Brief Report: Competency-Based Supervision in Motivational Interviewing for Advanced Psychology Trainees: Targeting an A Priori Benchmark

Motivational interviewing (MI) is an evidence based intervention with considerable support for promoting behavior change across a broad range of health and mental health issues. Despite its effectiveness, challenges associated with learning the approach may limit its full implementation in many clinical settings. The aim of the present study was to evaluate a supervised MI training practicum implemented within a doctoral internship/postdoctoral fellowship training Program. The goal of the practicum was to enable each trainee to achieve expert competence in MI. Participants were 29 psychology doctoral interns and 1 postdoctoral fellow who participated in the training as part of their internship or fellowship program. Training included an initial workshop followed by a supervised practicum during which progress towards an a priori established expert competence benchmark was tracked through the use of an established coding system. Results indicated that trainees were satisfied with the supervision received. Three trainees did not achieve the a priori benchmark due to schedule conflicts. The 27 trainees who achieved the benchmark required between 4 and 20 supervision sessions to do so (mean = 9.22, SD = 3.77). With the exception of reflective listening skill, prior training, baseline skill, and self-reported motivation were not associated with number of supervision sessions required to achieve the benchmark. Implications for training and dissemination of MI in clinical settings are discussed.

Abuse of medications that theoretically are without abuse potential

The potential for abuse of medications that are controlled substances is well known. Abuse of certain noncontrolled prescription drugs and over-the-counter medications also may occur. To some degree, any medication that exerts psychoactive effects may be abused if taken in high enough doses or by means that result in high serum or cerebrospinal fluid levels. Many clinicians may be unaware of the potential for abuse of these medications. This review examines evidence of the possibility of abuse of several common medications that theoretically do not have abuse potential, including cough and cold preparations, antihistamines, anticholinergics, antipsychotics, antidepressants, anticonvulsants, skeletal muscle relaxants, and antiemetics. Means by which such medications may be abused and biochemical and physiological mechanisms fostering their abuse also are discussed.

Proactive tobacco treatment and population-level cessation: a pragmatic randomized clinical trial

IMPORTANCE

Current tobacco use treatment approaches require smokers to request treatment or depend on the provider to initiate smoking cessation care and are therefore reactive. Most smokers do not receive evidence-based treatments for tobacco use that include both behavioral counseling and pharmacotherapy.

OBJECTIVE

To assess the effect of a proactive, population-based tobacco cessation care model on use of evidence-based tobacco cessation treatments and on population-level smoking cessation rates (ie, abstinence among all smokers including those who use and do not use treatment) compared with usual care among a diverse population of current smokers.

DESIGN, SETTING, AND PARTICIPANTS

The Veterans Victory Over Tobacco Study, a pragmatic randomized clinical trial involving a population-based registry of current smokers aged 18 to 80 years. A total of 6400 current smokers, identified using the Department of Veterans Affairs (VA) electronic medical record, were randomized prior to contact to evaluate both the reach and effectiveness of the proactive care intervention.

INTERVENTIONS

Current smokers were randomized to usual care or proactive care. Proactive care combined (1) proactive outreach and (2) offer of choice of smoking cessation services (telephone or in-person). Proactive outreach included mailed invitations followed by telephone outreach to motivate smokers to seek treatment with choice of services.

MAIN OUTCOMES AND MEASURES

The primary outcome was 6-month prolonged smoking abstinence at 1 year and was assessed by a follow-up survey among all current smokers regardless of interest in quitting or treatment utilization.

RESULTS

A total of 5123 participants were included in the primary analysis. The follow-up survey response rate was 66%. The population-level, 6-month prolonged smoking abstinence rate at 1 year was 13.5% for proactive care compared with 10.9% for usual care (P = .02). Logistic regression mixed model analysis showed a significant effect of the proactive care intervention on 6-month prolonged abstinence (odds ratio [OR], 1.27 [95% CI, 1.03-1.57]). In analyses accounting for nonresponse using likelihood-based not-missing-at-random models, the effect of proactive care on 6-month prolonged abstinence persisted (OR, 1.33 [95% CI, 1.17-1.51]).

