A randomized clinical trial of Motivational Interviewing to reduce alcohol and drug use among patients with depression

Integrated telehealth intervention to reduce chronic pain and unhealthy drinking among people living with HIV: protocol for a randomized controlled trial

BACKGROUND

Unhealthy alcohol use represents a significant risk for morbidity and mortality among people living with HIV (PLWH), in part through its impact on HIV management. Chronic pain, a common comorbidity, exacerbates suboptimal engagement in the HIV care continuum and has reciprocal detrimental effects on alcohol outcomes. There are no integrated, accessible approaches that address these comorbid conditions among PLWH to date. This paper describes a research study protocol of an integrated telehealth intervention to reduce unhealthy drinking and chronic pain among PLWH (Motivational and Cognitive-Behavioral Management for Alcohol and Pain [INTV]).

METHODS

Two-hundred and fifty PLWH with unhealthy drinking and chronic pain will be recruited nationally via online advertisement. Informed consent and baseline assessments occur remotely, followed by 15 days of ecological momentary assessment to assess alcohol use, chronic pain, functioning, and mechanisms of behavior change. Next, participants will be randomized to either the INTV or Control (CTL) condition. Individuals in both conditions will meet with a health counselor through videoconferencing following randomization, and those in the INTV condition will receive 6 additional sessions. At 3- and 6-months post-baseline, participants will complete outcome assessments. It is hypothesized that the INTV condition will result in reduced unhealthy alcohol use and pain ratings compared to the CTL condition.

CONCLUSION

This protocol paper describes a randomized controlled trial which tests the efficacy of a novel, integrated telehealth approach to reduce unhealthy alcohol use and chronic pain for PLWH, two common comorbid conditions that influence the HIV treatment cascade.

CLINICALTRIALS

GOV IDENTIFIER

NCT05503173.

Factors associated with suicidal ideation among people with HIV engaged in care

BACKGROUND

People with HIV (PWH) are at elevated risk for suicidal ideation (SI), yet few studies have examined how substance use, clinical and sociodemographic factors are associated with SI among PWH.

METHOD

We used substance use (Tobacco, Alcohol, Prescription Medication, and Other Substance Use [TAPS]) and depression (PHQ-9) data from computerized screening of adult PWH in primary care clinics in Northern California, combined with health record data on psychiatric diagnoses, HIV diagnosis, treatment, and control (HIV RNA, CD4), insurance, and neighborhood deprivation index (NDI) to examine factors associated with SI (PHQ-9 item 9 score > 0). Adjusted odds ratios (aOR) for SI were obtained from logistic regression models.

RESULTS

Among 2829 PWH screened (92 % male; 56 % white; mean (SD) age of 54 (13) years; 220 (8 %) reported SI. Compared with no problematic use, SI was higher among those reporting one (aOR = 1.65, 95 % CI = 1.17, 2.33), two (aOR = 2.23, 95 % CI = 1.42, 3.49), or ≥ 3 substances (aOR = 4.49, 95 % CI = 2.41, 8.39). SI risk was higher for those with stimulant use (aOR = 3.55, 95 % CI = 2.25, 5.59), depression (aOR = 4.18, 95 % CI = 3.04, 5.74), and anxiety diagnoses (aOR = 1.67, 95 % CI = 1.19, 2.34), or Medicaid (aOR = 2.11, 95%CI = 1.24, 3.60) compared with commercial/other insurance. SI was not associated with HIV-related measures or NDI.

LIMITATIONS

SI was assessed with a single PHQ-9 item. Simultaneous SI and exposure data collection restricts the ability to establish substance use as a risk factor.

CONCLUSIONS

HIV care providers should consider multiple substance use, stimulant use, depression or anxiety, and public insurance as risk factors for SI and provide interventions when needed.

Reduced alcohol use increases drink-refusal self-efficacy: Evidence from a contingency management study for DWI arrestees

BACKGROUND

Several therapies and interventions to reduce drinking first target drink-refusal self-efficacy (DRSE) to influence drinking behavior. While higher self-efficacy scores are correlated with better outcomes, it is unclear that increased self-efficacy is the causative step leading to improved outcomes. Instead, this correlation may result from reduced drinking that increased self-efficacy. The current study sought to understand how changes in drinking behavior can influence DRSE.

METHODS

Data were from 211 driving while intoxicated (DWI) arrestees participating in an 8-week contingency management (CM) study to reduce drinking. Some of participants were mandated by the courts to wear transdermal alcohol monitoring devices (Mandated group) and some were not mandated (Non Mandated group). All wore a transdermal alcohol monitor during the 8-week study and were randomized to CM or a Control condition stratified by the mandate group. Participants completed weekly assessments of DRSE. Group-based trajectory-modeling identified three drinking behavior trajectory groups.

RESULTS

While there were no differences in baseline DRSE between the three trajectory groups, participants in the low- and moderate-frequency drinking behavior groups significantly increased DRSE across the study.

CONCLUSION

The present study indicates that being able to maintain abstinence or reduce heavy drinking may increase DRSE.

Comparing the effectiveness of a brief intervention to reduce unhealthy alcohol use among adult primary care patients with and without depression: A machine learning approach with augmented inverse probability weighting

BACKGROUND

The combination of unhealthy alcohol use and depression is associated with adverse outcomes including higher rates of alcohol use disorder and poorer depression course. Therefore, addressing alcohol use among individuals with depression may have a substantial public health impact. We compared the effectiveness of a brief intervention (BI) for unhealthy alcohol use among patients with and without depression.

METHOD

This observational study included 312,056 adult primary care patients at Kaiser Permanente Northern California who screened positive for unhealthy drinking between 2014 and 2017. Approximately half (48%) received a BI for alcohol use and 9% had depression. We examined 12-month changes in heavy drinking days in the previous three months, drinking days per week, drinks per drinking day, and drinks per week. Machine learning was used to estimate BI propensity, follow-up participation, and alcohol outcomes for an augmented inverse probability weighting (AIPW) estimator of the average treatment (BI) effect. This approach does not depend on the strong parametric assumptions of traditional logistic regression, making it more robust to model misspecification.

RESULTS

BI had a significant effect on each alcohol use outcome in the non-depressed subgroup (-0.41 to -0.05, all ps < .003), but not in the depressed subgroup (-0.33 to -0.01, all ps > .28). However, differences between subgroups were nonsignificant (0.00 to 0.11, all ps > .44).

CONCLUSION

On average, BI is an effective approach to reducing unhealthy drinking, but more research is necessary to understand its impact on patients with depression. AIPW with machine learning provides a robust method for comparing intervention effectiveness across subgroups.

Cost-Effectiveness of Motivational Interviewing to Reduce Alcohol and Cannabis Use Among Patients With Depression

OBJECTIVE

Motivational interviewing (MI) is a promising intervention for helping patients with mental health problems reduce their substance use. Examining the cost-effectiveness of MI and associations between MI and the use of health services can inform appropriate intervention strategies for these patients.

