A behavioral treatment for opioid-dependent patients with antisocial personality

Psychological interventions for antisocial personality disorder

BACKGROUND

Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review).

OBJECTIVES

To evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also searched reference lists and contacted study authors to identify studies.

SELECTION CRITERIA

Randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called 'standard Maintenance'(SM) in some studies). Eight of the 18 psychological interventions reported data on our primary outcomes. Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants. Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks). Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%. Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention. One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention. Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence). One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up. Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. 'Driving whilst intoxicated' programme (DWI) + incarceration versus incarceration One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months. Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19). The certainty of the evidence for all outcomes was very low. Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants' level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention. Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU. Psychosocial risk management (PSRM; 'Resettle') versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence).

AUTHORS' CONCLUSIONS

There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour. Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.

Psychoanalytic-Interactional Therapy versus Psychodynamic Therapy by Experts for Personality Disorders: A Randomized Controlled Efficacy-Effectiveness Study in Cluster B Personality Disorders

BACKGROUND

With regard to cluster B personality disorders, most psychotherapeutic treatments focus on borderline personality disorder. Evidence-based treatments for patients with other cluster B personality disorders are not yet available. Psychoanalytic-interactional therapy (PIT) represents a transdiagnostic treatment for severe personality disorders. PIT has been applied in clinical practice for many years and has proven effective in open studies. In a randomized controlled trial, we compared manual-guided PIT to nonmanualized pychodynamic therapy by experts in personality disorders (E-PDT) in patients with cluster B personality disorders.

METHODS

In an inpatient setting, patients with cluster B personality disorders were randomly assigned to manual-guided PIT (n = 64) or nonmanualized E-PDT (n = 58). In addition, a quasi-experimental control condition was used (n = 46) including both patients receiving treatment as usual and patients waiting for treatment. Primary outcomes were level of personality organization and overall psychological distress. As secondary outcomes, depression, anxiety and interpersonal problems were examined.

RESULTS

No significant improvements were found in the control patients. Both PIT and E-PDT achieved significant improvements in all outcome measures and were superior to the control condition. No differences were found between PIT and E-PDT in any outcome measure at the end of treatment. The type of cluster B personality disorder had no impact on the results.

CONCLUSIONS

In an inpatient setting, both PIT and E-PDT proved to be superior to a control condition in cluster B personality disorders. In a head-to-head comparison, both treatments appeared to be equally effective. Further research on the treatment of cluster B personality disorders is required.

Psycho-education for substance use and antisocial personality disorder: a randomized trial

BACKGROUND

Antisocial personality disorder often co-exists with drug and alcohol use disorders.

METHODS

This trial examined the effectiveness of offering psycho-education for antisocial personality disorder in community substance use disorder treatment centers in Denmark. A total of 176 patients were randomly allocated to treatment as usual (TAU, n = 80) or TAU plus a psycho-educative program, Impulsive Lifestyle Counselling (ILC, n = 96) delivered by site clinicians (n = 39). Using follow-up interviews 3 and 9 months after randomization, we examined changes in drug and alcohol use (Addiction Severity Index Composite Scores), percent days abstinent (PDA) within last month, and aggression as measured with the Buss-Perry Aggression Questionnaire-Short Form and the Self-Report of Aggression and Social Behavior Measure.

RESULTS

Overall engagement in psychological interventions was modest: 71 (76 %) of participants randomized to psycho-education attended at least one counselling session, and 21 (23 %) attended all six sessions. The Median number of sessions was 2. All patients reduced drug and alcohol problems at 9 months with small within-group effect sizes. Intention-to-treat analyses indicated significant differences between ILC and TAU in mean drugs composite score (p = .018) and in PDA (p = .041) at 3 months. Aggression declined in both groups, but no differences between ILC and TAU were observed in terms of alcohol problems or aggression at any follow-up.