CONCLUSIONS AND RELEVANCE

Proactive, population-based tobacco cessation care using proactive outreach to connect smokers to evidence-based telephone or in-person smoking cessation services is effective for increasing long-term population-level cessation rates.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00608426.

Guidance for New Motivational Interviewing Trainers When Training Addiction Professionals: Findings from a Survey of Experienced Trainers

Evidence-based practices, such as motivational interviewing (MI), are not widely used in community alcohol and drug treatment settings. Successfully broadening the dissemination of MI will require numerous trainers and supervisors who are equipped to manage common barriers to technology transfer. The aims of the our survey of 36 MI trainers were: 1) to gather opinions about the optimal format, duration, and content for beginning level addiction-focused MI training conducted by novice trainers and 2) to identify the challenges most likely to be encountered during provision of beginning-level MI training and supervision, as well as the most highly recommended strategies for managing those challenges in addiction treatment sites. It is hoped that the findings of this survey will help beginning trainers equip themselves for successful training experiences.

Unrecognized physical illness prompting psychiatric admission

BACKGROUND

We assessed factors that might contribute to clinicians erroneously attributing medically based changes in a patient's mental status to psychiatric illness.

METHODS

Records of 1340 patients admitted to a VA hospital psychiatric unit and 613 to a public hospital psychiatric unit from 2001 to 2007 were reviewed. Cases admitted because of an unrecognized medical disorder underwent further analysis of the preadmission assessment and documented history of mental illness.

RESULTS

Of 1340 patients whose records were reviewed, 55 (2.8%) had a medical disorder that caused their symptoms. Compared with patients admitted to medical units, patients inappropriately admitted to psychiatric units had lower rates of completion of medical histories, physical examinations, cognitive assessments, indicated laboratory and/or radiologic studies, and treatment of abnormal vital signs (P < .001 in each case). Among patients admitted to psychiatric units, 85.5% had a history of mental illness vs 30.9% of comparable admissions to medical units (Chi2(1) = 35.85; P < .001).

CONCLUSIONS

Key assessment procedures are less likely to be performed in patients with mental status changes who are admitted to psychiatric units than in comparable patients admitted to medical units. Symptoms of patients with a history of mental illness are more likely to be attributed to psychiatric illness than are those of patients without such a history.

Carisoprodol: abuse potential and withdrawal syndrome

Carisoprodol (N-isopropyl-2 methyl-2-propyl-1,3-propanediol dicarbamate; N-isopropylmeprobamate) is a centrally acting skeletal muscle relaxant whose primary active metabolite is meprobamate, a substance with well established abuse potential similar to that of benzodiazepines. A number of reports show that carisoprodol has been abused for its sedative and relaxant effects, to augment or alter the effects of other drugs, and by the intentional combination of carisoprodol and other noncontrolled medications because of the relative ease (as compared to controlled substances) of obtaining prescriptions. The diversion and abuse of carisoprodol and its adverse health effects appear to have dramatically increased over the last several years. Clinicians have begun to see a withdrawal syndrome consisting of insomnia, vomiting, tremors, muscle twitching, anxiety, and ataxia in patients who abruptly cease intake of large doses of carisoprodol. Hallucinations and delusions may also occur. The withdrawal symptoms are very similar to those previously described for meprobamate withdrawal, suggesting that what may actually be occurring is withdrawal from meprobamate accumulated as a result of intake of excessive amounts of carisoprodol. However carisoprodol itself is capable of modulating GABA(A) function, and this may contribute both to the drugs abuse potential and to the occurrence of a withdrawal syndrome with abrupt cessation of intake. Carisoprodol has been classified as a controlled substance in several states in the US and restrictions on the use of the drug have been imposed in some European countries. Carisoprodol is metabolized to a controlled substance, has clear evidence of abuse potential and increasing incidence of abuse, and has shown evidence of a withdrawal syndrome with abrupt cessation from intake. This article will discuss the abuse potential of carisoprodol and the associated withdrawal syndrome, and consider implications for future use of the drug.

