Realizing the untapped promise of single-session interventions for eating disorders

OBJECTIVE

Multilevel treatment barriers prevent up to 80% of individuals experiencing eating disorders (EDs) from accessing care. This treatment gap creates a critical need to identify interventions that are accessible, easily completable, and optimized for effectiveness by targeting core mechanisms linked to ED onset and maintenance. We propose single-session interventions (SSIs) as a promising path toward catalyzing innovation in the development of accessible, effective ED interventions. SSIs are structured programs that intentionally involve one encounter with a program or provider; they may serve as stand-alone or adjunctive clinical supports. All SSIs are built to acknowledge that any session might be someone's last-and that any single session can nonetheless yield meaningful clinical benefit.

METHOD

We define SSIs, summarize research supporting their utility for ED symptoms and other mental health problems, and recommend future directions for work in this domain.

RESULTS

Single-session interventions may hold promise to reduce some ED symptoms and risk factors, including restrictive eating and negative body image. Steps toward realizing this promise include (1) testing whether existing evidence-based SSIs (e.g., for depression) can also reduce EDs, risk factors, and symptoms; (2) developing novel SSIs that target modifiable ED risk factors and symptoms largely unaddressed by SSIs, such as purging and binge eating; (3) studying diverse implementation pathways; (4) capitalizing on SSIs' transdiagnostic utility to broaden funding opportunities; and (5) educating ED researchers and clinicians about SSIs.

DISCUSSION

Understanding the strengths and limits of mechanism-targeted SSIs for ED-related problems could be a low-risk, high-reward avenue toward reducing EDs at scale.

PUBLIC SIGNIFICANCE

Most individuals experiencing EDs never access any form of treatment, creating an urgent need to identify ED interventions built to overcome barriers to engaging with care. This Forum article introduces SSIs as a promising path to rapidly developing and testing accessible, evidence-based ED supports; supplementing existing ED treatment models; and reducing the individual, familial, and societal burdens of EDs at scale.

Integration in Psychedelic-Assisted Treatments: Recurring Themes in Current Providers’ Definitions, Challenges, and Concerns

Integration therapy, an integral part of psychedelic-assisted treatment, usually includes sessions devoted to making meaning of relevant psychedelic experiences after subjective effects have subsided. As the psychedelic renaissance continues, offers for this integration therapy have proliferated. In the present project, semi-structured interviews with 30 integration therapists focused on definitions of integration as well as challenges and concerns that they associated with the practice. A mixed-methods approach revealed 19 themes that coders identified reliably. Prevalent themes included expressing concern about nonresponsive clients, defining integration as a bridge between the psychedelic experience and daily life, and apprehensions about the commercialization of psychedelic psychotherapy. Interviewees viewed integration as a process that begins prior to the administration of substances, never ends, makes sense of the psychoactive experience, creates behavioral change, is personalized, and makes the individual whole. Most participants also discussed issues related to client resistance, unrealistic expectations of psychedelic psychotherapy, problems associated with power differentials, the importance of an integration therapist’s connection to other service providers, and the need for self-care. These data might help the standardization of integration therapy, inform lay impressions of the process, and help generate hypotheses for continued research on this aspect of psychedelic-assisted treatment. These data also suggest that psychedelic integration practitioners would appreciate regular support from a community of like-minded colleagues.

Harnessing the Single-Session Intervention approach to promote scalable implementation of evidence-based practices in healthcare

Effective implementation of evidence-based practices often involves multi-level strategies targeting individual-, organizational-, and system-level determinants of change. Although these multi-level implementation approaches can successfully facilitate EBP uptake, they tend to be complex and resource intensive. Accordingly, there is a need for theory-driven, generalizable approaches that can enhance efficiency, cost-effectiveness, and scalability of existing implementation approaches. We propose the Single-Session Intervention approach as an unexplored path to developing low-cost and scalable implementation strategies, especially those targeting individual-level behavior change. We argue that single-session strategies (S3) for implementation, which can simultaneously target myriad barriers to individual behavior change, may promote clinicians' EBP uptake and sustainment in a manner that is low-resource and scalable. We first overview the evidence-base supporting the Single-Session Intervention approach for patient-level outcomes; situate this approach within the implementation science literature by outlining its intersections with a leading framework, the Theoretical Domains Framework (TDF), as an exemplar; and illustrate how the TDF might directly inform the design and evaluation of single-session strategies for EBP implementation. Overall, single-session strategies (S3) for implementation reflect a promising but yet-to-be-tested means of streamlining and scaling individual-level behavior change efforts in healthcare settings. Future partnered research is needed to gauge the potential of this approach across diverse clinical and community contexts.

Association of a Health Coaching and Transportation Assistance Intervention at a Free Ophthalmology Homeless Shelter Clinic With Follow-up Rates

Importance

Eye health in the homeless population is important, yet follow-up to referral appointments in this population remains low.

Objective

To investigate the association of health coaching and transportation vouchers with follow-up rates at a free ophthalmology homeless shelter clinic.

Design, Setting, and Participants

A prospective cohort study was conducted from January 9, 2019, to March 4, 2020, among all 71 patients evaluated at a free ophthalmology clinic at a single homeless shelter in San Francisco, California.

Exposures

If indicated, patients were referred for advanced ophthalmologic care at a county hospital and free eyeglasses from a nonprofit organization.

Main Outcomes and Measures

The primary outcome was follow-up rates to referral appointments. The secondary outcomes were prespecified baseline variables hypothesized to be associated with follow-up. The intervention began September 4, 2019. Follow-up rates were compared between the preintervention (n = 37) and postintervention (n = 34) groups. The hypothesis was formulated before data collection.

