Cognitive behaviour therapy (CBT) for the treatment of co-occurring depression and substance use: Current evidence and directions for future research

Workforce estimate to treat mental disorders in the Kingdom of Saudi Arabia

BACKGROUND

Mental, neurological, and substance abuse (MNS) disorders describe a range of conditions that affect the brain and cause distress or functional impairment. In the Middle East and North Africa (MENA), MNS disorders make up 10.88 percent of the burden of disease as measured in disability-adjusted life years. The Kingdom of Saudi Arabia (KSA) is one of the main providers of mental health services and one of the largest contributors to mental health research in the region. Within the past decade, mental health resources and services has increased.

METHODS

We employ a needs-based workforce estimate as a planning exercise to arrive at the total number of psychiatrists, nurses, and psychosocial care providers needed to meet the epidemiological need of mental health conditions of the population of KSA. Estimates for a potential mental health workforce gap were calculated using five steps: Step 1-Quantify target population for priority mental health conditions. Step 2-Identify number of expected cases per year. Step 3-Set target service coverage for each condition. Step 4-Estimate cost-effective health care service resource utilization for each condition. Step 5-Estimate service resources needed for each condition.

RESULTS

The planning exercise indicates an epidemiologic need for a total of 17,100 full-time-equivalent (FTE) health care providers to treat priority MNS disorders. KSA appears to have a need-based shortage of 10,400 health workers to treat mental disorders. A total of 100 psychiatrists, 5700 nurses, and 4500 psychosocial care providers would be additionally needed (that is, above and beyond current levels) to address the priority mental health conditions. The shortfall is particularly severe for nurses and psychosocial workers who make up 98.9 percent of the shortfall. This shortage is substantial when compared to other high-income countries. Overall, the workforce needed to treat MNS conditions translates to 49.2 health workers per 100,000 population.

CONCLUSION

Challenges to addressing the shortfall are Saudi specific which includes awareness of cultural customs and norms in the medical setting. These challenges are compounded by the lack of Saudi nationals in the mental health workforce. Saudi nationals make up 29.5 percent of the physician workforce and 38.8 percent of the nursing workforce. Policymakers and planners supplement this shortfall with non-Saudi providers, who must be mindful of Saudi-specific cultural considerations. Potential solutions to reducing the shortfall of mental health care workers includes nurse task shifting and training of general practitioners to screen for, and treat, a subset of MNS disorders.

Bidirectional associations between depressive symptoms and cigarette, e-cigarette, cannabis, and alcohol use: Cross-lagged panel analyses among young adults before and during COVID-19

BACKGROUND

The literature regarding bidirectional relationships of depressive symptoms to cigarette and alcohol use is mixed, and limited regarding e-cigarette and cannabis use. Moreover, COVID-19 has significantly impacted mental health and substance use, especially among young adults. Thus, this is a critical period for focused research on these relationships among young adults.

METHODS

We analyzed longitudinal data (assessments in Fall 2018, 2019, and 2020) from 3,006 young adults (Mage = 24.56 [SD = 4.72], 54.8% female, 31.6% sexual minority, 71.6% White, 5.3% Black, 12.2% Asian, 11.4% Hispanic) from 6 US metropolitan statistical areas. Cross-lagged panel models were conducted to examine bidirectional associations between depressive symptoms and past 30-day use of cigarettes, e-cigarettes, cannabis, and alcohol (respectively), controlling for sociodemographics.

RESULTS

During the study period, depressive symptoms decreased before the pandemic but increased during, cigarette and e-cigarette use decreased in both periods, alcohol use showed no change before but increases during the pandemic, and cannabis use increased in both periods. Additionally, each outcome demonstrated greater stability before versus during COVID-19. Finally, greater antecedent depressive symptoms correlated with more days of subsequent cigarette (β = 0.03, SE = 0.01, p =.011) and e-cigarette use (β = 0.03, SE = 0.01, p =.021), but fewer days of alcohol use (β = -0.02, SE = 0.01, p =.035). W2 cannabis use and alcohol use, respectively, were related to W3 depressive symptoms (cannabis: β = 0.09, SE = 0.02, p <.001; alcohol: β = 0.06, SE = 0.02, p =.002). No other cross-lagged associations were significant.

CONCLUSIONS

Intervention efforts targeting depression and substance use should explicitly address the potential for onset and escalation of substance use and depressive symptoms, respectively, especially during societal stressors.

Driving After Cannabis Use Among Young Adults in Michigan

Introduction: Driving after cannabis use is associated with a number of risks. Examination of driving after cannabis use among young adults is particularly important, as young adults have the highest rates of cannabis use and among the highest rates of traffic crashes. The current study examines rates and correlates of driving after cannabis use among young adults (aged 18-25) who reported past month cannabis use. Methods: Participants were from Michigan and recruited through paid Facebook and Instagram advertisements between February and March 2018 (n=461). Results: Nearly a third (31.9%) of the sample reported driving after cannabis use in the past month. Young adults who were employed (aOR=1.872, p=0.045), had medical cannabis cards (aOR=2.877, p<0.001), endorsed coping reasons for use (aOR=2.992, p=0.007), and endorsed social/recreational reasons for use (aOR=1.861, p=0.034) had greater odds of driving after cannabis use. Students had lower odds of driving after use (aOR=0.573, p=0.011). Conclusions: Employment and having a medical cannabis card may be important risk markers for identifying individuals more likely to drive after use of cannabis. Prevention efforts could provide psychoeducation at dispensaries to individuals with medical cannabis cards about the risks of driving after use. Coping motives for cannabis use may also be useful in identifying young adults at the greatest risk of driving after use of cannabis.

