objectives: The present study examined poly-victimization and developmental patterns of anxiety as predictors of continued substance dependence problems. Methods: The Pathways to Desistance data were used in the present study. A subset of this sample was used in analyses comprising 261 juvenile offenders who reported lifetime drug and/or alcohol dependence at baseline. Firth logistic regression was used to estimate the impact that covariates had on the odds that individuals in this subsample had continued substance dependence in adulthood. Results: Results indicated that increased poly-victimization score pertaining to direct victimization at baseline was associated with increased odds of continued substance dependence problems in adulthood. Further, presentation of high and chronic anxiety symptomatology during adolescence was associated with increased risk for continued dependence. Conclusions/Importance: Drug dependent adolescents who demonstrate chronic anxiety and/or have experienced polyvictimization are at-risk for continuity of dependent in adulthood. Youth should be screened for these issues and targeted with treatment.

Cue-Elicited Anxiety and Alcohol Craving as Indicators of the Validity of ALCO-VR Software: A Virtual Reality Study

BACKGROUND

This study is part of a larger project aiming to develop a virtual reality (VR) software to be implemented as a clinical tool for patients diagnosed with alcohol use disorder (AUD). The study is based on previous research in which we identified factors that elicit craving for alcohol in a sample of AUD patients, and which led to the development of a virtual reality software to be used in cue exposure treatments of alcohol use disorder (ALCO-VR). The main objective of this study was to test the effectiveness of ALCO-VR to elicit cue-induced craving and anxiety responses among social drinkers (SD) and AUD patients. Our secondary objective was to explore which responses (cue-induced craving or anxiety) can best differentiate between AUD patients and the SD group.

METHOD

Twenty-seven individuals (13 AUD patients and 14 SD) participated in this study after giving written informed consent. Their anxiety and alcohol craving levels were measured by different instruments at different stages of the procedure. The VR equipment consisted of Oculus Rift technology, and the software consisted of the ALCO-VR platform.

RESULTS

Our data indicate that the ALCO-VR software can elicit responses of anxiety and alcohol craving, especially in the group of AUD patients. The cue-induced anxiety response differentiated AUD patients and the SD group better than the cue-induced craving response.

CONCLUSIONS

The general interest in applying new technologies to the assessment and treatment of mental health disorders has led to the development of immersive real-life simulations based on the advantages of VR technology. Our study concluded that the ALCO-VR software can elicit anxiety and craving responses and that cue-induced anxiety responses can distinguish between AUD and SD groups better than cue-induced craving. The data on craving and anxiety were assessed consistently by different instruments. In addition, we consider that ALCO-VR is able to ecologically assess cue-induced anxiety and alcohol craving levels during exposure to VR alcohol-related environments.

Guided Self-Help Works: Randomized Waitlist Controlled Trial of Pacifica, a Mobile App Integrating Cognitive Behavioral Therapy and Mindfulness for Stress, Anxiety, and Depression

Background

Despite substantial improvements in technology and the increased demand for technology-enabled behavioral health tools among consumers, little progress has been made in easing the burden of mental illness. This may be because of the inherent challenges of conducting traditional clinical trials in a rapidly evolving technology landscape.

Objective

This study sought to validate the effectiveness of Pacifica, a popular commercially available app for the self-management of mild-to-moderate stress, anxiety, and depression.

Methods

A total of 500 adults with mild-to-moderate anxiety or depression were recruited from in-app onboarding to participate in a randomized waitlist controlled trial of Pacifica. We conducted an all-virtual study, recruiting, screening, and randomizing participants through a Web-based participant portal. Study participants used the app for 1 month, with no level of use required, closely mimicking real-world app usage. Participants in the waitlist group were given access to the app after 1 month. Measurements included self-reported symptoms of stress, anxiety, depression, and self-efficacy. We performed an intent-to-treat analysis to examine the interactive effects of time and condition.

Results

We found significant interactions between time and group. Participants in the active condition demonstrated significantly greater decreases in depression, anxiety, and stress and increases in self-efficacy. Although we did not find a relationship between overall engagement with the app and symptom improvement, participants who completed relatively more thought record exercises sustained improvements in their symptoms through the 2-month follow-up to a greater degree than those who completed fewer. In addition, we found that participants who reported concomitantly taking psychiatric medications during the trial benefitted less from the app, as measured by the symptoms of anxiety and stress.

Conclusions

This study provides evidence that Pacifica, a popular commercially available self-help app, is effective in reducing self-reported symptoms of depression, anxiety, and stress, particularly among individuals who utilize thought records and are not taking psychiatric medication.

Trial Registration

ClinicalTrials.gov NCT03333707; https://clinicaltrials.gov/ct2/show/NCT03333707 (Archived by WebCite at http://www.webcitation.org/78YE07ADB)