LETS Act: a behavioral activation treatment for substance use and depression

Heterogeneity in choice models of addiction: the role of context

RATIONALE

Theories of addiction guide scientific progress, funding priorities, and policy development and ultimately shape how people experiencing or recovering from addiction are perceived and treated. Choice theories of addiction are heterogenous, and different models have divergent implications. This breeds confusion among laypeople, scientists, practitioners, and policymakers and reduces the utility of robust findings that have the potential to reduce the global burden of addiction-associated harms.

OBJECTIVE

Here we differentiate classes of choice models and articulate a novel framing for a class of addiction models, called contextual models, which share as a first principle the influence of the environment and other contextual factors on behavior within discrete choice contexts.

RESULTS

These models do not assume that all choice behaviors are voluntary, but instead that both proximal and distal characteristics of the choice environment-and particularly the benefits and costs of both drug use and non-drug alternatives-can influence behavior in ways that are outside of the awareness of the individual. From this perspective, addiction is neither the individual's moral failing nor an internal uncontrollable urge but rather is the result of environmental contingencies that reinforce the behavior.

CONCLUSIONS

Contextual models have implications for guiding research, practice, and policy, including identification of novel target mechanisms while also improving existing interventions.

Impact of a brief distress intolerance intervention on acute stress modulation of response inhibition neurophysiology in cannabis use disorder

BACKGROUND

The prevalence of cannabis use in the US has increased within the past two decades. Moreover, cannabis use disorder (CUD) is associated with significant disability, but the underlying neural mechanisms of CUD are unclear. Distress intolerance (DI), a psychological risk factor for CUD, may confer risk in part via impaired inhibitory control (IC) capacity during acute stress. DI and cannabis use problems have been associated with altered N2 amplitude, an IC-related event-related potential, in prior cross-sectional studies, but whether altered N2 is a state marker of CUD severity, a pathoplastic factor responsive to intervention and predictive of CUD symptom change over time, or an enduring trait-like vulnerability is unclear. In this secondary analysis, we tested the impact of a DI-targeted intervention on acute stress-related modulation of the N2 and whether pre-intervention N2 predicted CUD symptom change through follow-up.

METHOD

Sixty participants were randomly assigned to a DI-targeted or control intervention. Participants completed an IC task before and after a stress induction at pre- and post-intervention lab visits while EEG activity was recorded.

RESULTS

The DI intervention did not alter the N2 compared to a control intervention. Pre-intervention post-stress IC-related N2 was associated with worse CUD severity but did not predict changeover time.

CONCLUSION

Findings are consistent with blunted N2 after acute stress acting as a stable marker of CUD severity rather than a pathoplastic factor predictive of CUD trajectory. Future research should investigate whether stress-related blunting of N2 is a consequence of severe CUD or a pre-existing vulnerability.

A contextualized reinforcer pathology approach to addiction

Behavioural economic accounts of addiction conceptualize harmful drug use as an operant reinforcer pathology, emphasizing that a drug is consumed because of overvaluation of smaller immediate rewards relative to larger delayed rewards (delay discounting) and high drug reinforcing value (drug demand). These motivational processes are within-individual determinants of behaviour. A third element of learning theory posits that harmful drug use depends on the relative constraints on access to other available activities and commodities in the choice context (alternative reinforcers), reflecting the substantial influence of environmental factors. In this Perspective, we integrate alternative reinforcers into the contemporary behavioural economic account of harmful drug use - the contextualized reinforcer pathology model - and review empirical literature across the translational spectrum in support of this model. Furthermore, we consider how increases in drug-related mortality and health disparities in addiction can be understood and potentially ameliorated via a contextualized reinforcer pathology model in which lack of alternative reinforcement is a major risk factor for addiction.