The Impact of Depressive Symptoms on Response to Integrated Cognitive Behavioral Therapy for Substance Use Disorders and Intimate Partner Violence

Purpose

Past studies demonstrated the efficacy of integrated cognitive-behavioral therapy (CBT) for substance use disorder (SUD) and intimate partner violence (IPV) as well as high rates of depressive symptoms in this population. However, little is known about how depressive symptoms impact treatment outcomes. We hypothesized that integrated CBT, but not standard drug counseling (DC), would buffer the negative effects of depressive symptoms on treatment response.

Design/methodology/approach

A secondary analysis of a randomized trial compared men assigned to 12 weeks of integrated CBT for SUD and IPV (n=29) to those in DC (n=34).

Findings

Most (60%) of the sample reported any depressive symptoms. Controlling for baseline IPV, reporting any depressive symptoms was associated with more positive cocaine screens during treatment. Among men with depressive symptoms, integrated CBT but not DC was associated with fewer positive cocaine screens. Controlling for baseline alcohol variables, integrated CBT and depressive symptoms were each associated with less aggression outside of intimate relationships (e.g., family, strangers) during treatment. For men without depressive symptoms, integrated CBT was associated with less non-IPV aggression compared to DC. Effects were not significant for other substances, IPV, or at follow-up.

Originality

Although integrated CBT's efficacy for improving SUD and IPV has been established, moderators of treatment response have not been investigated.

Practical Implications

Integrated CBT buffered depressive symptoms' impact on cocaine use, yet only improved non-IPV aggression in men without depressive symptoms.

Research Limitations/Implications

This study found some evidence for differential response to CBT by depressive symptoms on cocaine and aggression at end of treatment, which did not persist three months later. Future studies should explore mechanisms of integrated CBT for SUD and IPV, including mood regulation, on depressive symptoms in real-world samples.

"Take Care of You" - Efficacy of integrated, minimal-guidance, internet-based self-help for reducing co-occurring alcohol misuse and depression symptoms in adults: Results of a three-arm randomized controlled trial

BACKGROUND

Depression and harmful alcohol use are two of the top five leading causes of years of life lost to disability in high-income countries. Integrated treatment targeting both at the same time is often considered more complicated and difficult and, therefore, more expensive. Consequently, integrated internet-based interventions could be a valuable addition to traditional care.

METHODS

A three-arm randomized controlled trial was conducted comparing the effectiveness of (1) an integrated, minimal-guidance, adherence-focused self-help intervention designed to reduce both alcohol use and depression symptoms (AFGE-AD); (2) a similar intervention designed to reduce alcohol use only (AFGE-AO), and (3) internet access as usual (IAU) as a control condition, in at least moderately depressed alcohol misusers from February 2016-March 2020. We recruited 689 alcohol misusers (51.6 % males, mean age = 42.8 years) with at least moderate depression symptoms not otherwise in treatment from the general population. Six months after baseline, 288 subjects (41.8 %) were reachable for the final assessment.

RESULTS

All interventions yielded reduced alcohol-use after six months (AFGE-AD: -16.6; AFGE-AO: -19.8; IAU: -13.2). Those who undertook active-interventions reported significantly fewer standard drinks than controls (AFGE-AD: p = .048, d=0.10; AFGE-AO: p = .004, d=0.20). The two active-intervention groups also reported significantly less severe depression symptoms than controls (AFGE-AD: p = .006, d=0.41; AFGE-AO: p = .008, d=0.43). Testing revealed noninferiority between the two interventions.

CONCLUSIONS

This study documented sustained effectiveness of the first integrated, fully internet-based self-help intervention developed for the reduction of both alcohol use and depression symptoms in at least moderately depressed adult alcohol misusers recruited from the general population.

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.

CANreduce 2.0 Adherence-Focused Guidance for Internet Self-Help Among Cannabis Users: Three-Arm Randomized Controlled Trial

Background

Despite increasing demand for treatment among cannabis users in many countries, most users are not in treatment. Internet-based self-help offers an alternative for those hesitant to seek face-to-face therapy, though low effectiveness and adherence issues often arise.

Objective

Through adherence-focused guidance enhancement, we aimed to increase adherence to and the effectiveness of internet-based self-help among cannabis users.

Methods

From July 2016 to May 2019, cannabis users (n=775; male: 406/575, 70.6%, female: 169/575, 29.4%; age: mean 28.3 years) not in treatment were recruited from the general population and were randomly assigned to (1) an adherence-focused guidance enhancement internet-based self-help intervention with social presence, (2) a similar intervention with an impersonal service team, and (3) access to internet as usual. Controls who were placed on a waiting list for the full intervention after 3 months underwent an assessment and had access to internet as usual. The primary outcome measurement was cannabis-use days over the preceding 30 days. Secondary outcomes included cannabis-dependence severity, changes in common mental disorder symptoms, and intervention adherence. Differences between the study arms in primary and secondary continuous outcome variables at baseline, posttreatment, and follow-up were tested using pooled linear models.

