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Siljeholm O, Eckerström J, Molander O, Sundbye J, Hammarberg A. 'Before, we ended up in conflicts, now we can provide support'-Experiences of Community Reinforcement and Family Training (CRAFT) for parents of young adults with hazardous substance use. BMC Psychiatry 2024; 24:464. [PMID: 38907237 PMCID: PMC11191224 DOI: 10.1186/s12888-024-05913-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/14/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND The prevalence of hazardous substance use is highest in the age between 18 and 25, but few young adults enter treatment. Community Reinforcement and Family Training (CRAFT) is a support program for concerned significant others (CSOs) of individuals with diverse substance use disorders and is proven efficacious in promoting treatment entry. The aim of the current study was to investigate the experiences of CRAFT among parents of substance using young adults. METHODS We used a qualitative design conducting semi-structured interviews with 10 parents of young adults (18-24 years) with hazardous substance use. The participants were recruited from a randomized controlled trial of the CRAFT program. The transcribed interviews were analyzed using thematic analysis. RESULTS We divided the results into three overall domains-Reasons for entering the CRAFT program, Strengths of the CRAFT program and Limitations of the CRAFT program - with three to four themes under each domain. The parents appreciated the accessible support at a time when they needed it due to feelings of shock and powerlessness, and they described communication strategies together with positive reinforcement as the two most helpful CRAFT-sessions. Regarding limitations of CRAFT in the current population, the parents wanted more accessible support for the young adults when they were ready to enter treatment, and described difficulties to practice CRAFT-components due to changing life-circumstances and fear of aggravated health for their young adults. CONCLUSION The results provide arguments for the health care system to implement support programs to parents of young adults with hazardous substance use. The results show that CRAFT is suitable for the current population, but with some possible additions due to changing circumstances that are common in the young adult developmental phase emerging adulthood. TRIAL REGISTRATION The trial was pre-registered at isrctn.com, reference number ISRCTN12212515 date: November 7, 2018.
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Affiliation(s)
- Ola Siljeholm
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
- Stockholm Centre for Dependency Disorders, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
| | - Joachim Eckerström
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Olof Molander
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Jennie Sundbye
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
- Stockholm Centre for Dependency Disorders, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Anders Hammarberg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
- Stockholm Centre for Dependency Disorders, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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Osilla KC, Manuel JK, Becker K, Nameth K, Burgette L, Ober AJ, DeYoreo M, Lodge BS, Hurley B, Watkins KE. It takes a village: A pilot study of a group telehealth intervention for support persons affected by opioid use disorder. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 161:209290. [PMID: 38272117 DOI: 10.1016/j.josat.2024.209290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 11/28/2023] [Accepted: 01/11/2024] [Indexed: 01/27/2024]
Abstract
INTRODUCTION Opioid use disorder (OUD) has devastating effects on individuals, families, and communities. The Community Reinforcement and Family Training (CRAFT) is a Support Person (SP)-focused intervention that aims to increase SPs' communication strategies, positive reinforcement/rewards, and social support. This pilot study, called eINSPIRE (INtegrating Support Persons Into REcovery), adapted CRAFT for delivery via group telehealth. The aims were to evaluate the feasibility, acceptability, and preliminary effectiveness of this intervention on patient buprenorphine retention and SP mental health. METHODS The study recruited patients receiving buprenorphine treatment in a primary care setting across five community health centers with their SP (N = 100 dyads). SP participants were randomly assigned to receive usual care (UC) or the eINSPIRE intervention. We interviewed Patients and SPs at baseline and three months later. The study collected patient buprenorphine retention data from the electronic medical record three months post-baseline. RESULTS About 88 % (656/742) of potentially eligible patients were able to nominate a SP and 69 % (100/145) of nominated SPs were eligible and consented to the study. eINSPIRE groups had low reach (25 % of SPs attended), but high exposure (M = 7 of 10 sessions attended) and acceptability (classes helped them with their patient's OUD). The proportion of eINSPIRE patients (68 %) and UC patients (53 %) retained on buprenorphine at follow-up were similar (p = 0.203). SPs in both conditions reported similar reductions in their depression, anxiety, and impairment symptoms. CONCLUSIONS Preliminary data suggest that eINSPIRE groups may not be feasible in primary care without further adaptations for this population. A future study with a larger sample size is needed to elucidate the observed distribution differences in buprenorphine retention. Future research should also explore methods to reduce barriers to SP session attendance to improve the reach of this evidence-based intervention.
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Affiliation(s)
- Karen Chan Osilla
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, 1070 Arastradero Road, Palo Alto, CA 94304, United States.
| | - Jennifer K Manuel
- University of California San Francisco, Department of Psychiatry and Behavioral Sciences, 675 18th St, San Francisco, CA 94143, United States; San Francisco VA Health Care System, 4150 Clement St, San Francisco, CA 94121, United States
| | - Kirsten Becker
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, United States
| | - Katherine Nameth
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, 1070 Arastradero Road, Palo Alto, CA 94304, United States
| | - Lane Burgette
- RAND Corporation, 1200 S Hayes St, Arlington, VA 22202, United States
| | - Allison J Ober
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, United States
| | - Maria DeYoreo
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, United States
| | | | - Brian Hurley
- University of California Los Angeles, Department of Family Medicine, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States; County of Los Angeles, Department of Public Health, Bureau of Substance Abuse Prevention and Control 1000 S. Fremont Avenue, Alhambra, CA 91803, United States
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Hogue A, Porter NP, Ozechowski TJ, Becker SJ, O'Grady MA, Bobek M, Cerniglia M, Ambrose K, MacLean A, Hadland SE, Cunningham H, Bagley SM, Sherritt L, O'Connell M, Shrier LA, Harris SK. Standard Versus Family-Based Screening, Brief Intervention, and Referral to Treatment for Adolescent Substance Use in Primary Care: Protocol for a Multisite Randomized Effectiveness Trial. JMIR Res Protoc 2024; 13:e54486. [PMID: 38819923 PMCID: PMC11179044 DOI: 10.2196/54486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 03/30/2024] [Accepted: 04/25/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Screening, brief intervention, and referral to treatment for adolescents (SBIRT-A) is widely recommended to promote detection and early intervention for alcohol and other drug (AOD) use in pediatric primary care. Existing SBIRT-A procedures rely almost exclusively on adolescents alone, despite the recognition of caregivers as critical protective factors in adolescent development and AOD use. Moreover, controlled SBIRT-A studies conducted in primary care have yielded inconsistent findings about implementation feasibility and effects on AOD outcomes and overall developmental functioning. There is urgent need to investigate the value of systematically incorporating caregivers in SBIRT-A procedures. OBJECTIVE This randomized effectiveness trial will advance research and scope on SBIRT-A in primary care by conducting a head-to-head test of 2 conceptually grounded, evidence-informed approaches: a standard adolescent-only approach (SBIRT-A-Standard) versus a more expansive family-based approach (SBIRT-A-Family). The SBIRT-A-Family approach enhances the procedures of the SBIRT-A-Standard approach by screening for AOD risk with both adolescents and caregivers; leveraging multidomain, multireporter AOD risk and protection data to inform case identification and risk categorization; and directly involving caregivers in brief intervention and referral to treatment activities. METHODS The study will include 2300 adolescents (aged 12-17 y) and their caregivers attending 1 of 3 hospital-affiliated pediatric settings serving diverse patient populations in major urban areas. Study recruitment, screening, randomization, and all SBIRT-A activities will occur during a single pediatric visit. SBIRT-A procedures will be delivered digitally on handheld tablets using patient-facing and provider-facing programming. Primary outcomes (AOD use, co-occurring behavior problems, and parent-adolescent communication about AOD use) and secondary outcomes (adolescent quality of life, adolescent risk factors, and therapy attendance) will be assessed at screening and initial assessment and 3-, 6-, 9-, and 12-month follow-ups. The study is well powered to conduct all planned main and moderator (age, sex, race, ethnicity, and youth AOD risk status) analyses. RESULTS This study will be conducted over a 5-year period. Provider training was initiated in year 1 (December 2023). Participant recruitment and follow-up data collection began in year 2 (March 2024). We expect the results from this study to be published in early 2027. CONCLUSIONS SBIRT-A is widely endorsed but currently underused in pediatric primary care settings, and questions remain about optimal approaches and overall effectiveness. In particular, referral to treatment procedures in primary care remains virtually untested among youth. In addition, whereas research strongly supports involving families in interventions for adolescent AOD, SBIRT-A effectiveness trial testing approaches that actively engage family members in primary care are absent. This trial is designed to help fill these research gaps to inform the critical health decision of whether and how to include caregivers in SBIRT-A activities conducted in pediatric primary care. TRIAL REGISTRATION ClinicalTrials.gov NCT05964010; https://www.clinicaltrials.gov/study/NCT05964010. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/54486.