Results

Among the 71 patients, 50 (70.4%) were men, and the mean (SD) age was 51.9 (12.4) years. A total of 28 patients (39.4%) were referred for free eyeglasses, 14 (19.7%) to the county hospital for advanced care, and 7 (9.9%) to both. Of those referred, the difference in follow-up from the postintervention to preintervention groups was 53.8% (95% CI, 39.8%-67.9%; P < .001). Compared with patients who did not follow up, those who did had a mean difference of 59 more days at the shelter (95% CI, 39-80 days; P = .003). Among patients with a visual acuity of 20/40 or worse in the better-seeing eye, the mean difference between those who did not follow up and those who did was 61% (95% CI, 44%-78%; P = .003). The mean difference in follow-up between patients who were born in the US and patients not born in the US was 89% (95% CI, 79%-98%; P = .02). Of those in the postintervention group, the difference in presentation to follow-up for patients with a high school diploma compared with those without was 59% (95% CI, 37%-81%; P = .001).

Conclusions and Relevance

This study suggests that a health coaching and bus token intervention improved follow-up rates at a free ophthalmology homeless shelter clinic by at least 39.8%; this improvement supports considering implementation of this intervention when developing public assistance programs if independent corroboration is provided. Barriers to follow-up included a shorter duration of stay at the homeless shelter, visual acuity better than 20/40, not being born in the US, and lower educational level, although the size of this study does not permit determining if some or all of these are associated with one another.

Curing the broken brain model of addiction: Neurorehabilitation from a systems perspective

The dominant biomedical perspective on addictions has been that they are chronic brain diseases. While we acknowledge that the brains of people with addictions differ from those without, we argue that the "broken brain" model of addiction has important limitations. We propose that a systems-level perspective more effectively captures the integrated architecture of the embodied and situated human mind and brain in relation to the development of addictions. This more dynamic conceptualization places addiction in the broader context of the addicted brain that drives behavior, where the addicted brain is the substrate of the addicted mind, that in turn is situated in a physical and socio-cultural environment. From this perspective, neurorehabilitation should shift from a "broken-brain" to a systems theoretical framework, which includes high-level concepts related to the physical and social environment, motivation, self-image, and the meaning of alternative activities, which in turn will dynamically influence subsequent brain adaptations. We call this integrated approach system-oriented neurorehabilitation. We illustrate our proposal by showing the link between addiction and the architecture of the embodied brain, including a systems-level perspective on classical conditioning, which has been successfully translated into neurorehabilitation. Central to this example is the notion that the human brain makes predictions on future states as well as expected (or counterfactual) errors, in the context of its goals. We advocate system-oriented neurorehabilitation of addiction where the patients' goals are central in targeted, personalized assessment and intervention.

Brief psychological treatments for emotional disorders in Primary and Specialized Care: A randomized controlled trial

Background/Objective Brief transdiagnostic psychotherapies are a possible treatment for emotional disorders. We aimed to determine their efficacy on mild/moderate emotional disorders compared with treatment as usual (TAU) based on pharmacological interventions. Method: This study was a single-blinded randomized controlled trial with parallel design of three groups. Patients (N = 102) were assigned to brief individual psychotherapy (n = 34), brief group psychotherapy (n = 34) or TAU (n = 34). Participants were assessed before and after the interventions with the following measures: PHQ-15, PHQ-9, PHQ-PD, GAD-7, STAI, BDI-II, BSI-18, and SCID. We conducted per protocol and intention-to-treat analyses. Results: Brief psychotherapies were more effective than TAU for the reduction of emotional disorders symptoms and diagnoses with moderate/high effect sizes. TAU was only effective in reducing depressive symptoms. Conclusions: Brief transdiagnostic psychotherapies might be the treatment of choice for mild/moderate emotional disorders and they seem suitable to be implemented within health care systems.

Evidence-Based Brief Psychological Treatment for Emotional Disorders in Primary and Specialized Care: Study Protocol of a Randomized Controlled Trial

Emotional Disorders (EDs) are very prevalent in Primary Care (PC). However, general practitioners (GPs) have difficulties to make the diagnosis and the treatment of this disorders that are usually treated with drugs. Brief psychological therapies may be a new option to treat EDs in a PC context. This article aims to present a study protocol to evaluate the effectiveness and the efficiency of an adaptation to brief format of the "Unified Protocol (UP) for the transdiagnostic treatment of EDs." This is a single-blinded RCT among 165 patients with EDs. Patients will be randomly assigned to receive brief psychological treatment based on UP, conventional psychological treatment, conventional psychological treatment plus pharmacological treatment, minimum intervention based on basic psychoeducational information, or pharmacological treatment only. Outcome measure will be the following: GAD-7, STAI, PHQ-9, BDI-II, PHQ-15, PHQ-PD, and BSI-18. Assessments will be carried out by blinded raters at baseline, after the treatment and 6-month follow-up. The findings of this RCT may encourage the implementation of brief therapies in the PC context, what would lead to the decongestion of the public health system, the treatment of a greater number of people with EDs in a shorter time, the reduction of the side effects of pharmacological treatment and a possible economic savings for public purse. Clinical Trial Registration: ClinicalTrial.gov, identifier NCT03286881. Registered September 19, 2017.

Game Plan: Development of a Web App Designed to Help Men Who Have Sex With Men Reduce Their HIV Risk and Alcohol Use

Background

Men who have sex with men (MSM) are at high risk for HIV, and alcohol use is a major risk factor for HIV infection. Internet-facilitated brief interventions have been shown to reduce alcohol use and HIV-risk behavior in other at-risk populations, but have so far incorporated limited content and have not been tested among MSM.

Objective

This manuscript describes Game Plan, an interactive, tablet-optimized web application designed to help heavy drinking, high-risk MSM consider reducing their alcohol use and sexual risk behavior. In this paper, we discuss the rationale, goals, and flow for each of Game Plan’s components, which were modelled after common in-person and web-based brief motivational interventions for these behaviors.