Associations between Alcohol-Free Sources of Reinforcement and the Frequency of Alcohol and Cannabis Co-Use among College Freshmen

Co-use of alcohol and cannabis is common among young adults in the United States. A behavioral economics framework indicates that greater engagement in substance-free sources of reinforcement may be protective against co-use frequency. The current study tested the association between proportionate alcohol-free reinforcement and the frequency of co-use among college freshmen. Participants (N = 86) were freshmen who enrolled in a freshman orientation course and completed surveys at the beginning of the semester. Past month alcohol use, cannabis use, and reinforcement from alcohol-free and alcohol-involved activities were assessed. A zero-inflated Poisson regression was used to test the association between proportionate alcohol-free reinforcement and days of co-use. The results indicated that proportionate alcohol-free reinforcement was negatively associated with co-use days in the count model when controlling for alcohol use days and gender as covariates (β: -3.28, p = 0.016). Proportionate alcohol-free reinforcement did not significantly differentiate individuals who did not engage in co-use in the zero-inflated model (β: -1.68, p = 0.497). The study suggested that greater proportionate alcohol-free reinforcement may be associated with lower engagement in the co-use of alcohol and cannabis among young adults. Increasing engagement in alcohol-free sources of reinforcement may be considered a target for co-use prevention or harm reduction efforts.

A pilot study on the feasibility, acceptability, and preliminary efficacy of a brief text message intervention for co-occurring alcohol misuse and PTSD symptoms in a community sample

Accessible, brief, and self-directed intervention are needed to improve treatment access for individuals with co-occuring PTSD and alcohol misuse. This pilot study tests the feasibility, acceptability, and preliminary efficacy of a brief text message intervention based on cognitive behavioral therapy plus message framing (CBT + Framing) compared to active control providing kind support and attention (KAM), to reduce PTSD symptoms and alcohol use. Two waves of community-based data collection (Wave 1 n = 50; Wave 2 n = 59) were completed. Participants self-reported symptoms at baseline, post-intervention, and 8-week follow-up. Engagement and retention were high, suggesting messages were feasible and acceptable. Across waves and conditions, from baseline to follow-up primary outcomes of PTSD symptoms (medium to large effects), weekly drinks (medium effects), and heavy episodic drinking (small to medium effects) decreased. Consistent with hypotheses, CBT + Framing outperformed KAM for PTSD at post in Wave 2 and for number of heavy drinking episodes at both post and follow-up in Wave 1. Contrary to hypotheses, KAM outperformed CBT + Framing for PTSD at post in Wave 1, and minimal differences were observed between conditions for weekly drinks in both waves. Future studies should continue to develop and test brief, accessible interventions.

Learn, Engage, Act, Dedicate (LEAD): development and feasibility testing of a task-shifted intervention to improve alcohol use, depression and family engagement for fathers

BACKGROUND

Men's depression, alcohol use, and family problems commonly co-occur to create of cluster of mental health problems. Yet, few treatments exist to address these problems, especially in low and middle-income countries (LMICs). This paper describes the development and initial feasibility and acceptability of a novel task-shifted intervention to address this cluster of men's mental health problems with a focus on engaging and retaining men in treatment.

METHODS

The intervention, Learn, Engage, Act, Dedicate (LEAD), is based in behavioral activation blended with motivational interviewing and was pilot tested in Kenya. To develop LEAD, we engaged in a community-engaged multi-step, collaborative process with local Kenyan stakeholders. LEAD was piloted with nine fathers reporting problem drinking. To assess initial feasibility and acceptability, recruitment and participation were tracked and descriptive statistics were generated given engagement of men was key for proof of concept. Semi-structured interviews were conducted with participants and analyzed using thematic content analysis.

RESULTS

The development process resulted in a weekly 5-session intervention rooted in behavioral activation, motivational interviewing, and masculinity discussion strategies. These approaches were combined and adapted to fit contextually salient constructs, such as the importance of the man as provider, and streamlined for lay providers. Feasibility and acceptability results were promising with high attendance, acceptability of delivery and intervention content, and perceived intervention helpfulness.

CONCLUSION

Results describe an acceptable task-shifted treatment that may engage men in care and addresses a cluster of common mental health problems among men in ways that consider social determinants like masculinity. Findings set the stage for a larger trial. Trial registration ISRCTN, ISRCTN130380278. Registered 7 October 2019-Retrospectively registered, http://www.isrctn.com/ISRCTN13038027.