Using vouchers to increase continuing care participation in veterans: does magnitude matter?

The present study examined the comparative effects of adding contingency management (CM) schedules to an existing substance abuse continuing care program, with the goal of increasing attendance. We retrospectively examined the attendance of 135 veterans enrolled in one of three CM programs and a quasi-control condition of 55 veterans. Results indicated that participants enrolled in the two higher magnitude CM voucher programs increased both continuing care attendance and length of participation. Findings support the use of CM to increase continuing care attendance among veterans with substance use disorders, and suggest that voucher magnitude and bonuses both had a positive impact.

Perception of osteopathic medicine among allopathic physicians in the deep central southern United States

CONTEXT

Relatively few osteopathic physicians (DOs) practice in the deep central southern geographic region as compared to other parts of the United States.

OBJECTIVE

To assess the potential effects of underrepresentation on the perception of osteopathic medicine among allopathic physicians (MDs) in this geographic region.

METHODS

A 20-item, Likert scale survey was designed to evaluate participant perceptions of the osteopathic medical profession. The instrument was mailed to 468 MDs who reside and practice in the deep central southern region of the United States.

RESULTS

One hundred seven individuals completed the survey for a response rate of 22.9%. Although the majority of respondents (71 [66.3%]) recognized the distinctiveness of the osteopathic medical profession, they were not necessarily able to articulate these differences clearly through their responses to other survey items. In addition, survey participants expressed was a belief that residency training programs accredited by the Accreditation Council for Graduate Medical Education were more beneficial to osteopathic medical graduates than those approved by the American Osteopathic Association (94 [87.8%]). Finally, there was a perception that research efforts supporting "the scientific basis of osteopathic medicine" were inadequate (53 [49.5%]). The one demographic factor that had a statistically significant (P<.001) positive impact on perceptions of osteopathic medicine among these MDs was previous contact with DOs.

CONCLUSION

Underrepresentation of DOs in the deep central southern region of the United States appears to have an impact on the perception of osteopathic medicine among MDs insofar as direct or indirect contact with osteopathic physicians led to improved perceptions among this cohort.

Tramadol: basic pharmacology and emerging concepts

Tramadol hydrochloride is a widely prescribed, centrally acting analgesic marketed in over 90 countries. Before being released in the U.S. in 1995, the drug had been available in Europe for almost two decades. Thus, the pharmacokinetic and pharmacodynamic properties of tramadol have been extensively investigated. However, additional information about the drug continues to be discovered. Tramadol exists as a racemic mixture with the (+)-enantiomer and the (-)-enantiomer, and at least some of their metabolites, having different effects. Tramadol has dual mechanisms of action by which analgesia may be achieved: micro-opioid receptor activation and enhancement of serotonin and norepinephrine transmission. Serotonin syndrome may occur in patients taking combinations of tramadol and other agents that increase serotonin activity. The relative degree of contribution of each mechanism toward pain control is not fully understood. By increasing serotonin and norepinephrine neurotransmission, tramadol may conceivably also exert a degree of antidepressant effect. Therefore, tramadol may be of particular value in patients with chronic pain who also suffer from depression. This drug has been shown to be beneficial in the treatment of a wide range of acute and chronic pain syndromes, including neuropathic pain. While abuse of tramadol may occur, several large studies have demonstrated that the incidence of abuse is rather low, about one case per 100,000 patients.

Anxiety sensitivity as a moderator of the association between smoking rate and panic-relevant symptoms among a community sample of middle-aged adult daily smokers

The aim of the present investigation was to evaluate the moderating role of anxiety sensitivity (AS) in the relation between smoking rate and panic vulnerability variables among a community-based sample of adults. Results indicated that the interaction between AS and smoking rate significantly predicted anxious arousal, agoraphobic avoidance, and anticipatory anxiety. Specifically, participants who reported higher levels of AS and heavier smoking rates reported the highest levels of panic vulnerability. These data suggest that this combination of high AS and heavier smoking is particularly problematic in regard to panic symptoms.

