Cognitive-behavioral therapies for depression and substance use disorders: An overview of traditional, third-wave, and transdiagnostic approaches

A systematic review and meta-analysis of psychosocial interventions for persons with comorbid anxiety and substance use disorders

BACKGROUND & AIMS

Anxiety and substance use disorders are highly comorbid and represent two of the leading causes of disease burden globally. Psychosocial interventions are important treatment options for people with co-occurring anxiety and substance use (A-SUD). To date, few reviews have assessed the efficacy of psychosocial treatments for patients with A-SUD. This systematic review and meta-analysis aims to synthesize this literature and assess the efficacy of psychosocial interventions among patients with A-SUD.

METHODS

We searched all relevant records published until March 2023 in Medline, EMBASE, PsycINFO, CINAHL and Google Scholar. Two authors extracted and reconciled relevant data and assessed risk of bias. Random effects models were used to calculate effect sizes using Hedges' g for post treatment and follow-up time points. Main outcomes of the review were anxiety, alcohol use, and use of other substances. We examined effects on depression as a secondary outcome since it commonly co-occurs with A-SUD.

RESULTS

Psychosocial interventions for co-occurring A-SUD showed moderate effects on anxiety (g = 0.44), alcohol (Hedges' g = 0.29), and other substance use (g = 0.38) at post intervention. Large effects were observed on depression (g = 0.88) at post intervention with high heterogeneity. These effects were maintained at follow-up for anxiety (Hedges' g = 0.38), other substances (g = 0.44), and depression (g = 0.50). Moderation analyses for demographic factors, intervention characteristics, community level factors, anxiety reduction, and alcohol use reduction, were non-significant.

CONCLUSIONS

The current meta-analysis investigated the effects of psychosocial interventions on patients with anxiety and co-occurring SUD. The analyses indicated promising moderate-sized effects of treatment on anxiety, alcohol, all other drug use, and depression. The findings point to important avenues for psychosocial treatment while highlighting critical gaps in knowledge to be addressed in future research.

A narrative systematic review of associations and temporality between use of methamphetamine, ecstasy/MDMA, or cocaine with anxiety or depressive symptoms

OBJECTIVE

Anxiety and depression are prevalent mental health problems in people who use illicit stimulants. Improved understanding of the temporal relationship between methamphetamine, ecstasy/MDMA, or cocaine use with anxiety or depression informs public health interventions and treatment options for those experiencing this co-occurrence. This narrative systematic review sought to examine associations and temporality between the use of methamphetamine, ecstasy/MDMA, or cocaine, with anxiety or depressive symptoms. Method Systematic searches of 4 electronic databases were conducted up to August 2023. Study eligibility included the measurement of anxiety and/or depressive symptoms, and frequency of illicit stimulant use (methamphetamine, cocaine, or ecstasy/MDMA) at two separate time points, with data analysis of the association between these variables. The Joanna Briggs Critical Appraisal Checklist was utilised to assess quality. Data was extracted, and a narrative synthesis incorporating an eight-criteria framework to assess associations was conducted. Results 4432 studies were screened for eligibility; 11 studies (3 RCTs and 8 prospective cohort studies) were included. Evidence for an association between depressive symptoms and methamphetamine use was demonstrated in six studies, with temporal evidence in three studies supporting methamphetamine use preceding depressive symptoms. Three studies reported an association between cocaine use and depressive symptoms. Evidence for associations with any of the illicit stimulants and anxiety symptoms was lacking.

CONCLUSIONS

There was some evidence to support a case for temporality, particularly for methamphetamine use and depressive symptoms. Investing in longitudinal studies is pivotal to understanding the dynamic and reciprocal relationship between illicit stimulant use and anxiety or depressive symptoms. A limitation of the study was the variation in the measurement and analysis of outcomes.

Stimulant Use Associated With Psychosocial Factors, HIV Risk, and Concurrent Hazardous Alcohol Use Among US Adults: Exploratory Cross-Sectional Questionnaire Study

BACKGROUND

Stimulant use is a major public health problem that contributes to morbidity and mortality among men who have sex with men (MSM) in the United States. To reduce the harms associated with stimulant use, there is a need to identify the factors associated with stimulant use to inform interventions. Additionally, there is a need to use large crowdsourcing platforms like Amazon Mechanical Turk (MTurk) to engage more individuals who use substances across the United States.

OBJECTIVE

We identified the correlates of stimulant use among people who use alcohol or stimulants in the United States recruited using MTurk.

METHODS

Participants who were aged ≥18 years in the United States and reported alcohol or stimulant (ie, cocaine, crack cocaine, and methamphetamine) use were deemed eligible and recruited via the web platform MTurk. Participants completed a baseline survey, which assessed sociodemographics, psychosocial (ie, depression, affect, self-esteem, and stress) factors, substance use, and sexual behaviors. Data were collected and analyzed with STATA (version 17; StataCorp). Stratifying by MSM status, bivariate and multivariable logistic regression models were built in STATA to examine the correlates of stimulant use. Multivariable models controlled for age, race, health insurance, and relationship status.

RESULTS

Of 272 participants, 201 (73.9%) identified as male, 134 (49.2%) were MSM, 52 (19.1%) were from racial and ethnic minoritized communities, and 158 (58%) were in a relationship. The mean age was 36.10 (SD 10.3) years. A total of 40 (14.7%) participants reported stimulant use in the past 6 months. Factors significantly associated with stimulant use were being MSM (adjusted odds ratio [aOR] 4.61, 95% CI 1.97-10.81), a higher Alcohol Use Disorders Identification Test-Concise score (aOR 1.24, 95% CI 1.08-1.42), more intense cravings for alcohol in the past 24 hours (aOR 1.03, 95% CI 1.01-1.04), a higher depression score (aOR 1.06, 95% CI 1.01-1.12), a greater number of male partners in the last 6 months (aOR 1.32, 95% CI 1.08-1.61), a greater number of female partners in the last 6 months (aOR 1.42, 95% CI 1.04-1.92), and being diagnosed with a sexually transmitted infection (eg, syphilis, gonorrhea, chlamydia, herpes simplex virus, human papillomavirus, and other) in the last 6 months (aOR 14.61, 95% CI 3.45-61.87). Additionally, there was a significant additive interaction between MSM status and negative affect, such that the impact of negative affect on stimulant use was significantly greater among MSM compared with non-MSM (relative excess risk due to interaction 0.085, 95% CI 0.037-0.13).