Methods

The development of Game Plan was informed by a thorough user-focused design research process that included (1) audits of existing interventions, (2) focus groups with stakeholders and (3) intended users (high-risk, heavy drinking MSM), and (4) usability testing. The aesthetic, features, and content of the app were designed iteratively throughout this process

Results

The fully-functional Game Plan app provides (1) specific and personal feedback to users about their level of risk, (2) exercises to help prompt users to reflect on whether their current behavior aligns with other important life goals and values, and for those open to change, (3) exercises to help users understand factors that contribute to risk, and (4) a change planning module. In general, this flow was constructed to roughly align with the two phases described in early accounts of motivational interviewing (MI): (1) Content intended to elicit intrinsic motivation for change, and when/if sufficient motivation is present, (2) content intended to translate that motivation into specific goals and plans for change. This sequence first focuses on the user’s HIV risk behavior, followed by their alcohol use and the connection between the two. The app’s overall aesthetic (eg, branding, color palettes, icons/graphics) and its onboarding sequence was also designed to align with the “spirit” of MI by conveying respect for autonomy, open-mindedness (ie, avoiding judgment), and empathy.

Conclusions

Should future research support its efficacy in facilitating behavior change, Game Plan could represent a wide-reaching and scalable tool that is well-suited for use in settings where delivering evidence-based, in-person interventions would be difficult or cost-prohibitive.

A pilot randomized trial of Motivational Interviewing compared to Psycho-Education for reducing and preventing underage drinking in American Indian adolescents

Underage drinking is an important public health issue for American Indian and Alaska Native (AI/AN) adolescents, as it is for U. S. teens of all ethnicities. One of the demonstrated risk factors for the development of alcohol use disorders in AI/AN is early age of initiation of drinking. To address this issue a randomized trial to assess the efficacy of Motivational Interviewing (MI) compared to Psycho-Education (PE) to reduce and prevent underage drinking in AI/AN youth was developed and implemented. Sixty-nine youth received MI or PE and 87% were assessed at follow-up. For teens who were already drinking, participating in the intervention (MI or PE) was associated, at follow-up, with lower quantity×frequency (q×f) of drinking (p=0.011), fewer maximum drinks per drinking occasion (p=0.004), and fewer problem behaviors (p=0.009). The MI intervention resulted in male drinkers reporting a lower q×f of drinking (p=0.048) and female drinkers reporting less depression (p=0.011). In teens who had not started drinking prior to the intervention, 17% had initiated drinking at follow-up. As a group they reported increased quantity×frequency of drinking (p=0.008) and maximum drinks (p=0.047), but no change in problem behaviors. These results suggest that intervening against underage drinking using either MI or PE in AI/AN youth can result in reduced drinking, prevention of initiation of drinking, and other positive behavioral outcomes. Brief interventions that enhance motivation to change as well as Psycho-Education may provide a successful approach to reducing the potential morbidity of underage drinking in this high-risk group.

Patient-centered primary care for adults at high risk for AUDs: the Choosing Healthier Drinking Options In primary CarE (CHOICE) trial

BACKGROUND

Most patients with alcohol use disorders (AUDs) never receive alcohol treatment, and experts have recommended management of AUDs in primary care. The Choosing Healthier Drinking Options In primary CarE (CHOICE) trial was a randomized controlled effectiveness trial of a novel intervention for primary care patients at high risk for AUDs. This report describes the conceptual and scientific foundation of the CHOICE model of care, critical elements of the CHOICE trial design consistent with the Template for Intervention Description and Replication (TIDieR), results of recruitment, and baseline characteristics of the enrolled sample.

METHODS

The CHOICE intervention is a multi-contact, extended counseling intervention, based on the Chronic Care Model, shared decision-making, motivational interviewing, and evidence-based options for managing AUDs, designed to be practical in primary care. Outpatients who received care at 3 Veterans Affairs primary care sites in the Pacific Northwest and reported frequent heavy drinking (≥4 drinks/day for women; ≥5 for men) were recruited (2011-2014) into a trial in which half of the participants would be offered additional alcohol-related care from a nurse. CHOICE nurses offered 12 months of patient-centered care, including proactive outreach and engagement, repeated brief motivational interventions, monitoring with and without alcohol biomarkers, medications for AUDs, and/or specialty alcohol treatment as appropriate and per patient preference. A CHOICE nurse practitioner was available to prescribe medications for AUDs.

RESULTS

A total of 304 patients consented to participate in the CHOICE trial. Among consenting participants, 90% were men, the mean age was 51 (range 22-75), and most met DSM-IV criteria for alcohol abuse (14%) or dependence (59%). Many participants also screened positive for tobacco use (44%), depression (45%), anxiety disorders (30-41%) and non-tobacco drug use disorders (19%). At baseline, participants had a median AUDIT score of 18 [Interquartile range (IQR) 14-24] and a median readiness to change drinking score of 5 (IQR 2.75-6.25) on a 1-10 Likert scale.

CONCLUSION

The CHOICE trial tested a patient-centered intervention for AUDs and recruited primary care patients at high risk for AUDs, with a spectrum of severity, co-morbidity, and readiness to change drinking. Trial registration The trial is registered at clinicaltrial.gov (NCT01400581).

Clickotine, A Personalized Smartphone App for Smoking Cessation: Initial Evaluation

Background

Tobacco smoking is the leading cause of preventable death in the United States, and the annual economic burden attributable to smoking exceeds US $300 billion. Obstacles to smoking cessation include limited access and adherence to effective cessation interventions. Technology can help overcome these obstacles; many smartphone apps have been developed to aid smoking cessation, but few that conform to the US clinical practice guideline (USCPG) have been rigorously tested and reported in the literature. Clickotine is a novel smartphone app for smoking cessation, designed to deliver the essential features of the USCPG and engineered to engage smokers by personalizing intervention components.

Objective

Our objective was to assess the engagement, efficacy, and safety of Clickotine in an initial, single-arm study. Outcomes measured were indicators of engagement with the smartphone app (number of app opens, number of interactions with the Clickotine program, and weeks active with Clickotine), cessation outcomes of 7- and 30-day self-reported abstinence from smoking, and negative health events.