METHOD

Kaiser Permanente adult patients with depression symptoms (Patient Health Questionnaire [PHQ-9] score > 5) seen in outpatient psychiatry (N = 302) who reported unhealthy alcohol use or other substance use (primarily cannabis) were randomized to three sessions of MI (intervention) or printed literature (control) with telephone follow-up interviews at 6 and 12 months. Cost-effectiveness analyses compared intervention costs associated with 30-day abstinence from unhealthy alcohol use (i.e., any days of ≥4/≥5 drinks for women/men) and cannabis use. Multivariable analyses examined associations between MI and healthcare utilization at 12 months (emergency department, primary care, psychiatry, and addiction treatment).

RESULTS

MI resulted in greater likelihood of abstaining from unhealthy alcohol use (70.0% vs. 60.2%, p < .01) and cannabis use (74.6% vs. 63.9%, p < .01) than the control at 6 months, but outcomes did not differ at 12 months. The 6-month incremental cost-effectiveness ratios were $1,207-$1,523 per abstinent patient for unhealthy drinking and $1,040-$1,313 per abstinent patient for cannabis. There were no differences between groups on health service utilization.

CONCLUSIONS

MI cost more than the control condition but yielded better outcomes at 6 months; MI had no relationship to health service utilization. Findings can inform implementation of substance use interventions through understanding MI's potential clinical and cost impact and its relationship to health services use.

Interventions for Co-occurring Cannabis Use and Depression

This review aimed to investigate the effective intervention options for depression in patients with a history of cannabis use. The study eligibility criteria were as follows: English-language, peer-reviewed human studies; data not previously reported elsewhere; randomized controlled trials, non-randomized trials comparing an intervention group and a control group, and single-group trials.

In total, eight studies of interventions for patients with depression who reported cannabis use were identified. Four studies evaluated the effectiveness of the following three pharmacological interventions: extended quetiapine release, extended venlafaxine release, and fluoxetine. However, all studies failed to demonstrate the effectiveness of these drugs. Four studies evaluated the following psychological interventions: motivational interviewing (MI) and cognitive behavior therapy (CBT). These studies found that CBT may improve depression symptoms and cannabis dependence, and MI was associated with improvements in cannabis dependence.

CBT and MI may be effective in improving depression and reducing cannabis use. However, the conclusions of this review are limited because of the small number of studies and their low quality. Higher-quality research is required to evaluate the effectiveness of CBT, MI, and other interventions for comorbid cannabis use and depression.

Prediction of Dropout in a Randomized Controlled Trial of Adjunctive Light Treatment in Patients with Non-Seasonal Depression and Evening Chronotype

The current study examined the possible predictors of dropout during a five-week light treatment (LT) with a gradual advance protocol in 93 patients with unipolar non-seasonal depression and evening chronotypes by comparing their clinical characteristics and performing a logistic regression analysis. Nineteen out of ninety-three (20%) subjects (80% female, 46.5 ± 11.7 years old) dropped out during the 5-week light treatment. Treatment non-adherence (i.e., receiving LT for less than 80% of the prescribed duration) over the first treatment week predicted a five-fold increase in risk of dropout during light therapy (OR: 5.85, CI: 1.41–24.21) after controlling for potential confounders, including age, gender, treatment group, rise time at the baseline, patient expectation, and treatment-emergent adverse events. There is a need to incorporate strategies to enhance treatment adherence and retention in both research and clinical settings. Chinese clinical trial registry (ChiCTR-IOR-15006937).

The Effect of Krocina™ on Decreasing Substance User Withdrawal Syndrome, Craving, Depression and Stress: A Double-Blind Randomized Parallel Clinical Trial

INTRODUCTION

Due to the association between substance use abstinence with some psychological syndromes, the use of herbal medicines such as Crocus sativus L. have been considered as a proper approach to controlling withdrawal syndrome. The present study aimed to identify the effect of Krocina™ in reducing withdrawal symptoms, craving, depression, stress, anxiety and durability of treatment in the detoxification period and abstinence phase.

METHODS

In a double-blind randomized parallel clinical trial, 72 opioid users passing the detoxification period who were referred to the Soroush Center during 2020, randomly categorized into the two groups. Motivational interviewing sessions and 15 mg of Krocina™ twice a day were provided for six weeks for the cases. The placebo group received pills with the same coating and motivational interviewing. Withdrawal symptoms, craving, depression, stress and anxiety were assessed at the start of the study and then weekly using the Clinical Opiate Withdrawal Scale, Obsessive-Compulsive Drug Use Scale, and the Depression Anxiety Stress Scales-21, respectively. SPSS-v16 was used for statistical analyses.

RESULTS

Drug withdrawal symptoms and craving did not indicate a significant difference by Krocina™ intervention during the time (p > 0.05). Furthermore, depression, stress and anxiety were statistically similar between Krocina™ and placebo groups (p > 0.05). Moreover, we found similar findings between the two groups when analyzing only patients with negative urinary test (F = 0.03;p = 0.86).

CONCLUSION

Our finding rejected the effectiveness of 30 mg/day of Krocina™ for six weeks as an effective substance for decreasing withdrawal symptoms, craving, depression, anxiety and stress at the detoxification period and abstinence phase.

A lay-counsellor delivered brief psychological treatment for men with comorbid Alcohol Use Disorder and depression in primary care: Secondary analysis of data from a randomized controlled trial

BACKGROUND

We investigated the feasibility, acceptability, safety, and preliminary effectiveness of the Counselling for Alcohol Problems (CAP) psychological intervention delivered by non-specialist health workers (NSHW) to participants with alcohol use disorder (AUD) and comorbid depression in primary care.

METHODS

We used data from a single blind randomised controlled trial conducted in ten primary health care centres in Goa, India. Adult male harmful or dependent drinkers with or without depression were randomized (1:1) to receive either CAP & enhanced usual care (EUC) or EUC only. Process indicators such as the number of completed counselling sessions were assessed and compared between comorbid and non-comorbid participants. Remission from AUD and depression along with abstinence were measured at 3 and 12 months post randomisation. Analyses were on an intention-to-treat basis, employing multivariable regression analyses.

RESULTS

271 participants had symptoms of comorbid depression; 241 did not. Both groups completed a similar number of counselling sessions (adjusted Mean Difference 0.05, 95 %CI -0.24-0.34;p = 0.72). Among comorbid participants, CAP did not lead to more frequent adverse events compared to EUC only (adjusted Odds Ratio [aOR] 0.84, 0.43-1.64;p = 0.62), and there was no evidence for an effect of CAP on remission from AUD or depression at 3 months (aOR 1.51, 0.84-2.74;p = 0.17 and aOR 0.74, 0.43-1.27;p = 0.28) and 12 months follow-up, respectively (aOR 1.69, 0.96-3.01;p = 0.08 and aOR 1.08, 0.62-1.87;p = 0.79).

CONCLUSIONS

Brief therapies like CAP can be safely delivered by NSHWs to patients with comorbid AUD and depression, but their effectiveness may be limited and requires further investigation.