CONCLUSIONS

Interventions that address stimulant use should use evidence-based approaches that reduce negative affect, depression, and cravings for alcohol. Additionally, interventions should be customized for MSM populations.

mHealth Coping Skills Training for Symptom Management (mCOPE) for colorectal Cancer patients in early to mid-adulthood: Study protocol for a randomized controlled trial

Background

Colorectal cancer (CRC) patients in early to mid-adulthood (≤50 years) are challenged by high symptom burden (i.e., pain, fatigue, distress) and age-related stressors (e.g., managing family, work). Cognitive behavioral theory (CBT)-based coping skills training interventions reduce symptoms and improve quality of life in cancer patients. However, traditional CBT-based interventions are not accessible to these patients (e.g., in-person sessions, during work day), nor designed to address symptoms within the context of this stage of life. We developed a mobile health (mHealth) coping skills training program for pain, fatigue and distress (mCOPE) for CRC patients in early to mid-adulthood. We utilize a randomized controlled trial to test the extent to which mCOPE reduces pain, fatigue and distress (multiple primary outcomes) and improves quality of life and symptom self-efficacy (secondary outcomes).

Methods/Design

Patients (N = 160) ≤50 years with CRC endorsing pain, fatigue and/or distress are randomized 1:1 to mCOPE or standard care. mCOPE is a five-session CBT-based coping skills training program (e.g., relaxation, activity pacing, cognitive restructuring) that was adapted for CRC patients in early to mid-adulthood. mCOPE utilizes mHealth technology (e.g., videoconference, mobile app) to deliver coping skills training, capture symptom and skills use data, and provide personalized support and feedback. Self-report assessments are completed at baseline, post-treatment (5-8 weeks post-baseline; primary endpoint), and 3- and 6-months later.

Conclusions

mCOPE is innovative and potentially impactful for CRC patients in early to mid-adulthood. Hypothesis confirmation would demonstrate initial efficacy of a mHealth cognitive behavioral intervention to reduce symptom burden in younger CRC patients.

Profiles of risk factors for depressive and anxiety symptoms during the COVID-19 pandemic: A latent class analysis

The COVID-19 pandemic has caused a high burden in the general population. The exposure to an accumulation of risk factors, as opposed to a single risk, may have been associated with higher levels of depressive and anxiety symptoms during the pandemic. This study aimed to (1) identify subgroups of individuals with distinct constellations of risk factors during the COVID-19 pandemic and (2) investigate differences in levels of depressive and anxiety symptoms. German participants (N = 2245) were recruited between June-September 2020 through an online survey (ADJUST study). Latent class analysis (LCA) and multiple group analyses (Wald-tests) were conducted to identify profiles of risk factors and examine differences in symptoms of depression (PHQ-9) and anxiety (GAD-2). The LCA included 14 robust risk factors of different domains, for example, sociodemographic (e.g., age), health-related (e.g., trauma), and pandemic-related (e.g., reduced income) factors. The LCA identified three risk profiles: High sociodemographic risk (11.7%), high social and moderate health-related risk (18.0%), and low general risk (70.3%). Individuals with high sociodemographic risk reported significantly higher symptom levels of depression and anxiety than the remaining groups. A better understanding of risk factor profiles could help to develop targeted prevention and intervention programs during pandemics.

Individually delivered mindfulness-based cognitive therapy in concomitant problematic substance use and emotional symptoms: A process-based case study

The process-based approach assumes that transdiagnostic psychological processes are involved in the onset and maintenance of mental disorders. Case conceptualization is used to identify such psychological processes and to individualize the intervention accordingly. This approach is fundamentally different from syndrome-based approaches in which standardized treatments are administered for psychiatric diagnoses or symptoms. In the current case, we proposed a process-based conceptualization and treatment for a woman with concomitant problematic substance use and emotional symptoms. Our idiosyncratic process-based conceptualization showed that for this person, substance abuse consisted in a maladaptive coping strategy to deal with repetitive negative thinking and poor emotion regulation skills, for which we decided to use a mindfulness-based intervention. Treatment comprised 8 weeks of individually delivered mindfulness-based cognitive therapy sessions. A comprehensive assessment of psychiatric symptoms and psychological processes was conducted at baseline, post-intervention and 3-month follow-up. The post-treatment assessment revealed that psychological processes targeted by the intervention were improved, together with the mindfulness trait. At the symptom-based level, we observed a significant reduction in substance abuse and emotional symptoms. Treatment gains were maintained at follow-up. From a process-based perspective, this result implies that the intervention successfully targeted the psychological processes underlying the presenting symptoms. Adopting a process-based approach rather than symptom- or syndrome-based approaches is a valuable alternative in the conceptualization and treatment of complex cases presenting with multiple comorbidities.

COVID-related stress and substance use: examining the role of sleep disturbance

The current investigation employed a cross-sectional design to evaluate the associations of COVID-19 stress, sleep disturbance, and substance use among a national sample of 143 adults (57.3% male, Mage = 38.5 years, SD = 11.28), surveyed at a single time-point using Amazon's MTurk platform. We hypothesized that COVID-19-related stress would be indirectly related to substance use outcomes (i.e. number of substance classes used daily, number of alcoholic drinks per occasion, substance use coping motives; but not substance use enhancement motives) through sleep disturbance severity. As expected, results indicated that the models examining indirect effects were statistically significant for number of substance classes used daily and substance use coping motives. However, there was no evidence that sleep disturbance explained the relation between COVID-19-related stress and number of alcoholic drinks per occasion or substance use enhancement motives. These findings underscore the importance of sleep disturbance in efforts to better understand how COVID-19-related stress is associated with certain types of substance use behavior.