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Affiliation(s)
- Aaron Hogue
- Family and Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, NY, United States
| | - Nicole P Porter
- Family and Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, NY, United States
| | | | - Sara J Becker
- Center for Dissemination and Implementation Science, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Megan A O'Grady
- University of Connecticut Health Center, Farmington, CT, United States
| | - Molly Bobek
- Family and Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, NY, United States
| | - Monica Cerniglia
- Family and Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, NY, United States
| | - Kevin Ambrose
- Family and Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, NY, United States
| | - Alexandra MacLean
- Family and Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, NY, United States
| | - Scott E Hadland
- Division of Adolescent and Young Adult Medicine, Massachusetts General Hospital for Children, Boston, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Hetty Cunningham
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, NY, United States
| | - Sarah M Bagley
- Department of Pediatrics, Chobanian & Avedisian School of Medicine, Boston, MA, United States
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, United States
| | - Lon Sherritt
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Cornerstone Systems Northwest, Lynden, WA, United States
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Maddie O'Connell
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Lydia A Shrier
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Sion Kim Harris
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, United States
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Siljeholm O, Edvardsson K, Bergström M, Hammarberg A. Community Reinforcement and Family Training versus counselling for parents of treatment-refusing young adults with hazardous substance use: A randomized controlled trial. Addiction 2024; 119:915-927. [PMID: 38225922 DOI: 10.1111/add.16429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 12/08/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND AND AIMS Despite the high prevalence and negative effects of hazardous substance use, few young adults enter treatment. Community Reinforcement and Family Training (CRAFT), a support programme for concerned significant others of people with substance use disorders, has proved efficacious in promoting treatment entry. The aim of the current trial was to compare the efficacy of CRAFT with an active control for parents of young adults (aged 18-24 years) with hazardous substance use. DESIGN This was a randomized controlled superiority trial comparing CRAFT (n = 58) with an active control group receiving manualized counselling (n = 55), with outcome assessments at 6, 12 and 24 weeks (primary end-point). A sequential design with a stopping rule was added post recruitment commencement. SETTING The study took place in two outpatient clinics for young adults in Stockholm, Sweden, and subsequently via video-conference due to COVID-19. PARTICIPANTS Between October 2018 and May 2021, 113 participants (92% female) who were parents of young adults (87% male) were recruited. Recruitment was discontinued when 70% of the planned sample had been recruited, following an interim analysis of the primary outcome showing no difference between conditions. INTERVENTION AND COMPARATOR Participants were randomized (ratio 1 : 1) to eight manual-based individual CRAFT sessions or five individual manual-based counselling sessions + one voluntary psychoeducative group session, delivered over maximum 14 weeks. MEASUREMENTS The primary outcome measure was the rate of young adult entry in substance use treatment during the trial period (24 weeks). FINDINGS At the 24 weeks follow-up, 19 (33%) of CRAFT participants and 17 (31%) of counselling participants had reported young adult treatment entry, with no difference between conditions (odds ratio CRAFT versus counselling 0.84, 95% confidence interval = 0.35; 1.99, P = 0.700). Both conditions reported clinically relevant reductions in young adult substance use, but no change in participants' levels of depression, anxiety or stress. CONCLUSIONS This trial showed no statistically significant evidence that Community Reinforcement and Family Training (CRAFT), a support programme for concerned significant others of people with substance use disorders, is more efficacious than manual-based counselling regarding treatment entry for young adults.
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Affiliation(s)
- Ola Siljeholm
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Kerstin Edvardsson
- Child Health and Parenting (CHAP), Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Malin Bergström
- Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institutet, Stockholm, Sweden
- Clinical Epidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anders Hammarberg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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Fishman M, Wenzel K, Gauthier P, Borodovsky J, Murray O, Subramaniam G, Levy S, Fredyma E, McLeman B, Marsch LA. Engagement, initiation, and retention in medication treatment for opioid use disorder among young adults: A narrative review of challenges and opportunities. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024:209352. [PMID: 38494051 DOI: 10.1016/j.josat.2024.209352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/24/2024] [Accepted: 03/06/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Opioid Use Disorder (OUD) is a catastrophic public health problem for young adults (YAs) and their families. While medication for OUD (MOUD) is safe, effective, and recognized as the standard of care, its' uptake and success have been limited in YAs compared to older adults. METHODS This narrative review summarizes the existing literature and highlights select studies regarding barriers to YA MOUD, potential explanations for those barriers, and strategies to overcome them. RESULTS Barriers are prominent along the entire cascade of care, including: treatment engagement and entry, MOUD initiation, and MOUD retention. Hypothesized explanations for barriers include: developmental vulnerability, inadequate treatment system capacity, stigma against MOUD, among others. Interventions to address barriers include: promotion of family involvement, increasing provider capacity, integration of MOUD into primary care, assertive outreach, and others. CONCLUSIONS Integrating an adapted version of family coaching from the Community Reinforcement Approach and Family Training (CRAFT) and other models into YA MOUD treatment serves as an example of an emerging novel practice that holds promise for broadening the funnel of engagement in treatment and initiation of MOUD, and enhancing treatment outcomes. This and other developmentally-informed approaches should be evaluated as part of a high-priority clinical and research agenda for improving OUD treatment for YAs.
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Affiliation(s)
- Marc Fishman
- Maryland Treatment Centers, 3800 Frederick Avenue, Baltimore, MD 21229, USA; Johns Hopkins University School of Medicine, Dept of Psychiatry, 3800 Frederick Avenue, Baltimore, MD 21229, USA.