Methods

We recruited US residents between 18 and 65 years of age who owned an iPhone and smoked 5 or more cigarettes daily for the study via online advertising. Respondents were prescreened for eligibility by telephone and, if appropriate, directed to a Web portal to provide informed consent, confirm eligibility, and download the Clickotine app. Participants completed study assessments via the online portal at baseline and after 8 weeks. Data were collected in Amazon S3 with no manual data entry, and access to all data was maximally restrictive, logged, and auditable.

Results

A total of 416 participants downloaded the app and constituted the intention-to-treat (ITT) sample. On average, participants opened the Clickotine app 100.6 times during the 8-week study (median 69), logged 214.4 interactions with the Clickotine program (median 178), and remained engaged with Clickotine for 5.3 weeks (median 5). Among the ITT sample, 45.2% (188/416) reported 7-day abstinence and 26.2% (109/416) reported 30-day abstinence from smoking after 8 weeks. Completer analysis focused on 365 (87.7%) of the 416 enrolled participants who completed the 8-week questionnaire revealed that 51.5% (188/365) of completers reported 7-day abstinence and 29.9% (109/365) reported 30-day abstinence. Few adverse events, mostly consistent with nicotine withdrawal symptoms, were reported and overall no safety signal was detected.

Conclusions

In this initial single-arm trial, Clickotine users appeared to demonstrate encouraging indicators of engagement in terms of the number of app opens, number of program interactions, and continued engagement over time. Clickotine users reported encouraging quit rates while reporting few adverse events. Future research is warranted to assess Clickotine’s efficacy in a randomized controlled trial.

Trial Registration

Clinicaltrials.gov NCT02656745; https://clinicaltrials.gov/ct2/show/NCT02656745 (Archived by WebCite at http://www.webcitation.org/6peTT4x60)

Brief intervention: a promising framework for child and youth mental health?

There is a discrepancy between the demand for mental health treatment amongst children, young people and their carers, and the capacity of the current service system to provide evidence based interventions. Innovative models of care are required to redress this discrepancy. One such model is the single session model, which provides a single or small number of solution focused sessions targeting one or two identified problems. Single session interventions have been trialled across a range of presenting concerns including child and youth mental health services. This paper provides a rationale for offering a brief focused intervention as part of a broader Child and Youth Mental Health Service, and introduces a model of how brief intervention fits within a broader system of care.

Kontrolliertes Trinken bei Alkoholkonsumstörungen: Eine systematische Übersicht

Hintergrund: Verhaltenstherapeutische Behandlungen zum selbstkontrollierten Trinken (KT) wurden in den letzten 50 Jahren vielfältig erforscht. Eine aktuelle Übersicht über den gegenwärtigen Status dieses Ansatzes liegt nicht vor. Fragestellung: Es wird ein systematischer Überblick über die Konzept- und Forschungsgeschichte des KT (Definition, theoretische Wurzeln, Behandlungsmethoden), Wirksamkeit von KT-Behandlung (inkl. Prognosefaktoren) sowie Implementierung von KT in das Behandlungssystem (Akzeptanz und Verbreitung) vorgenommen. Methodik: Gemäß den PRISMA Richtlinien wurde in den Datenbanken PsycINFO, Medline und Psyndex nach psychologischen Behandlungen zum selbstkontrollierten Alkoholkonsum bei Menschen mit klinisch relevanten Alkoholproblemen recherchiert und 676 einschlägige Beiträge identifiziert. Ergebnisse: KT wird als regelgeleitet-planvoller Alkoholkonsum definiert. Seine theoretischen Wurzeln reichen von Lerntheorien bis zur Psychologie der Selbstregulation. In der Behandlung haben Behavioral Self-Control Trainings frühere Methoden (z. B. aversive Konditionierung, Kontingenzmanagement und Reizexposition) abgelöst. Einzel und Gruppenbehandlungen sowie Selbsthilfemanuale zum KT erweisen sich über das gesamte Spektrum des problematischen Alkoholkonsums als kurz- und langfristig wirksam zur Reduktion des Alkoholkonsums und alkoholassoziierter Probleme wie auch zur Förderung des Übergangs zur Abstinenz. Prognostisch bedeutsam sind v. a. der Zielentscheid des Patienten pro KT und seine Zuversicht in die Realisierbarkeit von KT. Akzeptanz und Verbreitung von KT haben in den letzten Jahrzehnten zugenommen und variieren u. a. länderspezifisch. Schlussfolgerungen: Angesichts der Wirksamkeit von KT-Behandlungen sowie gesundheitspolitischer, ethischer, therapeutischer und ökonomischer Überlegungen sollten Reduktionsbehandlungen gleichrangig neben Abstinenzbehandlungen in ein zieloffen ausgerichtetes Behandlungssystem integriert werden.

A case study approach to the examination of a telephone-based health coaching intervention in facilitating behaviour change for adults with Type 2 diabetes

AIMS AND OBJECTIVES

This study aims to examine the effectiveness of the use of telephone empowerment-based health coaching as a cost-effective alternative to changing health behaviours of adults with Type 2 diabetes.

BACKGROUND

Guidelines regarding lifestyle management to reduce the risk of complications in diabetes include changing patterns of eating, physical activity and smoking cessation. Traditional education/behavioural methods of support for behaviour change reveal mixed and mainly short-term effects.

DESIGN

A mixed method case study approach was used (n = 10).

METHODS

Data were collected by means of physiological measurements survey and focus group interview both before and after telephone a coaching intervention.

RESULTS

Participants took greater responsibility for health and revealed high self-efficacy scores. Short-term benefits were seen in physiological variables at three months but these deteriorated with the cessation of the intervention indicating the need for continuous support.

CONCLUSION

Telephone coaching is a cost-effective approach to supporting health behaviour change for those with diabetes. It embraces the principles of empowerment and warrants further evaluation in supporting long-term behavioural changes. As such coaching emerges as a suitable proposition for this cohort.