Results

All groups exhibited reduced cannabis-use days after 3 months (social presence: –8.2 days; service team: –9.8 days; internet as usual: –4.2 days). The participants in the service team group (P=.01, d=.60) reported significantly fewer cannabis-use days than those in the internet as usual group; the reduction of cannabis use in the social presence group was not significant (P=.07, d=.40). There was no significant difference between the 2 intervention groups regarding cannabis-use reduction. The service team group also exhibited superior improvements in cannabis-use disorder, cannabis-dependence severity, and general anxiety symptoms after 3 months to those in the internet as usual group.

Conclusions

The adherence-focused guidance enhancement internet-based self-help intervention with an impersonal service team significantly reduced cannabis use, cannabis-use disorder, dependence severity, and general anxiety symptoms.

Trial Registration

ISRCTN Registry ISRCTN11086185; http://www.isrctn.com/ISRCTN11086185

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Co-occurring opioid and sedative use disorder: Gender differences in use patterns and psychiatric co-morbidities in the United States

Non-medical use of both opioids and sedatives increases risk of overdose or accident. The purpose of the present study was to describe rates of co-use, to examine baseline characteristics and psychiatric conditions potentially associated with meeting criteria for co-occurring opioid use disorder and sedative use disorder, and to examine whether these relationships varied by gender. Participants were 330 individuals from the NESARC-III who met criteria for current opioid use disorder. Gender-stratified logistic regression analyses, accounting for the survey design, were used to identify psychiatric conditions associated with meeting criteria for co-occurring sedative use disorder. Results indicated that 16.4% of the sample also met criteria for sedative use disorder. Notably, 55.6% of the sample attained opioids through their own prescription. Of those with co-occurring sedative use disorder, 47.2% attained sedatives through their own prescription. Posttraumatic stress disorder (OR = 3.02, 95% CI = 1.40-6.51) and antisocial personality disorder (OR = 2.72, 95% CI = 1.37-5.41) were associated with co-occurring sedative use disorder among both men and women with opioid use disorder. Depressive disorders (OR = 2.12, 95% CI = 1.01-4.42) and schizotypal personality disorder (OR = 5.78, 95% CI = 2.48-13.49) were associated with co-occurring sedative use disorder in women only. Results of the present study highlight the importance of prescription monitoring, further research into gender-informed treatments, and implementation of treatments for substance use and co-occurring symptoms.

Australian Indigenous model of mental healthcare based on transdiagnostic cognitive-behavioural therapy co-designed with the Indigenous community: protocol for a randomised controlled trial

BACKGROUND

A four- to seven-fold increase in the prevalence of current mood, anxiety, substance use and any mental disorders in Indigenous adults compared with non-Indigenous Australians has been reported. A lifetime prevalence of major depressive disorder was 23.9%. High rates of comorbid mental disorders indicated a transdiagnostic approach to treatment might be most appropriate. The effectiveness of psychological treatment for Indigenous Australians and adjunct Indigenous spiritual and cultural healing has not previously been evaluated in controlled clinical trials.

AIMS

This project aims to develop, deliver and evaluate the effectiveness of an Indigenous model of mental healthcare (IMMHC). Trial registration: ANZCTR Registration Number: ACTRN12618001746224 and World Health Organization Universal Trial Number: U1111-1222-5849.

METHOD

The IMMHC will be based on transdiagnostic cognitive-behaviour therapy co-designed with the Indigenous community to ensure it is socially and culturally appropriate for Indigenous Australians. The IMMHC will be evaluated in a randomised controlled trial with 110 Indigenous adults diagnosed with a current diagnosis of depression. The primary outcome will be the severity of depression symptoms as determined by changes in Beck Depression Inventory-II score at 6 months post-intervention. Secondary outcomes include anxiety, substance use disorder and quality of life. Outcomes will be assessed at baseline, 6 months post-intervention and 12 months post-intervention.

RESULTS

The study design adheres to the Consolidated Standards of Reporting Trials (CONSORT) statement recommendations and CONSORT extensions for pilot trials. We followed the Standard Protocol Items for Randomised Trials statement recommendations in writing the trial protocol.

CONCLUSIONS

This study will likely benefit participants, as well as collaborating Aboriginal Medical Services and health organisations. The transdiagnostic IMMHC has the potential to have a substantial impact on health services delivery in the Indigenous health sector.

A Meta-Analysis of Program Characteristics for Youth with Disruptive Behavior Problems: The Moderating Role of Program Format and Youth Gender

There is high variability in efficacy for interventions for youth with disruptive behavior problems (DBP). Despite evidence of the unique correlates and critical consequences of girls' DBP, there is a dearth of research examining treatment efficacy for girls. This meta-analysis of 167 unique effect sizes from 29 studies (28,483 youth, 50% female; median age: 14) suggests that existing treatments have a medium positive effect on DBP (g = .33). For both boys and girls, the most effective interventions included (a) multimodal or group format, (b) cognitive skills or family systems interventions, and (c) length-intensive programs for (d) younger children. Boys demonstrated significantly greater treatment gains from group format interventions compared to girls, which is particularly important given that the group program format was the most prevalent format for boys and girls, with 14 studies involving 10,433 youth encompassing this category. This is the first meta-analysis to examine the effect of program characteristics in a sample of programs selected to be specifically inclusive of girls. Given that girls are underrepresented in intervention research on DBP, findings are discussed in terms of gender-responsive considerations and elucidating how key aspects of program structure can support more effective intervention outcomes for youth.