Controlled Trial Examining the Strength-Based Grit Wellbeing and Self-Regulation Program for Young People in Residential Settings for Substance Use

This cohort-controlled trial examined whether the 12-session Grit Wellbeing and Self-regulation Program enhanced the treatment outcomes of young people accessing residential alcohol and other drug (AOD) treatment. Grit focuses on increasing wellbeing and reducing substance use and mental health problems by building self-regulation skills, strengths, social connections, and health behaviours. Participants were 194 (66% male, Mage 27.40) young people (aged 18-35 years) accessing a six-week residential treatment program for substance use. Participants received standard treatment, or standard treatment plus Grit (two sessions/week for six weeks). The primary outcome was substance use, measured as: (i) global substance use and (ii) alcohol, methamphetamine, and cannabis use involvement. Secondary outcomes included wellbeing, depression, anxiety, and vocational engagement. Participants were assessed at baseline, and 6-weeks (secondary outcomes only), 3-months, 6-months, and 12-months post-program enrolment. Results revealed that both groups showed a significant improvement in all outcomes at three months, and improvements were maintained at 6- and 12-month follow-ups. The Grit group had a larger reduction in methamphetamine and cannabis use involvement compared to the control group. This study presents promising evidence that a six-week residential program can achieve improvements in AOD use, depression, anxiety, wellbeing and vocational engagement. Further, targeting self-regulation may enhance such programs.

Behavioral activation, affect, and self-efficacy in the context of alcohol treatment for women with elevated depressive symptoms

Women with Alcohol use disorder (AUD) are more likely than men to have co-occurring depression, drink to cope with negative affect (NA), and cite negative affect as a contributor to relapse. Among AUD treatment seekers, low behavioral activation, NA, and reduced self-efficacy in abstaining from alcohol (e.g., in tempting situations) are relapse risk factors. This study investigated the association between behavioral activation, affective states, and self-efficacy among treatment-seeking women. Participants were 70 women (M = 40.50, SD = 11.59 years of age) with elevated depressive symptoms seeking AUD treatment. The Behavioral Activation for Depression Scale (BADS) was used to assess environmental engagement. The Alcohol Abstinence Self-Efficacy (AASE) scale was used to assess temptation to drink in contexts of positive and negative affect, and general positive and negative affect were assessed with the Positive and Negative Affect Schedule. Results indicated that behavioral activation was directly correlated with positive affect (PA; r = .62, p < .001) and inversely correlated with depression (r = -.35, p = .004), negative affect (r = -.39, p = .001), and temptation to drink in the context of negative affect (r = -.33, p = .006). After controlling for depressive symptoms, behavioral activation continued to be associated with greater general positive affect (β = .595, p < .001) and lower temptation to drink in the context of negative affect (β = -.348 p = .008). Our results suggest a nuanced association between behavioral activation, negative affect, and temptations to drink that is not accounted by depressive symptoms. Self-efficacy to abstain from drinking in a negative affect context should be considered when designing AUD interventions for women. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Prevalence of mental disorders among people with opioid use disorder: A systematic review and meta-analysis

BACKGROUND

Opioid use disorder (OUD) and mental disorders are major public health issues and comorbidity is common. Among people with OUD, comorbid mental disorders are associated with poorer health outcomes. To our knowledge, this is the first systematic review and meta-analysis to estimate prevalence of specific mental disorders among people with OUD.

METHODS

We searched Embase, MEDLINE, and PsycInfo from 1990 to 2021 for observational studies of depression, anxiety, post-traumatic stress disorder (PTSD), bipolar, personality, and other pre-specified mental disorders among people with OUD. We pooled current and lifetime estimates of each disorder using random-effects meta-analyses with 95% Confidence Intervals (CIs). Meta-regressions and stratified analyses were used to assess heterogeneity of prevalence estimates by methodological factors and sample characteristics.

FINDINGS

Of the 36,971 publications identified, we included data from 345 studies and 104,135 people with OUD in at least one pooled estimate. Among people with OUD, the prevalence of current depression was 36.1% (95%CI 32.4-39.7%), anxiety was 29.1% (95%CI 24.0-33.3%), attention-deficit/hyperactivity disorder was 20.9% (95%CI 15.7-26.2%), PTSD was 18.1% (95%CI 15.4-20.9%), and bipolar disorder was 8.7% (95%CI 6.7-10.7%). Lifetime prevalence of anti-social personality disorder was 33.6% (95%CI 29.1-38.0%) and borderline personality disorder was 18.2% (95% CI 13.4-23.1%). Sample characteristics and methodological factors, including sex, were associated with variance of multiple prevalence estimates.

INTERPRETATION

Our findings emphasise the need for access to mental disorder treatment among people with OUD. Specific mental disorder estimates may inform clinical guidelines, treatment services, and future research for people with OUD, including subpopulations with distinct treatment needs.

Supporting Youth and Families in Gaza: A Randomized Controlled Trial of a Family-Based Intervention Program

Background: A total of 450 million children are now living in active conflict zones. The negative consequences for children are significant and long lasting. In response to the urgent need for sustainable interventions for children and families, the current study evaluated a brief (12 hr, 8 session) family-based coping and support program, Promoting Positive Family Futures (PPFF), in Gaza. Methods: Families (n = 68, mother/father/adolescent triads) were randomized into the PPFF intervention or another lengthier (50 hr, 25 session) locally well-established psychosocial support program (treatment as usual; TAU). Results: Improvements were found for both conditions for paternal and maternal depression, emotion regulation using cognitive reappraisal, family-wide emotional security, and adolescent adjustment. Effect sizes were medium to large (d = 0.35–1.27). Fathers in the PPFF condition reported lower depression and higher emotion regulation using cognitive reappraisal at post-test than did fathers in the TAU condition. Mothers in the PPFF condition reported higher levels of emotion regulation using cognitive reappraisal at post-test than did mothers in the TAU condition. PPFF was also indirectly associated with improved depression at post-test for both mothers and fathers via improvements in emotion regulation using cognitive reappraisal and with adolescent adjustment at six months via improvements in maternal emotion regulation using cognitive reappraisal. Conclusions: These findings suggest that the PPFF intervention has many benefits comparable with a longer and locally well-established program. PPFF was also associated with unique positive implications for family-wide adjustment over time. Support was also identified for transdiagnostic processes of improvement associated with the PPPF intervention consistent with the theoretical models informing the approach.

Comparing a mindfulness- and CBT-based guided self-help Internet- and mobile-based intervention against a waiting list control condition as treatment for adults with frequent cannabis use: a randomized controlled trial of CANreduce 3.0

BACKGROUND

Though Internet- and mobile-based interventions (IMIs) and mindfulness-based interventions (generally delivered in-situ) appear effective for people with substance use disorders, IMIs incorporating mindfulness are largely missing, including those targeting frequent cannabis use.