RELEVANCE TO CLINICAL PRACTICE

Health coaching has a positive impact on health behaviours for those with diabetes. Health coaching facilitates an increase in personal control of health and builds confidence in self-managing diabetes. Patients feel really supported and become motivated towards self-care.

Lost in translation? Moving contingency management and cognitive behavioral therapy into clinical practice

In the treatment of addictions, the gap between the availability of evidence-based therapies and their limited implementation in practice has not yet been bridged. Two empirically validated behavioral therapies, contingency management (CM) and cognitive behavioral therapy (CBT), exemplify this challenge. Both have a relatively strong level of empirical support but each has weak and uneven adoption in clinical practice. This review highlights examples of how barriers to their implementation in practice have been addressed systematically, using the Stage Model of Behavioral Therapies Development as an organizing framework. For CM, barriers such as cost and ideology have been addressed through the development of lower-cost and other adaptations to make it more community friendly. For CBT, barriers such as relative complexity, lack of trained providers, and need for supervision have been addressed via conversion to standardized computer-assisted versions that can serve as clinician extenders. Although these and other modifications have rendered both interventions more disseminable, diffusion of innovation remains a complex, often unpredictable process. The existing specialty addiction-treatment system may require significant reforms to fully implement CBT and CM, particularly greater focus on definable treatment goals and performance-based outcomes.

Randomized trial of intensive motivational interviewing for methamphetamine dependence

An intensive, 9-session motivational interviewing (IMI) intervention was assessed using a randomized clinical trial of 217 methamphetamine (MA) dependent individuals. Intensive motivational interviewing (IMI) was compared with a single standard session of MI (SMI) combined with eight nutrition education sessions. Interventions were delivered weekly over 2 months. All study participants also received standard outpatient group treatment three times per week. Both study groups showed significant decreases in MA use and Addiction Severity Index drug scores, but there were no significant differences between the two groups. However, reductions in Addiction Severity Index psychiatric severity scores and days of psychiatric problems during the past 30 days were found for clients in the IMI group but not the SMI group. SMI may be equally beneficial to IMI in reducing MA use and problem severity, but IMI may help alleviate co-occurring psychiatric problems that are unaffected by shorter MI interventions. Additional studies are needed to assess the problems, populations, and contexts for which IMI is effective.

Ultra-brief intervention for problem drinkers: results from a randomized controlled trial

Background

There are a number of evidence-based, in-person clinical inteventions for problem drinkers, but most problem drinkers will never seek such treatments. Reaching the population of non-treatment seeking problem drinkers will require a different approach. Accordingly, this randomized clinical trial evaluated an intervention that has been validated in clinical settings and then modified into an ultra-brief format suitable for use as an indicated public health intervention (i.e., targeting the population of non-treatment seeking problem drinkers).

Methodology/Principal Findings

Problem drinkers (N = 1767) completed a baseline population telephone survey and then were randomized to one of three conditions – a personalized feedback pamphlet condition, a control pamphlet condition, or a no intervention control condition. In the week after the baseline survey, households in the two pamphlet conditions were sent their respective interventions by postal mail addressed to ‘Check Your Drinking.’ Changes in drinking were assessed post intervention at three-month and six-month follow-ups. The follow-up rate was 86% at three-months and 76% at six-months. There was a small effect (p = .04) in one of three outcome variables (reduction in AUDIT-C, a composite measure of quantity and frequency of drinking) observed for the personalized feedback pamphlet compared to the no intervention control. No significant differences (p>.05) between groups were observed for the other two outcome variables – number of drinks consumed in the past seven days and highest number of drinks on one occasion.

Conclusions/Significance

Based on the results of this study, we tentatively conclude that a brief intervention, modified to an ultra-brief, public health format can have a meaningful impact.

Trial Registration

ClinicalTrials.gov NCT00688584.

Attitudes towards nicotine, alcohol and drug dependence among physicians in Israel

Prevalence of substance use and substance use disorders in Israel is similar to those in other developed countries. The aim of this study was to examine attitudes of physicians in Israel towards nicotine, alcohol and drug use and dependence. A national sample of physicians from different fields of medical specialty (n = 208, response rate 26%) responded to a 50-item questionnaire. Questions included general questions regarding substance use and addictions, as well as specific questions focusing on nicotine, alcohol, cannabis and heroin use. The poor response rate in this survey dictates caution in interpretation the results. However, they suggest that among medical specialties, psychiatrists had higher levels of self-reported competency in treating addictions and lower rates of moralism towards addictions. Across substances, the highest rates of moralism and lowest ratings of treatment efficacy were directed towards individuals with alcohol dependence. Physicians generally reported experiencing lower levels of satisfaction and higher levels of aggression when treating individuals with alcohol or drug dependence compared with other patients. Physicians' attitudes towards addictions have a significant role in the care that clients with addictions receive. Medical education programs in Israel should devote provisions towards educating physicians about addictions.

A brief self-help toolkit intervention for gambling problems: a randomized multisite trial

Two studies conducted in Massachusetts and Nevada evaluated the efficacy of a self-help toolkit for problem gambling. Individuals concerned about gambling-related problems, in response to public notices and newspaper advertisements, volunteered for a randomized trial of the self-help toolkit, Your First Step to Change: Gambling. Participants were randomly assigned to 1 of 3 conditions: (a) a printed toolkit, (b) the toolkit and a brief guide to the toolkit's content, or (c) assignment to a wait-list condition. Participants, 145 in Massachusetts and 170 in Nevada, reported their gambling behavior, beliefs and attitudes about chance, and recent and planned help seeking at baseline, 88% at 1 month later, and 79% at 3 months later. Findings for the complete and intent-to-treat analyses at both sites indicated that participants significantly improved. At the end of the study period, significantly more toolkit recipients than control group participants reported recently abstaining from gambling. Minimally invasive, self-directed resources like this self-help toolkit can assist remediating gambling-related problems among gamblers who do not engage in formal treatment.

