The Effectiveness of Cognitive Behavioral Therapy Techniques for the Treatment of Substance Use Disorders: A Narrative Review of Evidence

Coping-strategies as a mediator between emotional disorders and problematic alcohol use

BACKGROUND

Epidemiological studies reveal a high prevalence of alcohol use and comorbidity rates with emotional disorders. This study aims to explore the possible mediational effect of stress-coping strategies on the relationship between symptoms of emotional disorders and problematic alcohol use.

METHODS

The sample included 1014 participants (33.82% male, 66.17% female) aged 18 to 75 years (M = 33.0, SD = 15.15). Three mediation analyzes were carried out, for depressive, anxious and somatization symptomatology measured with the LSB-50 in which they acted as an independent variable, the coping strategies of the CSQ as a mediating variable and the problematic alcohol use, measured with AUDIT, as a dependent variable. Additionally, sex, age, educational level, and socioeconomic status were entered as covariates.

RESULTS

In all the models, problematic alcohol use was mediated by Problem-Solving Focus and Open Emotional Expression. However, while in depressive symptoms was a fully mediation, in anxious and somatization symptomatology was partially mediated.

CONCLUSIONS

The similarities found may be due to shared variance between emotional disorders. Interventions focused on Problem-Solving Focus could improve the emotional symptoms and the problematic alcohol use.

STAT: schema therapy for addiction treatment, a proposal for the integrative treatment of addictive disorders

The nature and origins of addictions and of their adjunctive behaviors, as well as their chronicity, call for treatments that conceptualize and treat them as the long-term and complex processes that they are. Addictions are often comorbid with personality problems and with trauma histories. Patients suffering from these disorders often show poor engagement with treatment and high rates of relapse, possibly because available treatments have yet to address the patient suffering from addiction in a more integrated or holistic manner. In particular, comprehensive treatment models for addictive disorders - like treatments for personality disorders or trauma - are likely to require the integration of behavioral, cognitive, and emotion-focused interventions within a facilitative therapeutic relationship. However, most current treatment models, including ones which are highly effective in stabilization or behavioral change, lack one or more components of treatment that could sustain longer term recovery, wellness, and health for a higher percentage of patients. In this article, I propose approaching addictions and their treatment from the perspective of schema therapy, an integrative, developmental model with a strong track record of positive outcomes in addressing personality disorder symptoms and long-standing trauma histories, commonly comorbid with addictive disorders. In advancing this proposal, I begin by providing some background tying together addictions, attachment, and personality, suggesting they be treated simultaneously to achieve improved outcomes. Then, after briefly reviewing the leading approaches to the treatment of addictions, I introduce the idea that schema therapy is well-situated - both theoretically and practically - to address many of the shortcomings of existing treatment options. In particular, I note how addictive and co-occurring colluding behaviors are deeply intertwined with both early and continued frustration of core developmental needs. I illustrate how the addictive cycle is perpetuated through the process of schema reinforcement and through the operation of schema modes. I then demonstrate how these key terms (i.e., needs, schemas, and modes) inform the patient's assessment and case formulation, guiding treatment interventions from a strong therapeutic relationship that focuses on integrating recovery behavior change, healing dysfunctional schemas and modes, and preventing relapse.

Community Mental Health Services for Frequent Emergency Department Users: A Qualitative Study of Outcomes Perceived by Program Clients and Case Managers

PURPOSE OF STUDY

This study aimed to investigate the perceived outcomes and mechanisms of change of a community mental health service combining system navigation and intensive case management supports for frequent emergency department users presenting with mental illness or addiction.

PRIMARY PRACTICE SETTING

The study setting was a community mental health agency receiving automated referrals directly from hospitals in a midsize Canadian city for all individuals attending an emergency department two or more times within 30 days for mental illness or addiction.

METHODOLOGY AND SAMPLE

Qualitative interviews with 15 program clients. Focus groups with six program case managers. Data were analyzed using pragmatic qualitative thematic analysis.