METHODS

This paper details the protocol for a three-arm randomized controlled trial comparing a mindfulness-based self-help IMI (arm 1) and cognitive-behavioral therapy (CBT)-based self-help IMI (arm 2) versus being on a waiting list (arm 3) in their effectiveness reducing cannabis use in frequent cannabis users. Predictors of retention, adherence and treatment outcomes will be identified and similarities between the two active intervention arms explored. Both active interventions last six weeks and consist of eight modules designed to reduce cannabis use and common mental health symptoms. With a targeted sample size of n = 210 per treatment arm, data will be collected at baseline immediately before program use is initiated; at six weeks, immediately after program completion; and at three and six months post baseline assessment to assess the retention of any gains achieved during treatment. The primary outcome will be number of days of cannabis use over the preceding 30 days. Secondary outcomes will include further measures of cannabis use and use of other substances, changes in mental health symptoms and mindfulness, client satisfaction, intervention retention and adherence, and adverse effects. Data analysis will follow ITT principles and primarily employ (generalized) linear mixed models.

DISCUSSION

This RCT will provide important insights into the effectiveness of an IMI integrating mindfulness to reduce cannabis use in frequent cannabis users.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number Registry: ISRCTN14971662 ; date of registration: 09/09/2021.

Development of a Telephone-Delivered Acceptance and Commitment Therapy Intervention for People Living with HIV who are Hazardous Drinkers

Alcohol use among people living with HIV (PWH) has been increasingly recognized as an important component of HIV care. Transdiagnostic treatments, such as Acceptance and Commitment Therapy (ACT), that target core processes common to multiple mental health and substance-related problems, may be ideal in HIV treatment settings where psychological and behavioral health comorbidities are high. In advance of a randomized clinical trial (RCT), the overall objective of this study was to systematically adapt an ACT-based intervention originally developed for smoking cessation, into an ACT intervention for PWH who drink at hazardous levels. Consistent with the ADAPT-ITT model, the adaptation progressed systematically in several phases, which included structured team meetings, three focus group discussions with PWH (N = 13), and in-depth interviews with HIV providers (N = 10), and development of standardized operating procedures for interventionist training, supervision, and eventual RCT implementation. The procedures described here offer a template for transparent reporting on early phase behavioral RCTs.

Prospective examination of the therapeutic role of psychological flexibility and cognitive reappraisal in the ceremonial use of ayahuasca

BACKGROUND

Evidence suggests that psychedelic-assisted therapy carries transdiagnostic efficacy in the treatment of mental health conditions characterized by low mood and the use of avoidance coping strategies.

AIMS

While preliminary evidence suggests that psychological flexibility and emotion regulation processes play an important role within psychedelic therapy, this prospective study addressed methodological gaps in the literature and examined the ability of ayahuasca to stimulate acute states of cognitive reappraisal and long-term changes in psychological flexibility and mood. The study also explored whether moderating factors predisposed participants to experience therapeutic changes.

METHODS

Participants (N = 261) were recruited from three Shipibo ayahuasca retreat centers in Central and South America and completed assessments on mood, psychological flexibility, and acute ceremonial factors. Expectancy, demand characteristics, and invalid responding were controlled for with several validity scales.

RESULTS/OUTCOMES

Participants reported significant reductions in negative mood after three months, as well as increases in positive mood and psychological flexibility. Acute experiences of reappraisal during the ayahuasca ceremony exerted the strongest moderating effects on increases in positive mood and psychological flexibility. Increases in psychological flexibility statistically mediated the effects of acute psychological factors, including reappraisal, on changes in positive mood.

CONCLUSIONS/INTERPRETATION

These results highlight the role of acute psychological processes, such as reappraisal, and post-acute increases in psychological flexibility as putative mechanisms underlying positive outcomes associated with psychedelics. These results also provide support for the integration of third-wave and mindfulness-based therapy approaches with psychedelic-assisted interventions.

Acceptability of an mHealth App for Youth With Substance Use and Mental Health Needs: Iterative, Mixed Methods Design

BACKGROUND

Treating substance use disorders (SUDs) during adolescence can prevent adult addiction and improve youth outcomes. However, it can be challenging to keep adolescents with SUDs engaged in ongoing services, thus limiting potential benefits. Developmentally appropriate tools are needed to improve treatment engagement during and between sessions for youth with SUDs and mental health disorders. Mobile health apps may augment or replace psychotherapy components; however, few have been developed specifically for youth with SUDs following user-guided design principles, which may limit their appropriateness and utility. Formative research on acceptability to intended end users is needed before the efficacy of such tools can be examined.

OBJECTIVE

This study involves user-centered, iterative development and initial user testing of a web-based app for adolescents with SUDs and mental health concerns.

METHODS

Adolescents aged 14 to 17 years with past-year involvement in outpatient psychotherapy and behavioral health clinicians with adolescent SUD treatment caseloads were recruited. Across 2 assessment phases, 40 participants (alpha: 10 youths and 10 clinicians; beta: 10 youths and 10 clinicians) viewed an app demonstration and completed semistructured interviews and questionnaires about app content and functionality.

RESULTS

Participants expressed positive impressions of the app and its potential utility in augmenting outpatient therapy for youth with SUDs and mental health concerns. Noted strengths included valuable educational content, useful embedded resources, and a variety of activities. Adolescents and clinicians favored the app over conventional (paper-and-pencil) modalities, citing convenience and familiarity. The app was found to be user-friendly and likely to improve treatment engagement. Adolescents suggested the inclusion of privacy settings, and clinicians recommended more detailed instructions and simplified language.

CONCLUSIONS

The novel app developed here appears to be a promising, acceptable, and highly scalable resource to support adolescents with SUDs and mental health concerns. Future studies should test the efficacy of such apps in enhancing adolescent behavioral health treatment engagement and outcomes.