Comparison of motivational interviewing with acceptance and commitment therapy: a conceptual and clinical review

BACKGROUND

Motivational Interviewing (MI) and Acceptance and Commitment Therapy (ACT) are two emerging therapies that focus on commitment to behavior change.

AIM

The aim was to provide the first systematic comparison of MI with ACT.

METHOD

A systematic comparison was undertaken of MI and ACT at the conceptual level, with a focus on their philosophical and theoretical bases, and at the clinical level, with a focus on the therapeutic relationship, use of language in therapy, and use of values in therapy.

RESULTS

Conceptually, MI and ACT have distinct philosophical bases. MI's theoretical basis focuses on language content, whereas ACT's theoretical basis focuses on language process. Clinically, ACT and MI have distinct approaches to the therapeutic relationship, fundamentally different foci on client language, and different uses of client values to motivate behavior change. ACT, but not MI, directly targets the willingness to experience thoughts, feelings, and sensations.

CONCLUSIONS

Despite their conceptual and clinical differences, MI and ACT are complementary interventions. Collaborations between MI and ACT researchers may yield fruitful cross-fertilization research on core processes and clinical outcomes.

Adding motivational interviewing and thought mapping to cognitive-behavioral group therapy: results from a randomized clinical trial

OBJECTIVE

Recent factor-analytic studies of obsessive-compulsive disorder identified consistent symptom dimensions. This study was designed in order to observe which obsessive compulsive symptom dimensions could be changed by adding two individual sessions of motivational interviewing and thought mapping of cognitive-behavioral group therapy using a randomized clinical trial.

METHOD

Forty outpatients with a primary diagnosis of obsessive-compulsive disorder were randomly assigned to receive cognitive-behavioral group therapy (control group) or motivational interviewing+thought mapping plus cognitive-behavioral group therapy. To evaluate changes in symptom dimensions, the Dimensional Yale-Brown Obsessive-Compulsive Scale was administered at baseline and after treatment.

RESULTS

At post-treatment, there were statistically significant differences between cognitive-behavioral group therapy and motivational interviewing+thought mapping+cognitive behavioral group therapy groups in the mean total Dimensional Yale-Brown Obsessive-Compulsive Scale score, and in the contamination and aggression dimension score. Hoarding showed a statistical trend towards improvement.

CONCLUSION

These findings suggest that adding motivational interviewing+thought mapping to cognitive-behavioral group therapy can facilitate changes and bring about a decrease in the scores in different obsessive-compulsive disorder symptom dimensions, as measured by the Dimensional Yale-Brown Obsessive-Compulsive Scale. Nonetheless, additional trials are needed to confirm these results.

Screening and brief intervention for substance misuse among patients with traumatic brain injury

BACKGROUND

Research on screening and brief interventions (SBI) for substance misuse has demonstrated efficacy in a variety of medical settings including emergency departments and trauma centers. However, SBI has not yet been evaluated for persons who incur traumatic brain injury (TBI)-a substantial patient subpopulation for whom substance-related problems are frequent. To examine whether research on SBI efficacy and effectiveness can be generalized to persons with TBI, a systematic review of the literature was conducted to analyze how TBI populations were included in previous studies and whether there was evidence of differential outcomes.

METHODS

Peer-reviewed studies that investigated SBI for misuse of alcohol or other drugs, that were implemented in emergency departments or trauma centers, and that were published in English since 1985 were examined. From 174 articles initially identified, 28 studies were determined to meet inclusion criteria.

RESULTS

The review revealed that research conducted on SBI for injury populations systematically neglected patients with more severe TBI and those who presented with sufficient confusion that they could not provide informed consent.

CONCLUSIONS

Future effectiveness studies should examine barriers to routine clinical use of SBI and evaluate the generalizability of expected benefits to the full spectrum of injured patients. Researchers should also develop and evaluate systematic accommodations for persons with neurobehavioral impairments who would benefit from brief interventions for substance misuse.

A randomized clinical trial to examine enhancing cognitive-behavioral group therapy for obsessive-compulsive disorder with motivational interviewing and thought mapping

BACKGROUND

Obsessive-compulsive disorder (OCD) is characterized by repeated and persistent attempts to control thoughts and actions with rituals. These rituals are used in order to prevent feared or personally distressing outcomes. Cognitive behavioral group therapy (CBGT) has been reported to be effective for treating OCD patients. However, about one-third (30%) of patients do not benefit from CBGT. Some of these patients do not show significant improvement and continue to use rituals following CBGT, partially because they fail to complete the exposure and ritual prevention (ERP) exercises. Consequently, it is important to motivate patients to fully engage in CBGT treatment and complete the ERP exercises.

AIMS

A randomized behavioral trial examined 12 weeks of manual directed CBGT, with the addition of individual sessions of Motivational Interviewing (MI) and Thought Mapping (TM), and compared treatment outcome to the effectiveness of CBGT group alone.

METHOD

Subjects were randomized (n=93) into a CBGT group or a CBGT group with MI+TM.

RESULTS

When the two groups were compared, both groups reduced OCD symptoms. However, symptom reduction and remission were significantly higher in the MI+TM CBGT group. Positive outcomes were also maintained, with additional symptom reduction at the 3-month follow-up for the MI+TM CBGT group.

CONCLUSIONS

Adding two individual sessions of MI and TM before CBGT successfully reduced OCD symptoms and was more effective than using CBGT group alone.

Training Therapists in Evidence-Based Practice: A Critical Review of Studies From a Systems-Contextual Perspective

Evidence-based practice (EBP), a preferred psychological treatment approach, requires training of community providers. The systems-contextual (SC) perspective, a model for dissemination and implementation efforts, underscores the importance of the therapist, client, and organizational variables that influence training and consequent therapist uptake and adoption of EBP. This review critiques the extant research on training in EBP from an SC perspective. Findings suggest that therapist knowledge improves and attitudinal change occurs following training. However, change in therapist behaviors (e.g., adherence, competence, and skill) and client outcomes only occurs when training interventions address each level of the SC model and include active learning. Limitations as well as areas for future research are discussed.