RESULTS

Participants generally reported perceiving that the program contributed to reduced emergency department use, reduced mental illness symptom severity, and improved quality of life. Perceived outcomes were more mixed for outcomes related to addiction. Reported mechanisms of change emphasized the importance of positive working relationships between program clients and case managers, as well as focused efforts to develop practical skills.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Community mental health services including intensive case management for frequent emergency department users presenting with mental illness or addiction were perceived to effectively address client needs while reducing emergency department resource burden. Similar programs should emphasize the development of consistent and warm working relationships between program clients and case managers, as well as practical skills development to support client health and well-being.

Evaluating the effectiveness of a mobile app-based self-guided psychological interventions to reduce relapse in substance use disorder: protocol for a randomized controlled trial

Background

Substance Use Disorder (SUD) persists as a significant public health challenge worldwide, with an estimated prevalence of approximately 10-15% across the global populace. This condition is characterized by a notably high risk of lapses and relapses, even subsequent to treatment interventions. Mobile health interventions, owing to their widespread accessibility, emerge as a promising approach to diminish the risk of relapse post-treatment and to broaden the scope of care, especially in regions with a scarcity of trained medical professionals.

Method

This study is designed to assess the effectiveness of mobile interventions in mitigating cravings and preventing lapses among individuals diagnosed with SUD. Employing a two-armed, randomized controlled trial framework, the study will evaluate a self-administered psychological intervention delivered through a mobile application, Nałogometr 2.0. Over a period of three months, participants will engage with intervention modules that primarily incorporate mindfulness techniques and Cognitive Behavioral Therapy (CBT) principles. Ecological Momentary Assessment (EMA) will be utilized to gather longitudinal data on a range of variables that are indicative of craving intensity and the risk of lapse. In addition to this, a monthly-administered battery of questionnaires will be employed to gauge the severity of substance dependence, as well as to measure levels of anxiety, depression, and overall life satisfaction.

Results

Results will be submitted for publication in peer-reviewed journals.

Clinical trial registration

https://clinicaltrials.gov/, identifier [NCT05730504].

Treatment Approaches for Problematic Pornography Use: A Systematic Review

Problematic pornography use (PPU) is an emerging condition associated with several negative psychological and sexual outcomes. This study aimed to systematically review treatment approaches for PPU. Potentially eligible studies were searched for in PubMed/MEDLINE, Embase, PsycINFO, and Web of Science up to April 1, 2023. The quality of the evidence was assessed with the use of the Joanna Briggs Institute's checklists, the Cochrane risk-of-bias tools, and the GRADE approach. A total of 8936 references were retrieved, and 28 studies were included in the systematic review (n = 500 participants). Included studies were case reports (k = 16), case series (k = 1), quasi-experimental investigations (k = 7), and randomized clinical trials (k = 4). The majority of included studies presented overall low quality and significant risk of bias, with all interventions receiving a low or very low rating according to the GRADE approach. Most studies investigated psychological interventions, with the predominance of second and third wave cognitive behavioral therapy interventions. Pharmacological treatments included opioid antagonists (naltrexone in most cases) and antidepressants, while one study investigated a protocol that included rTMS. Several investigations described the combination of psychological and pharmacological approaches. Most studies did not report on side effects, with online and self-help interventions presenting significant issues in terms of treatment adherence. Even though there are promising options that may have efficacy for the treatment of patients with PPU, the literature in the topic still presents significant limitations that compromise the reaching of more definitive conclusions.

Cognitive Behavioral Immersion for Substance Use Disorders: A Feasibility and Pilot Study of a Peer-Based Coaching Program in the Metaverse

Introduction: Cognitive Behavioral Immersion (CBI) is a novel cognitive-behavioral skills program delivered by lay coaches in the metaverse through immersive virtual reality technology. Objectives: The objective for this study was to run a feasibility and pilot study of CBI for individuals in recovery from a substance use disorder. Methods: Data from 48 participants were used and program usage was assessed. Participants were asked to complete questionnaires assessing affect, perceived online social support, and group therapy alliance throughout their participation in the program. Structured qualitative interviews were also conducted with a subset of participants (n = 11) to understand the feasibility of the novel program. Results: Participants experienced a significant increase in their positive affect and non-significant decrease in their negative affect during their most recently attended session. Participants also experienced a nonsignificant increase in online social support across their participation in the program. Structured qualitative interviews revealed eight primary themes, including both advantages (community, psychoeducational impact, immersion, comparability with other interventions, coping in the pandemic, and anonymity) and areas of improvement (challenges and technological usability) of the program. Conclusion: This study provides preliminary support for the feasibility and potential effects of CBI and its incorporation of lay coaches to lead cognitive-behavioral skills groups in the metaverse. Future research is encouraged to examine the feasibility and efficacy of this program for a broader array of clinical presentations.