| | - Kevin Wenzel
- Maryland Treatment Centers, 3800 Frederick Avenue, Baltimore, MD 21229, USA
| | - Phoebe Gauthier
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Suite 315, Lebanon, NH 03766, USA
| | - Jacob Borodovsky
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Suite 315, Lebanon, NH 03766, USA
| | - Owen Murray
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Suite 315, Lebanon, NH 03766, USA
| | - Geetha Subramaniam
- Center for Clinical Trials Network, National Institute on Drug Abuse, 301 North Stonestreet Ave, Bethesda, MD 20892, USA
| | - Sharon Levy
- Boston Children's Hospital, Division of Addiction Medicine, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Emma Fredyma
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Suite 315, Lebanon, NH 03766, USA
| | - Bethany McLeman
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Suite 315, Lebanon, NH 03766, USA
| | - Lisa A Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Suite 315, Lebanon, NH 03766, USA
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Hellum R, Bilberg R, Mejldal A, Nielsen AS. Potential factors affecting the impact of community reinforcement and family training. Secondary analysis of an RCT. BMC Public Health 2024; 24:213. [PMID: 38233850 PMCID: PMC10795348 DOI: 10.1186/s12889-024-17656-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/03/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND In addition to increasing the quality of life among concerned significant others (CSOs), Community Reinforcement and Family training (CRAFT) aim at helping CSOs motivate treatment-refusing identified patients (IPs) into treatment through a positive reinforcement process. The aim of the present study was to investigate if the following factors, measured at baseline, have an influence on IP future treatment engagement (1) Type of relation between CSO and the IP (2) The amount of time the CSO spend with the IP (3) if the IP knows that the CSOs seeks help, and (4) The CSO's own alcohol use. METHODS A secondary analysis from the Danish CRAFT study. CSOs completed a self-administered questionnaire at baseline, after three months, and six months. To investigate the relationship between the four variables and treatment engagement, logistic regression was used. RESULTS CSO's relation to the IP, the frequency of contact between the CSO and the IP, and the CSO's AUDIT score at the time of the baseline interview were not associated with the IP's treatment engagement. If CSO at baseline had informed the IP that the CSO participated in CRAFT, odds for IP treatment engagement were significantly higher (adjusted OR [(CI)] = 2.29 [1.13; 4.63] (p < 0.05), relative to if IP not being informed. CONCLUSIONS CRAFT has a higher impact on the likelihood for treatment seeking, if the CSOs inform the IP about his or her own help seeking in order to change the situation. The underlying mechanism behind this is needs further investigations.
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Affiliation(s)
- Rikke Hellum
- The Unit of Clinical Alcohol Research (UCAR), Institute of Clinical Research, University of Southern Denmark, J.B. Winsløws vej 18, Odense C, 5000, Denmark
- Department of Mental Health Odense, Region of Southern Denmark, J.B. Winsløws vej 18, Odense C, 5000, Denmark
| | - Randi Bilberg
- The Unit of Clinical Alcohol Research (UCAR), Institute of Clinical Research, University of Southern Denmark, J.B. Winsløws vej 18, Odense C, 5000, Denmark
- Department for Data, Innovation and Research, Lillebaelt Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Anna Mejldal
- The Unit of Clinical Alcohol Research (UCAR), Institute of Clinical Research, University of Southern Denmark, J.B. Winsløws vej 18, Odense C, 5000, Denmark
- Odense Patient Data Explorative Network (OPEN), Odense University Hospital, J.B. Winsløws vej 9A, Odense C, 5000, Denmark
| | - Anette Søgaard Nielsen
- The Unit of Clinical Alcohol Research (UCAR), Institute of Clinical Research, University of Southern Denmark, J.B. Winsløws vej 18, Odense C, 5000, Denmark.
- Department of Mental Health Odense, Region of Southern Denmark, J.B. Winsløws vej 18, Odense C, 5000, Denmark.
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Croak B, Archer M, Harwood H, Stevelink SAM, Greenberg N, Rafferty L. Evaluation of Community Reinforcement and Family Therapy in the UK military community. Eur J Psychotraumatol 2023; 14:2282904. [PMID: 38010161 PMCID: PMC10993804 DOI: 10.1080/20008066.2023.2282904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/06/2023] [Indexed: 11/29/2023] Open
Abstract
Background: Partners and family can play a key role in encouraging military service and ex-service personnel to seek help for their mental health. Community Reinforcement Approach and Family Training (CRAFT) was developed to equip concerned significant others (CSOs) of those experiencing substance use disorders with skills to encourage their loved one to enter treatment and improve their own well-being. It was adapted in the US for CSOs of ex-service personnel with post-traumatic stress disorder (PTSD) (VA-CRAFT).Objective: This study aimed to evaluate an adaptation of VA-CRAFT for use with CSOs of serving and ex-service personnel experiencing PTSD and Common Mental Disorders in the UK (UKV-CRAFT).Method: Acceptability of UKV-CRAFT was assessed with interviews with experts, namely key stakeholders (n = 15) working in support provision for serving and ex-service personnel. In addition, individuals who took part in a small-scale demonstrative trial of UKV-CRAFT (three CSOs and three facilitators who delivered UKV-CRAFT) provided feedback.Results: UKV-CRAFT was viewed positively, with interviewees highlighting that programmes like UKV-CRAFT filled a gap in provision for UK Armed Forces families as most services were only available to the serving or ex-service personnel. Interviewees praised how UKV-CRAFT enhanced CSO well-being and communication with their loved one. Concerns over the confidentiality of taking part in UKV-CRAFT were raised due to the perceived negative effects of highlighting a loved one's mental ill health, especially for CSOs of serving personnel. Ideas for improvement included broadening access to all CSOs regardless of whether their loved one was seeking treatment.Conclusion: Interviewees regarded UKV-CRAFT as a potentially useful intervention suggesting it could be proactively offered universally to support timely help-seeking if required. We recommend further evaluation of UKV-CRAFT on a wider scale, incorporating our recommendations, to assess its effectiveness accurately.
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Affiliation(s)
- Bethany Croak
- King’s Centre for Military Health Research, Department of Psychological Medicine, King’s College London, London, United Kingdom
| | - Marc Archer
- King’s Centre for Military Health Research, Department of Psychological Medicine, King’s College London, London, United Kingdom
- School of Health, Social Care and Life Sciences, University of the Highlands and Islands, Inverness, United Kingdom
| | - Hannah Harwood
- King’s Centre for Military Health Research, Department of Psychological Medicine, King’s College London, London, United Kingdom
| | - Sharon A. M. Stevelink
- King’s Centre for Military Health Research, Department of Psychological Medicine, King’s College London, London, United Kingdom
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Neil Greenberg
- King’s Centre for Military Health Research, Department of Psychological Medicine, King’s College London, London, United Kingdom
| | - Laura Rafferty
- King’s Centre for Military Health Research, Department of Psychological Medicine, King’s College London, London, United Kingdom
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Hogue A, Bobek M, MacLean A, Schumm JA, Wenzel K, Fishman M. Relationship-Oriented Recovery System for Youth (RORSY): Clinical Protocol for Transition-Age Youth with Opioid Use Disorders. HSOA JOURNAL OF ADDICTION & ADDICTIVE DISORDERS 2023; 10:144. [PMID: 38707487 PMCID: PMC11068080 DOI: 10.24966/aad-7276/100144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
This article introduces the Relationship-Oriented Recovery System for Youth (RORSY) protocol, which is designed to increase uptake of Medications for Opioid Use Disorder (MOUD) and related services among adolescents and young adults. Youth exhibit alarmingly poor rates of MOUD initiation and adherence, OUD services involvement and long-term recovery success. RORSY attends to three developmentally unique recovery needs of this age group: assess and bolster youth recovery capital, prioritize involvement of concerned significant others, and use digital direct-to-consumer recovery supports. RORSY contains five evidence-informed intervention modules that can be flexibly tailored to meet the individual and relationship needs of a given youth: Relational Orientation, Youth Recovery Management Planning, Relational Recovery Management Planning, Relationship Skills Building, and Digital Recovery Support Planning. The article concludes with practice and policy recommendations for making relationship-building a top clinical priority for addressing youth OUD.