A meta-analysis of the effect of substance use interventions on emotion outcomes

OBJECTIVE

Emotional distress has been posited as a key underlying mechanism in the development and maintenance of substance use disorder (SUD), and patients seeking SUD treatment are often experiencing high levels of negative emotion and/or low levels of positive emotion. But the extent to which SUD interventions impact emotional outcomes among general SUD populations is yet unquantified. The current meta-analysis aims to fill this gap.

METHOD

A total of 11,754 records were screened for randomized, controlled trials examining the effect of behavioral SUD interventions on emotion outcomes. Our search yielded a total of 138 effect sizes calculated based on data from 5,146 individuals enrolled in 30 independent clinical trials. Random-effects meta-analysis was used to calculate pooled effect sizes, and metaregression analyses examined study-level moderators (e.g., intervention type).

RESULTS

Findings indicated a small but significant effect of SUD interventions on emotion outcomes, d = 0.157, 95% CI [0.052, 0.262] (k = 30). The effect size for negative emotion was nominally bigger, d = 0.162, 95% CI [0.056, 0.269] (k = 30), whereas the effect for positive emotion did not reach statistical significance, d = 0.062, 95% CI [-0.089, 0.213] (k = 7). Studies featuring SUD interventions designed to specifically target emotions (i.e., affect-regulation, mindfulness-based treatments) produced larger reductions in negative emotion compared with studies featuring interventions that did not contain specific emotion modules (e.g., contingency management).

CONCLUSIONS

Findings suggest that SUD interventions-especially mindfulness-based and affect-regulation treatments-indeed significantly reduce negative emotion, although relatively small effect sizes indicate potential room for improvement. Conclusions regarding positive emotion should be considered preliminary because of the limited numbers of samples assessing these outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Study protocol: a randomised controlled trial of a telephone delivered social wellbeing and engaged living (SWEL) psychological intervention for disengaged youth

BACKGROUND

Internationally, from 12.2-23.4% of youth (aged 16-24 years) are not in employment, education or training (NEET). These disengaged youth are more likely to experience social exclusion, increased psychological distress and poor quality of life. Youth at risk of disengagement are less likely to access traditional support services, requiring development of innovative interventions.

METHODS

The trial is a single blind, three arm, randomised controlled trial evaluating the effectiveness of a telephone delivered psychological intervention for disengaged youth (12-25 years). Participants will be randomised to receive either (i) SWEL, (ii) Befriending, or (iii) Single Session Psycho-Education. Therapy will be over an 8 week period with a minimum of four and maximum of eight sessions for the SWEL or Befriending conditions, or a single session for the Psycho-Education condition. Outcomes will be assessed at baseline and at 2, 8 and 14-month follow-up with the primary outcome being re-engagement in education, training or employment.

DISCUSSION

This large, multi-site, randomised controlled trial will inform the delivery of services for young people at risk of disengaging from education or training. The provision of psychological therapy by telephone increases access by youth - especially those in rural and remote areas - both to the trial and the treatment, if adopted by services. The outcomes of this trial could have meaningful societal impact for a vulnerable population. It is expected that recruitment, intervention and retention will present challenges for the trial given the focus on disengaged youth.

TRIAL REGISTRATION

ANZCTR, ACTRN12614001212640 , Registered 18 Nov 2014. Retrospectively registered.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the participating institutions. Results of the trial will be submitted for publication in peer reviewed journals and findings presented at scientific conferences and to key service providers and policy makers.

Understanding the Role of Alcohol, Anxiety, and Trait Mindfulness in the Perpetration of Physical and Sexual Dating Violence in Emerging Adults

This study examines alcohol consumption, anxiety, trait mindfulness, and physical and sexual dating violence aggression (PDV and SDV) among 735 emerging adults (18-25 years) in an urban emergency department. Of the total sample, 27.2% perpetrated PDV and 16.5% perpetrated SDV. Alcohol was positively associated with PDV/SDV. Anxiety was positively associated with PDV. Mindfulness was negatively associated with PDV/SDV. Interaction analyses revealed women had lower PDV with higher nonjudgment facet of mindfulness. Higher act aware was associated with lower PDV regardless of high versus low alcohol. Findings indicate different contributing factors among perpetrators of PDV/SDV; some factors may be attenuated by mindfulness.

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 .

The Effects of Social Presence on Adherence-Focused Guidance in Problematic Cannabis Users: Protocol for the CANreduce 2.0 Randomized Controlled Trial

Background

In European countries, including Switzerland, cannabis is the most commonly used illicit drug. Offering a Web-based self-help tool could potentially reach users who otherwise would not seek traditional help. However, such Web-based self-help tools often suffer from low adherence.

Objective

Through adherence-focused guidance enhancements, the aim of this study was to increase adherence in cannabis users entering a Web-based self-help tool to reduce their cannabis use and, in this way, augment its effectiveness.

Methods

This paper presents the protocol for a three-arm randomized controlled trial (RCT) to compare the effectiveness of (1) an adherence-focused, guidance-enhanced, Web-based self-help intervention with social presence; (2) an adherence-focused, guidance-enhanced, Web-based self-help intervention without social presence; and (3) a treatment-as-usual at reducing cannabis use in problematic users. The two active interventions, each spanning 6 weeks, consist of modules designed to reduce cannabis use and attenuate common mental disorder (CMD) symptoms, including depression, anxiety, and stress-related disorder symptoms based on the approaches of motivational interviewing and cognitive behavioral therapy. With a target sample size of 528, data will be collected at baseline, 6 weeks, and 3 months after baseline. The primary outcome measurement will be the number of days of cannabis use on the preceding 7 days. Secondary outcomes will include the quantity of cannabis used in standardized cannabis joints, the severity of cannabis dependence, changes in CMD symptoms, and adherence to the program. Data analysis will follow the intention-to-treat principle and employ (generalized) linear mixed models.