Exploring regulation and function of dopamine D3 receptors in alcohol use disorder. A PET [11C]-(+)-PHNO study

Preclinical studies support an important role of dopamine D3 receptors (DRD3s) in alcohol use disorder (AUD). In animals, voluntary alcohol consumption increases DRD3 expression, and pharmacological blockade of DRD3s attenuates alcohol self-administration and reinstatement of alcohol seeking. However, these findings have yet to be translated in humans. This study used positron emission tomography (PET) and [¹¹C]-(+)-PHNO to compare receptor levels in several dopamine D2 receptor (DRD2) and DRD3 regions of interest between AUD subjects in early abstinence (n = 17; 6.59 ± 4.14 days of abstinence) and healthy controls (n = 18). We recruited non-treatment seeking subjects meeting DSM-5 criteria for AUD. We examined the relationship between DRD2/3 levels and both alcohol craving and alcohol motivation/wanting, using a cue reactivity procedure and an intravenous alcohol self-administration (IVASA) paradigm, respectively. [¹¹C]-(+)-PHNO binding levels in AUD subjects were significantly lower than binding in HCs when looking at all DRD2/3 ROIs jointly (Wilk's Λ = .58, F(6,28) =3.33, p = 0.013, η²_p = 0.42), however there were no region-specific differences. Binding values demonstrate -12.3% and -16.1% lower [¹¹C]-(+)-PHNO binding in the SMST and SN respectively, though these differences did not withstand Bonferroni corrections. There was a positive association between [¹¹C]-(+)-PHNO binding in the SN (almost exclusively reflective of DRD3) and alpha (lower values reflect higher alcohol demand) in the APT after Bonferroni corrections (r = 0.66, p = 0.0080). This demonstrates that AUD subjects with lower DRD3 levels in the SN exhibit increased demand for alcohol. These results replicate previous findings demonstrating reduced DRD2/3 levels while also supporting a lack of DRD3 upregulation and potential downregulation in early abstinent AUD. Furthermore, the finding that binding in the SN is associated with alcohol demand warrants further examination.

FullFix: a randomised controlled trial of a telephone delivered transdiagnostic intervention for comorbid substance and mental health problems in young people

INTRODUCTION

Transdiagnostic cognitive-behavioural therapy (CBT) targets common psychological factors that underlie multiple disorders. While transdiagnostic interventions are a promising new approach, limited research has evaluated these treatments within the alcohol and other drug (AOD) sector for young people with comorbid mental health symptoms. This project will examine the feasibility and preliminary efficacy of FullFix-a new risk-targeted transdiagnostic CBT telehealth programme for comorbid AOD and depression/anxiety disorders in young people. Secondary aims are to identify moderators and mediators of treatment outcomes, to determine how and why treatment is effective and who is most likely to benefit.

METHODS/DESIGN

Participants will be 130 young people (aged 16-35) accessing AOD services in Queensland, Australia, with comorbid mental health symptoms. They will be randomised to receive either the FullFix intervention plus standard AOD care or standard AOD care alone. Primary outcomes on AOD use and mental health symptoms will be reassessed at 6 weeks, 3 months, 6 months and 12 months, along with secondary outcomes of emotion regulation, social connectedness, perceived self-efficacy, coping skills and quality of life. The trial commenced on October 2018 and expected completion date is September 2021.

ETHICS AND DISSEMINATION

Ethical approval for this trial was provided by the University of Queensland (#2018001185). The results of the trial will be disseminated through publication in a peer-reviewed scientific journal, scientific presentations at conferences and distributed via a report and presentations to the partner organisation.

TRIAL REGISTRATION NUMBER

ACTRN12618001563257.

Addiction treatment in the postpartum period: an opportunity for evidence-based personalized medicine

Substance use disorders (SUD) are becoming rapidly more prevalent in women and a leading cause of pregnancy associated deaths, with most deaths occurring during the 12 months after pregnancy. The postpartum period can be quite intense, especially for women seeking addiction recovery. There is a call to reconceptualize the obstetrical postpartum care model into one that extends specialised care and is tailored to an individual's specific needs. Although SUD treatment improves maternal and infant outcomes as well as decreases overdose risk, many women do not receive consistent SUD treatment during the postpartum period. Thus, SUD treatments should consider following the same guidance as obstetrics to reconceptualize how SUD treatment is delivered postpartum. Clinically, this translates into substantially modifying traditional siloed SUD treatment structures to meet the unique needs of this vulnerable patient population. At the same time, more research is urgently needed to inform these advancements in clinical care to ensure they are evidence-based and effective. In this article, we review the existing evidence as well as highlight opportunities for both clinicians and researchers to advance the integration of tailored approaches for postpartum women into personalised SUD medical and behavioural treatments.

Reward Processing and Circuit Dysregulation in Posttraumatic Stress Disorder

Past decades have witnessed substantial progress in understanding of neurobiological mechanisms that contribute to generation of various PTSD symptoms, including intrusive memories, physiological arousal and avoidance of trauma reminders. However, the neurobiology of anhedonia and emotional numbing in PTSD, that have been conceptualized as reward processing deficits - reward wanting (anticipation of reward) and reward liking (satisfaction with reward outcome), respectively, remains largely unexplored. Empirical evidence on reward processing in PTSD is rather limited, and no studies have examined association of reward processing abnormalities and neurocircuitry-based models of PTSD pathophysiology. The manuscript briefly summarizes "state of the science" of both human reward processing, and of PTSD implicated neurocircuitry, as well as empirical evidence of reward processing deficits in PTSD. We then summarize current gaps in the literature and outline key future directions, further illustrating it by the example of two alternative explanations of PTSD pathophysiology potentially affecting reward processing via different neurobiological pathways. Studying reward processing in PTSD will not only advance the understanding of their link, but also could enhance current treatment approaches by specifically targeting anhedonia and emotional symptoms in PTSD patients.

The Psychosocial Predictors and Day-Level Correlates of Substance Use Among Participants Recruited via an Online Crowdsourcing Platform in the United States: Daily Diary Study

BACKGROUND

Alcohol consumption and stimulant use are major public health problems and contribute to morbidity and mortality in the United States. To inform interventions for substance use, there is a need to identify the day-level correlates of substance use by collecting repeated measures data in one's natural environment. There is also a need to use crowdsourcing platforms like Amazon Mechanical Turk (MTurk) to efficiently engage larger populations of people who use alcohol and stimulants in research.

OBJECTIVE

We aimed to (1) utilize daily diaries to examine the temporal relationship between day-level cravings for alcohol and stimulant/substance use (ie, heavy drinking or any drug use) in a given day over 14 days and (2) assess whether depression, negative affect, and self-esteem measured at baseline predict substance use in a given day over 14 days among people who use alcohol and/or stimulants in the United States.