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Affiliation(s)
| | | | | | - Jeremiah A Schumm
- OneFifteen, Inc./Samaritan Behavioral Health, Inc., Wright
State University, Dayton, USA
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Timko C, Cucciare MA, Lor MC, Stein M, Vest N. Patient-Concerned Other Dyads' 12-Step Involvement and Patients' Substance Use: A Latent Class Growth Model Analysis. J Stud Alcohol Drugs 2023; 84:762-771. [PMID: 37219032 PMCID: PMC10600972 DOI: 10.15288/jsad.22-00378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 04/10/2023] [Indexed: 05/24/2023] Open
Abstract
OBJECTIVE This study aimed to inform clinical practice by identifying subgroups of patient-concerned other (CO) dyads. Patients with alcohol use disorders (AUDs) were characterized on Alcoholics Anonymous (AA) involvement and substance use together with COs' Al-Anon involvement. Predictors and recovery maintenance outcomes of subgroup membership were examined. METHOD Participants were 279 patient-CO dyads. Patients were in residential treatment for AUD. Parallel latent class growth model analysis characterized 12-step involvement and substance use at treatment entry and 3-, 6-, and 12-month follow-ups. RESULTS Three classes were as follows: 38% Low AA/Low Al-Anon (patients' low AA and COs' low Al-Anon involvement, and patients' high-to-moderate substance use), 10% High AA/High Al-Anon (patients' high AA and COs' high Al-Anon involvement, and patients' moderate-to-low substance use), and 52% High AA/Low Al-Anon (patients' high AA and COs' low Al-Anon involvement, and patients' moderate-to-low substance use). At follow-up, the Low AA/Low Al-Anon classes' patients were less likely to have spirituality as recovery support, confidence about staying abstinent, and satisfaction with recovery progress. The High AA classes' COs had less concern about patients' drinking and scored higher on positive aspects of relationships with patients. CONCLUSIONS Clinicians should encourage patients' and COs' 12-step group involvement (12-step practices' engagement). Among patients treated for AUD, AA involvement was related to better outcomes, and to COs' lessened concern about the patients' drinking. COs' Al-Anon involvement was associated with having a more positive view of their relationship with the patient. That more than one third of dyads had low 12-step group involvement suggests that treatment programs may need to facilitate involvement in non-12-step mutual-help groups.
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Affiliation(s)
- Christine Timko
- Center for Innovation to Implementation, Department of Veterans Affairs Health Care System, Palo Alto, California
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Michael A. Cucciare
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, North Little Rock, Arkansas
- Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas
| | - Mai Chee Lor
- Center for Innovation to Implementation, Department of Veterans Affairs Health Care System, Palo Alto, California
| | - Michael Stein
- Boston University School of Public Health, Department of Community Health Sciences, Boston, Massachusetts
| | - Noel Vest
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
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Merkouris SS, Rodda SN, Aarsman SR, Hodgins DC, Dowling NA. Effective behaviour change techniques for family and close friends: A systematic review and meta-analysis across the addictions. Clin Psychol Rev 2023; 100:102251. [PMID: 36716584 DOI: 10.1016/j.cpr.2023.102251] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/09/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023]
Abstract
This systematic review aimed to determine whether the use of specific behaviour change technique (BCT) groups are associated with greater effectiveness for psychosocial interventions delivered to family and close friends (FCFs) impacted by addiction. A systematic search of peer-reviewed and grey literature published until August 2021 identified 32 studies in 38 articles. An established BCT taxonomy (93 BCTs clustered into 16 groups) was adapted (inclusion of seven additional BCT groups) and applied to 57 interventions. The meta-analyses indicated that some, but not all, FCF outcomes were improved by the exclusion of BCTs within several groups (Reward and Threat, Scheduled Consequences, Confrontation of the Addicted Person to Engage in Treatment, and Goals and Planning) and inclusion of BCTs within the Restoring a Balanced Lifestyle group. Addicted person outcomes were improved by the inclusion of some BCTs within several groups (Repetition and Substitution, Reward and Threat, Scheduled Consequences, and Restoring a Balanced Lifestyle). Relationship functioning outcomes were improved by the inclusion of BCTs within the Confrontation of the Addicted Person to Engage in Treatment group. Future research involving the development and evaluation of numerous interventions or comprehensive multi-component interventions that can address the various needs of FCFs, without counteracting them, is required.
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Affiliation(s)
- S S Merkouris
- School of Psychology, Deakin University, Geelong, Victoria 3220, Australia.
| | - S N Rodda
- School of Psychology, Deakin University, Geelong, Victoria 3220, Australia; Department of Psychology and Neuroscience, Auckland University of Technology, Auckland 1010, New Zealand
| | - S R Aarsman
- School of Psychology, Deakin University, Geelong, Victoria 3220, Australia
| | - D C Hodgins
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
| | - N A Dowling
- School of Psychology, Deakin University, Geelong, Victoria 3220, Australia; Melbourne Graduate School of Education, University of Melbourne, Parkville, Victoria 3010, Australia
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11
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Brandhorst I, Uwe Petersen K, Hanke S, Batra A, Renner T, Maria Barth G. Training for Parents of Adolescents with Gaming Disorder. SUCHT 2022. [DOI: 10.1024/0939-5911/a000790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Abstract: Aim: Parents can influence the Internet use (IUD) or gaming disorder (GD) in their children in various ways. However, there is scant published research and limited structured guidelines on the subject. This article describes a group training for parents that does not require the participation of the affected individuals. Methods: In this non-controlled pilot study, 42 parents (31 families) participated, completing diagnostic questionnaires before and after group training (adolescent’s GD Symptomatology, adolescent’s internalizing and externalizing problems, the parent’s and adolescent’s quality of life). The training included six sessions and was divided into four main topics (psychoeducation, parent-child-communication, analysing and changing, own limits and needs). Results: The training was well-received by the participants. The training itself and most of the content were rated as helpful. From the parents’ point of view, there were significant improvements in the GD symptomatology, the adolescent’s internalizing and externalizing problems, and adolescent’s quality of life. The parents’ quality of life was already at an average high level at the beginning of the training and hardly changed. Conclusions: The training program is easy to implement and is considered beneficial. There are indications that positive changes are triggered by the training, even though the affected persons themselves are not involved. A randomized controlled efficacy study is still pending.
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Affiliation(s)
- Isabel Brandhorst
- Department of Psychiatry, Psychosomatics and Psychotherapy in Childhood and Adolescence, University Hospital Tübingen, Germany
| | - Kay Uwe Petersen
- Department of Psychiatry and Psychotherapy, Section of Addiction Medicine and Addiction Research, University Hospital Tübingen, Germany
| | - Sara Hanke
- Department of Psychiatry and Psychotherapy, Section of Addiction Medicine and Addiction Research, University Hospital Tübingen, Germany
| | - Anil Batra
- Department of Psychiatry and Psychotherapy, Section of Addiction Medicine and Addiction Research, University Hospital Tübingen, Germany
| | - Tobias Renner
- Department of Psychiatry, Psychosomatics and Psychotherapy in Childhood and Adolescence, University Hospital Tübingen, Germany
| | - Gottfried Maria Barth
- Department of Psychiatry, Psychosomatics and Psychotherapy in Childhood and Adolescence, University Hospital Tübingen, Germany
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12
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Social Factors Predict Treatment Engagement in Veterans with PTSD or SUD. J Behav Health Serv Res 2022; 50:286-300. [PMID: 36456866 DOI: 10.1007/s11414-022-09823-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 12/03/2022]
Abstract
Veterans with PTSD and SUDs often fail to initiate, or prematurely discontinue, mental health treatment in Veteran Affairs Medical Centers (VAMC). While much is known about clinical characteristics and demographic factors impacting treatment engagement in this population, less is known about the role of social factors. This retrospective study examines primary care-based screening assessment and specialty mental healthcare appointment data in a VAMC, to test whether social factors predict treatment initiation and appointment attendance. Findings reveal veterans were more likely to initiate treatment when (a) those with SUDs (n = 235) reported more frequent negative exchanges with others and (b) those with PTSD (n = 2107) reported more perceived support or being partnered. Those with PTSD who were partnered had higher appointment attendance rates. Findings suggest social factors are relevant to treatment initiation among veterans with PTSD and SUDs and that close others may be helpful in facilitating referrals.