Results

The project commenced in August 2016; recruitment is anticipated to end by December 2018. First results are expected to be submitted for publication in summer 2019.

Conclusions

This study will provide detailed insights on if and how the effectiveness of a Web-based self-help intervention aiming to reduce cannabis use in frequent cannabis users can be improved by theory-driven, adherence-focused guidance enhancement.

Trial Registration

International Standard Randomized Controlled Trial Number Registry: ISRCTN11086185; http://www.isrctn.com/ISRCTN11086185 (Archived by WebCite at http://www.webcitation.org/6wspbuQ1M)

RCT of an integrated CBT-HIV intervention on depressive symptoms and HIV risk

Depression and depressive symptoms mediate the association between drug use and HIV risk. Yet, there are few interventions that target depressive symptoms and HIV risk for people who use drugs (PWUD). This study was a randomized controlled trial of an integrated cognitive behavioral therapy and HIV prevention intervention to reduce depressive symptoms, injection risk behaviors and increase condom use in a sample of urban people who used heroin or cocaine in the prior 6 months. A total of 315 individuals aged 18–55, who self-reported at least one HIV drug and sex risk behavior and scored ≥16 and <40 on the Centers for Epidemiologic Studies-Depression (CES-D) scale were randomized using a two-block design, stratified by sex to ensure equivalent numbers, to a 10 session intervention arm (n = 162) or a single session control arm (n = 153). The outcomes of interest were decreases in CES-D score and injection risk behaviors and increases in condom use. The sample was majority African American (85%) and unemployed (94%). Nearly half (47%) reported injection in the prior 6 months and only 19% were taking medication for depression. Follow-up assessments were conducted at 6 and 12 months. Retention at 12 months was 94%. Intervention arm was associated with statistically significantly lower CES-D score at 12 month compared to control. No differences were observed between arms in injection risk. At 6 month, intervention was associated with greater odds of condom use with non-main partner. These findings suggest the potential role of the integrated intervention in reducing depressive symptoms, but weak impact on HIV risk. This trial is registered with ClinicalTrials.gov under the title “Neighborhoods, Networks, Depression, and HIV Risk” number NCT01380613.

Emotion Regulation Enhancement of Cognitive Behavior Therapy for College Student Problem Drinkers: A Pilot Randomized Controlled Trial

This pilot randomized clinical trial tested an emotion regulation enhancement to Cognitive Behavior Therapy (CBT) with 29 college student problem drinkers with histories of complex trauma and current clinically significant traumatic stress symptoms. Participants received eight face-to-face sessions of manualized internet-supported CBT for problem drinking with or without trauma-focused emotion regulation skills (Trauma Affect Regulation: Guide for Education and Therapy, TARGET). Both interventions were associated with sustained (at one-month follow-up) reductions in self-reported drinking frequency, drinking related impairment, and heavy drinking in the past week, as well as post-traumatic stress disorder (PTSD) and complex PTSD symptoms, and improvement in self-reported emotion regulation. The enhanced intervention was associated with significantly greater sustained reductions in complex PTSD symptoms and resulted in medium/large effect size reductions in days of alcohol use (versus small effects by CBT). Emotion regulation enhancement of CBT for college student problem drinkers with interpersonal trauma histories warrants further investigation.

QuikFix: enhanced motivational interviewing interventions for youth substance use

Purpose

This paper explores the background principles, theories, and components of the QuikFix intervention for primary and comorbid substance use in young people.

Design/methodology/approach

QuikFix is a brief Motivational Interviewing (MI) intervention utilising cognitive-behavioural coping skills training to reduce vulnerability to substance use and comorbid mental health problems in young people. It is delivered in two to three brief sessions including an assessment. A new version, QuikFix PI (Personality Intervention) which incorporates coping skills training targeting, sensation seeking, impulsive, depressive and anxiety personality styles that may underlie primary and comorbid substance use problems is presented.

Findings

The original QuikFix intervention has demonstrated efficacy in young alcohol and cannabis users with comorbid depression and anxiety symptoms. The efficacy of the new personality targeted version of QuikFix is currently being tested in a large randomized controlled trial among young people with alcohol related injuries/illnesses. Future research is required to determine the efficacy of QuikFix PI in comorbid populations including those with behavioural disorders.

Practical implications

QuikFix interventions can be delivered via telephone or face-to-face in clinical settings for clients with primary substance use and comorbid depression and anxiety symptoms.

Originality/value

This paper describes a novel two to three session manualised personality targeted substance use intervention. The full original QuikFix treatment manual is available online (Hides and Carroll 2010).

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

Purpose

Substance use disorders (SUDs) often co-occur with major depressive disorder (MDD), yet treatments targeting this comorbidity are limited, especially in resource limited settings where individuals with SUDs often receive treatment.

Design/methodology/approach

Based upon principles of reinforcement and behavioral economic models of substance use, as well as the Brief Behavioral Activation Treatment for Depression (BATD; Lejuez et al., 2011), the Life Enhancement Treatment for Substance Use (LETS ACT; Daughters et al., 2008) was developed to meet the unique needs of patients with MDD-SUD comorbidity.

Findings

The current manuscript presents a summary of the theoretical foundations and key components of LETS ACT.