Genesis of change: Substance use treatment for forensic patients with mental health concerns

Substance use disorders are highly prevalent among forensic patients. They are associated with many challenges for patients with these problems, including their ability to rehabilitate and successfully move through secure forensic mental health services, as well as increasing risk for recidivism. Traditionally, forensic services have been more adept at focusing on and treating the primary mental health diagnosis alone and have been less likely to prioritise this co-occurring patient need. Opportunities exist to foster effective treatment strategies for substance use disorders, and past research has produced positive outcomes among forensic patients in studies in both Australia and the UK to navigate a new course for patients with these problems. By providing empirically validated, co-produced and culturally competent treatment responses, forensic patients living with substance use disorders will have the opportunity to significantly improve their wellbeing and progress through the system. They will also be more prepared and equipped to face challenges upon discharge into the community, including increased availability of alcohol and other drugs, social stigma and barriers to employment. Moreover, by prioritising effective substance use treatment programs during inpatient rehabilitation, services can reduce the levels of post-discharge recidivism.

Structural racism and reflections from Latinx heavy drinkers: Impact on mental health and alcohol use

BACKGROUND

Discrimination and social inequity increase risk for alcohol use disorders among Latinxs. An alcohol intervention trial that led to significant reductions in alcohol-related consequences also produced significant reductions in mental health symptoms for Latinx heavy drinkers. In the current qualitative study, we explore this trial's mental health effect by examining participants' perspectives on the social context of immigration, i.e., structural barriers, and associations among the immigrant experience, stigma, depressive/anxiety symptomatology, and alcohol consumption.

METHODS

Study participants were eligible if they completed the clinical trial, exhibited levels of depressive and anxiety symptoms that exceeded the range for clinical depression (≥18, CES-D) and anxiety (≥12, BAI) at baseline, and demonstrated significant declines in depression and anxiety symptoms 12 months following their completion of the trial. The study coded 24 participant transcripts using ATLAS.ti and thematic analysis.

RESULTS

Participants reported their responses to structural barriers (e.g., a lack of educational supports, difficulties accessing safety net programs). Reported experiences of exclusion and discrimination were associated with depressive and anxiety symptoms. Stigmatization processes included feeling isolated and contributed to poor mental health. Participants reported drinking to cope with low mood.

CONCLUSIONS

Structural barriers are exclusionary because they limit full participation and communicate who does/does not belong along race/ethnic lines, i.e., structural racism. Feeling stigmatized for being different was associated with feelings of anxiety and depression among our immigrant participants. Future interventions must focus on stressors associated with the constraints of being an immigrant. Understanding how structural barriers and structural racism impact health behavior can enrich the design and impact of interventions for socially disadvantaged Latinx individuals.

More behavioral recommendations produce more change: A meta-analysis of efficacy of multibehavior recommendations to reduce nonmedical substance use

Death and morbidity associated with substance use have risen continuously over the last few decades, increasing the need for rigorous examination of promising programs. Interventions attempting to change multiple behaviors have been designed to address interconnected problems such as use of both alcohol and drugs. This meta-analysis aimed to examine the efficacy of multibehavior interventions to curb nonmedical substance use in relation to the theoretical relation among different substance use behaviors. Specifically, our synthesis aimed to estimate the optimal number of recommendations for intervention efficacy and evaluate the impact of different combinations of recommendations on intervention efficacy. A synthesis of multibehavior interventions addressing nonmedical substance use was conducted to measure behavioral changes between the pretest and the follow-up. These changes were then compared across different numbers of recommendations. Sixty-nine reports and 233 effect sizes (k of conditions = 155, n = 28,295) were included. A positive linear relation was found between the number of targeted behaviors and intervention efficacy, which was stronger for drug use than alcohol use. Furthermore, recommendations on drug use worked better when paired with recommendations targeting other behaviors, whereas recommendations on alcohol use worked more independently. Lastly, multibehavior interventions were especially efficacious when delivered by experts. Overall, our synthesis indicated that targeting multiple substances is beneficial for changing drug use outcomes, but less so for alcohol use outcomes. Therefore, in the current substance use epidemic, innovative multibehavior programs appear to hold promise, especially to combat nonmedical drug use. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Addressing social stressors in a brief motivational interview improve mental health symptoms for Latinx heavy drinkers

OBJECTIVE

Depressive and anxiety symptoms co-occur with hazardous drinking among Latinxs. This secondary analysis of a clinical trial to reduce hazardous drinking (motivational interviewing adapted to address social stressors [CAMI] vs. motivational interviewing [MI]) examined effects on anxiety/depressive symptoms. Discrimination and acculturation were examined as moderators.

METHODS

Latinx (n = 296) hazardous drinkers (2+ occasions/month of heavy drinking; 4/5 drinks/occasion, females/males) were randomized to CAMI/MI. Generalized estimating equations analyzed how treatment conditions and interactions were related to depressive and anxiety symptoms after controlling for covariates.

RESULTS

Baseline symptoms (anxiety, depression) exceeded clinical thresholds (Anxiety ≥8, M = 14.62, SD = 13.52; Depression ≥ 12, M = 18.78, SD = 12.57). Cultural adaptation of motivational interviewing (CAMI) showed significantly lower anxiety and depressive symptoms (6/12 months, respectively) than MI. CAMI with high baseline discrimination reported significantly less depression than MI (12 months).

CONCLUSIONS

Explicitly addressing social stressors may be a beneficial adjunct to treatment for Latinx drinkers.

Motivational Coaching Improves Intrinsic Motivation in Adult Fitness Program Participants

The purpose of this study was to measure intrinsic motivation following the implementation of motivational coaching strategies in a semester long personalized adult fitness program. Sixty individuals (40 female/ 20 male, age= 48 ± 15 yrs) participated as clients in an undergraduate exercise training program led by student trainers at Taylor University. The program took place during two consecutive semesters, therefore subject participation ranged from one to two semesters. In addition to personalized exercise prescription, student trainers implemented motivational strategies using a motivational coaching guide aimed at increasing individuals' overall intrinsic motivation. Trainers utilized a coaching checklist to record the motivational strategies used with their client each session. Intrinsic motivation was assessed before and after each program semester using an Intrinsic Motivation Inventory (IMI) and Motivational Client Scale (MCS). Clients' scores on the IMI increased from 3.38 ± 0.37 to 3.58 ± 0.31 (p<0.001; d= 0.587). Particularly, perceived competence increased from 3.01 ± 0.52 to 3.41 ± 0.49 (p<0.001; d= 0.793). Correspondingly, MCS scores also increased from 3.47 ± 0.72 to 3.87 ± 0.60 (p<0.001; d= 0.608). Specifically, clients' response to challenge increased from 3.48 ± 0.98 to 4.15 ± 0.65 (p<0.001; d=0.809). Our data indicate that it is possible to improve intrinsic motivation by implementing motivational strategies into a supervised adult fitness program. This finding suggests motivational coaching may be an important part of a standard training protocol for fitness trainers to help combat a public health concern: initiation and adherence to exercise.

A randomized clinical trial of mobile phone motivational interviewing for alcohol use problems in Kenya

AIM

To test the effectiveness of a motivational interviewing (MI) intervention using the mobile phone among adults with alcohol use problems.

DESIGN

A randomized clinical trial of mobile MI and standard in-person MI with 1- and 6-month follow-up, including a 1-month waitlist control followed by mobile MI.