CONCLUSIONS

Moderate short-term improvements in substance use were associated with randomization to Impulsive Lifestyle Counselling. The findings support the usefulness of providing psycho-education to outpatients with antisocial personality disorder.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN67266318 , 17/7/2012.

Prevalence of antisocial personality disorder among Chinese individuals receiving treatment for heroin dependence: a meta-analysis

Background

Studies from Western countries consistently report very high rates of comorbid Antisocial Personality Disorder (ASPD) among individuals with heroin addiction, but the reported proportion of Chinese individuals with heroin addiction who have co-morbid ASPD varies widely, possibly because Chinese clinicians do not consider personality issues when treating substance abuse problems.

Aim

Conduct a meta-analysis of studies that assessed the proportion of Chinese individuals with heroin dependence who have comorbid ASPD.

Methods

We searched for relevant studies in both Chinese databases (China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, Taiwan Electronic Periodical Services) and western databases (PubMed, EMBASE, and PsycInfo). Two authors independently retrieved the literature, identified studies that met pre-defined inclusion and exclusion criteria, assessed the quality of included studies, and extracted the data used in the analysis. Statistical analysis was performed using StatsDirect 3.0 and R software.

Results

The search yielded 15 eligible studies with a total of 3692 individuals with heroin dependence. Only 2 of the studies were rated as high-quality studies. All studies were conducted in rehabilitation centers or hospitals. The pooled lifetime prevalence of ASPD in these subjects was 30% (95%CI: 23%-38%), but the heterogeneity of results across studies was great (I² =95%, p<0.001). Men had a higher prevalence than women (44% vs. 21%), and injection heroin users had higher prevalence than those who smoked heroin (44% vs. 27%). Studies that were methodologically stronger had higher reported prevalence of ASPD among heroin dependent individuals.

Conclusions

There are substantial methodological problems in the available literature about ASPD in Chinese individuals receiving treatment for heroin dependence, but we estimate that about one-third of them meet criteria for ASPD. Further work is needed to increase clinicians’ awareness of this issue; to compare the pathogenesis, treatment responsiveness and recidivism of those with and without ASPD; and to develop and test targeted interventions for this difficult-to-treat subgroup of individuals with heroin dependence.

Gender differences in prevalence and correlates of antisocial personality disorder among heroin dependent users in compulsory isolation treatment in China

BACKGROUND

Little is known about gender difference in correlates of antisocial personality disorder (ASPD) among drug users.

OBJECTIVE

To detect gender difference in correlates of ASPD in a Chinese heroin dependent sample.

METHODS

Structured interviews were conducted among 882 heroin dependent users in two compulsory isolation settings in Changsha, China. Descriptive statistics were employed to report sample characteristics by gender. Bivariate relationships were examined between co-occurring ASPD and variables measuring demographic, drug use, and psychiatric co-morbidities. Multivariate logistic regressions with stepwise forward method were conducted to determine independent predictors for co-occurring ASPD. All analyses examining correlates of co-occurring ASPD were conducted for the total, the male and the female participants respectively to detect both the common and the unique correlates of ASPD by gender.

RESULTS

Of the total participants, 41.4% (54.2% of males and 15.4% of females) met the DSM-IV criteria of ASPD. For male participants, lower educational level, unemployment, unmarried, younger age at first heroin use, previous history of compulsory treatment, larger amounts of heroin used per day and poly-drug abuse during past month before admission, as well as psychiatric co-morbidities of lifetime major depressive disorder and borderline personality disorder were independent predictors for co-occurring ASPD; while for female participants, only three variables: younger age at first heroin use, paranoid personality disorder and borderline personality disorder were independent predictors for co-occurring ASPD.

CONCLUSIONS

Gender differences in prevalence and correlates of ASPD among heroin dependent users were detected. The findings highlight a need for gender-specific interventions.