METHODS

Individuals aged ≥18 years in the United States, who reported alcohol or stimulant (ie, cocaine, crack cocaine, and methamphetamine) use in the past year, were recruited using MTurk between March 26 and April 13, 2018. Eligible participants completed a baseline survey and 14 daily surveys online. The baseline survey assessed sociodemographics and psychosocial (ie, depression, affect, self-esteem, and stress) factors. Daily surveys assessed substance use and cravings for alcohol and stimulants. Four multivariable random-intercept logistic regression models were built to examine psychosocial constructs separately along with other significant predictors from bivariate analyses while controlling for age and education.

RESULTS

Among a total of 272 participants, 220 were White, 201 were male, and 134 were men who have sex with men (MSM). The mean age was 36.1 years (SD 10.5). At baseline, 173 participants engaged in any current or past hazardous alcohol consumption, 31 reported using cocaine, 19 reported using methamphetamine, 8 reported using crack cocaine, and 104 reported any noninjection or injection drug use in the past 6 months. Factors independently associated with substance use were depression (adjusted odds ratio [aOR] 1.11, 95% CI 1.02-1.21; P=.01), negative affect (aOR 1.08, 95% CI 1.01-1.16; P=.01), lower levels of self-esteem (aOR 0.90, 95% CI 0.82-0.98; P=.02), and cravings for alcohol (aOR 1.02, 95% CI 1.01-1.03; P<.001) and stimulants (aOR 1.03, 95% CI 1.01-1.04; P=.01). MSM had higher odds of engaging in substance use in all models (model 1: aOR 4.90, 95% CI 1.28-18.70; P=.02; model 2: aOR 5.47, 95% CI 1.43-20.87; P=.01; model 3: aOR 5.99, 95% CI 1.55-23.13; P=.009; and model 4: aOR 4.94, 95% CI 1.29-18.84; P=.01).

CONCLUSIONS

Interventions for substance use should utilize evidenced-based approaches to reduce depression, negative affect, and cravings; increase self-esteem; and engage MSM. Interventions may also consider leveraging technology-based approaches to reduce substance use among populations who use crowdsourcing platforms.

Third wave cognitive and behavioral processes and therapies for addictive behaviors: An introduction to the Special Issue

Third wave cognitive and behavioral therapies have garnered significant attention in the study and treatment of addiction. Such treatments employ a process-oriented, transdiagnostic approach to mitigate problematic thought and behavioral patterns and consequences associated with substance use. Although initial evidence is promising, much remains unknown regarding the impact of third wave processes on substance use behavior and treatment outcomes. Additionally, more work is needed to elucidate the potential of novel third wave treatments on substance use outcomes. If proven successful, third wave processes and therapies may hold the key to disrupt the huge financial, societal, and personal burden associated with addiction. This Special Issue highlights recent, scientifically rigorous, clinically applicable advances in current understanding of third wave cognitive and behavioral processes and therapies for substance use. Research presented in this Special Issue covers topics ranging from the role and application of mindfulness in the etiology of substance use behavior, treatment outcomes, and familial support; the potential of transdiagnostic factors as important considerations for vulnerable groups; and the development and refinement of novel technological and integrated interventions. This Special Issue is organized into three parts classified as third wave processes and substance use behavior; third wave processes in traditional substance use treatment and their malleability; and third wave treatments for substance use among special populations. It is hoped that this issue will alert readers to the significance of this work, illustrate the many domains currently being explored via process-oriented, transdiagnostic treatment, and identify promising and impactful areas for research.

Developing a Latent Coping Resources Factor for Recovery from Substance Use Disorder

It is crucial for individuals with substance use disorders, especially those with a co-occurring mental health disorder, to access effective coping resources. We quantify coping through four domains of individual resources (self-esteem, self-efficacy, perceived social support, and hope) to examine the extent to which individuals with varying psychiatric severity can access coping-related resources. Since sex is an additionally important consideration in treatment, we also explore both sexes' access to coping-related resources. We generate a multilevel latent variable of coping resources in class structures, one for males and one for females, to measure (1) the extent individuals with varying psychiatric presentations (types, symptoms, severity) are able to access this latent resource and (2) to control for house level effects. Our variables of self-esteem, self-efficacy, perceived social support, and hope all coalesced into a latent variable, named coping resources. Furthermore, we find that psychiatric severity is negatively related to coping resources at the individual level, but function differently for males and females at the house level. Treatment guidelines should address the nuanced needs of individuals and consider individual differences, such as sex, that impact access to coping resources.

Predictors of premature treatment termination in a large residential addiction medicine program

BACKGROUND

While inpatient programs are a common setting for addiction treatment, patients' premature termination is a major concern. Predicting premature treatment termination has the potential to substantially improve patient outcomes by identifying high-risk profiles and suggesting care paths that might reduce dropout. The current study examined the predictors of premature termination from an inpatient addiction medicine service.

METHODS

In 1082 patients admitted to a large inpatient addiction medicine service, we used intake assessments of severity of alcohol use disorder, illicit drug use disorder, post-traumatic stress disorder (PTSD), anxiety disorders, and major depressive disorder to predict planned termination (n = 922) or premature termination (n = 160). We used two complementary analytic approaches-traditional binary logistic regression and a data-driven latent profile analysis (LPA).

RESULTS

Binary logistic regression revealed that alcohol use severity, illicit drug use severity, and PTSD severity significantly predicted termination status, although alcohol use severity notably exhibited an inverse relationship. The LPA revealed four distinct profiles, with one profile exhibiting a significantly higher rate of premature termination and another exhibiting a significantly lower rate of premature termination. The high-risk profile was characterized by high drug severity, high comorbid psychopathology (PTSD, depression, and anxiety symptoms), but low alcohol severity. The low-risk profile was characterized by high alcohol severity, but low drug use and low comorbid psychopathology.

CONCLUSIONS

These results provide converging evidence that illicit drug severity and psychiatric severity, and particularly PTSD, were associated with premature termination. Moreover, the LPA revealed distinct latent subgroups of patients with meaningfully higher and lower risk of premature termination, suggesting that addiction services should develop strategies for identifying high-risk individuals or develop care paths for high-risk symptom clusters. Approaches that are trauma-informed or otherwise focus on the management of comorbid psychiatric conditions may be particularly appropriate for reducing premature termination.