Psychometric evaluation of the National Opinion Research Center DSM-IV Screen for Gambling Problems (NODS)

The present study examined the reliability, validity, and clinical utility of a brief self-report measure of gambling behavior, the National Opinion Research Center DSM-IV Screen for Gambling Problems (NODS). Participants were 157 consecutively enrolled male military veterans taking part in substance use disorder treatment. The NODS displayed good internal consistency. Concurrent and discriminant validity were demonstrated by comparing scores on the NODS to scores on the South Oaks Gambling Screen and to a measure of medical problems, respectively. Overall, the NODS appears to be a reliable, valid, and clinically useful measure of gambling problems among patients in substance use disorder treatment programs.

Sequential Treatment for Nicotine Dependence and Postcessation Weight Concern in a Female Diagnosed with Paranoid Schizophrenia

Despite declines in smoking prevalence, some populations represent significant challenges to tobacco cessation programs, including smokers with psychiatric comorbidity and/or weight concerns. Few studies have found effective interventions for tobacco cessation or addressed the prevalence of smoking-related concerns in psychiatric populations. The side effects of many psychotropic medications, decreased participation in physical activity, and weight gain following cessation suggest that postcessation weight concerns and actual weight gain may be significant barriers to cessation as well. Therefore, serial interventions, rather than simultaneous ones, seem well suited to address these issues. This case study represents the piloting of serial cessation and postcessation weight gain prevention interventions in a female diagnosed with paranoid schizophrenia. Results suggested that the serial implementation of cognitive-behavioral interventions can be effective in promoting tobacco cessation in individuals with co-occurring disorders.

Relation between cognitive testing performance and pattern of substance use in males at treatment entry

This study examined the frequency and pattern of cognitive impairment in individuals entering substance use disorder treatment and additionally examined the relation between pattern of cognitive impairment and type of substance(s) used: alcohol (n = 116), cocaine (n = 49), alcohol/cocaine (n = 76), and alcohol/multiple substance (n = 54). The Cognistat, a screening measure of cognitive functioning, and the Addiction Severity Index were given to male veterans at the time of entering 3- to 4-week residential/day drug treatment. The most prominent areas of impairment were memory (37% of the total sample) and similarities or abstract concept formation (21% of the total sample). Moderate or greater severity of impairment was noted on at least one Cognistat scale in 35% of the participants. Results indicated no significant differences in the patterns of cognitive domain impairment between groups based on type(s) of substances used at the time of entering treatment. Multiple substance use was significantly related to greater levels of psychiatric problems as identified by the Alcohol Severity Index. Given the rate of impairment in memory and verbal abstract reasoning noted, it is suggested that cognitive screening be a standard consideration in residential substance use disorder treatment to assist in treatment selection and delivery that is optimized to provide maximal benefit to patients.

The Marijuana Check-up: promoting change in ambivalent marijuana users

AIMS

To evaluate the efficacy of a two-session assessment and feedback intervention designed to reach and increase motivation for change in marijuana users who were experiencing negative consequences but were ambivalent about change.

DESIGN

Random assignment to one of two types of feedback conditions or a delayed feedback control (DFC) with follow-up assessments at 7 weeks, 6 months and 12 months. Setting University of Washington research center in Seattle, Washington.

PARTICIPANTS

A total of 188 adult male and female marijuana users who responded to advertisements. Interventions A personalized feedback (PF) condition utilizing motivational interviewing was compared to an educational control condition labeled multi-media feedback (MMF).

MEASUREMENTS

Marijuana use, dependence symptoms, other associated negative consequences and motivational constructs were assessed at all time-points.

FINDINGS

PF participants reported fewer days of use per week, fewer periods of use per day and fewer dependence symptoms at 7 weeks than those in the MMF and DFC conditions. PF participants also reported fewer days of use per week compared to MMF participants at the 12-month follow-up and fewer dependence symptoms at both the 6- and 12-month follow-ups compared to MMF participants.

CONCLUSIONS

The PF intervention, delivered in the context of a check-up, shows potential as a way of reaching and motivating change in marijuana users with a diagnosable disorder who otherwise are not ready to approach treatment. Ways of augmenting the modest absolute levels of change are discussed.