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13
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McCarthy JM, Wood AJ, Shinners MG, Heinrich H, Weiss RD, Mueser KT, Meyers RJ, Carol EE, Hudson JI, Öngür D. Pilot development and feasibility of telehealth Community Reinforcement and Family Training (CRAFT) for early psychosis and substance use. Psychiatry Res 2022; 317:114804. [PMID: 36030701 PMCID: PMC10127150 DOI: 10.1016/j.psychres.2022.114804] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 10/31/2022]
Abstract
Substance use is associated with poor outcomes for individuals with early psychosis. Community Reinforcement and Family Training (CRAFT) is an evidence-based approach that helps families to reduce substance use, engage in treatment, and improve family wellbeing, but it has not yet been studied for psychosis and substance use. The present study aimed to develop and evaluate a telehealth intervention utilizing CRAFT for families experiencing early psychosis and substance use. Twenty family members completed six to eight telehealth sessions of CRAFT adapted for early psychosis (CRAFT-EP). Participants completed an assessment battery at baseline, mid- and post-intervention, a three-month follow-up, surveys after each session, and a focus group to measure mean percentage of sessions completed, mean program satisfaction ratings, telehealth preference, and qualitative feedback. Participants had 100% session completion, and program satisfaction was at or near excellent for 99% of sessions. Half of participants preferred a primarily virtual hybrid program, whereas 45% preferred exclusively virtual visits. Communication was the most helpful topic, and participants requested additional written examples and resources. CRAFT-EP is feasible and acceptable to serve as the active intervention in a pilot randomized controlled trial comparing treatment as usual plus CRAFT-EP to treatment as usual.
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Affiliation(s)
- Julie M McCarthy
- Division of Psychotic Disorders, McLean Hospital, 115 Mill St., Belmont, MA 02478, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Andrea J Wood
- Division of Psychotic Disorders, McLean Hospital, 115 Mill St., Belmont, MA 02478, USA
| | - M Grace Shinners
- Division of Psychotic Disorders, McLean Hospital, 115 Mill St., Belmont, MA 02478, USA
| | - Hadley Heinrich
- Division of Psychotic Disorders, McLean Hospital, 115 Mill St., Belmont, MA 02478, USA
| | - Roger D Weiss
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA; Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA, USA
| | - Kim T Mueser
- Center for Psychiatric Rehabilitation, Departments of Occupational Therapy and Psychological and Brain Sciences, Boston University, Boston, MA, USA
| | - Robert J Meyers
- Center on Alcoholism, Substance Abuse and Addiction, University of New, Albuquerque, NM, USA
| | - Emily E Carol
- Division of Psychotic Disorders, McLean Hospital, 115 Mill St., Belmont, MA 02478, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - James I Hudson
- Division of Psychotic Disorders, McLean Hospital, 115 Mill St., Belmont, MA 02478, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Dost Öngür
- Division of Psychotic Disorders, McLean Hospital, 115 Mill St., Belmont, MA 02478, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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14
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Lodge BS. A Call for Kindness, Connection, and Science. J Subst Abuse Treat 2022; 141:108839. [PMID: 35872567 DOI: 10.1016/j.jsat.2022.108839] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/27/2022] [Accepted: 07/07/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION This personal narrative describes our family's struggle with my adult son's substance use disorder (SUD). Years of traditional tough love treatment programs worsened his SUD and our relationship. When he experienced drug induced psychosis and was hospitalized, I realized I needed to change my approach and understand his behaviors. METHODS I reached out to the recovery community and spoke with many individuals who had walked in my son's shoes. They described feelings of loneliness, self-loathing, and hopelessness while being on the receiving end of tough love. They further described the contrast between those negative feelings, and the life affirming hope associated with communication, empathy, and inclusion. I became inspired to research programs that are based on communication, science, and connection, rather than isolation, judgment, and punishment. RESULTS Family and community are powerful tools and can motive change. An evidence-based program called CRAFT (Community Reinforcement and Family Training) encourages relationships and teaches families skills to connect with their loved ones by effectively communicating and reinforcing positive behaviors, even in the context of unhealthy behaviors. Receiving praise for healthy behavior, recognition for good work, or even a positive acknowledgement for taking baby steps toward self-care can activate the same dopamine-producing reward system as drugs. Individuals with SUD can learn how to feel good in ways that do not involve using substances. Traditional patient-focused treatment programs, which encourage separation, punishment, and distance should not be considered the only approach to treatment. CONCLUSIONS Loved ones are not powerless. While we can't make a person change, we can contribute to making them want to change. We have more influence than we once thought possible and need to proactively seek out empirically supported family-based programs that reinforce these approaches.
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15
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Hellum R, Bilberg R, Andersen K, Bischof G, Hesse M, Nielsen AS. Primary Outcome from a cluster-randomized trial of three formats for delivering Community Reinforcement and Family Training (CRAFT) to the significant others of problem drinkers. BMC Public Health 2022; 22:928. [PMID: 35538465 PMCID: PMC9087923 DOI: 10.1186/s12889-022-13293-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 04/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community Reinforcement and Family Training (CRAFT) is an intervention designed to help the concerned significant others (CSOs) of people with alcohol problems who are reluctant to seek treatment. It aims to improve the well-being of CSOs and teach them how to change their behavior in order to positively influence the "identified patient" (IP) to seek treatment. METHODS The aim of the present pragmatic cluster-randomized trial was to compare the effectiveness of three formats for delivering CRAFT in real life settings: group sessions, individual sessions, and written material only (control group). Eighteen public treatment centers for alcohol use disorders were randomly assigned to deliver CRAFT in one of the three formats as part of their daily clinical routine. CSOs were recruited via pamphlets, general practitioners, and advertisements on social media. Trained clinicians delivered CRAFT in individual and group format, and self-administered CRAFT was limited to handing out a self-help book. The primary outcome was treatment engagement of the IP after three months. RESULTS A total of 249 CSOs were found to be eligible and randomly assigned to receive CRAFT delivered in group, individual, or self-administered format. The three-month follow-up rate was 60%. At three months follow-up, 29% (n = 32) of the CSOs who received group/individual CRAFT reported that their IP had engaged in treatment. The corresponding rate for the CSOs who received self-administered CRAFT was lower (15%; n = 5) but did not differ significantly from the other group of CSOs (Odds ratio (OR) = 2.27 (95% CI: 0.80, 6.41)). CONCLUSION We hypothesized that CSOs receiving CRAFT in a group format would improve the most, but although our findings pointed in this direction, the differences were not statistically significant. TRIAL REGISTRATION Clinical trials.gov ID: NCT03281057 . Registration date:13/09/2017.