SETTING

A primary health center in rural Kenya.

PARTICIPANTS

Three hundred adults screening positive for alcohol use problems were randomized and received immediate mobile MI (n = 89), in-person MI (n = 65) or delayed mobile MI (n = 76) for waiting-list controls 1 month after no treatment, with 70 unable to be reached for intervention.

INTERVENTION AND COMPARATOR

One MI session was provided either immediately by mobile phone, in-person at the health center or delayed by 1 month and then provided by mobile phone.

MEASUREMENTS

Alcohol use problems were repeatedly assessed using the Alcohol Use Disorder Identification Test (AUDIT) and the shorter AUDIT-C. The primary outcome was difference in alcohol score 1 month after no intervention for waiting-list control versus 1 month after MI for mobile MI. The secondary outcomes were difference in alcohol score for in-person MI versus mobile MI one and 6 months after MI.

FINDINGS

For our primary outcome, average AUDIT-C scores were nearly three points higher (difference = 2.88, 95% confidence interval = 2.11, 3.66) for waiting-list controls after 1 month of no intervention versus mobile MI 1 month after intervention. Results for secondary outcomes supported the null hypothesis of no difference between in-person and mobile MI at 1 month (Bayes factor = 0.22), but were inconclusive at 6 months (Bayes factor = 0.41).

CONCLUSION

Mobile phone-based motivational interviewing may be an effective treatment for alcohol use problems among adults visiting primary care in Kenya. Providing mobile motivational interviewing may help clinicians in rural areas to reach patients needing treatment for alcohol use problems.

Virtual Nature as an Intervention for Reducing Stress and Improving Mood in People with Substance Use Disorder

Substance use disorder (SUD) afflicts a large percentage of the United States population, with negative implications that cost more than $420 billion annually. This population often experiences negative emotions throughout the recovery process, including anxiety, depression, stress, and negative affect. Currently, evidence-based treatment strategies for SUD include cognitive behavioral therapy, motivational interviewing, 12-step programs, and mindfulness-based treatment. One intervention that has not been studied at length among individuals with SUD is use of the natural environment as treatment. Among other patient populations, nature has been shown to reduce stress and anxiety by regulating autonomic nervous system function, reducing symptoms of depression, and improving mood. The purpose of this study was to investigate whether viewing nature videos could similarly reduce stress and improve mood in individuals with SUD. A crossover design was used to compare viewing a nature scene and practicing mindfulness-based activities for women with SUD at a residential treatment facility. Over four weeks, participants engaged in the two activities for the first 10 minutes of their daily program. Immediately before and after each 10 minute session, measures were taken for heart rate, in beats per minute (BPM); affect, using the Positive and Negative Affect Scale (PANAS); and overall mood, using a 10-point rating scale from "very unpleasant" to "pleasant." Thirty-six women completed the study. For viewing a nature scene and practicing the mindfulness-based activities, there were statistically significant reductions in mean negative affect scores (p=0.001) and heart rate (p ≤ 0.001). In addition, for participants in both conditions, overall mood improved significantly (p=0.030). The results from this study provide initial evidence that viewing nature has similar benefits to MBT in the treatment of stress and negative mood associated with the SUD recovery process and may be an additional, cost-effective treatment strategy for individuals with SUD.

Evaluating the combination of a Brief Motivational Intervention plus Cognitive Behavioral Therapy for Depression and heavy episodic drinking in college students

[Correction Notice: An Erratum for this article was reported in Vol 34(2) of Psychology of Addictive Behaviors (see record 2020-16883-001). In the original article the order of authorship was incorrect. The correct second and third authors should appear instead as Brian Borsari and Jennifer E. Merrill.] Heavy episodic drinking (HED) and depressive symptoms often co-occur among college students and are associated with significant impairment. However, evidence-based treatments for these common co-occurring conditions are not available for college students. The current study compared the effectiveness of a treatment combining Cognitive-Behavioral Therapy for Depression and Brief Motivational Interviewing (CBT-D + BMI) versus Cognitive-Behavioral Therapy for Depression (CBT-D) alone among 94 college students with HED and depressive symptoms. Both treatment programs were associated with significant reductions of similar magnitude in HED, alcohol-related problems (ARP), and depressive symptoms at the end of treatment and at the 1-month follow-up assessment. Moderation analyses indicated that, among college students with fewer depressive symptoms at baseline, CBT-D was associated with greater sustained reduction in heavy drinking relative to CBT-D + BMI at the 1-month follow-up. Although the study did not include a no-treatment condition, the magnitude of improvement during treatment in both groups was greater than what is expected with passage of time. Although clinicians in college counseling centers may lack specialty training for co-occurring conditions, CBT-D is widely implemented in college settings. Our findings suggest that CBT-D may reduce both depressive symptoms and HED in college students and may be used to address a significant public health problem. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Telehealth interventions to reduce alcohol use in men with HIV who have sex with men: Protocol for a factorial randomized controlled trial

BACKGROUND

Heavy alcohol use is prevalent among men who have sex with men (MSM) living with HIV and is associated with reduced antiretroviral therapy adherence, reduced HIV viral suppression, and reduced survival. We recently found that compared to HIV treatment as usual, three sessions of in-person motivational interviewing (MI) substantially reduced drinking in MSM with HIV. In an effort to enhance the effectiveness and efficiency of this intervention, the present study will test whether MI is more effective than brief intervention when delivered by videoconferencing, whether interactive text messaging (ITM) can enhance the effects of alcohol intervention, and whether extended duration of intervention is more effective than brief duration.

METHODS

Using a 2 × 2 × 2 factorial design, we will randomly assign 224 heavy-drinking MSM with HIV to: MI or brief intervention (BI); ITM or no ITM; Standard or Extended intervention (EI). All participants will receive intervention immediately after baseline assessment via videoconferencing and at 1-month post baseline via telephone. Participants randomized to EI will receive additional intervention sessions at 3, 6, and 9 months. Participants randomized to ITM will receive daily interactive texts about alcohol use for 1 month, with those randomized to EI receiving weekly interactive texts through 9 months. Alcohol and HIV-related outcomes will be assessed at 6 and 12 months post baseline.

CONCLUSION

By testing the combinations of interventions that can most effectively reduce alcohol use among MSM with HIV, this study will set the stage for wider-scale implementation of an optimized intervention combination.

Psychological interventions for co-occurring depression and substance use disorders

BACKGROUND

Comorbid depression and substance use disorders are common and have poorer outcomes than either disorder alone. While effective psychological treatments for depression or substance use disorders are available, relatively few randomised controlled trials (RCTs) have examined the efficacy of these treatments in people with these comorbid disorders.

OBJECTIVES

To assess the efficacy of psychological interventions delivered alone or in combination with pharmacotherapy for people diagnosed with comorbid depression and substance use disorders.

SEARCH METHODS

We searched the following databases up to February 2019: Cochrane Central Register of Controlled Trials, PubMed, Embase, CINAHL, Google Scholar and clinical trials registers. All systematic reviews identified, were handsearched for relevant articles.