The Role of Affect in Psychosocial Treatments for Substance Use Disorders

PURPOSE OF REVIEW

This paper provides a narrative review of studies published over the past five years that have examined the role of affect, including both affective symptoms and affective disorders, in psychosocial treatments for substance use disorder.

RECENT FINDINGS

A growing body of literature suggests that affective symptoms and affective disorders may moderate substance use disorder treatment efficacy, mediate the effects of treatment on substance use outcomes, and may be directly changed by substance use disorder treatment.

SUMMARY

Substance use disorders and affective disorders commonly co-occur, and both affect and affective disorders are associated with substance use disorder treatment outcomes. Future research should continue to examine affect as a moderator, mediator, and outcome of substance use disorder treatments. In particular, new studies that are designed to test precision medicine hypotheses would greatly expand our understanding of the role of affective symptoms and disorders in substance use disorder treatment.

Rumination and problematic substance use among individuals with a long-term history of illicit drug use

BACKGROUND

Rumination is a cognitive process that is implicated in the development and maintenance of various forms of psychopathology, including problematic substance use. Most studies on the role of rumination in substance use have been conducted among community samples or individuals with alcohol use disorders and have predominately focused on overall rumination rather than differentiating between its subtypes, ruminative brooding and ruminative reflection. The current study therefore aimed to investigate i) whether rumination subtypes are associated with problematic substance use among people with a long-term history of illicit drug use independently of related psychological disorders (depression and post-traumatic stress disorder [PTSD]), and ii) whether gender moderates these relationships.

METHODS

This cross-sectional study used data from the Australian Treatment Outcome Study (ATOS); a naturalistic prospective cohort study of people with heroin dependence. At the 11-year follow-up of ATOS, a total of 380 participants completed measures of rumination, depression, PTSD, and indices of problematic substance use.

RESULTS

Hierarchical logistic regression analyses indicated that higher brooding scores were associated with current heroin dependence (OR = 1.11, CI: 1.01-1.22), polydrug use (OR = 1.16, CI: 1.06-1.28) and experience of injection related health problems (OR = 1.08, CI: 1.00-1.17), independently of depression, PTSD, and other covariates. Reflection was not related to any of the substance use measures. These results were not moderated by gender.

CONCLUSIONS

Findings indicate that ruminative brooding is related to a poorer substance use profile among people with long-term illicit drug use and highlight the potential benefits of targeting brooding during substance use treatment.

Transcranial Direct Current Stimulation on Opium Craving, Depression, and Anxiety: A Preliminary Study

OBJECTIVES

Transcranial direct current stimulation can be effective in reducing the craving for food, alcohol, and methamphetamine. Because its effects have not been tested on patients with opium use disorder, we investigated its efficacy when it is combined with a standard methadone maintenance therapy protocol.

METHODS

We carried out a pretest-posttest control group method to evaluate the effect of transcranial direct current stimulation at the dorsolateral prefrontal cortex (right anodal/left cathodal) on opium craving, depression, and anxiety symptoms. We considered opium craving as a primary outcome as well as depression and anxiety symptoms as secondary outcomes. Sixty participants with opium use disorder were randomly assigned into 3 groups (n = 20 for each group): (1) an active transcranial direct current stimulation with methadone maintenance treatment (active tDCS group), (2) sham transcranial direct current stimulation with methadone maintenance treatment (sham tDCS group), and (3) only methadone maintenance treatment (methadone maintenance treatment group). All participants completed the Desire for Drug Questionnaire, Obsessive-Compulsive Drug Use Scale, Beck Depression Inventory II, and Beck Anxiety Inventory a week before and a week after the treatment. The outcomes were assessed by independent assessors who were blind to the treatment conditions.

RESULTS

The active tDCS group had a significant reduction in opium craving, depression, and anxiety symptoms compared with the other 2 groups.

CONCLUSIONS

Our results provide a preliminary support for using the transcranial direct current stimulation along with methadone maintenance therapy in the treatment of patients with opium use disorder.

Cannabis-associated impairments in the fading affect bias and autobiographical memory specificity

We investigated potential relationships between cannabis use and 2 phenomena associated with autobiographical remembering: the fading affect bias (FAB) and memory specificity. The FAB is an emotional affect regulation mechanism that is observed when the intensity of affect associated with experiencing negative memories fades faster than the intensity of affect associated with experiencing positive memories. Memory specificity refers to the level of detail with which events are recalled. No studies have examined the relationships between cannabis use, the FAB, and memory specificity simultaneously. Chronic cannabis users (N = 47) and non-users (N = 52) recalled and described positive and negative autobiographical events and rated the affective intensity for the events at the time of occurrence and at time of test. Participants retrieved additional memories using a sentence-completion recall task, which were coded for specificity. Cannabis users showed reduced fading affect for unpleasant events and reduced memory specificity compared to non-users.

Distress tolerance trajectories following substance use treatment

OBJECTIVE

Distress tolerance (DT), the ability to withstand aversive internal states, represents an important risk factor for substance use relapse and a potential treatment target. Neurobiological research in substance using populations suggests that continued substance use could erode DT, whereas abstinence could bolster it. The current study characterized trajectories of behavioral and self-reported indices of DT and examined the prospective effect of substance use on DT trajectories among those seeking treatment for substance use.

METHOD

Individuals (N = 263, Mage = 42.68, SD = 11.8, 70.7% male, 94.7% African American) in residential substance use treatment completed subjective (Distress Tolerance Scale) and behavioral (Mirror Tracing Persistence Task-computerized version) DT measures, as well as report of daily substance use (timeline follow-back) over 5 assessment time-points from pretreatment to 12 months posttreatment. Latent curve modeling estimated DT trajectories and their associations with substance use behavior, including abstinence duration (days until first use) and substance use frequency (percentage of substance use days between assessments).

RESULTS

Self-reported and behavioral DT indicators both exhibited positive, nonlinear change over time (standardized slope parameter estimates: Distress Tolerance Scale β = 0.61, p < .01; Mirror Tracing Persistence Task β = 0.34, p < .01). Abstinence duration was associated with greater improvement in behavioral (β = .20, p = .03) DT specifically. Frequency of use was statistically significantly associated with attenuated behavioral DT at 6-month (β = -.12, p = .03) and 12-month follow-ups (β = -.08, p = .045).