Originality/value

A specific focus on increasing dissemination via the flexible delivery dependent on patient and treatment setting characteristics is provided throughout.

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

BACKGROUND

The co-occurrence of depression and substance use disorders (SUD) is highly prevalent and associated with poor treatment outcomes for both disorders. As compared to individuals suffering from either disorder alone, individuals with both conditions are likely to endure a more severe and chronic clinical course with worse treatment outcomes. Thus, current practice guidelines recommend treating these co-occurring disorders simultaneously.

OBJECTIVES

The overarching aims of this narrative are two-fold: (1) to provide an updated review of the current empirical status of integrated psychotherapy approaches for SUD and depression comorbidity, based on models of traditional cognitive-behavioral therapy (CBT) and newer third-wave CBT approaches, including acceptance- and mindfulness-based interventions and behavioral activation (BA); and (2) to propose a novel theoretical framework for transdiagnostic CBT for SUD-depression, based upon empirically grounded psychological mechanisms underlying this highly prevalent comorbidity.

RESULTS

Traditional CBT approaches for the treatment of SUD-depression are well-studied. Despite advances in the development and evaluation of various third-wave psychotherapies, more work needs to be done to evaluate the efficacy of such approaches for SUD-depression.

CONCLUSION

Informed by this summary of the evidence, we propose a transdiagnostic therapy approach that aims to integrate treatment elements found in empirically supported CBT-based interventions for SUD and depression. By targeting shared cognitive-affective processes underlying SUD-depression, transdiagnostic treatment models have the potential to offer a novel clinical approach to treating this difficult-to-treat comorbidity and relevant, co-occurring psychiatric disturbances, such as posttraumatic stress.

The efficacy of behavioural activation treatment for co-occurring depression and substance use disorder (the activate study): a randomized controlled trial

BACKGROUND

Epidemiological studies suggest that compared with the general population, mood disorders are up to 4.7 times more prevalent in substance dependent samples. Comorbid substance use disorder (SUD) and depression has been associated with a more severe and protracted illness course and poorer treatment outcomes. Despite this, the development and assessment of behavioural interventions for treating depression among individuals with SUDs have received little empirical attention. Behavioural Activation Treatment for Depression (BATD-R) is an empirically supported treatment for depression that has shown some efficacy among substance users. This paper describes the study protocol of a parallel, single blind, randomised controlled trial to determine the efficacy and feasibility of a modified version of the BATD-R (Activate) in reducing symptoms of depression and substance dependence among individuals in residential rehabilitation (RR) and opioid substitution therapy (OST).

METHODS/DESIGN

A sample of approximately 200 individuals with depressive symptomatology in treatment for SUD will be recruited from RR and OST services in New South Wales, Australia. Dynamic random allocation following minimisation methodology will be used to assign participants to one of two groups. The control group will receive treatment as usual (TAU), which will be the model of care provided in accordance with standard practice at participating RR and OST services. The intervention group will receive Activate, comprising 10 individual 60-min therapy sessions with a psychologist employed on the research team, in addition to TAU. Data collection will occur at baseline (pre-intervention), and 3-months and 12-months post baseline.

DISCUSSION

The association between depression and substance dependence has been well documented, yet practical and effective treatments are scarce. The findings of the present study will contribute significantly to understanding the types of programs that are effective in treating this comorbidity.

TRIAL REGISTRATION

This trial is registered with the Australian and New Zealand Clinical Trials registry, ACTRN12613000876796 . Registered on 7 August, 2013.

Effects of Affective and Anxiety Disorders on Outcome in Problem Gamblers Attending Routine Cognitive-Behavioural Treatment in South Australia

This study evaluated the influence of 12-month affective and anxiety disorders on treatment outcomes for adult problem gamblers in routine cognitive-behavioural therapy. A cohort study at a state-wide gambling therapy service in South Australia. Primary outcome measure was rated by participants using victorian gambling screen (VGS) 'harm to self' sub-scale with validated cut score 21+ (score range 0-60) indicative of problem gambling behaviour. Secondary outcome measure was Work and Social Adjustment Scale (WSAS). Independent variable was severity of affective and anxiety disorders based on Kessler 10 scale. We used propensity score adjusted random-effects models to estimate treatment outcomes for sub-populations of individuals from baseline to 12 month follow-up. Between July, 2010 and December, 2012, 380 participants were eligible for inclusion in the final analysis. Mean age was 44.1 (SD = 13.6) years and 211 (56%) were males. At baseline, 353 (92.9%) were diagnosed with a gambling disorder using VGS. For exposure, 175 (46%) had a very high probability of a 12-month affective or anxiety disorder, 103 (27%) in the high range and 102 (27%) in the low to moderate range. For the main analysis, individuals experienced similar clinically significant reductions (improvement) in gambling related outcomes across time (p < 0.001). Individuals with co-varying patterns of problem gambling and 12 month affective and anxiety disorders who present to a gambling help service for treatment in metropolitan South Australia gain similar significant reductions in gambling behaviours from routine cognitive-behavioural therapy in the mid-term.

Pain acceptance and opiate use disorders in addiction treatment patients with comorbid pain

OBJECTIVES

Studies from pain treatment settings indicate that poor acceptance of pain may be an important and modifiable risk factor for higher severity of opioid use. However, the degree to which pain acceptance relates to opioid use severity in the addiction treatment population is unknown. In this study of addiction treatment patients with co-morbid pain, we examined correlates of severity of opiate (heroin and prescription opioid) use, with a particular focus on the role of pain acceptance.

