A 6-Month Randomized Trial of a Smartphone Application, UControlDrink, in Aiding Recovery in Alcohol Use Disorder

BACKGROUND AND AIMS

Alcohol use disorder (AUD) is a substantial problem, causing early death and great economic burden. Research has highlighted the potential positive impact of technological interventions, such as smartphone applications (app) in treatment of AUD. The aim of this study was to explore the effectiveness of a smartphone app, incorporating computerized cognitive behavioural therapy and text messaging support, on alcohol outcomes over 6 months in a post-rehabilitation setting.

METHODS

A total of 111 participants with AUD were recruited into this randomized controlled trial, following completion of a 30-day rehabilitation programme. The intervention group (n = 54) used the smartphone app "UControlDrink" (UCD) over 6 months with treatment as usual (TAU), and the control group (n = 57) received TAU. All subjects suffered from AUD as the primary disorder, with other major psychiatric disorders excluded. All intervention subjects used the UCD smartphone app in the treatment trial, and all subjects underwent TAU consisting of outpatient weekly support groups. Drinking history in the previous 90 days was measured at baseline and at 3- and 6-month follow-ups. Additional measurements were made to assess mood, anxiety, craving, and motivation. Results were analysed using intention-to-treat analyses.

RESULTS

Retention in the study was 72% at 3 months and 52% at 6 months. There was a significant reduction in heavy drinking days in the intervention group relative to TAU over the 6 months, p < 0.02.

CONCLUSIONS

The UCD smartphone app demonstrates a significant benefit to reducing heavy drinking days over a 6-month post-rehabilitation period in AUD.

A learning algorithm for predicting mental health symptoms and substance use

Learning health systems use data to generate knowledge that informs clinical care, but few studies have evaluated how to leverage patient-reported mental health symptoms and substance use data to make patient-specific predictions. We developed a general Bayesian prediction algorithm that uses self-reported psychiatric symptoms and substance use within a population to predict future symptoms and substance use for individuals in that population. We validated our approach in 2444 participants from two clinical cohorts - the National Network of Depression Centers and the Johns Hopkins HIV Clinical Cohort - by predicting symptoms of depression, anxiety, and mania as well as alcohol, heroin, and cocaine use and comparing our predictions to observed symptoms and substance use. When we dichotomized mental health symptoms as moderate-severe vs. none-mild, individual predictions yielded areas under the ROC curve (AUCs) of 0.84 [95% confidence interval 0.80-0.88] and 0.85 [0.82-0.88] for symptoms of depression in the two cohorts, AUCs of 0.84 [0.79-0.88] and 0.85 [0.82-0.88] for symptoms of anxiety, and an AUC of 0.77 [0.72-0.82] for manic symptoms. Predictions of substance use yielded an AUC of 0.92 [0.88-0.97] for heroin use, 0.90 [0.82-0.97] for cocaine use, and 0.90 [0.88-092] for alcohol misuse. This rigorous, mathematically grounded approach could provide patient-specific predictions at the point of care. It can be applied to other psychiatric symptoms and substance use indicators, and is customizable to specific health systems. Such approaches can realize the potential of a learning health system to transform ever-increasing quantities of data into tangible guidance for patient care.

Patterns and temporal change of psychopathological symptoms among inpatients with alcohol use disorder undergoing a twelve-step based treatment

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Psychopathological symptom profiles and trajectories were examined among AUD inpatients.

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Three quantitatively different subgroups were identified in terms of psychopathological symptoms.

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Classes were discriminated by different psychopathological symptom change trajectories.

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Subgroups with more severe psychopathological symptoms used alcohol in a more harmful way.

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Drinking of the more severely affected classes were more motivated by coping and conformity motives.

Background

Patients diagnosed with Alcohol Use Disorder (AUD) present an increased risk for experiencing severe internalizing and externalizing symptoms. Involvement in twelve-step based treatment programs, such as the Minnesota Model (MM), can contribute to improvement of an individual’s psychopathological symptom profile. The present study’s main objective was to examine profiles and change trajectories of psychopathological symptoms of AUD subgroups during an eight-week long period of MM treatment attendance.

Method

Inpatients with AUD (N = 303) who attended MM treatment programs participated in the present study. Latent Class Growth Analysis (LCGA) was used to evaluate the psychopathological symptom change trajectories assessed by using the Brief Symptom Inventory (BSI). Multiple comparisons and multinomial logistic regression were performed to validate the subgroups.

Results

Three subgroups were identified: low severity (48.5%), moderate severity (35.2%), and high severity (16.2%) symptomatic subgroups. The moderate severity class demonstrated the largest effect in terms of symptoms decrease. Higher severity classes showed significantly higher rates of harmful alcohol drinking and drinking motives.