Meta-review on the efficacy of psychological therapies for the treatment of substance use disorders

This meta-review aimed to summarize the current state of knowledge provided by meta-analyzes on the efficacy of psychotherapies for substance use disorders. A systematic search was performed in PubMed, PsycINFO, Web of Science and Google Scholar. Meta-analyzes were included if they quantitatively examined the efficacy of a psychotherapy on substance use. Among the 6866 potential articles that were screened for eligibility, 23 meta-analyzes were eligible (78 effect sizes). Each meta-analysis included 2-156 studies, with samples ranging between approximately 130 to over 33,000 individuals. The quality of evidence was evaluated as being globally of low to moderate quality. Substances were categorized as: alcohol (k = 12), cannabis (k = 7), stimulants (k = 4), opioids (k = 3) and benzodiazepines (k = 1). Interventions comprised brief intervention, cognitive-behavioral therapy, contingency management, voucher-based reinforcement therapy, motivational interview, motivational enhancement therapy, significant other people involved in the treatment, and cue-expose therapy. Concerning solely significant results, small benefits were observed for significant other people involved in treatment, motivational interviewing, and the combination of cognitive-behavioral therapy with motivational interviewing for alcohol use disorder. Likewise, small-to-moderate effects were found for motivational approaches, and cognitive-behavioral therapy as well as the combination of cognitive-behavioral therapy and motivational enhancement therapy in the case of cannabis use disorder. Small effects were observed for contingency management as well as cognitive behavioral-therapy for amphetamine-type use disorder. Small effects were similarly found for contingency management for cocaine use disorder. Concerning opioid use disorder, moderate effects were observed for contingency management and voucher-based reinforcement intervention. For benzodiazepine use disorder, small effects were noted for cognitive-behavioral therapy with taper. Results often displayed small to moderate heterogeneity when reported and were generally compared to inactive controls, such as treatment-as-usual. In all, the psychosocial treatments for substance use disorders included in this meta-review have shown to be at best moderately effective over inactive controls in the short term. Nevertheless, further trials are needed as well as meta-analyzes on interventions not included in this meta-review.

Culturally adapted motivational interviewing with cognitive behavior therapy and mindfulness-based relapse prevention for substance use disorder in Pakistan (CAMAIB): protocol for a feasibility factorial randomised controlled trial

BACKGROUND

The use of psychoactive substances significantly impacts the health, social and economic aspects of families, communities and nations. There is a need to develop and test psychological interventions aimed for individuals with substance use disorder (SUD) in lower- and middle-income countries (LMICs), such as in Pakistan. The aim of this exploratory trial is to test the feasibility and acceptability of two culturally adapted psychological interventions in a factorial randomised controlled trial (RCT).

METHODS

The proposed project will be conducted in three phases. The first phase of the study will focus on cultural adaptation of the interventions through qualitative interviews with key stakeholders. The second phase will be to refine and produce manually assisted interventions. Third and last stage would be to assess the feasibility of the culturally adapted interventions through a factorial RCT. The study will be carried out in Karachi, Hyderabad, Peshawar, Lahore and Rawalpindi, Pakistan. Recruitment of participants will take place from primary care and volunteer organisations/drug rehabilitation centres. A total of 260 individuals diagnosed with SUD (n = 65) in each of the four arms will be recruited. The intervention will be delivered weekly over a period of 12 weeks in both individual and group settings. Assessments will be carried out at baseline, at 12th week (after completion of intervention) and 24th week post-randomisation. The analysis will determine the feasibility of recruitment, randomisation, retention and intervention delivery. Acceptability of intervention will be determined in terms of adherence to intervention, i.e. the mean number of sessions attended, number of home assignments completed, attrition rates, as well as through process evaluation to understand the implementation process, context, participants' satisfaction, and impact of the study intervention. The health resource use and impact on the quality of life will be established through health economic data.