SELECTION CRITERIA

The review includes data from RCTs of psychological treatments for people diagnosed with comorbid depression and substance use disorders, using structured clinical interviews. Studies were included if some of the sample were experiencing another mental health disorder (e.g. anxiety); however, studies which required a third disorder as part of their inclusion criteria were not included. Studies were included if psychological interventions (with or without pharmacotherapy) were compared with no treatment, delayed treatment, treatment as usual or other psychological treatments.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Seven RCTs of psychological treatments with a total of 608 participants met inclusion criteria. All studies were published in the USA and predominately consisted of Caucasian samples. All studies compared different types of psychological treatments. Two studies compared Integrated Cognitive Behavioural Therapy (ICBT) with Twelve Step Facilitation (TSF), another two studies compared Interpersonal Psychotherapy for Depression (IPT-D) with other treatment (Brief Supportive Therapy (BST) or Psychoeducation). The other three studies compared different types or combinations of psychological treatments. No studies compared psychological interventions with no treatment or treatment as usual control conditions. The studies included a diverse range of participants (e.g. veterans, prisoners, community adults and adolescents). All studies were at high risk of performance bias, other main sources were selection, outcome detection and attrition bias. Due to heterogeneity between studies only two meta-analyses were conducted. The first meta-analysis focused on two studies (296 participants) comparing ICBT to TSF. Very low-quality evidence revealed that while the TSF group had lower depression scores than the ICBT group at post-treatment (mean difference (MD) 4.05, 95% confidence interval (CI) 1.43 to 6.66; 212 participants), there was no difference between groups in depression symptoms (MD 1.53, 95% CI -1.73 to 4.79; 181 participants) at six- to 12-month follow-up. At post-treatment there was no difference between groups in proportion of days abstinent (MD -2.84, 95% CI -8.04 to 2.35; 220 participants), however, the ICBT group had a greater proportion of days abstinent than the TSF group at the six- to 12-month follow-up (MD 10.76, 95% CI 3.10 to 18.42; 189 participants). There were no differences between the groups in treatment attendance (MD -1.27, 95% CI -6.10 to 3.56; 270 participants) or treatment retention (RR 0.95, 95% CI 0.72 to 1.25; 296 participants). The second meta-analysis was conducted with two studies (64 participants) comparing IPT-D with other treatment (Brief Supportive Psychotherapy/Psychoeducation). Very low-quality evidence indicated IPT-D resulted in significantly lower depressive symptoms at post-treatment (MD -0.54, 95% CI -1.04 to -0.04; 64 participants), but this effect was not maintained at three-month follow-up (MD 3.80, 95% CI -3.83 to 11.43) in the one study reporting follow-up outcomes (38 participants; IPT-D versus Psychoeducation). Substance use was examined separately in each study, due to heterogeneity in outcomes. Both studies found very low-quality evidence of no significant differences in substance use outcomes at post-treatment (percentage of days abstinent, IPD versus Brief Supportive Psychotherapy; MD -2.70, 95% CI -28.74 to 23.34; 26 participants) or at three-month follow-up (relative risk of relapse, IPT-D versus Psychoeducation; RR 0.67, 95% CI 0.30 to 1.50; 38 participants). There was also very low-quality evidence for no significant differences between groups in treatment retention (RR 1.00, 95% CI 0.81 to 1.23; 64 participants). No adverse events were reported in any study.

AUTHORS' CONCLUSIONS

The conclusions of this review are limited due to the low number and very poor quality of included studies. No conclusions can be made about the efficacy of psychological interventions (delivered alone or in combination with pharmacotherapy) for the treatment of comorbid depression and substance use disorders, as they are yet to be compared with no treatment or treatment as usual in this population. In terms of differences between psychotherapies, although some significant effects were found, the effects were too inconsistent and small, and the evidence of too poor quality, to be of relevance to practice.

Interventions to Reduce Unhealthy Alcohol Use among Primary Care Patients with HIV: the Health and Motivation Randomized Clinical Trial

BACKGROUND

Unhealthy alcohol use has adverse effects on HIV treatment. Screening, brief intervention, and referral to treatment (SBIRT) has some evidence of efficacy but may not be sufficient for those with low motivation or comorbid substance use.

OBJECTIVE

To examine the effectiveness of motivational interviewing (MI) and emailed feedback (EF) among primary care HIV-positive patients, compared with treatment as usual care (UC) only, which included SBIRT.

DESIGN

Randomized clinical trial.

PARTICIPANTS

Six hundred fourteen adult HIV-positive patients in Kaiser Permanente Northern California who reported prior-year unhealthy alcohol use.

INTERVENTION

Participants were randomized to either three sessions of MI (one in person and two by phone), information regarding alcohol risks via EF through a patient portal, or UC alone. MI and EF participants who reported unhealthy alcohol use at 6 months were offered additional MI and EF treatment, respectively.

MAIN MEASURES

Participant-reported unhealthy alcohol use (defined as ≥ 4/≥ 5 drinks per day for women/men), alcohol problems at 12 months, based on blinded telephone interviews. Secondary outcomes included drug use and antiretroviral (ART) adherence.

KEY RESULTS

At 12 months, there were no overall group differences, but in all three arms, there were declines in unhealthy alcohol use and alcohol-related problems (p < 0.001). Participants reporting low motivation to reduce drinking at baseline were less likely to report unhealthy alcohol use if they received MI vs. EF and UC (p = 0.013). At 6 months, reported illegal drug use/misuse of prescription drugs other than marijuana was lower in the MI arm than EF or UC (p = 0.012). There were no differences in ART adherence between groups.

CONCLUSIONS

In a randomized trial of HIV-positive patients using two behavioral interventions compared with SBIRT alone, participants in all three conditions reduced unhealthy alcohol use. MI may provide added benefit for patients with low motivation or who report illegal drug use/misuse of prescription drugs.

TRIAL REGISTRATION

NCT01671501 ( ClinicalTrials.gov ).

Implementing electronic substance use disorder and depression and anxiety screening and behavioral interventions in primary care clinics serving people with HIV: Protocol for the Promoting Access to Care Engagement (PACE) trial

BACKGROUND

Substance use disorders (SUDs) and psychiatric disorders are common among people with HIV (PWH) and lead to poor outcomes. Yet these conditions often go unrecognized and untreated in primary care.

METHODS

The Promoting Access to Care Engagement (PACE) trial currently in process examines the impact of self-administered electronic screening for SUD risk, depression and anxiety in three large Kaiser Permanente Northern California primary care clinics serving over 5000 PWH. Screening uses validated measures (Tobacco, Alcohol, Prescription medication, and other Substance use [TAPS]; and the Adult Outcomes Questionnaire [AOQ], which includes the Patient Health Questionnaire [PHQ-9] and Generalized Anxiety Disorder [GAD-2]) delivered via three modalities (secure messaging, tablets in waiting rooms, and desktop computers in exam rooms). Results are integrated automatically into the electronic health record. Based on screening results and physician referrals, behavioral health specialists embedded in primary care initiate motivational interviewing- and cognitive behavioral therapy-based brief treatment and link patients to addiction and psychiatry clinics as needed. Analyses examine implementation (screening and treatment rates) and effectiveness (SUD, depression and anxiety symptoms; HIV viral control) outcomes using a stepped-wedge design, with a 12-month intervention phase implemented sequentially in the clinics, and a 24-month usual care period prior to implementation in each clinic functioning as sequential observational phases for comparison. We also evaluate screening and treatment costs and implementation barriers and facilitators.