Conclusions

The present study identified three severity-based subgroups which indicate that psychopathology sits on a spectrum of severity among AUD patients. The findings highlight the associations between AUD and internalizing symptoms, negative reinforcement drinking motives, and the symptomatic improvement that can occur among those participating in MM treatment programs.

Factors associated with women achieving and maintaining abstinence from alcohol: a rapid evidence assessment

Purpose

The purpose of this paper is to review the literature on the factors related to women’s ability to achieve and maintain abstinence from alcohol.

Design/methodology/approach

A rapid evidence assessment was carried out in four stages: definitions and research questions were agreed, search and selection were completed, data were extracted, quality of studies was assessed, and findings were synthesised and presented.

Findings

Medline, PsycINFO, CINAHL and ASSIA were searched for cohort studies published in English during January 2000–February 2015. Expanded search terms for Women, Alcohol and Abstinence, and Cohort were used to identify relevant studies for inclusion, resulting in 1,040 records. Of these, 32 manuscripts from 31 studies were eligible for inclusion in the review. Alcohol-related factors such as increased quantity and frequency of alcohol consumption were related to lower likelihood of achieving and maintaining abstinence; treatment factors such as type of treatment and number of treatment episodes were related to higher and lower likelihood; demographic factors such as financial problems and poor housing status were related to lower likelihood; and psychological factors such as craving, other drug use and comorbid health problems were linked to lower likelihood.

Originality/value

To the authors’ knowledge, this is the first time the factors related to the specific outcome of abstinence in women have been synthesised. Many of the factors found are also known to contribute to vulnerability for developing alcohol problems. The review revealed the paucity of studies with female only samples, or where results for women were reported separately.

Alcohol use disorder relapse factors: A systematic review

A relapsing-remitting course is very common in patients with an Alcohol Use Disorder (AUD). Understanding the determinants associated with alcohol resumption remains a formidable task. This paper examines relapse determinants based on a systematic review of recent alcohol literature (2000-2019). Relevant databases were consulted for articles that contained information about specific relapse determinants and reported statistical significance of each relapse determinant in predicting relapse. Relapse was broadly defined based on the characterization in the included articles. From the initial identified 4613 papers, a total of 321 articles were included. Results encompass multiple relapse determinants, which were ordered according to biopsychosocial and spiritual categories, and presented, using a descriptive methodology. Psychiatric co-morbidity, AUD severity, craving, use of other substances, health and social factors were consistently significantly associated with AUD relapse. Conversely, supportive social network factors, self efficacy, and factors related to purpose and meaning in life, were protective against AUD relapse. Despite heterogeneity in different methods, measures, and sample characteristics, these findings may contribute to a better therapeutic understanding in which specific factors are associated with relapse and those that prevent relapse. Such factors may have a role in a personalized medicine framework to improve patient outcomes.

Predictive modeling in e-mental health: A common language framework

Recent developments in mobile technology, sensor devices, and artificial intelligence have created new opportunities for mental health care research. Enabled by large datasets collected in e-mental health research and practice, clinical researchers and members of the data mining community increasingly join forces to build predictive models for health monitoring, treatment selection, and treatment personalization. This paper aims to bridge the historical and conceptual gaps between the distant research domains involved in this new collaborative research by providing a conceptual model of common research goals. We first provide a brief overview of the data mining field and methods used for predictive modeling. Next, we propose to characterize predictive modeling research in mental health care on three dimensions: 1) time, relative to treatment (i.e., from screening to post-treatment relapse monitoring), 2) types of available data (e.g., questionnaire data, ecological momentary assessments, smartphone sensor data), and 3) type of clinical decision (i.e., whether data are used for screening purposes, treatment selection or treatment personalization). Building on these three dimensions, we introduce a framework that identifies four model types that can be used to classify existing and future research and applications. To illustrate this, we use the framework to classify and discuss published predictive modeling mental health research. Finally, in the discussion, we reflect on the next steps that are required to drive forward this promising new interdisciplinary field.

[Psychiatric readmissions: individual and organizational factors]

BACKGROUND

Psychiatric readmission often constitutes a criterion to assess the effects of various therapies, as well as the impact of organizational changes in the healthcare system. It is used to characterize relapse or decompensation. The purpose of this study was to determine readmission rates and identify individual and organizational factors associated with significant variations in these rates.

METHODS

Adult psychiatric readmissions were identified from the full-time hospital stays registered in psychiatric wards in 2011-2012 in the Nord and Pas-de-Calais departments of France, available in the medical the RimP psychiatric admission database. Readmission rates for various follow-up periods after discharge were measured by Kaplan-Meier survival analysis and multivariate analysis was conducted using the Cox proportional hazards model.