Act Healthy: A Randomized Clinical Trial Evaluating a Behavioral Activation Intervention to Address Substance Use and Medication Adherence Among Low-Income, Black/African American Individuals Living with HIV/AIDS

There is a need for parsimonious behavioral interventions to support HIV and substance use treatment outcomes for low-income, Black/African American individuals living with HIV. This randomized clinical trial (N = 61) evaluated Act Healthy (AH), an integrated behavioral intervention to reduce substance use and improve medication adherence, compared to supportive counseling (SC) plus Life-Steps medication adherence counseling on substance use, craving, adherence-related outcomes, and depression over one year. Participants in AH had significantly steeper decreases in cravings compared to SC, but no significant differences in substance use. Across both groups, there was a significant increase in probability of being on antiretroviral therapy (ART) (86% on ART at 12 months vs. 56% at baseline), and a significant decrease in medication nonadherence. Findings provide preliminary support for an intervention to reduce cravings and strategies to improve ART use in a hard-to-reach, vulnerable population at high risk for poor treatment outcomes and ongoing HIV transmission. TRIAL REGISTRATION: ClinicalTrials.gov trial registration number: identifier: NCT01351454. Retrospectively registered on May 10, 2011.

A Mobile App to Enhance Behavioral Activation Treatment for Substance Use Disorder: App Design, Use, and Integration Into Treatment in the Context of a Randomized Controlled Trial

Background

Group-based formats typically used in low-resource substance use disorder (SUD) treatment settings result in little individual attention to help reinforce and guide skill use, which may contribute to poor posttreatment outcomes. Smartphone apps offer a convenient, user-friendly, and cost-effective tool that can extend the reach of effective SUD treatments. A smartphone app was developed and integrated into a group-based, brief behavioral activation (BA) treatment for SUD to increase engagement in treatment skills outside clinician-administered sessions.

Objective

This study aims to describe the features of the app and its use and integration into treatment, report the participants’ self-reported feasibility and acceptability of the app, and discuss challenges and provide recommendations for future smartphone app integration into behavioral treatments for SUD.

Methods

A total of 56 individuals recruited from intensive outpatient SUD treatment received a smartphone-enhanced BA treatment, the Life Enhancement Treatment for Substance Use. Self-reported weekly app use and reasons for nonuse were assessed at posttreatment and at 1- and 3-month follow-ups. In addition, 2-tailed t tests and chi-square tests compared the self-reported use of each app component and overall app use over time.

Results

Participant feedback suggested that the integration of the smartphone app into the Life Enhancement Treatment for Substance Use was feasible and well accepted, and participants found the app useful for planning value-based activities outside of sessions. Self-reported app engagement decreased over the follow-up period: 72% (39/54) of participants reported using the app at posttreatment, decreasing to 69% (37/54) at the 1-month follow-up and 37% (20/54) at the 3-month follow-up. Participants reported forgetting to use the app as a primary reason for nonuse.

Conclusions

This study provides support for the feasibility and acceptability of smartphone-enhanced BA treatment, offering promise for future research testing the integration of technology into SUD treatment. Design decisions may help streamline smartphone integration into treatment, for example, allowing participants to download the treatment app on their own phones or use a low-cost study smartphone (or offering both options). Long-term app engagement may be increased via built-in reminders, alerts, and in-app messages.

Trial Registration

ClinicalTrials.gov NCT02707887; https://clinicaltrials.gov/ct2/show/study/NCT02707887

Building community-based helping practices by training peer-father counselors: A novel intervention to reduce drinking and depressive symptoms among fathers through an expanded masculinity lens

BACKGROUND

Problem drinking and co-occurring depression symptoms affect men at high rates and are associated with increased risk of family violence. In low- and middle-income countries, there is a large treatment gap for services due to a lack of human resources. Moreover, masculine norms are a barrier to men seeking treatment for drinking and depression in healthcare settings. We examined an approach for engaging peer-fathers to deliver an intervention to reduce alcohol use, improve depressive symptoms, and increase family involvement among fathers in Kenya with problem drinking. The intervention-LEAD (Learn, Engage, Act, Dedicate)-combines motivational interviewing, behavioral activation, and masculinity discussion strategies.

METHODS

Community and religious leaders nominated fathers with no mental health training to serve as counselors (N=12); clients were recruited through community referrals. Nominated fathers completed a 10-day training beginning with treatment principles followed by manualized content. Three counselors were selected after training based on quantitative and qualitative assessments of communication skills, intervention knowledge, willingness to learn, ability to use feedback, and empathy. Supervision was tiered with local supervisors and clinical psychologist consultation. During LEAD delivery, counselor fidelity, delivery quality, and general and intervention-specific competencies were assessed. To evaluate acceptability, qualitative interviews were conducted with lay-counselors and clients (N=11). Descriptive statistics were calculated for quantitative outcomes; interviews were analyzed using thematic analysis.