DISCUSSION

The study examines innovative, technology-facilitated strategies for improving assessment and treatment in primary care. Results may help to inform substance use, mental health, and HIV services.

TRIAL REGISTRATION

NCT03217058.

A qualitative evaluation of an ACT-based substance misuse treatment programme for service users within a secure mental health setting

Purpose

The purpose of this paper is to understand service users’ experience of a new acceptance and commitment therapy (ACT)-based substance misuse programme. The programme is designed for people in secure mental health services, presenting with complex mental health difficulties and co-occurring substance misuse problems.

Design/methodology/approach

A qualitative approach informed an exploratory pilot of this novel intervention. Service users completing a 16-week ACT programme were invited to participate in the current study. Out of the nine individuals enroled on the programme, six opted to take part in the exploratory pilot and completed semi-structured interviews following part 1 of the programme (eight weeks). Four of these participants proceeded into part 2 of the programme (eight weeks) and completed a further semi-structured interview.

Findings

The thematic analysis identified five main themes: “Increased awareness of personal values and the impact of substance use on values”, “Taking committed action towards values”, “Coping skills and the application of skills to manage difficult thoughts and feelings”, “Personal development” and “Use of metaphors/analogies”.

Research limitations/implications

A quantitative evaluation of clinical outcomes is recommended to gauge further programme effectiveness.

Practical implications

The findings provide preliminary support for the use of an ACT-based substance misuse programme in a secure mental health setting.

Originality/value

This study evaluates the use of a novel ACT-based substance misuse intervention with people in secure mental health care with co-occurring mental health and substance misuse difficulties. This paper provides an in-depth understanding of service users’ experience of participating in this new treatment programme.

Identification and management of alcohol use and illicit substance use in outpatient psychiatric clinics in Sweden: a national survey of clinic directors and staff

Background

Swedish national guidelines recommend that all health care settings systematically screen patients for alcohol use and illicit substance use. When hazardous use is identified, it should immediately be addressed, preferably through brief interventions (BI). It is well known that the prevalence of alcohol use and illicit substance use among psychiatric patients is high, but it is not known to what extent screening and BI are routinely carried out in such clinics.

Methods

Two online surveys investigating the use of screening and BI for alcohol and illicit substances were constructed; one for psychiatric outpatient clinic directors and one for staff at these clinics. The main analyses were calculated as simple frequencies. In secondary analyses, we investigated the associations between substance abuse training, type of clinic and screening/BI delivery. For these analyses, the Chi square test was used.

Results

Most clinic directors reported that they have guidelines to screen for alcohol (93.1%) and illicit substance use (78.9%) at initial assessment. Fifty percent reported having guidelines for delivering BI when identifying hazardous alcohol use (35.9% for hazardous illicit substance use). Among staff, 66.6% reported always screening for alcohol use and 57.8% reported always screening for illicit substance use at initial assessment. Further, 36.7% reported that they usually deliver BI when identifying hazardous alcohol use (35.7% for hazardous illicit substance use). Secondary analyses indicated that staff with substance abuse training were significantly more likely to screen for alcohol use than staff without such training. Further, staff at psychosis clinics were significantly less likely to screen for both alcohol and substance use than staff at both general and specialist psychiatric clinics.

Conclusions

Most clinic directors reported having clear guidelines for staff to screen for alcohol use and illicit substance use, but fewer staff members than expected indicated that these guidelines were adhered to. Providing training about substance use disorders for staff may increase use of screening for alcohol use, and psychosis clinics may need to improve their screening routines.

Electronic supplementary material

The online version of this article (10.1186/s13722-019-0140-x) contains supplementary material, which is available to authorized users.

Psychiatric comorbidity and Healthcare Effectiveness Data and Information Set (HEDIS) measures of alcohol and other drug treatment initiation and engagement across 7 health care systems

Background: Psychiatric comorbidity is common among patients with alcohol and other drug (AOD) use disorders. To better understand how psychiatric comorbidity influences AOD treatment access in health care systems, the present study examined treatment initiation and engagement among a large, diverse sample of patients with comorbid psychiatric and AOD use disorders. Methods: This study utilized data from a multisite observational study examining Healthcare Effectiveness Data and Information Set (HEDIS) measures of initiation and engagement in treatment (IET) among patients with AOD use disorders from 7 health care systems. Participants were aged 18 or older with at least 1 AOD index diagnosis between October 1, 2014, and August 15, 2015. Data elements extracted from electronic health records and insurance claims data included patient demographic characteristics, ICD-9 (International Classification of Diseases, Ninth Revision) diagnostic codes, and procedure codes. Descriptive analyses and multivariate logistic regression models were used to examine the relationship between patient-level factors and IET measures. Results: Across health care systems, out of a total of 86,565 patients who had at least 1 AOD index diagnosis during the study period, 66.2% (n = 57,335) patients also had a comorbid psychiatric disorder. Among patients with a comorbid psychiatric disorder, 34.9% (n = 19,998) initiated AOD treatment, and of those, 10.3% (n = 2,060) engaged in treatment. After adjusting for age, sex, and race/ethnicity, patients with comorbid psychiatric disorders were more likely to initiate (odds ratio [OR] = 3.20, 95% confidence interval [CI] = 3.08, 3.32) but no more likely to engage (OR = 0.56, 95% CI = 0.51, 0.61) in AOD treatment, compared with those without a comorbid psychiatric disorder. Conclusions: Findings suggest that identification of comorbid psychiatric disorders may increase initiation in AOD treatment. However, innovative efforts are needed to enhance treatment engagement both generally and especially for individuals without diagnosed psychiatric conditions.

The Korean Cohort for the Model Predicting a Suicide and Suicide-related Behavior: Study rationale, methodology, and baseline sample characteristics of a long-term, large-scale, multi-center, prospective, naturalistic, observational cohort study

BACKGROUND

The Korean Cohort for the Model Predicting a Suicide and Suicide-related Behavior (K-COMPASS) study is a prospective, naturalistic, observational cohort study, aiming to identify predictors of suicide attempt and suicide characteristics in the Korean suicidal population. The findings intend to contribute to a thorough understanding of suicidal phenomena and development of suicide prevention guidelines. The present cross-section study examines the study rationale, methodology, and baseline characteristics of the participants.

METHODS

Participants were enrolled via the hospital and community gateways, establishing the hospital-based cohort (HC) and community-based cohort (CC), respectively. Baseline assessment was conducted on sociodemographic, clinical, diagnostic, and psychopathological aspects. The Columbia-Suicide Severity Rating Scale was used to investigate suicidality.