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Affiliation(s)
- Rikke Hellum
- The Unit of Clinical Alcohol Research (UCAR), Institute of Clinical Research, University of Southern Denmark, J.B. Winsløws vej 18, 5000, Odense C, Denmark
| | - Randi Bilberg
- The Unit of Clinical Alcohol Research (UCAR), Institute of Clinical Research, University of Southern Denmark, J.B. Winsløws vej 18, 5000, Odense C, Denmark.
| | - Kjeld Andersen
- Psychiatric Department, Region of Southern Denmark, Odense, Denmark
| | - Gallus Bischof
- The Department of Psychiatry and Psychotherapy, University of Luebeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Morten Hesse
- Centre for Alcohol and Drug Research, Department of Psychological and Behavioral Sciences, Aarhus University, Artillerivej 90, 2, 2300, Copenhagen S, Denmark
| | - Anette Søgaard Nielsen
- The Unit of Clinical Alcohol Research (UCAR), Institute of Clinical Research, University of Southern Denmark, J.B. Winsløws vej 18, 5000, Odense C, Denmark
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16
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Chen CY, Lin CC, Kao JT, Yeh WL, Lin CY, Tsai YF. Predicting Hazardous Alcohol Drinking Behaviors in Family Members of Hazardous Alcohol-Drinker Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19095497. [PMID: 35564892 PMCID: PMC9105135 DOI: 10.3390/ijerph19095497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 12/04/2022]
Abstract
Family members of hazardous or harmful alcohol drinkers suffer many consequences of their relative’s alcohol-drinking behaviors and risk developing their own hazardous alcohol drinking behaviors. Studies of alcohol-related healthcare problems have mainly focused on patients, with few studies on their family members. This cross-sectional study explored factors predicting hazardous alcohol drinking behaviors in family members of hazardous alcohol-drinker patients. Participants were recruited from four randomly chosen hospitals in Taiwan. Data were collected using self-report questionnaires on family members’ alcohol use, perceived stress, coping mechanisms, social support, health, quality of life, protective factors against hazardous alcohol drinking, facilitative factors for hazardous alcohol drinking, and demographics. The 318 family members who participated in this study were divided by their Chinese-version Alcohol Use Disorders Identification Test scores into two groups: hazardous alcohol drinkers (score ≥ 8) and non-hazardous alcohol drinkers (score < 8). Significant factors predicting hazardous alcohol drinking behaviors were found by logistic regression to be the frequency of using general coping mechanisms (OR = 1.29, p < 0.01), the frequency of using strategies to cope with patients’ drinking-related behaviors (OR = 0.89, p < 0.01), factors protecting against hazardous alcohol drinking (OR = 0.76, p < 0.01) and factors facilitating hazardous alcohol drinking (OR = 1.52, p < 0.01). Interventions should be designed for family members of hazardous alcohol drinkers to address these four significant predictors.
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Affiliation(s)
- Ching-Yen Chen
- Department of Psychiatry, Chang Gung Memorial Hospital at Keelung, Keelung City 204, Taiwan;
- College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan; (C.-C.L.); (W.-L.Y.)
| | - Chen-Chun Lin
- College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan; (C.-C.L.); (W.-L.Y.)
- Department of Hepato-Gastroenterology, Chang Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan
| | - Jung-Ta Kao
- School of Medicine, College of Medicine, China Medical University, Taichung City 404, Taiwan;
- Division of Hepato-Gastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung City 404, Taiwan
| | - Wen-Ling Yeh
- College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan; (C.-C.L.); (W.-L.Y.)
- Department of Orthopedics, Lotung Poh-Ai Hospital, Luodong Township, Yilan County 265, Taiwan
| | - Chiao-Yun Lin
- Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan;
| | - Yun-Fang Tsai
- Department of Psychiatry, Chang Gung Memorial Hospital at Keelung, Keelung City 204, Taiwan;
- School of Nursing, College of Medicine, Chang Gung University, 259, Wen-Hwa 1st Road, Taoyuan City 333, Taiwan
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City 333, Taiwan
- Correspondence: ; Tel.: +886-3-2118800 (ext. 3204); Fax: +886-3-2118868
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Hogue A, Schumm JA, MacLean A, Bobek M. Couple and family therapy for substance use disorders: Evidence-based update 2010-2019. JOURNAL OF MARITAL AND FAMILY THERAPY 2022; 48:178-203. [PMID: 34435387 DOI: 10.1111/jmft.12546] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 06/24/2021] [Accepted: 08/04/2021] [Indexed: 06/13/2023]
Abstract
This article updates the evidence-based on couple and family therapy interventions for substance use disorders (SUD) since publication of the previous JMFT reviews in 2012. It first summarizes previous reviews along with findings from more recent reviews and meta-analytic studies. It then presents study design and methods criteria used to select 13 studies of couple and family therapy for level of support evaluation. Cumulative level of support designations are then determined for identified treatment approaches. Findings indicate that systemic family therapy is well-established as a standalone treatment, and behavioral family therapy and behavioral couple therapy are probably efficacious as standalone treatments and well-established as part of a multicomponent treatment. The article then suggests practice guidelines with regard to treatment modality considerations and implementation challenges. It concludes with future directions for delivering couple and family interventions in routine systems of care for SUD.
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Affiliation(s)
- Aaron Hogue
- Partnership to End Addiction, Suite, New York, USA
| | - Jeremiah A Schumm
- School of Professional Psychology, Wright State University and OneFifteen, Inc./Samaritan Behavioral Health, Inc., Dayton, Ohio, USA
| | | | - Molly Bobek
- Partnership to End Addiction, Suite, New York, USA
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18
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Hellum R, Bilberg R, Bischof G, Nielsen AS. How concerned significant others experience Community Reinforcement and Family Training (CRAFT) - a qualitative study. BMC FAMILY PRACTICE 2021; 22:241. [PMID: 34861827 PMCID: PMC8641252 DOI: 10.1186/s12875-021-01596-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 11/24/2021] [Indexed: 11/15/2022]
Abstract
Introduction Heavy drinking causes serious harm, not only to the drinker but also to relationships and concerned significant others (CSOs). Community Reinforcement and Family Training (CRAFT) is an intervention developed to help the CSOs of substance users. The aim of this study was to investigate the drivers and aims underlying CSO participation in CRAFT, as well as their experience of the intervention itself and their module preferences. Method This is a qualitative study based on data from semi-structured interviews with 11 female help-seeking CSOs of individuals with alcohol problems. The participants were recruited from an RCT study of a variety of CRAFT delivery formats (group sessions + written material, individual sessions + written material or self-delivered CRAFT with written material only). The interviews were audio-recorded, transcribed, and analyzed by Interpretative Phenomenological Analysis. Results CSOs reported CRAFT helpful when both delivered by means of individual sessions or group sessions. The “Communication Element” in CRAFT, the module focusing on positive reinforcement and acquiring a clearer understanding of AUD, appeared to be particularly helpful elements of CRAFT. Furthermore, being met with acceptance and non-judgmental attitudes seemed to count highly for the CSOs. The written material a helpful supplement to the face-to-face interventions. The written material a helpful supplement to the face-to-face interventions. Conclusion CSOs who participated in the CRAFT intervention felt helped by its components, irrespective of delivery format.
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Affiliation(s)
- Rikke Hellum
- Unit of Clinical Alcohol Research, Clinical Institute, University of Southern Denmark, J.B. Winsløws vej 18, 5000, Odense C, Denmark. .,Psychiatric Department, Odense University Hospital, J.B. Winsløws vej 18, 5000, Odense C, Denmark. .,Odense Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark.
| | - Randi Bilberg
- Unit of Clinical Alcohol Research, Clinical Institute, University of Southern Denmark, J.B. Winsløws vej 18, 5000, Odense C, Denmark.,Psychiatric Department, Odense University Hospital, J.B. Winsløws vej 18, 5000, Odense C, Denmark.,Odense Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Gallus Bischof
- Department of Psychiatry and Psychotherapy, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Anette Søgaard Nielsen
- Unit of Clinical Alcohol Research, Clinical Institute, University of Southern Denmark, J.B. Winsløws vej 18, 5000, Odense C, Denmark.,Psychiatric Department, Odense University Hospital, J.B. Winsløws vej 18, 5000, Odense C, Denmark.,Odense Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
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Hogue A, Becker SJ, Wenzel K, Henderson CE, Bobek M, Levy S, Fishman M. Family involvement in treatment and recovery for substance use disorders among transition-age youth: Research bedrocks and opportunities. J Subst Abuse Treat 2021; 129:108402. [PMID: 34080559 PMCID: PMC8380649 DOI: 10.1016/j.jsat.2021.108402] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 04/02/2021] [Accepted: 04/05/2021] [Indexed: 12/30/2022]
Abstract
This article presents a narrative review and conceptual framework for research on family involvement across the continuum of substance use disorder (SUD) services for transition-age youth (ages 15-26). Though families are powerful resources for enhancing treatment and recovery success among youth with SUDs, they are not routinely included in clinical practice. This article summarizes youth SUD prevalence and service utilization rates and presents developmental and empirical rationale for increasing family involvement in services. It then describes key research issues on family involvement across the SUD services continuum: Problem Identification, Treatment Engagement, Active Treatment, Recovery Support. Within each phase, it highlights bedrock research findings and suggests promising opportunities for advancing the scientific knowledge base on family involvement. The main goals are to endorse family-oriented practices for immediate adoption in routine care and identify areas of research innovation that could significantly enhance the quality of youth SUD services.