Use of an electronic clinical reminder for brief alcohol counseling is associated with resolution of unhealthy alcohol use at follow-up screening

BACKGROUND/OBJECTIVE

Brief alcohol counseling is a foremost US prevention priority, but no health-care system has implemented it into routine care. This study evaluated the effectiveness of an electronic clinical reminder for brief alcohol counseling ("reminder"). The specific aims were to (1) determine the prevalence of use of the reminder and (2) evaluate whether use of the reminder was associated with resolution of unhealthy alcohol use at follow-up screening.

METHODS

The reminder was implemented in February 2004 in eight VA clinics where providers routinely used clinical reminders. Patients eligible for this retrospective cohort study screened positive on the AUDIT-C alcohol screening questionnaire (February 2004-April 2006) and had a repeat AUDIT-C during the 1-36 months of follow-up (mean 14.5). Use of the alcohol counseling clinical reminder was measured from secondary electronic data. Resolution of unhealthy alcohol use was defined as screening negative at follow-up with a >/=2-point reduction in AUDIT-C scores. Logistic regression was used to identify adjusted proportions of patients who resolved unhealthy alcohol use among those with and without reminder use.

RESULTS

Among 4,198 participants who screened positive for unhealthy alcohol use, 71% had use of the alcohol counseling clinical reminder documented in their medical records. Adjusted proportions of patients who resolved unhealthy alcohol use were 31% (95% CI 30-33%) and 28% (95% CI 25-30%), respectively, for patients with and without reminder use (p-value = 0.031).

CONCLUSIONS

The brief alcohol counseling clinical reminder was used for a majority of patients with unhealthy alcohol use and associated with a moderate decrease in drinking at follow-up.

Concept analysis of adherence in the context of cardiovascular risk reduction

TOPIC

Cardiovascular disease is the number one cause of death in the United States. Examination of the concept of adherence is essential to provide informed patient-centered care to prevent the development and progression of this largely preventable disease.

OBJECTIVE

The purpose of this concept analysis is to explore and clarify the concept of adherence. This analysis will provide a framework for those seeking a better understanding of patient decision-making, reduction of relapse to unhealthy behaviors, and increased long-term adherence to cardiovascular health recommendations. Reviews of major theories related to health behavior are reviewed in the second part of the article and are linked to the concept of adherence.

METHOD

Following a review of the literature, Morse's guidelines were utilized to present a concept analysis of adherence and the related terms concordance and compliance from the disciplines of nursing, health psychology, ethics, pharmacy, and medicine.

RESULTS

Adherence is dependent on the collaborative relationship between patient and healthcare provider. Adherence is influenced by the meaning of health, heart disease, and sense of personal risk as well as socioeconomic status, decision support, motivation, and desire for change, self-efficacy, and sources of credible health information. Attributes of successful adherence include alignment of patient behavior and health recommendations, mastery of new health knowledge and behavior, continued collaborative relationships between the patient and healthcare provider, and ability to meet outcome targets.

CONCLUSION

Adherence is defined as persistence in the practice and maintenance of desired health behaviors and is the result of active participation and agreement. Adherence is dependent on the development of a concordant relationship and its measurement should be specific utilizing the correct tools. Special attention should be paid to shared decision-making between patient and healthcare provider.

Ultra-brief intervention for problem drinkers: research protocol

BACKGROUND

Helping the large number of problem drinkers who will never seek treatment is a challenging issue. Public health initiatives employing educational materials or mass media campaigns have met with mixed success. However, clinical research has developed effective brief interventions to help problem drinkers. This project will employ an intervention that has been validated in clinical settings and then modified into an ultra-brief format suitable for use as a public health intervention. The major objective of this study is to conduct a randomized controlled trial to establish the effectiveness of an ultra-brief, personalized feedback intervention for problem drinkers.

METHODS/DESIGN

Problem drinkers recruited on a baseline population telephone survey conducted in a major metropolitan city in Canada will be randomized to one of three conditions - a personalized feedback pamphlet condition, a control pamphlet condition, or a no intervention control condition. In the week after the baseline survey, households in the two pamphlet conditions will be sent their respective pamphlets. Changes in drinking will be assessed post intervention at three-month and six-month follow-ups. Drinking outcomes will be compared between experimental conditions using Structural Equation Modeling. The primary hypothesis is that problem drinkers from households who receive the personalized feedback pamphlet intervention will display significantly improved drinking outcomes at three and six-month follow-ups as compared to problem drinkers from households in the no intervention control condition. Secondary hypotheses will test the impact of the intervention on help seeking, and explore the mediating or moderating role of perceived drinking norms, perceived alcohol risks and the problem drinker's social reasons for drinking.

DISCUSSION

This trial will provide information on the effectiveness of a pamphlet-based personalized feedback intervention for problem drinkers in a community setting.

TRIAL REGISTRATION

ClinicalTrials.gov registration #NCT00688584.

A nine session manual of motivational enhancement therapy for methamphetamine dependence: adherence and efficacy

Motivational enhancement therapy (MET) is a brief therapy shown to be effective for problem drinkers. Because the response to MET for other addictive disorders is mixed, we assessed the utility of increasing the number of sessions in subjects with methamphetamine (MA) dependence. One therapist was trained in a nine-session manual of MET, which was tested over eight weeks in 30 MA-dependent outpatients. Adherence to the manual was assessed by two raters, who reviewed a random sample of 15 audiotaped therapy sessions. Interventions were rated on a seven-point Likert scale for frequency/extensiveness (1 = not at all to 7 = extensively) and skill level (1 = unacceptable to 7 = high level of mastery). Ratings of adherence were moderate for frequency/extensiveness (4.2 +/- 2.2 and 4.3 +/- 1.8; Mean +/- SD) and high for skill level (5.4 +/- 0.6 and 5.2 +/- 0.4). Subjects attended 7.0 +/- 2.5 (78%) of nine sessions. Self-reported days of methamphetamine use decreased from 841/1793 (47%) of the 60 days prior to study entry to 448/1458 (31%) during the study (p = 0.011). MA-positive urine samples decreased from 76/118 (64%) during screening to 93/210 (44%) during treatment (p = 0.015). The MET manual was readily learned, and subjects attended a high proportion of therapy sessions with marked reductions in methamphetamine use.