Contingency management for patients with cooccurring disorders: evaluation of a case study and recommendations for practitioners

Research indicates that contingency management (CM) has potential to improve a number of outcomes (e.g. substance use, treatment attendance, quality of life) among individuals with substance use and cooccurring disorders. However, multiple factors must be considered on a case-by-case basis in order to promote optimal treatment effects. The present study describes an individualized CM protocol for a US Veteran with substance dependence and cooccurring severe mental illness. CM targeted attendance at outpatient appointments and appropriate use of hospital resources. Effects of CM were assessed by comparing the 3-month baseline and CM periods. The CM intervention marginally reduced unnecessary hospital admissions, resulting in cost savings to the medical center of over $5,000 in three months for this individual. However, CM did not affect outpatient attendance. Several complications arose, highlighting challenges in using CM in populations with substance use and cooccurring disorders. Practical suggestions are offered for maximizing the effects of CM.

Personality disorders and the 3-year course of alcohol, drug, and nicotine use disorders

CONTEXT

Little is known about the role of a broad range of personality disorders in the course of substance use disorder (SUD) and whether these differ by substance. The existing literature focuses mostly on antisocial personality disorder and does not come to clear conclusions.

OBJECTIVE

To determine the association between the 10 DSM-IV personality disorders and the persistence of common SUDs in a 3-year prospective study of a national sample.

DESIGN

Data were drawn from participants in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) who had alcohol dependence (n = 1172), cannabis use disorder (n = 454), or nicotine dependence (n = 4017) at baseline and who were reinterviewed 3 years later. Control variables included demographic characteristics, family history of substance disorders, baseline Axis I disorders and treatment status, and prior SUD duration. Main Outcome Measure  Persistent SUD, defined as meeting full criteria for the relevant SUD throughout the 3-year follow-up period.

RESULTS

Persistent SUD was found among 30.1% of participants with alcohol dependence, 30.8% with cannabis use disorder, and 56.6% with nicotine dependence at baseline. Axis I disorders did not have strong or consistent associations with persistent SUD. In contrast, antisocial personality disorder was significantly associated with persistent alcohol, cannabis, and nicotine use disorders (adjusted odds ratios, 2.46-3.51), as was borderline personality disorder (adjusted odds ratios, 2.04-2.78) and schizotypal personality disorder (adjusted odds ratios, 1.65-5.90). Narcissistic, schizoid, and obsessive-compulsive personality disorders were less consistently associated with SUD persistence.

CONCLUSIONS

The consistent findings on the association of antisocial, borderline, and schizotypal personality disorders with persistent SUD indicates the importance of these personality disorders in understanding the course of SUD. Future studies should examine dimensional representations of personality disorders and the role of specific components of these disorders, biological and environmental contributors to these relationships, and potential applications of these findings to treatment development.

Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence

BACKGROUND

Maintenance treatments are effective in retaining patients in treatment and suppressing heroin use. Questions remain regarding the efficacy of additional psychosocial services.

OBJECTIVES

To evaluate the effectiveness of any psychosocial plus any agonist maintenance treatment versus standard agonist treatment for opiate dependence

SEARCH STRATEGY

We searched the Cochrane Drugs and Alcohol Group trials register (June 2011), Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2011), PUBMED (1996 to 2011); EMBASE (January 1980 to 2011); CINAHL (January 2003 to 2011); PsycINFO (1985 to 2003) and reference list of articles.

SELECTION CRITERIA

Randomised controlled trials and controlled clinical trial comparing any psychosocial plus any agonist with any agonist alone for opiate dependence.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality quality and extracted data.