METHODS

Patients in residential addiction treatment with comorbid pain (N=501) were stratified into low, moderate and high severity of opiate use. Demographic and clinical characteristics were compared across opiate severity categories.

RESULTS

72% (N=360) of the participants had symptoms that were consistent with an opiate use disorder. Younger age, Caucasian race, female gender, cocaine use and lower pain acceptance were associated with higher severity of opiate use, whereas pain intensity was not. Controlling for demographic and other risk factors, such as substance use and pain intensity, higher pain acceptance was associated with lower odds of severe prescription opioid (AOR 0.50, 95% CI 0.38-0.68 for a one SD increase in pain acceptance) and heroin use (AOR 0.57, 95% CI 0.44-0.75 for a one SD increase in pain acceptance).

CONCLUSIONS

Problematic opiate use is common in addictions treatment patients with chronic pain. Lower pain acceptance is related to greater opiate use severity, and may be an important modifiable target for interventions to successfully treat both pain and opiate use disorders.

Treatment of comorbid alcohol use disorders and depression with cognitive-behavioural therapy and motivational interviewing: a meta-analysis

BACKGROUND AND AIMS

To review published studies on the effectiveness of combining cognitive-behavioural therapy (CBT) and motivational interviewing (MI) to treat comorbid clinical and subclinical alcohol use disorder (AUD) and major depression (MDD) and estimate the effect of this compared with usual care.

METHODS

We conducted systematic literature searches in PubMed, PsycINFO and Embase up to June 2013 and identified additional studies through cross-references in included studies and systematic reviews. Twelve studies comprising 1721 patients met our inclusion criteria. The studies had sufficient statistical power to detect small effect sizes.

RESULTS

CBT/MI proved effective for treating subclinical and clinical AUD and MDD compared with controls, with small overall effect sizes at post-treatment [g=0.17, confidence interval (CI)=0.07-0.28, P<0.001 for decrease of alcohol consumption and g=0.27, CI: 0.13-0.41, P<0.001 for decrease of symptoms of depression, respectively]. Subgroup analyses revealed no significant differences for both AUD and MDD. However, digital interventions showed a higher effect size for depression than face-to-face interventions (g= 0.73 and g=0.23, respectively, P=0.030).

CONCLUSIONS

Combined cognitive-behavioural therapy and motivational interviewing for clinical or subclinical depressive and alcohol use disorders has a small but clinically significant effect in treatment outcomes compared with treatment as usual.

Randomized controlled trial of MICBT for co-existing alcohol misuse and depression: outcomes to 36-months

Integrated psychological treatment addressing co-existing alcohol misuse and depression has not been compared with single-focused treatment. This trial evaluates changes over 36 months following randomization of 284 outpatients to one of four motivational interviewing and cognitive-behavior therapy (MICBT) based interventions: (1) brief integrated intervention (BI); or BI plus 9 further sessions with (2) an integrated-, (3) alcohol-, or (4) depression-focus. Outcome measures included changes in alcohol consumption, depression (BDI-II: Beck Depression Inventory) and functioning (GAF: Global Assessment of Functioning), with average improvements from baseline of 21.8 drinks per week, 12.6 BDI-II units and 8.2 GAF units. Longer interventions tended to be more effective in reducing depression and improving functioning in the long-term, and in improving alcohol consumption in the short-term. Integrated treatment was at least as good as single-focused MICBT. Alcohol-focused treatment was as effective as depression-focused treatment at reducing depression and more effective in reducing alcohol misuse. The best approach seems to be an initial focus on both conditions followed by additional integrated- or alcohol-focused sessions.

Can 12 step fellowship and cognitive behaviour therapy work together? A hypothesis on an integrated treatment approach for mild dual diagnosis

Purpose

The purpose of this paper is to investigate research in the field of addictions utilising CBT and 12 step fellowship methods and to create an evidence base for an integrated treatment method utilising both approaches.

Design/methodology/approach

Research on CBT and 12 step fellowships and their current applications in addiction treatment are presented. Models of severe mental illness are referenced and the use of directive and guided referrals are used as a basis to build the paper's hypothesis. A mode of action how the treatments may work together is presented.

Findings

Findings indicate that guided treatment approaches for dual diagnosis are more likely to lead to long term therapeutic gains. Discussion involves the practical implications of this treatment and its ability to create a synergistic approach.

Practical implications

Implications include the potential for streamlined treatment approaches which have the potential to increase treatment adherence and outcomes. Implications, such as the joint use of social reinforcement techniques between 12 step fellowship approaches and CBT, are also discussed.

Originality/value

There is no previous research on the application of CBT and 12 step treatment modalities working together in a structured manner. Previous work has focussed primarily on severe mental illness. The current paper aims to provide an approach to treatment which utilises several modes of treatment to create more robust treatments for people suffering from dual diagnoses.

Psychological interventions for alcohol misuse among people with co-occurring depression or anxiety disorders: a systematic review

OBJECTIVE

Depression, anxiety and alcohol misuse frequently co-occur. While there is an extensive literature reporting on the efficacy of psychological treatments that target depression, anxiety or alcohol misuse separately, less research has examined treatments that address these disorders when they co-occur. We conducted a systematic review to determine whether psychological interventions that target alcohol misuse among people with co-occurring depressive or anxiety disorders are effective.