CONCLUSIONS

DT appears to improve appreciably posttreatment, and return to substance use may shape the degree of this improvement. Collectively, these findings support the conceptualization of DT as a malleable treatment target and emphasize the benefit of abstinence on improvement in DT. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Acceptance and Commitment Therapy (ACT) for HIV-infected Hazardous Drinkers: A Qualitative Study of Acceptability

Alcohol use is a significant problem in HIV care, and clinical trials of alcohol interventions for people living with HIV infection (PLWH) have produced mixed results. The purpose of this qualitative study was to collect preliminary data on the practical feasibility and acceptability of Acceptance and Commitment Therapy (ACT) as a treatment for PLWH who are hazardous drinkers. A total of 25 PLWH participated in individual interviews. Four major themes emerged from the thematic analysis: (I) Perceived Appropriateness for PLWH and People who use Alcohol and/or other Substances, (II) General Satisfaction and Dissatisfaction, (III) Positive and Negative Effects on Participants and (IV) Facilitators and Barriers to Implementing ACT Intervention Strategies.

Effects of behavioural activation on substance use and depression: a systematic review

INTRODUCTION

Substance use and depression co-occurrence is a frequent phenomenon and an important public health concern. Given the clinical implications and the high prevalence of both disorders, effective interventions are needed.

METHODS

The aim of this study is to review Behavioural Activation (BA) intervention effects to improve substance use behaviour and depression. A systematic review was conducted using MEDLINE, EMBASE, and PsycINFO. The Effective Public Health Practice Project Quality Assessment Tool (EPHPP) was used to assess the methodological quality of included studies. Two authors independently screened titles and abstracts, reviewed selected studies, and extracted data.

RESULTS

Of the 7286 studies identified, eight met inclusion criteria. Designs of the studies included six randomized controlled trials (RCTs), and two pre-post design studies. One trial received weak methodological quality, six moderate, and one strong. Three studies addressed smoking behaviour; two targeted opiate dependence; two focused on alcohol/drug dependence; and, one on crystal methamphetamine abuse. Results showed that BA had a positive effect on substance use outcomes in seven of the eight reviewed studies, and improved depression over time in six studies.

CONCLUSIONS

Although studies conducted so far are limited by their heterogeneity and sample sizes, results are promising. There is a need of well controlled and powered studies to establish and to confirm the effectiveness of BA for the treatment of substance use and depression. Future studies should include stronger methodological designs, larger sample sizes, and long-term follow-ups.

TRIAL REGISTRATION

PROSPERO registration number: CRD42016039412 .

Assessing the validity and reliability of the Turkish versions of craving beliefs and beliefs about substance use questionnaire in patients with heroin use disorder: demonstrating valid tools to assess cognition-emotion interplay

Background

Cognitions associated with craving and substance use are important contributors for the psychological theories of Substance use disorders (SUD), as they may affect the course and treatment. In this study, we aimed to validate Turkish version of two major scales ‘Beliefs About Substance Use’(BSU) and ‘Craving Beliefs Questionnaire’(CBQ) in patients with heroin use disorder and define the interaction of these beliefs with patient profile, depression and anxiety symptoms, with an aim to use these thoughts as targets for treatment.

Methods

One hundred seventy-six inpatients diagnosed with heroin use disorder and 120 participants in the healthy comparison group were evaluated with CBQ, BSU, Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI) and sociodemographic data questionnaire. Patient group was also evaluated with Addiction Profile Index. Reliability and validity analysis for scales were conducted. Linear regression analysis was conducted to evaluate the determinants of BSU and CBQ scores.

Results

Cronbach alpha level was 0.93 for BSU and 0.94 for CBQ. Patient group showed significantly higher CBQ, BSU, BAI and BDI scores (p < 0.001). BSU score significantly correlated with API-substance use profile score, API-diagnosis, BAI, BDI and CBQ (p < 0.005), whereas CBQ scores significantly correlated with API-diagnosis, API-impact on life, API-craving, API-total score, BSU, BAI, BDI and amount of cigarette smoking (p < 0.002). Number of previous treatments and age of onset for substance use were not correlated with either BSU or CBQ. BAI and BDI scores significantly predicted BSU score, however only BDI score predicted CBQ score (p < 0.003).

Conclusions

Craving beliefs were highly correlated with addiction profile. Anxiety and depression are significant modulators for patients’ beliefs about substance use and depression is a modulator for craving and maladaptive beliefs, validating emotion-cognition interplay in addiction.

Baseline patterns of substance use disorder severity and depression and anxiety symptoms moderate the efficacy of mindfulness-based relapse prevention

OBJECTIVE

Few studies have evaluated moderators of mindfulness-based relapse prevention (MBRP) for substance use disorders (SUDs). We tested whether baseline patterns of scores for SUD symptom severity and depression and anxiety symptoms moderated the efficacy of MBRP.

METHOD

We used a latent class moderation approach with data from a randomized trial of MBRP compared to cognitive-behavioral relapse prevention and treatment as usual (TAU; Bowen et al., 2014; N = 286, 71.8% male, 48.4% non-White, mean age = 38.44 years, SD = 10.92) and a randomized trial comparing MBRP to TAU (Bowen et al., 2009; N = 168, 63.7% male, 44.6% non-White, mean age = 40.45, SD = .28). Indicators for the latent class models were measures of SUD severity (Severity of Dependence Scale and Short Inventory of Problems), depression symptoms (Beck Depression Inventory), and anxiety symptoms (Beck Anxiety Inventory).

RESULTS

In both trials, 3 latent classes provided the best fit: a high-high class characterized by high SUD severity and depression and anxiety symptoms, a high-low class characterized by high SUD severity and low depression and anxiety symptoms, and a low-low class characterized by low SUD severity and depression and anxiety symptoms. In both trials, we found significant latent Class × Treatment interaction effects: There were significant and large effects of MBRP on substance use outcomes in the high-high and high-low classes, but no MBRP effect in the low-low class.

CONCLUSION

MBRP may be an optimal treatment for preventing relapse among clients with severe levels of SUD symptoms and depression and anxiety symptoms, as well as clients with only severe SUD symptoms. (PsycINFO Database Record