RESULTS

Peer-father lay counselors treated nine clients, with eight completing treatment. Counselors reached high rates of fidelity (93.8%) and high to optimal ratings on quality of delivery, clinical competency, and intervention-specific competencies. Qualitative results suggested high acceptability, with counselors expressing satisfaction and empowerment in their roles. Clients likewise described positive experiences with counselors.

CONCLUSIONS

Findings provide initial support for the acceptability and feasibility of recruitment, selection, and training processes for peer-father lay counselors to deliver LEAD through a lens of masculinity that aligned with clients help-acceptance practices.

Is behavioral activation an effective and acceptable treatment for co-occurring depression and substance use disorders? A meta-analysis of randomized controlled trials

BACKGROUND

Depression often co-occurs with substance use problems and is associated with poor treatment outcomes. While the efficacy of behavioral activation (BA) has been tested in clinical trials with substance users, outcomes have not yet been quantitatively synthesized.

METHODS

The study team performed a random effects meta-analysis of the randomized clinical trial evidence base. We compared outcomes for individual or group BA against passive or active controls. We also compared attendance and dropout rates. The meta-analysis used a grading of recommendations assessment, development, and evaluation (GRADE) approach to assess the quality of each meta-analytic comparison.

RESULTS

We included five trials in the meta-analysis (N = 195). The analysis found no significant differences between BA and controls with regard to depression (Post-treatment: k = 5; N = 195; SMD: 0.19, CI -0.10 to 0.49; p = 0.20; GRADE = Low; Follow-up: k = 5; N = 195; SMD: -0.10, CI -0.51 to -0.30; p = 0.62; GRADE = Low) or substance use (post-treatment: k = 4; N = 151; SMD: 0.14, CI -0.33 to -0.6; p = 0.57, GRADE = Low; Follow-up: k = 4; N = 151; SMD: 0.17, CI -0.34 to 0.69; p = 0.51, GRADE = Low) and there was little evidence of publication bias. The average session attendance rate for BA was 72%. An average dropout rate of 35% was reported for both BA and comparator conditions.

CONCLUSION

BA does not emerge as a differentially efficacious treatment for comorbid depression and substance use disorders, although it does appear to be an acceptable treatment option. Our confidence in the results are limited by the number and quality of the original studies and the possibility of the effect of small study bias. We make suggestions for improving the methodological quality and direction of future BA trials.

Drinking to Cope with Posttraumatic Stress: A Nationally Representative Study of Men with and without Military Combat Experience

Posttraumatic stress disorder (PTSD) and hazardous alcohol use are prevalent among trauma survivors. Despite higher rates of both PTSD and hazardous alcohol use among military combat veterans than civilians, scant research has examined whether military combat experience is associated with drinking alcohol to cope with PTSD symptoms. This study tested the hypothesis that compared to trauma-exposed men without combat experience, men with military combat experience would be more likely to endorse drinking alcohol to cope with their PTSD symptoms. Methods: Interview data from N = 11,474 men who reported at least one lifetime traumatic experience were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a face-to-face interview study that recruited a nationally representative sample of adults living in the United States between 2004 and 2005. Results: Among men endorsing lifetime trauma exposure, men with military combat experience (n = 1,386) were more likely than men without combat experience (n = 10,088) to report drinking alcohol to cope (7.22 vs. 2.61% in unweighted analyses, 6.46 vs. 2.37% in weighted analyses). Total number of lifetime trauma types, lifetime PTSD severity, and lifetime alcohol abuse/dependence were significantly associated with drinking to cope in bivariate and multivariate analyses. Military combat experience was significantly associated with drinking to cope in multivariate analyses adjusting for lifetime PTSD diagnosis. Military combat experience was not significantly associated with drinking to cope in multivariate analyses adjusting for lifetime PTSD symptom count. Conclusions: Although military combat experience was significantly associated with drinking to cope in bivariate analyses, multivariate analyses yielded mixed findings: combat experience was significantly associated with drinking to cope in models adjusting for PTSD diagnosis, but not in models adjusting for PTSD symptom count. Findings highlight the importance of assessing and targeting PTSD symptom-related alcohol use, even in the absence of alcohol abuse/dependence. Results from this preliminary study could inform future research on drinking to cope with PTSD symptoms among military combat veterans and other trauma survivors.