MAIN RESULTS

35 studies, 4319 participants, were included. These studies considered thirteen different psychosocial interventions. Comparing any psychosocial plus any maintenance pharmacological treatment to standard maintenance treatment, results do not show benefit for retention in treatment, 27 studies, 3124 participants, RR 1.03 (95% CI 0.98 to 1.07), abstinence by opiate during the treatment, 8 studies, 1002 participants, RR 1.12 (95% CI 0.92 to 1.37), compliance, three studies, MD 0.43 (95% CI -0.05 to 0.92), psychiatric symptoms, 3 studies, MD 0.02 (-0.28 to 0.31), depression, 3 studies, MD -1.70 (95% CI -3.91 to 0.51) and results at the end of follow up as number of participants still in treatment, 3 studies, 250 participants, RR 0.90 (95% CI 0.77 to 1.07) and participants abstinent by opioid, 3 studies, 181 participants, RR 1.15 (95% CI 0.98 to 1.36). Comparing the different psychosocial approaches, results are never statistically significant for all the comparisons and outcomes.

AUTHORS' CONCLUSIONS

For the considered outcomes, it seems that adding any psychosocial support to standard maintenance treatments do not add additional benefits. Data do not show differences also for contingency approaches, contrary to all expectations. Duration of the studies was too short to analyse relevant outcomes such as mortality. It should be noted that the control intervention used in the studies included in the review on maintenance treatments, is a program that routinely offers counselling sessions in addition to methadone; thus the review, actually, did not evaluate the question of whether any ancillary psychosocial intervention is needed when methadone maintenance is provided, but the narrower question of whether a specific more structured intervention provides any additional benefit to a standard psychosocial support. These interventions probably can be measured and evaluated by employing diverse criteria for evaluating treatment outcomes, aimed to rigorously assess changes in emotional, interpersonal, vocational and physical health areas of life functioning.

Poly-substance use and antisocial personality traits at admission predict cumulative retention in a buprenorphine programme with mandatory work and high compliance profile

BACKGROUND

Continuous abstinence and retention in treatment for alcohol and drug use disorders are central challenges for the treatment providers. The literature has failed to show consistent, strong predictors of retention. Predictors and treatment structure may differ across treatment modalities. In this study the structure was reinforced by the addition of supervised urine samples three times a week and mandatory daily work/structured education activities as a prerequisite of inclusion in the program.

METHODS

Of 128 patients consecutively admitted to buprenorphine maintenance treatment five patients dropped out within the first week. Of the remaining 123 demographic data and psychiatric assessment were used to predict involuntary discharge from treatment and corresponding cumulative abstinence probability. All subjects were administered the Structured Clinical Interview for DSM-IV-TR, and the Symptom Checklist 90 (SCL-90), the Alcohol Use Disorder Identification Test (AUDIT), the Swedish universities Scales of Personality (SSP) and the Sense of Coherence Scale (SOC), all self-report measures. Some measures were repeated every third month in addition to interviews.

RESULTS

Of 123 patients admitted, 86 (70%) remained in treatment after six months and 61 (50%) remained in treatment after 12 months. Of those discharged involuntarily, 34/62 individuals were readmitted after a suspension period of three months. Younger age at intake, poly-substance abuse at intake (number of drugs in urine), and number of conduct disorder criteria on the SCID Screen were independently associated with an increased risk of involuntary discharge. There were no significant differences between dropouts and completers on SCL-90, SSP, SOC or AUDIT.

CONCLUSION

Of the patients admitted to the programme 50% stayed for the first 12 months with continuous abstinence and daily work. Poly-substance use before intake into treatment, high levels of conduct disorder on SCID screen and younger age at intake had a negative impact on retention and abstinence.

Comorbid pain and opioid addiction: psychosocial and pharmacological treatments

Treating comorbid pain (nonmalignant) and opioid addiction is a complex endeavor that requires cooperation of multi-modal treatment teams incorporating pharmacological, psychological, and social components. There are multiple barriers for patients, mental health practitioners, and physical health practitioners to provide complete treatment for this difficult treatment population. In this article, we will review which treatments have been empirically validated in this treatment population, where further research is required, and considerations for potential "best approaches" to use for patient treatment while waiting for empirically validated treatment data. We will also discuss some complementary and alternative medicine approaches that have empirical validity in treating either pain or addiction individually, though empirical validity for the treatment of comorbid pain and addiction has not been established.