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Affiliation(s)
- Aaron Hogue
- Partnership to End Addiction, United States of America.
| | - Sara J Becker
- Center for Alcohol and Addictions Studies, Brown University School of Public Health, United States of America
| | - Kevin Wenzel
- Maryland Treatment Centers, United States of America
| | | | - Molly Bobek
- Partnership to End Addiction, United States of America
| | - Sharon Levy
- Boston Children's Hospital, Harvard Medical School, United States of America
| | - Marc Fishman
- Maryland Treatment Centers, United States of America
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20
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Hogue A, Bobek M, Levy S, Henderson CE, Fishman M, Becker SJ, Dauber S, Porter N, Wenzel K. Conceptual framework for telehealth strategies to increase family involvement in treatment and recovery for youth opioid use disorder. JOURNAL OF MARITAL AND FAMILY THERAPY 2021; 47:501-514. [PMID: 33760249 PMCID: PMC9830952 DOI: 10.1111/jmft.12499] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 01/29/2021] [Accepted: 02/02/2021] [Indexed: 06/12/2023]
Abstract
With opioid use at crisis levels, it is imperative to support youth ages with opioid use disorders (OUD) in taking medication and accessing behavioral services over long periods. This article presents a conceptual framework for telehealth strategies that can be adopted to increase family involvement across a four-stage continuum of youth OUD treatment and recovery: Treatment Preparation, Treatment Initiation, Treatment Stabilization, OUD Recovery. It first identifies provider-delivered tele-interventions that can enhance OUD services in each of the four stages, including family outreach, family engagement, family-focused intervention, and family-focused recovery maintenance. It then introduces several types of direct-to-family tele-supports that can be used to supplement provider-delivered interventions. These include both synchronous tele-supports (remote interactions that occur in real time) such as helplines, peer-to-peer coaching, and online support groups; and asynchronous tele-supports (communications that occur without participants being simultaneously present) such as automated text messaging, self-directed internet-based courses, and digital web support.
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Affiliation(s)
- Aaron Hogue
- Family and Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, NY, USA
| | - Molly Bobek
- Family and Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, NY, USA
| | - Sharon Levy
- Adolescent Substance Use and Addiction Program, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Craig E. Henderson
- Department of Psychology, Sam Houston, State University, Huntsville, TX, USA
| | | | - Sara J. Becker
- Center for Alcohol and Addictions, Studies, Brown University School of Public, Health, Providence, RI, USA
| | - Sarah Dauber
- Family and Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, NY, USA
| | - Nicole Porter
- Family and Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, NY, USA
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21
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Archer M, Harwood H, Stevelink S, Rafferty L, Greenberg N. Community reinforcement and family training and rates of treatment entry: a systematic review. Addiction 2020; 115:1024-1037. [PMID: 31770469 DOI: 10.1111/add.14901] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/29/2019] [Accepted: 11/11/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Adaptations with different modes of delivery and target addictions have found highly divergent rates of success for Community Reinforcement Approach and Family Training (CRAFT). This study aims to clarify which (1) treatment components and (2) participant characteristics contribute to rates of identified patient (IP) treatment entry. METHOD Systematic review of CRAFT evaluation studies of all designs (controlled and uncontrolled) with data synthesis and narrative analysis of addiction treatment services and university research departments in North America and Europe. RESULTS A total of 691 concerned significant others (CSOs), predominately female spouses/parents, participating in 20 distinct treatment conditions from 14 studies. The main outcome of IP treatment entry rate reported by CSOs up to 12 months after starting CRAFT with key predictors/correlates including IP addiction, IP-CSO relationship, CRAFT modality and integration of treatment for IP. Meta-analysis found CRAFT to be twice as effective as controls/comparison groups. Multi-modality treatment, including both individual and group sessions, yielded the highest IP treatment entry rates (77 and 86%), with progressively lower rates for individual (12.5-71%), group (60%) and self-directed workbook (13.3-40%) modalities. While all five studies targeting gambling addiction had consistently low rates (12.5-23%), other treatment components, including therapist training, treatment fidelity and integrating treatment for the IP, were implicated. CONCLUSIONS Adaptations of Community Reinforcement Approach and Family Training for different delivery modalities and addictions have yielded widely varying rates of treatment engagement for the identified patient, with those offering the most comprehensive support to the concerned significant other, including individual and group sessions, having highest levels of engagement success.
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Affiliation(s)
- Marc Archer
- King's Centre for Military Health Research, King's College London, Weston Education Centre, London, UK
| | - Hannah Harwood
- King's Centre for Military Health Research, King's College London, Weston Education Centre, London, UK
| | - Sharon Stevelink
- King's Centre for Military Health Research, King's College London, Weston Education Centre, London, UK.,Department of Psychological Medicine, King's College London, De Crespigny Park, London, UK
| | - Laura Rafferty
- King's Centre for Military Health Research, King's College London, Weston Education Centre, London, UK
| | - Neil Greenberg
- King's Centre for Military Health Research, King's College London, Weston Education Centre, London, UK.,Academic Department of Military Mental Health, King's College London, Weston Education Centre, London, UK
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22
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Ameral V, Yule A, McKowen J, Bergman BG, Nargiso J, Kelly JF. A Naturalistic Evaluation of a Group Intervention for Parents of Youth with Substance Use Disorders. ALCOHOLISM TREATMENT QUARTERLY 2019; 38:379-394. [PMID: 32863559 PMCID: PMC7451897 DOI: 10.1080/07347324.2019.1633978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Parents of youth with substance use disorders (SUDs) often play a vital role in successful treatment, yet little is known about interventions designed to help them cope with the stress of this role, especially as delivered in real-world settings. Evaluations of such interventions could potentially inform adaptations to enhance their clinical utility. Parents of youth with SUDs attending a clinician-led group based on the CRAFT model completed measures at intake, 4- and 8-weeks. Parents (n=545) attended an average of 3.7 sessions; 12% completed all 8 weeks. Analysis of demographic predictors of retention indicated that older parents attended more sessions on average. Overall stress did not change across time points (p>0.05). However, parents reported improvement in parent empowerment as measured by the Parent Empowerment Scale, a novel measure of parent empowerment in coping with their child's SUD (p<0.001). Clinician led evidence-informed group services may improve parents' perceived ability to help their child with their SUD. Low retention rates highlight the need to better understand the factors contributing to retention, and the potential value of adaptations to shorten the intervention. Programs serving youth with SUDs may wish to consider integrating such group services to support parents.