Feasibility, acceptability and future adaptation of the Chinese translated Behavioural activation (C-BA) treatment for depression: A pilot study

BACKGROUND

Although depression is prevalent among Chinese international students (CIS), only 4% of CIS seek treatment. Behavioural activation (BA) has been suggested as a culturally sensitive treatment for depression that has the potential to meet the clinical needs of CIS. The current pilot study tested the feasibility, acceptability and themes for future cultural adaptations of a Chinese translated BA treatment (C-BA) among CIS.

METHODS

Six CIS with elevated depressive symptoms (Beck Depression Inventory, BDI ≥ 14) completed a six-session individual C-BA treatment and assessments at pre- and post-treatment and a 1-month follow-up. Primary outcome measures included treatment feasibility, acceptability and qualitative interview data informing future adaption of C-BA. Exploratory analyses examined group changes in depressive symptoms over time and clinically significant symptom changes on individual levels.

RESULTS

All participants found the treatment to be highly feasible and culturally acceptable, and were highly engaged in the treatment. Themes of future cultural adaptions were generated from the qualitative interviews. Significant decreases in depressive symptoms were observed at a one1-month post-treatment follow-up assessment.

CONCLUSIONS

Preliminary evidence suggests that C-BA has the potential to be a culturally sensitive treatment for depression among CIS. CIS demonstrated openness to psychotherapy and high treatment engagement.

Psychosocial factors associated with treatment outcomes in women with obesity and major depressive disorder who received behavioral activation for depression

Behavioral activation is an empirically supported treatment for depression, but much is unknown about factors associated with treatment response. The present study aimed to determine whether baseline levels and subsequent changes in psychosocial factors were associated with improvement in depression in women with comorbid obesity who received behavioral activation treatment for depression and a lifestyle intervention. Multilevel modeling was used to estimate the associations between psychosocial factors and change in depression scores during the first 10 weeks of treatment and associations between changes in psychosocial factors from baseline to 6-month follow-up and change in depression over the same time period. No baseline psychosocial factors were associated with depression improvement during treatment (p = 0.110-0.613). However, greater improvement in hedonic capacity (p = 0.001), environmental reward (p = 0.004), and social impairment (p = 0.012) were associated with greater reductions in depression over 6 months. Findings highlight the differential relationship specific psychosocial factors have with depression treatment outcomes.

Neural reward response to substance-free activity images in opiate use disorder patients with depressive symptoms

BACKGROUND

Deficits in the ability to experience reward from natural, substance-free activities and stimuli is a common mechanism contributing to both opiate use disorder and depressive symptoms, and is a target of behavioral-focused treatments for substance use and depression. Although the neural response to monetary, positive affect-eliciting and social images has been investigated, the neural response to images representing substance-free activity engagement remains untested. The current study tested the neural response to anticipation and receipt of substance-free activity engagement images and monetary reward in opiate use disorder patients with elevated depressive symptoms compared to healthy controls.

METHODS

Sixteen male opiate use disorder detoxification patients with elevated depressive symptoms (Beck Depression Inventory (BDI-II) ≥ 14) (OUDD M_age = 32.19 years, SD = 8.17 years) and seventeen male healthy controls (BDI-II < 14) (HC: M_age = 26.82 years, SD = 5.29 years) completed the Monetary Incentive Delay (MID) and newly developed Activity Incentive Delay (AID) tasks. Within- and between-group whole-brain contrasts tested activation during anticipation ([reward]-[non-reward]) and receipt ([win]-[non-win]) of substance-free activity image, monetary, and substance-free activity relative to monetary (AID-MID), reward.

RESULTS

OUDD demonstrated significantly lower activation in reward regions during anticipation and significantly greater activation during receipt of substance-free activity image reward compared to HC. OUDD demonstrated significantly lower activation during anticipation of substance-free activity reward relative to monetary reward, compared to HC.

CONCLUSIONS

The observed reduction in frontostriatal response to reward anticipation of substance-free activity engagement images in OUDD, yet increased neural response to reward receipt, supports theory linking reductions in reward processing with deficits in motivation for substance-free activity engagement.