RESULTS

A total of 800 suicidal people aged 15 years or older were enrolled from 8 university hospitals and 8 community mental health welfare centers (CMHWCs), among whom 480 (60%) were suicidal ideators and 320 (40%) were attempters. The ideators comprised 207 CC and 273 HC participants, whereas the attempters, 34 CC and 286 HC participants. Despite their lower severity in some measures, including suicidal ideation, compared with their HC counterparts, the CC participants within each group of ideators or attempters presented clinically significant psychopathology. Moreover, alcohol use problems and past suicide attempt were more likely to be found in CC participants. Only 11.1% to 21.6% of the participants in each of the four groups (defined by the cohorts and the ideators/attempters) were on any type of psychiatric treatment.

CONCLUSIONS

Suicidal visitors to CMHWCs need to be as closely monitored as suicidal patients in university hospitals, especially considering their association with problem drinking and past suicide attempt. A cautious assumption is that the high suicide rate in Korea might be partly attributable to the low proportion of patients receiving psychiatric services.

Medical and non-medical marijuana use in depression: Longitudinal associations with suicidal ideation, everyday functioning, and psychiatry service utilization

BACKGROUND

Marijuana use is clinically problematic in depression, and non-medical and medical use may both contribute to barriers to care in this population. Among outpatients with depression, we examined the differential impact of medical or non-medical marijuana use, relative to no-use, on psychopathology and service use over time.

METHOD

Participants were 307 psychiatry outpatients participating in a trial of drug/alcohol use treatment for depression. Measures of past 30-day marijuana use, depression/anxiety symptoms, psychiatry visits, and functional data related to health status were collected at baseline, 3, 6, and 12 months. Regressions (baseline and 1 year) and growth models (over time) predicted clinical and psychiatry visit outcomes, from medical or non-medical marijuana use (no-use = reference).

RESULTS

At baseline, 40.0% of the sample used marijuana and more reported non-medical (71.7%) than medical (28.2%) use. Relative to non-users at baseline, patients using medically had worse mental/physical health functioning (p's < 0.05), and non-medical use was associated with higher suicidal ideation (B = 1.08, p = .002), worse mental health functioning (B = -3.79, p = .015), and fewer psychiatry visits (B = -0.69, p = .009). Patients using non-medically over time improved less in depression symptoms (B = 1.49, p = .026) and suicidal ideation (B = 1.08, p = .003) than non-users.

LIMITATIONS

Participants were psychiatry outpatients, limiting generalizability.

CONCLUSIONS

Marijuana use, especially non-medical use, among patients with depression may impede depression symptom improvement while lessening the likelihood of psychiatry visits. Marijuana use and associated barriers to care should receive consideration by depression treatment providers.

The suitability of motivational interviewing versus cognitive behavioural interventions on improving self-care in patients with heart failure: A literature review and discussion paper

BACKGROUND

Chronic heart failure remains a major public health concern due to its high prevalence and disease burden. Although self-care has been advocated as the sustainable solution, it remains inadequate. Recent studies have shown the potential of integrating structured counselling elements into traditional educational programs to enhance self-care but the optimal counselling method remains unclear.

AIM

To compare the applicability of cognitive behavioural interventions and motivational interviewing on improving self-care behaviours in patients with chronic heart failure.

METHOD

A systematic three-step search strategy was used to identify studies that incorporated cognitive behavioural interventions and/or motivational interviewing to improve heart failure self-care. Quantitative and qualitative trial studies that met the inclusion criteria were appraised using the Joanna Brigg's Institute criteria.

RESULTS

Motivational interviewing showed higher potential in improving HF self-care behaviours, but sustainability remains unclear. Cognitive behavioural interventions only showed effectiveness when applied to patients with comorbid depressive symptoms. Statistically significant results were only elucidated upon statistical adjustments and examination of behaviours individually. Potential effective components of CBI include setting up environmental reminders, addressing misconceptions and skills-training while that of MI was the communication style.

CONCLUSION

MI and CBI could be used synergistically by extracting their key effective components to strengthen the intention-behaviour link in improving HF self-care behaviours. MI could be used to enhance the intention to change by evoking ambivalence and change talk. CBI could be used to enhance problem-solving skills and set environmental reminders to strengthen the translation of intention to behaviour.

Factors associated with hazardous alcohol use and motivation to reduce drinking among HIV primary care patients: Baseline findings from the Health & Motivation study

BACKGROUND

Limited primary care-based research has examined hazardous drinking risk factors and motivation to reduce use in persons with HIV (PWH).

METHODS

We computed prevalence ratios (PR) for factors associated with recent (<30 days) hazardous alcohol use (i.e., 4+/5+ drinks in a single day for women/men), elevated Alcohol Use Disorders Identification Test (AUDIT) scores, and importance and confidence (1-10 Likert scales) to reduce drinking among PWH in primary care.

RESULTS

Of 614 participants, 48% reported recent hazardous drinking and 12% reported high alcohol use severity (i.e., AUDIT zone 3 or higher). Factors associated with greater alcohol severity included moderate/severe anxiety (PR: 2.07; 95% CI: 1.18, 3.63), tobacco use (PR: 1.79; 1.11, 2.88), and other substance use (PR: 1.72; 1.04, 2.83). Factors associated with lower alcohol severity included age 50-59 years (PR: 0.46; 0.22, 2.00) compared with age 20-39 years, and having some college/college degree (PR: 0.61; 0.38, 0.97) compared with ≤high school. Factors associated with greater importance to reduce drinking (scores >5) included: moderate/severe depression (PR: 1.43; 1.03, 2.00) and other substance use (PR: 1.49; 1.11, 2.01). Lower importance was associated with incomes above $50,000 (PR: 0.65; 0.46, 0.91) and marijuana use (PR: 0.65; 0.49, 0.87). HIV-specific factors (e.g., CD4 and HIV RNA levels) were not associated with alcohol outcomes.

CONCLUSIONS

This study identified modifiable participant characteristics associated with alcohol outcomes in PWH, including anxiety and depression severity, tobacco use, and other substance use.

A developmental-based motivational intervention to reduce alcohol and marijuana use among non-treatment-seeking young adults: a randomized controlled trial

AIMS

To test the hypothesis that among non-treatment-seeking emerging adults (EA) who both use marijuana and have alcohol binges, a brief, longitudinally delivered, developmentally based motivational intervention would show greater reductions in the use of these two substances compared with a health education control condition.

DESIGN

Parallel, two-group, randomized controlled trial with follow-up interventions conducted at 1, 3, 6 and 9 months and final assessments at 12 and 15 months.

SETTING

Hospital-based research unit in the United States.

PARTICIPANTS

Community-based 18-25-year-olds who reported at least monthly binge drinking and at least weekly marijuana use.

INTERVENTION

Motivational intervention (EA-MI) focused primarily on themes of emerging adulthood (identity exploration, instability, self-focus, feeling in-between, a sense of possibilities) and the subjects' relationship to substance use (n = 110) compared with an attention-matched health education control condition (n = 116).

MEASUREMENTS

The primary outcomes were days of binge alcohol, marijuana and dual use day as measured using the timeline follow-back method analysing the treatment by time interaction to determine relative differences in the rate of change between intervention arms.