Stop Using Stuff: trial of a drug and alcohol intervention for young people with comorbid mental illness and drug and alcohol problems

OBJECTIVE

Substance abuse is a significant problem in the treatment of young people with their first psychosis. This study reports a randomized trial of a brief manualized cognitive behavioural therapy for substance abuse in young people with psychosis.

METHOD

Subjects were randomized between the study treatment and a group treated as usual. Treatment was a four to six session brief cognitive behavioural therapy (CBT) intervention developed specifically for this patient group - Stop Using Stuff (SUS).

RESULTS

Both groups improved across the trial. However, those exposed to the active treatment improved significantly on measures of the frequency of cannabis and alcohol abuse.

CONCLUSIONS

Brief interventions in substance abuse in young people with psychosis can help moderate substance use in this difficult to treat group.

Gambling behavior of student-athletes and a student cohort: what are the odds?

This study investigated the prevalence of gambling, gambling related NCAA violations, and disordered gambling in student-athletes (n = 736) with a comparison cohort of students (n = 1,071) at four universities. Student-athletes reported similar rates of gambling frequency, use of a bookmaker, and disordered gambling as students. After accounting for demographic differences, student-athletes were less likely to engage in sports wagering than students. Several risk factors for disordered gambling were identified, including being male and reporting at least one parent with a history of gambling problems. These findings suggest that problems associated with gambling are a university-wide issue with student-athletes meriting additional attention because of implications for the integrity of intercollegiate sports. Improved prevention and intervention efforts for collegiate gambling are recommended.

Parent-provider communication and parental satisfaction with care of children with psychosocial problems

OBJECTIVE

The objective of the present paper was to determine the association between parent-provider communication and parent ratings of satisfaction and quality of care for a group of parents of children identified with a psychosocial problem.

METHODS

A sample of 804 parents of children with psychosocial concerns enrolled in the Child Behavior Study (CBS) was used for the present analyses. As part of the CBS, parents of children with psychosocial problems answered questions that assessed parent-provider communication and parent ratings of satisfaction and quality of care.

RESULTS

Overall, parents reported good communication with their child's provider. Eighty-two percent of parents were very satisfied with the care received and 68% reported a very high quality of care. Parent-provider communication (e.g., collaboration and mutual understanding) was strongly related to parental reports of both satisfaction and quality of care.

CONCLUSIONS

Parent-provider communication is an important correlate of parental report of satisfaction and quality of care. Involvement of parents in the treatment planning process was particularly important in determining satisfaction and quality ratings within this sample.

PRACTICE IMPLICATIONS

When working with families with identified psychosocial concerns, the use of collaboration and an empathic style by providers may enhance the quality of care parents report receiving from their primary care clinicians.

Use of brief interventions for drug abusing teenagers within a middle and high school setting

BACKGROUND

Promising and encouraging results have been recently reported on the use of briefer interventions for adolescent drug abusers. Because middle- and high-school-based drug abuse intervention programs have grown in popularity over the past several decades, the use of brief interventions (BIs) in school settings merits consideration.

METHODS

We review several clinical and school contextual issues pertaining to the scientific efficacy, feasibility, and application of BIs for students who are abusing drugs.

RESULTS

Several advantages for employing BIs in a school setting are identified, including the relatively high base rate of students with mild-to-moderate drug involvement and the likelihood that school counselors can readily learn BI techniques. Caveats of implementing BIs include practical, systemic, and clinical barriers.

CONCLUSIONS

Despite concerns, schools are a viable setting in which to screen youth for drug abuse problems and to conduct a BI.

A randomized controlled trial of goal choice interventions for alcohol use disorders among men who have sex with men

This study tested the efficacy of behavioral treatments for alcohol use disorders (AUD) among men who have sex with men (MSM) and who are at risk for HIV transmission. HIV-negative MSM with current AUD (N = 198) were recruited, offered treatment focused on reducing drinking and HIV risk, and followed during treatment and 12 months posttreatment. Participants (n = 89) accepted treatment and were randomized to either 4 sessions of motivational interviewing (MI) or 12 sessions of combined MI and coping skills training (MI + CBT). Other participants (n = 109) declined treatment but were followed, forming a non-help-seeking group (NHS). MI yielded significantly better drinking outcomes during the 12-week treatment period than MI + CBT, but posttreatment outcomes were equivalent. NHS participants significantly reduced their drinking as well. Service delivery and treatment research implications are discussed.

Toward a biopsychosocial understanding of the patient-physician relationship: an emerging dialogue

Complexity theory has been used to view the patient-physician relationship as constituted by complex responsive processes of relating. It describes an emergent, psychosocial relational process through which patients and physicians continually and reciprocally influence each other's behavior and experience. As psychosocial responses are necessarily biopsychosocial responses, patients and physicians must likewise be influencing each other's psychobiology. This mutual influence may be subjectively experienced as empathy, and may be skillfully employed by the clinician to directly improve the patient's psychobiology.

Indicators of client engagement: influences on alcohol treatment satisfaction and outcomes

This investigation explored the relationship of client engagement variables (client expectations, therapeutic/working alliance, and session attendance) with treatment satisfaction and posttreatment drinking-related outcomes using data from 2 outpatient alcohol treatment studies (N=208). Path analysis was used to test a model in which engagement variables jointly influence client satisfaction with treatment and subsequent drinking-related outcomes. The proposed model fit well with the data and accounted for 14-23% of the variance in posttreatment outcomes. The relationships in the model suggest that the link between treatment satisfaction and outcome is clarified by examining client engagement variables, which relate indirectly to outcome by means of client satisfaction.

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.