Diminished alternative reinforcement as a mechanism linking conduct problems and substance use in adolescence: a longitudinal examination

AIMS

To determine whether diminished alternative reinforcement (i.e. engagement and enjoyment from substance-free activities) mediated the longitudinal association of conduct problems with substance use in early-mid-adolescence.

DESIGN

Structural equation modeling tested whether the association between wave 1 (baseline) conduct problems and wave 3 (24-month follow-up) substance use outcomes was mediated by diminished alternative reinforcement at wave 2 (12-month follow-up). Additional analyses tested whether sex and socio-economic status moderated this association.

SETTING

Ten high schools in Los Angeles, CA, USA, 2013-15.

PARTICIPANTS

Students (n = 3396, 53.5% female, mean [standard deviation (SD)] age at wave 1 baseline = 14.1 (0.42) years).

MEASUREMENTS

Self-reported conduct problems (11-item questionnaire), alternative reinforcement (44-item questionnaire) and use of alcohol, marijuana and combustible cigarettes during the past 6 months (yes/no) and the past 30 days (nine-level ordinal response based on days used in past 30 days).

RESULTS

Significant associations of wave 1 conduct problems with wave 3 marijuana use during the past 6 months (β = 0.25) and past 30 days (β = 0.26) were mediated by wave 2 diminished alternative reinforcement (β_{indirect effect} : 6 months = 0.013, 30 days = 0.017, Ps < 0.001). Associations of conduct problems with alcohol or combustible cigarette use were not mediated by alternative reinforcement. All associations did not differ by sex and socio-economic status.

CONCLUSIONS

Diminished alternative reinforcement may be a modifiable mechanism linking early adolescent conduct problems and subsequent marijuana use that could be targeted in prevention programs to offset the adverse health and social sequelae associated with comorbid conduct problems and marijuana use in early-mid adolescence.

The effect of a behavioral activation treatment for substance use on post-treatment abstinence: a randomized controlled trial

AIMS

To compare outcomes for a behavioral activation group treatment for substance use [life enhancement treatment for substance use (LETS ACT)] versus a time and group size-matched control condition delivered in a residential treatment setting.

DESIGN

Single-site two-arm parallel-group randomized clinical trial with follow-up assessment at 3, 6 and 12 months post-treatment.

SETTING

Residential substance use treatment facility in the United States.

PARTICIPANTS

Participants were 263 adults [mean age 42.7 (11.8); 29.5% female; 95.4% African American; 73.2% court mandated] whose insurance dictated 30-day (65.9%) or 90-day (34.1%) treatment duration.

INTERVENTION AND COMPARATOR

LETS ACT (n = 142) is a treatment developed originally for depression and modified for substance use. It teaches participants to increase positively reinforcing value-driven activities in order to counter depression and relapse. The control group [supportive counseling (SC); n = 121] received time and group size-matched supportive counseling. Treatment was delivered in five or eight 1-hour sessions depending on patient length of stay.

MEASUREMENTS

Percentage abstinent at follow-up, percentage of substance use days among those reporting use, depressive symptoms [Beck Depression Inventory (BDI)] and adverse consequences of drug use [Short Inventory of Problems-Alcohol and Drug (SIP-AD)].

FINDINGS

LETS ACT had significantly higher abstinence rates at 3 months [odds ratio (OR) = 2.2, 95% confidence interval (CI) = 1.3-3.7], 6 months (OR = 2.6, 95% CI= 1.3-5.0) and 12 months (OR = 2.9, 95% CI = 1.3-6.1) post-treatment compared with SC. LETS ACT participants reported significantly fewer adverse consequences from substance use at 12 months post-treatment [B = 4.50, standard error (SE) = 2.17, 95% CI = 0.22-8.78]. Treatment condition had no effect on percentage substance use days among those who resumed use or on change in depressive symptoms; the latter decreased over time only in those who remained abstinent after residential treatment irrespective of condition (B = 0.43, SE = 0.11, 95% confidence interval = 0.22-0.65).

CONCLUSIONS

A behavioral activation group treatment for substance use (LETS ACT) appears to increase the likelihood of abstinence and reduce adverse consequences from substance use up to 12 months post-treatment.