DATA SOURCES

We systematically searched the PubMed and PsychINFO databases from inception to March 2010. Individual searches in alcohol, depression and anxiety were conducted, and were limited to 'human' published 'randomized controlled trials' or 'sequential allocation' articles written in English.

STUDY SELECTION

We identified randomized controlled trials that compared manual guided psychological interventions for alcohol misuse among individuals with depressive or anxiety disorders. Of 1540 articles identified, eight met inclusion criteria for the review.

DATA EXTRACTION

From each study, we recorded alcohol and mental health outcomes, and other relevant clinical factors including age, gender ratio, follow-up length and drop-out rates. Quality of studies was also assessed.

DATA SYNTHESIS

Motivational interviewing and cognitive-behavioral interventions were associated with significant reductions in alcohol consumption and depressive and/or anxiety symptoms. Although brief interventions were associated with significant improvements in both mental health and alcohol use variables, longer interventions produced even better outcomes.

CONCLUSIONS

There is accumulating evidence for the effectiveness of motivational interviewing and cognitive behavior therapy for people with co-occurring alcohol and depressive or anxiety disorders.

Dual diagnosis and suicide risk in a Spanish outpatient sample

The present study compares dual-diagnosis patients with other groups of psychiatric patients to determine the differential characteristics in suicide risk and other clinical variables between them. During 2008 in Madrid, 837 outpatients were evaluated in addiction and mental health services. Three comparison groups were created according to current diagnosis: (i) dual patients, (ii) patients with substance use disorders but no other mental disorders, and (iii) patients with mental disorders but no substance use disorders. A multinomial logistic regression model was built to explore the risk associated with dual diagnosis. Criteria for dual diagnosis were met at the time of the study by 440 patients (52.6%). Dual patients showed several demographic and clinical differences and a higher risk for suicide than the other two comparison groups. Further research is needed to define suicide preventive strategies for dual patients.

Study protocol: a randomized controlled trial of a computer-based depression and substance abuse intervention for people attending residential substance abuse treatment

BACKGROUND

A large proportion of people attending residential alcohol and other substance abuse treatment have a co-occurring mental illness. Empirical evidence suggests that it is important to treat both the substance abuse problem and co-occurring mental illness concurrently and in an integrated fashion. However, the majority of residential alcohol and other substance abuse services do not address mental illness in a systematic way. It is likely that computer delivered interventions could improve the ability of substance abuse services to address co-occurring mental illness. This protocol describes a study in which we will assess the effectiveness of adding a computer delivered depression and substance abuse intervention for people who are attending residential alcohol and other substance abuse treatment.

METHODS/DESIGN

Participants will be recruited from residential rehabilitation programs operated by the Australian Salvation Army. All participants who satisfy the diagnostic criteria for an alcohol or other substance dependence disorder will be asked to participate in the study. After completion of a baseline assessment, participants will be randomly assigned to either a computer delivered substance abuse and depression intervention (treatment condition) or to a computer-delivered typing tutorial (active control condition). All participants will continue to complete The Salvation Army residential program, a predominantly 12-step based treatment facility. Randomisation will be stratified by gender (Male, Female), length of time the participant has been in the program at the commencement of the study (4 weeks or less, 4 weeks or more), and use of anti-depressant medication (currently prescribed medication, not prescribed medication). Participants in both conditions will complete computer sessions twice per week, over a five-week period. Research staff blind to treatment allocation will complete the assessments at baseline, and then 3, 6, 9, and 12 months post intervention. Participants will also complete weekly self-report measures during the treatment period.

DISCUSSION

This study will provide comprehensive data on the effect of introducing a computer delivered, cognitive behavioral therapy based co-morbidity treatment program within a residential substance abuse setting. If shown to be effective, this intervention can be disseminated within other residential substance abuse programs.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12611000618954.

Treatment of substance abusing patients with comorbid psychiatric disorders

OBJECTIVE

To update clinicians on the latest in evidence-based treatments for substance use disorders (SUD) and non-substance use disorders among adults and suggest how these treatments can be combined into an evidence-based process that enhances treatment effectiveness in comorbid patients.

METHOD

Articles were extracted from Pubmed using the search terms "dual diagnosis," "comorbidity" and "co-occurring" and were reviewed for evidence of effectiveness for pharmacologic and psychotherapeutic treatments of comorbidity.

RESULTS

Twenty-four research reviews and 43 research trials were reviewed. The preponderance of the evidence suggests that antidepressants prescribed to improve substance-related symptoms among patients with mood and anxiety disorders are either not highly effective or involve risk due to high side-effect profiles or toxicity. Second generation antipsychotics are more effective for treatment of schizophrenia and comorbid substance abuse and current evidence suggests clozapine, olanzapine and risperidone are among the best. Clozapine appears to be the most effective of the antipsychotics for reducing alcohol, cocaine and cannabis abuse among patients with schizophrenia. Motivational interviewing has robust support as a highly effective psychotherapy for establishing a therapeutic alliance. This finding is critical since retention in treatment is essential for maintaining effectiveness. Highly structured therapy programs that integrate intensive outpatient treatments, case management services and behavioral therapies such as Contingency Management (CM) are most effective for treatment of severe comorbid conditions.

CONCLUSIONS

Creative combinations of psychotherapies, behavioral and pharmacological interventions offer the most effective treatment for comorbidity. Intensity of treatment must be increased for severe comorbid conditions such as the schizophrenia/cannabis dependence comorbidity due to the limitations of pharmacological treatments.