RESULTS

Approximately 30,000 adults were hospitalized full-time in psychiatric units of the region during the study period. The 24-month readmission rate was 51.6% (95%CI: 50.8-52.3%). The Cox model showed that a diagnosis of schizophrenia (F2 - HR = 1.72 - 95%CI: 1.61-1.84 - p < 0.001) and personality disorder (F6 - HR = 1.45 - 95%CI: 1.32-1.58 - p < 0.001) was associated with a higher readmission rate. Readmission rates were higher among dependent patients in non-profit private hospitals.

CONCLUSION

Psychiatric readmission is a very frequent event and is linked to organizational as well as individual factors.

Review of the efficacy of treatments for bipolar disorder and substance abuse

The aim of this study was to provide a descriptive overview of different psychological and pharmacological interventions used in the treatment of patients with bipolar disorder and substance abuse, in order to determine their efficacy. A review of the current literature was performed using the databases Medline and PsycINFO (2005-2015). A total of 30 experimental studies were grouped according to the type of therapeutic modality described (pharmacological 19; psychological 11). Quetiapine and valproate have demonstrated superiority on psychiatric symptoms and a reduction in alcohol consumption, respectively. Group psychological therapies with education, relapse prevention and family inclusion have also been shown to reduce the symptomatology and prevent alcohol consumption and dropouts. Although there seems to be some recommended interventions, the multicomponent base, the lack of information related to participants during treatment, experimental control or the number of dropouts of these studies suggest that it would be irresponsible to assume that there are well established treatments.

Acceptance and Commitment Therapy in the Treatment of Alcohol Use Disorder and Comorbid Affective Disorder: A Pilot Matched Control Trial

This study examined whether acceptance and commitment therapy (ACT) enhances treatment as usual (TAU) in improving treatment outcomes in patients with alcohol use disorder (AUD) and comorbid affective disorder. Fifty-two participants were included in the study, of whom 26 were patients with AUD and either depression or bipolar disorder treated with ACT group therapy in parallel with TAU (inpatient integrated treatment) and 26 were matched controls who had received TAU alone. Drinking and craving outcomes were total alcohol abstinence, cumulative abstinence duration (CAD) and Obsessive Compulsive Drinking Scale (OCDS) scores at 3 and 6 months postintervention. Affective and anxiety outcomes were Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and Young Mania Rating Scale (YMRS) scores at these follow-ups. Baseline demographic and clinical characteristics were similar in both groups. Retention rates were high: 100% of the ACT group were followed up at 3 and 6 months; 92.3% and 84.6% of the TAU alone group were followed up at 3 and 6 months, respectively. Patients in the ACT group reported significantly higher CAD at 3 and 6 months, significantly lower BDI and BAI scores at 3 and 6 months, and significantly lower OCDS scores at 3 months, than those who received only TAU. No other significant differences in treatment outcomes were found between the groups. ACT provides added benefit to TAU in improving drinking, craving, depression and anxiety outcomes in patients with AUD and comorbid affective disorder. Most treatment improvements were sustained over a 6-month follow-up period.

Computerised cognitive behavioural therapy for alcohol use disorder: a pilot randomised control trial

Background

Cognitive behavioural therapy (CBT) has been used in the treatment of alcohol use disorder (AUD), generally in individual or group therapy, but not via computer.

Aim

This study examined the effectiveness of an interactive, personalised, computer-based CBT therapy in a randomised control trial.

Methods

We studied a group of 55 patients with AUD, randomised to either 5-hour-long computerised CBT sessions or a placebo cognitive-stimulating session, together with a 4-week inpatient rehabilitation treatment, and followed them for 3 months.

Results

There was a high degree of patient adherence to the protocol. Both groups did well, with a significant fall in alcohol outcome measures including number of drinks per drinking day, and number of drinking days, and an increase in abstinence rates in both groups to an equivalent level. The CBT group attended alcoholics anonymous groups more frequently, and had significant alterations in their alcohol self-efficacy outcomes, which correlated with their drinking outcomes. We concluded that computerised CBT is a potentially useful clinical tool that warrants further investigation in different treatment settings for AUD.

Craving as a predictor of treatment outcomes in heavy drinkers with comorbid depressed mood

Alcohol and depression comorbidity is high and is associated with poorer outcomes following treatment. The ability to predict likely treatment response would be advantageous for treatment planning. Craving has been widely studied as a potential predictor, but has performed inconsistently. The effect of comorbid depression on craving's predictive performance however, has been largely neglected, despite demonstrated associations between negative affect and craving. The current study examined the performance of craving, measured pre-treatment using the Obsessive subscale of the Obsessive Compulsive Drinking Scale, in predicting 18-week and 12-month post-treatment alcohol use outcomes in a sample of depressed drinkers. Data for the current study were collected during a randomized controlled trial (Baker, Kavanagh, Kay-Lambkin, Hunt, Lewin, Carr, & Connolly, 2010) comparing treatments for comorbid alcohol and depression. A subset of 260 participants from that trial with a Timeline Followback measure of alcohol consumption was analyzed. Pre-treatment craving was a significant predictor of average weekly alcohol consumption at 18 weeks and of frequency of alcohol binges at 18 weeks and 12 months, but pre-treatment depressive mood was not predictive, and effects of Baseline craving were independent of depressive mood. Results suggest a greater ongoing risk from craving than from depressive mood at Baseline.