Psychological interventions for antisocial personality disorder

BACKGROUND

Antisocial personality disorder (AsPD) is associated with a wide range of disturbance including persistent rule-breaking, criminality, substance use, unemployment, homelessness and relationship difficulties.

OBJECTIVES

To evaluate the potential beneficial and adverse effects of psychological interventions for people with AsPD.

SEARCH STRATEGY

Our search included CENTRAL Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsycINFO, ASSIA, BIOSIS and COPAC.

SELECTION CRITERIA

Prospective, controlled trials in which participants with AsPD were randomly allocated to a psychological intervention and a control condition (either treatment as usual, waiting list or no treatment).

DATA COLLECTION AND ANALYSIS

Three authors independently selected studies. Two authors independently extracted data. We calculated mean differences, with odds ratios for dichotomous data.

MAIN RESULTS

Eleven studies involving 471 participants with AsPD met the inclusion criteria, although data were available from only five studies involving 276 participants with AsPD. Only two studies focused solely on an AsPD sample. Eleven different psychological interventions were examined. Only two studies reported on reconviction, and only one on aggression. Compared to the control condition, cognitive behaviour therapy (CBT) plus standard maintenance was superior for outpatients with cocaine dependence in one study, but CBT plus treatment as usual was not superior for male outpatients with recent verbal/physical violence in another. Contingency management plus standard maintenance was superior for drug misuse for outpatients with cocaine dependence in one study but not in another, possibly because of differences in the behavioural intervention. However, contingency management was superior in social functioning and counselling session attendance in the latter. A multi-component intervention utilising motivational interviewing principles, the 'Driving Whilst Intoxicated program', plus incarceration was superior to incarceration alone for imprisoned drink-driving offenders.

AUTHORS' CONCLUSIONS

Results suggest that there is insufficient trial evidence to justify using any psychological intervention for adults with AsPD. Disappointingly few of the included studies addressed the primary outcomes defined in this review (aggression, reconviction, global functioning, social functioning, adverse effects). Three interventions (contingency management with standard maintenance; CBT with standard maintenance; 'Driving Whilst Intoxicated program' with incarceration) appeared effective, compared to the control condition, in terms of improvement in at least one outcome in at least one study. Each of these interventions had been originally developed for people with substance misuse problems. Significant improvements were mainly confined to outcomes related to substance misuse. No study reported significant change in any specific antisocial behaviour. Further research is urgently needed for this prevalent and costly condition.

[Evidence-based psychotherapy: addiction and personality disorders as comorbidities]

A large number of studies have shown that various psychotherapeutic methods have a positive effect on the course of addiction and personality disorders when they are treated separately. Co-morbid occurrence of both disorders is common but a chronologically separated treatment often leads to renewed occurrence of the symptoms of the initially treated disorder. Failures of abstinence motivation, severe drug craving and the activation of dysfunctional behavior patterns frequently lead to renewed consumption of addictive substances and thus endanger the further course of treatment. So far, evidence of effectiveness exists only for dialectic behavior therapy and dual focus schema therapy. This article summarizes the current state of knowledge and introduces both methods by highlighting the core therapeutic strategies.

Psychotherapy of personality disorders and concomitant substance dependence

PURPOSE OF REVIEW

Psychotherapy of patients with personality disorder and concomitant substance dependence requires an integrative approach. Although a number of studies have evaluated psychotherapy for one of these disorders, only few studies have described the effectiveness of treatment programs in comorbid patients. These limited findings provide a basis for the further development of treatments for personality disorder and concomitant substance dependence. This review gives an overview of the current state of research in this field.

RECENT FINDINGS

Although a large number of evaluation studies tested the effectiveness of several therapies for alcohol dependence, far fewer evaluated nonalcohol substance dependence. There are very few evaluations of the efficacy of psychotherapy for other forms of drug dependence. Only dialectical behavior therapy and dual-focus schema therapy have been tested for the treatment of personality disorder and substance dependence.