DISCUSSION

This study will provide evidence for feasibility and acceptability of culturally adapted manually assisted psychological interventions for individuals with SUD in the context of Pakistan. The study will have clinical implications if intervention is proven feasible and acceptable.

TRIAL REGISTRATION

Name of the registry: ClinicalTrials.gov, Trial registration number: NCT04885569 , Date of registration: 25th April 2021.

Neural cue-reactivity in pathological gambling as evidence for behavioral addiction: a systematic review

Increasing incidence of problem gambling has led to prioritizing the problem from the point of view of public health. Additionally, gambling disorder has been recently classified as a behavioral addiction, with implications for both its diagnosis and treatment. However, the shared neural substrate of addictions, to substances and behavioral, is still discussed. Thus, this systematic review aims to provide up-to-date knowledge from the past five years (2017-2022) concerning the neural correlates of gambling related stimuli (cue-reactivity) on the basis of a previous review (Brevers et al., Cognitive, Affective and Behavioral Neuroscience 18:718-729, 2019). A total of five studies were included in the review. Activation of brain areas related to memory, reward and executive functions could be the underlying mechanism of this behavioral addiction. Specifically, nucleus accumbens and striatum (ventral and dorsal), parahippocampal regions, the right amygdala and several prefrontal cortex regions have systematically been found more active in those subjects exposed to gambling-related cues. Also, the insula could play a pivotal role connecting these three systems in a highly integrated neural network with several implications for reward processing modulation, associative learning and top-down attentional regulation to improve saliency of addiction-related cues. These results are consistent with previous findings on other substance addictions, such as alcohol, tobacco, marijuana or cocaine. The study of neural reactivity to stimuli related to addiction could be useful as a biomarker of the severity of the disorder, the efficacy of the treatment, the risk of relapse, in addition to being an objective criterion to measure the effectiveness of prevention campaigns.

Alter Game: A Study Protocol on a Virtual "Serious Game" for Relapse Prevention in Patients With Gambling Disorder

Cognitive behavioral therapy (CBT) is the most successful protocol in gambling disorder (GD) treatment. However, it presents some weaknesses, especially concerning relapse prevention (RP). RP is one of the most important therapeutic steps, aiming at managing cravings and to avoid future relapse increasing perceived self-efficacy. Encouraging results come from the blending of psychotherapy and virtual reality (VR), containing gambling cues. The goal of Alter Game (approved by the Ethical Commission, Prot. No. 69346) is verifying the efficacy of an innovative psychological treatment for GD based on the integration of traditional CBT therapy and an immersive VR cue exposure therapy using a serious virtual game, which is a game designed for purposes other than entertainment. RP in virtual cue-exposure therapy allows pathological gamblers to manage the urge to gamble and to avoid relapse by becoming aware of which internal and external triggers are related to craving. We hypothesize that the integrated intervention will be more effective than simple CBT with regard to self-efficacy, craving, and gambling-related distortions. Four virtual ecological environments were developed, and a virtual app, Exludo, interfaced with a computerized multiparametric acquisition system for biofeedback, was created. A sample of about 60 patients aged between 18 and 65 with GD referring to the Addiction Medicine Unit of Verona (Rossi Hospital) will be recruited. Patients will be randomly assigned to the CBT group (16 CBT sessions) or the CBT + VR group (8 CBT sessions + 8 VR cue-exposure therapy sessions). The MCMI-III, the BIS-11, and the SOGS will be used to evaluate inclusion and exclusion criteria, while the Gambling Related Cognitions Scale and the Multidimensional Gambling Self-Efficacy Scale will be used to verify changes as a function of the treatment. Craving will be evaluated through VAS, and psychophysiological variables will be assessed through biofeedback. A pre-test/post-test experimental design with a 1-month follow-up will be conducted. This study will examine an innovative psychotherapeutic protocol for GD treatment, and it will help in identifying new virtual tools to increase the efficacy of traditional therapeutic approaches that could also be applied to treat other addictions.