FINDINGS

At baseline, the mean rate (days/30) of binge drinking was 5.23 (± 4.31) of marijuana use was 19.4 (± 10.0) and of dual (same day) use was 4.11 (± 4.13). Relative to baseline, there were reductions in the rate of binge alcohol use, marijuana use and days of combined binge alcohol and marijuana use (P < 0.001) at all follow-up assessments. However, the treatment × time interaction was not statistically significant for alcohol (P = 0.37), for marijuana (P = 0.07) or for dual use (P = 0.55). Averaged over all follow-ups, mean reductions in binge, marijuana and dual use days were 1.16, 1.45 and 1.08, respectively, in the health education arm, and 1.06, 1.69 and 0.96 in EA-MI. Bayes factors were < 0.01 for frequency of binge alcohol use and frequency of dual binge alcohol and marijuana and 0.016 for marijuana use.

CONCLUSIONS

A brief, longitudinally delivered, developmentally based motivational intervention for young adults did not produce reductions in binge alcohol, marijuana use or dual use days relative to a control condition.

Adverse impact of marijuana use on clinical outcomes among psychiatry patients with depression and alcohol use disorder

This study examined whether marijuana use was associated with clinically problematic outcomes for patients with depression and alcohol use disorder (AUD). The sample consisted of 307 psychiatry outpatients with mild to severe depression and past 30-day hazardous drinking/drug use, who participated in a trial of substance use treatment. Participants were assessed for AUD based on DSM-IV criteria. Measures of marijuana use, depression symptoms, and functional status related to mental health were collected at baseline, 3, and 6 months. Differences in these outcomes were analyzed among patients with and without AUD using growth models, adjusting for treatment effects. Marijuana was examined as both an outcome (patterns of use) and a predictor (impact on depression and functioning). Forty percent used marijuana and about half the sample met AUD criteria. Fewer patients with AUD used marijuana than those without AUD at baseline. Over 6 months, the proportion of patients with AUD using marijuana increased compared to those without AUD. Patients with AUD using marijuana had greater depressive symptoms and worse functioning than those without AUD. These findings indicate that marijuana use is clinically problematic for psychiatry outpatients with depression and AUD. Addressing marijuana in the context of psychiatry treatment may help improve outcomes.

Alcohol and Drug Use, Pain and Psychiatric Symptoms among Adults Seeking Outpatient Psychiatric Treatment: Latent Class Patterns and Relationship to Health Status

BACKGROUND

Substance use, psychiatric problems, and pain frequently co-occur, yet clinical profiles of treatment-seeking patients are poorly understood. To inform service and treatment planning, substance use and symptom patterns were examined in an outpatient psychiatry clinic, along with the relationship of these patterns to demographic characteristics and physical health.

METHODS

Patients (N = 405; age M = 38; 69% White; 60% female) presenting for intake in a psychiatry outpatient clinic completed a computerized assessment of psychiatric problems, drinking, and drug use. Substance use and psychiatric symptom patterns among the sample were identified using latent class analysis.

RESULTS

A 4-class model fit the data best: Class (1) Moderate symptoms/wide-range users (22.0%) had moderate depression and panic; tobacco, cocaine, hallucinogen, and ecstasy use; and high cannabis use. Class (2) Moderate depression/panic (37.8%) had moderate depression and panic. Class (3) Depression/anxiety, tobacco, and cannabis users (28.0%) had high depression, obsessions, and panic, and moderate pain severity, social phobia, compulsions, trauma, tobacco, and cannabis use. Class (4) Severe/wide range symptoms/users (12.0%) had high panic, depression, social phobia, obsessions, drug use, and moderate pain. Gender, ethnicity, and health status varied by class.

CONCLUSIONS

Findings highlight the preponderance of substance use (particularly cannabis) and its relationship to psychiatric symptom severity, pain, and health status among those presenting for mental health treatment.

Patterns of marijuana use among psychiatry patients with depression and its impact on recovery

BACKGROUND

Depression is associated with substance-related problems that worsen depression-related disability. Marijuana is frequently used by those with depression, yet whether its use contributes to significant barriers to recovery in this population has been understudied.

METHOD

Participants were 307 psychiatry outpatients with depression; assessed at baseline, 3-, and 6-months on symptom (PHQ-9 and GAD-7), functioning (SF-12) and past-month marijuana use for a substance use intervention trial. Longitudinal growth models examined patterns and predictors of marijuana use and its impact on symptom and functional outcomes.

RESULTS

A considerable number of (40.7%; n=125) patients used marijuana within 30-days of baseline. Over 6-months, marijuana use decreased (B=-1.20, p<.001), but patterns varied by demographic and clinical characteristics. Depression (B=0.03, p<.001) symptoms contributed to increased marijuana use over the follow-up, and those aged 50+(B=0.44, p<.001) increased their marijuana use compared to the youngest age group. Marijuana use worsened depression (B=1.24, p<.001) and anxiety (B=0.80, p=.025) symptoms; marijuana use led to poorer mental health (B=-2.03, p=.010) functioning. Medical marijuana (26.8%; n=33) was associated with poorer physical health (B=-3.35, p=.044) functioning.

LIMITATIONS

Participants were psychiatry outpatients, limiting generalizability.

CONCLUSIONS

Marijuana use is common and associated with poor recovery among psychiatry outpatients with depression. Assessing for marijuana use and considering its use in light of its impact on depression recovery may help improve outcomes.

The role of hazardous drinking reductions in predicting depression and anxiety symptom improvement among psychiatry patients: A longitudinal study

BACKGROUND

Co-occurrence of depression, anxiety, and hazardous drinking is high in clinical samples. Hazardous drinking can worsen depression and anxiety symptoms (and vice versa), yet less is known about whether reductions in hazardous drinking improve symptom outcomes.

METHODS

Three hundred and seven psychiatry outpatients were interviewed (baseline, 3-, 6-months) for hazardous drinking (drinking over recommended daily limits), depression (PHQ-9), and anxiety (GAD-7) as part of a hazardous drinking intervention trial. Longitudinal growth models tested associations between hazardous drinking and symptoms (and reciprocal effects between symptoms and hazardous drinking), adjusting for treatment effects.

RESULTS

At baseline, participants had moderate anxiety (M=10.81; SD=10.82) and depressive symptoms (M=13.91; SD=5.58); 60.0% consumed alcohol at hazardous drinking levels. Over 6-months, participants' anxiety (B=-3.03, p<.001) and depressive symptoms (B=-5.39, p<.001) improved. Continued hazardous drinking led to slower anxiety (B=0.09, p=.005) and depressive symptom (B=0.10, p=.004) improvement; reductions in hazardous drinking led to faster anxiety (B=-0.09, p=.010) and depressive (B=-0.10, p=.015) symptom improvement. Neither anxiety (B=0.07, p=.066) nor depressive (B=0.05, p=.071) symptoms were associated with hazardous drinking outcomes.

LIMITATIONS

Participants were psychiatry outpatients, limiting generalizability.

CONCLUSIONS

Reducing hazardous drinking can improve depression and anxiety symptoms but continued hazardous use slows recovery for psychiatry patients. Hazardous drinking-focused interventions may be helpful in promoting symptom improvement in clinical populations.