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Affiliation(s)
- Victoria Ameral
- Addiction Recovery Management Service, Massachusetts General Hospital, 15 Parkman Street, Boston, MA 02114
- VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA 02130
- Department of Psychiatry, Boston University School of Medicine, 72 E Concord St., Boston, MA 02118
| | - Amy Yule
- Addiction Recovery Management Service, Massachusetts General Hospital, 15 Parkman Street, Boston, MA 02114
| | - James McKowen
- Addiction Recovery Management Service, Massachusetts General Hospital, 15 Parkman Street, Boston, MA 02114
| | - Brandon G Bergman
- Recovery Research Institute, Massachusetts General Hospital, 151 Merrimac Street, Suite 601, Boston, MA 02114
| | - Jessica Nargiso
- Addiction Recovery Management Service, Massachusetts General Hospital, 15 Parkman Street, Boston, MA 02114
| | - John F Kelly
- Addiction Recovery Management Service, Massachusetts General Hospital, 15 Parkman Street, Boston, MA 02114
- Recovery Research Institute, Massachusetts General Hospital, 151 Merrimac Street, Suite 601, Boston, MA 02114
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23
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Hellum R, Nielsen AS, Bischof G, Andersen K, Hesse M, Ekstrøm CT, Bilberg R. Community reinforcement and family training (CRAFT) - design of a cluster randomized controlled trial comparing individual, group and self-help interventions. BMC Public Health 2019; 19:307. [PMID: 30871596 PMCID: PMC6416948 DOI: 10.1186/s12889-019-6632-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/06/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Around 585,000 people in Denmark engage in harmful use of alcohol with 140,000 suffering from outright alcohol dependence. The concerned significant others (CSOs) are affected by the drinking, often suffering almost as much as the person with alcohol use disorder. Community Reinforcement and Family Training (CRAFT) is aimed at CSOs who struggle unsuccessfully, in an effort to motivate their loved ones to stop drinking and seek treatment. The aims of this study are 1) To implement CRAFT interventions into the daily routine of operating Danish alcohol treatment centers 2) To investigate whether 6-week-individual CRAFT, 6-week-open group-based CRAFT or CRAFT based on self-help material, is efficient in getting problem drinkers to seek treatment for their alcohol problems 3) To investigate which of the three interventions (individual, group or self-directed CRAFT) is the most effective and in which group of population. METHODS The study is a three-arm, cluster randomized controlled trial: A: individual CRAFT, group CRAFT, and CRAFT as a self-help intervention. A total of 405 concerned significant others to persons with alcohol abuse will be recruited from 24 alcohol outpatient clinics. The participants will fill out a questionnaire regarding i.e. life quality, if the drinking person entered treatment (main outcome) and satisfaction with the intervention, at baseline and after 3 and 6 months. DISCUSSION We expect to establish evidence as to whether CRAFT is efficient in a Danish treatment setting and whether CRAFT is most effective at individual, group or self-help material only. TRIAL REGISTRATION Clinical trials.gov ID: NCT03281057 . Registration date: September 13th, 2017.
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Affiliation(s)
- Rikke Hellum
- Unit of Clinical Alcohol Research, Clinical Institute, University of Southern Denmark, J.B. Winsløws vej 18, 5000 Odense, Denmark
- Psychiatric Department, Odense University Hospital, J.B. Winsløws vej 18, 5000 Odense, Denmark
- Odense Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Anette Søgaard Nielsen
- Unit of Clinical Alcohol Research, Clinical Institute, University of Southern Denmark, J.B. Winsløws vej 18, 5000 Odense, Denmark
- Psychiatric Department, Odense University Hospital, J.B. Winsløws vej 18, 5000 Odense, Denmark
- Odense Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Gallus Bischof
- Department of Psychiatry and Psychotherapy, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Kjeld Andersen
- Unit of Clinical Alcohol Research, Clinical Institute, University of Southern Denmark, J.B. Winsløws vej 18, 5000 Odense, Denmark
- Psychiatric Department, Odense University Hospital, J.B. Winsløws vej 18, 5000 Odense, Denmark
| | - Morten Hesse
- Centre for Alcohol and Drug Research, Department of Psychological and Behavioral Sciences, Aarhus University, Artillerivej 90, 2, 2300 København S, Aarhus, Denmark
| | - Claus Thorn Ekstrøm
- Unit of Clinical Alcohol Research, Clinical Institute, University of Southern Denmark, J.B. Winsløws vej 18, 5000 Odense, Denmark
- Section of Biostatistics, University of Copenhagen, Øster Farimagsgade 5, 1014 København K, Denmark
| | - Randi Bilberg
- Unit of Clinical Alcohol Research, Clinical Institute, University of Southern Denmark, J.B. Winsløws vej 18, 5000 Odense, Denmark
- Psychiatric Department, Odense University Hospital, J.B. Winsløws vej 18, 5000 Odense, Denmark
- Odense Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
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24
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Kline ER. Commentary: Unmet need for mental health services among people screened but not admitted to an early psychosis intervention program. Schizophr Res 2019; 204:2-3. [PMID: 30609956 PMCID: PMC6402980 DOI: 10.1016/j.schres.2018.12.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 12/27/2018] [Indexed: 11/16/2022]
Abstract
A minority of expected incident First Episode Psychosis (FEP) cases come to the attention of FEP providers, and of these, a further minority actually receive specialty treatment. Edwards at al. find that within a London, Ontario catchment area, those not admitted to care are diagnostically similar to treated cases in terms of primary psychoses, but somewhat older, less socioeconomically advantaged, and more likely to struggle with substance use disorders. Those not admitted continue to exhibit high mental health needs and to circle the mental health system via emergency rooms, primary care, and hospital admission. FEP care advocates should be mindful of creating and improving systems that serve population health needs rather than focusing narrowly on the outcomes of those FEP patients who do successfully engage with specialty care.
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Affiliation(s)
- Emily R Kline
- Department of Psychiatry, Harvard Medical School at Beth Israel Deaconess Medical Center, USA.
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25
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Kidorf M, Brooner RK, Peirce J, Gandotra J, Leoutsakos JM. Mobilizing community support in people receiving opioid-agonist treatment: A group approach. J Subst Abuse Treat 2018; 93:1-6. [PMID: 30126535 DOI: 10.1016/j.jsat.2018.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 07/10/2018] [Accepted: 07/11/2018] [Indexed: 11/28/2022]
Abstract
This descriptive study evaluates a novel group intervention designed to help opioid-dependent patients in medication-assisted treatment identify and recruit drug-free individuals to support recovery efforts. The Social Network Activation Group works with patients who are actively using drugs and resistant to including drug-free family or friends in treatment. The group encourages patients to attend structured recovery, religious, or recreational activities in the community to find recovery support. For those with underutilized support, motivational interviewing and skills training are used to help patients resolve ambivalence and include family or friends in the treatment plan. Patients earn up to one methadone take-home each week that they attend the group and verify activity participation. They complete the group after introducing a drug-free family member or friend to their counselor. This study reports on a sample of 66 patients referred to this group as part of intensive outpatient treatment. Patients attended 71% of scheduled sessions and participated in a M = 4.3 activities. Mutual-help support groups (64%) and church (28%) were the activities most often attended. Thirty-six percent brought in a drug-free family or friend to meet their counselor. Family members were the most common choice (67%). The results demonstrate preliminary feasibility and mixed efficacy of the Social Network Activation Group for this highly select sample of patients, and provide additional evidence that many patients possess drug-free family or friends who are willing to support recovery efforts.
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Affiliation(s)
- Michael Kidorf
- Johns Hopkins University School of Medicine, United States of America.
| | - Robert K Brooner
- Johns Hopkins University School of Medicine, United States of America
| | - Jessica Peirce
- Johns Hopkins University School of Medicine, United States of America
| | - Jim Gandotra
- Johns Hopkins University School of Medicine, United States of America
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