SUMMARY

To date, two randomized controlled trials in 59 female-only patients with borderline personality disorder and substance abuse provided the best evidence-based data for the effectiveness of dialectical behavior therapy. For dual-focus schema therapy, a single randomized controlled trial indicated a curative effect in a small group of patients with personality disorder and substance dependence. Although the results of these studies are encouraging, further clinical trials need to be conducted in larger populations including male participants.

Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence

BACKGROUND

Maintenance treatments are effective in retaining patients in treatment and suppressing heroin use. Questions remain regarding the efficacy of additional psychosocial services offered by most maintenance programs.

OBJECTIVES

To evaluate the effectiveness of any psychosocial plus any agonist maintenance treatment versus standard agonist treatment for opiate dependence in respect of retention in treatment, use of substances, health and social status.

SEARCH STRATEGY

We searched: Cochrane Drugs and Alcohol Group's Register of Trials (February 2008), Cochrane Central Register of Controlled Trials (CENTRAL - The Cochrane Library issue 1, 2008), MEDLINE (January 1966 to February 2008), EMBASE (January 1980 to February 2008), CINAHL (January 2003-February 2008), PsycINFO (January 1985 to April 2003), reference lists of articles.

SELECTION CRITERIA

Randomised studies comparing any psychosocial plus any agonist with any agonist alone intervention for opiate dependence.

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Twenty eight trials, 2945 participants, were included. These studies considered twelve different psychosocial interventions and three pharmacological maintenance treatments. Comparing any psychosocial plus any maintenance pharmacological treatment to standard maintenance treatment, results do not show benefit for retention in treatment, 23 studies, 2193 participants, Relative Risk (RR) 1.02 (95% CI 0.97 to 1.07), use of opiate during the treatment, eight studies, 681 participants, RR 0.86 (95% CI 0.65 to 1.13), compliance, three studies, MD 0.43 (95% CI -0.05 to 0.92), psychiatric symptoms, four studies, MD 0.02 (-0.19 to 0.23), depression, four studies, MD -1.30 (95% CI -3.31 to 0.72) and results at follow up as number of participants still in treatment at the end of the follow-up , 289 participants, RR 0.91 (95% CI 0.77 to 1.06). In spite of results at follow up as number of participants abstinent at the end of the follow-up, five studies, 232 participants, show a benefit in favour of the associated treatment RR1.15 (95% CI 1.01 to 1.32). The remaining outcomes were analysed only in single studies considering a limited number of participants.Comparing the different psychosocial approaches, results are never statistically significant for all the comparisons and outcomes.

AUTHORS' CONCLUSIONS

Results suggest that adding any psychosocial support to maintenance treatments improve the number of participants abstinent at follow up; no differences for the other outcome measures. Data do not show differences between different psychosocial interventions also for contingency approaches, contrary to all expectations. Duration of the studies was too short to analyse relevant outcomes such as mortality.

Responding to the challenge of co-occurring disorders: suggestions for future research

This special issue consolidates some recent research findings and scientific thought on co-occurring disorders from both the substance abuse and mental health fields. This summary article recaps and synthesizes the main findings and themes, then considers additional issues in the field today to arrive at an agenda for future co-occurring disorders research. Plans must: (1) encourage and assist further development of treatment programs that respond to an array of types and severities of co-occurring disorders while taking into account the limited resources typically available; (2) continue the development and testing of continuing care models by exploring strategies that will sustain the recovery of treated individuals who remain vulnerable to relapse; and (3) contribute to our understanding of the mechanisms and processes that enable new interventions and practices to be adopted, implemented, and sustained. "Co-occurring disorders" is a relatively new area of research; this special issue illustrates the productivity of work to date and indicates the potential for advances to come.