Bipolar disorder and alcohol use disorder: a review

Bipolar disorder and alcohol use disorder represent a significant comorbid population, which is significantly worse than either diagnosis alone in presentation, duration, co-morbidity, cost, suicide rate, and poor response to treatment. They share some common characteristics in relation to genetic background, neuroimaging findings, and some biochemical findings. They can be treated with separate care, or ideally some form of integrated care. There are a number of pharmacotherapy trials, and psychotherapy trials that can aid program development. Post-treatment prognosis can be influenced by a number of factors including early abstinence, baseline low anxiety, engagement with an aftercare program and female gender. The future development of novel therapies relies upon increased psychiatric and medical awareness of the co-morbidity, and further research into novel therapies for the comorbid group.

The long-lasting effects of JDTic, a kappa opioid receptor antagonist, on the expression of ethanol-seeking behavior and the relapse drinking of female alcohol-preferring (P) rats

The current study assessed the effects of the selective kappa opioid antagonist JDTic on alcohol (EtOH)-seeking behavior, EtOH relapse, and maintenance responding for EtOH. Adult alcohol-preferring (P) rats were trained in 2-lever operant chambers to self-administer 15% EtOH (v/v) on a fixed-ratio 5 (FR-5) and water on a FR-1 schedule of reinforcement during 1-hr sessions. After 10 weeks, rats underwent extinction training for seven sessions. Rats were then maintained in their home cages for 3 weeks without EtOH access. All rats received an injection (s.c.) of 0, 1, 3, or 10 mg/kg JDTic (n=11-14/group) after the first week of the home cage period. Rats were then tested using the Pavlovian Spontaneous Recovery paradigm (PSR; an animal model of alcohol-seeking) for four sessions during which, responses on the EtOH and water levers were recorded but did not produce their respective reinforcer. Following PSR testing rats were returned to their home cages without access to EtOH for one week prior to the start of EtOH relapse testing. To examine EtOH relapse responding, rats were returned to the operant chambers and the EtOH (FR5) and water (FR1) levers were active. Finally, rats were then tested over 17 operant sessions to assess the effects of JDTic on maintenance responding for EtOH. Rats received 0, 1, 3, or 10 mg/kg JDTic (counterbalanced from the initial experiment) 30 minutes prior to the initial maintenance session. JDTic administered 14 and 25 days prior to testing dose-dependently reduced the expression of an EtOH PSR and relapse responding. In contrast, JDTic did not alter EtOH responding under maintenance conditions. Overall, the results of this study indicate that different mechanisms mediate EtOH self-administration under relapse and maintenance conditions and kappa opioid receptors are involved in mediating EtOH-seeking behavior and relapse responding but not on-going EtOH self-administration.

The effectiveness of continuing group psychotherapy for outpatients with alcohol dependence: 77-month outcomes

BACKGROUND

Group psychotherapy (PT) is one of the most common interventions used to treat alcohol dependence (AD), and it is assumed to be effective. Despite its common clinical use, long-term trials that have been conducted to examine the efficacy of group PT in the treatment of outpatients with AD are limited and often lack appropriate comparisons. On that basis, a long-term comparative trial was performed with the main objective of evaluating the effectiveness of continuing group PT for outpatients with AD.

METHODS

Quasi-experimental trial was conducted from January 2004 to May 2010 in 177 AD subjects who had completed an inpatient 10-week alcohol treatment program. Abstinence rates of the combined group (experimental group: outpatient individual PT plus group PT, N = 94) and the standard outpatient individual PT-only group (comparison group, N = 83) were statistically compared using Kaplan-Meier survival analysis. Predictive factors of abstinence rate for alcohol were assessed using Cox regression analysis.

RESULTS

Abstinence rates of the combined PT group were significantly high relative to those of the outpatient individual PT-only group. Significant predictive factors for the alcohol abstinence rate were outpatient group PT and age. Even after controlling for confounding factors, outpatient group PT was a significant predictive factor for the alcohol abstinence rate.

CONCLUSIONS

Our findings indicate that for AD patients who had completed an inpatient 10-week alcohol treatment, outpatient group PT appears to be an effective form of continuing care or aftercare within the context of an outpatient service delivery system.