P300 cognitive evoked potentials before and after liver transplantation

P300 cognitive evoked potentials have been shown to be effective for the assessment of mild hepatic encephalopathy but no investigations of their use with liver transplantation has been conducted. In this pilot study 12 subjects (7 male, 5 female, average age 43.9-years-old) underwent recording of auditory and visual P300 cognitive evoked potentials prior to liver transplantation and again 3-6 months subsequent to transplantation. Significant increases (p < 0.01) in P300 visual amplitude, as well as significant decreases in visual (p < 0.01) and auditory latencies (p < 0.01) were observed following transplantation. Auditory amplitudes increased but not to a statistically significant degree. P300 cognitive evoked potentials may provide a useful tool for monitoring the cerebral status of liver transplantation patients if combined with established methods such as cognitive testing and EEG. Further research of their usage with these patients is warranted.

Nocebo effects with antidepressant clinical drug trial placebos

We describe an individual who experienced unusual negative effects while taking a placebo during a clinical drug trial. A 26-year-old male took 29 inert capsules, believing he was overdosing on an antidepressant. Subsequently, he experienced hypotension requiring intravenous fluids to maintain an adequate blood pressure until the true nature of the capsules was revealed. The adverse symptoms then rapidly abated. The nocebo effect (undesirable symptoms following administration of an inert substance that the patient believes to be an active drug) may have significant negative impacts on certain patients. Further research is warranted to better understand this phenomenon.

Characteristics of psychotic patients with foreign accent syndrome

The authors describe three patients with foreign accent syndrome during psychotic episodes which resolve with improvement of psychotic symptoms. Psychotic symptoms were worse during the times patients had foreign accents, suggesting a relationship between the presence of the accent and the severity of the psychosis.

Affective Modulation of Pain in Substance-Dependent Veterans

OBJECTIVE

Prior work suggests that positive affect inhibits pain while negative affect facilitates it. The current study sought to determine whether: 1) affective modulation of pain extends to a patient population; 2) cocaine and alcohol dependence influences the pattern of modulation; and 3) affective modulation of pain is mediated by changes in arm temperature.

DESIGN

Thirty-seven participants with and without substance dependence (14 alcohol, 13 cocaine, 10 none) attended three experimental sessions intended to induce emotions (negative, neutral, positive) by picture-viewing. Following emotion-induction, participants were asked to submerge their arm in 33 degrees F water and keep it there until they reached tolerance. During submersion, pain ratings were made on a mechanical visual analog scale (M-VAS).

OUTCOME MEASURES

Latency from submersion to first movement of the M-VAS (pain threshold) and latency to arm removal (pain tolerance) were measured. Arm temperature and manipulation checks for emotion-induction (corrugator electromyogram, heart rate, skin conductance, self-report) were also recorded.

RESULTS

Manipulation checks confirmed that targeted affective states were achieved. Pain threshold and tolerance were higher after viewing pleasant pictures than after unpleasant ones. Although arm temperature did vary based on the affect induced, analyses suggested that temperature did not influence pain outcomes.

CONCLUSIONS

Affect modulates pain perception in patients and does not appear to be mediated by changes in arm temperature. Additionally, pain modulation was not significantly influenced by cocaine or alcohol dependence. These data are encouraging, because they suggest that nonpharmacological methods of pain modulation may be effective in substance-dependent individuals.

Quantitative EEG analysis before and after liver transplantation

Quantitative EEG has been shown to be effective for the assessment of hepatic encephalopathy. Initial quantitative EEG studies of patients who had undergone liver transplantation demonstrated improvement of frequency and the alpha-theta power ratio in the occipital area. This study involved the assessment of comprehensive quantitative EEG variables over the entire cortex following transplantation. Fourteen subjects underwent EEG recording prior to transplantation. Eight (6 without complications and 2 having problems with rejection) underwent the same recording between 3 and 6 months following transplantation. For all subjects, EEG variables showing significant changes from pre- to post-transplantation included posterior alpha frequency (increase, p < or = .03), central theta absolute power (decrease, p < or = .03), theta relative power over anterior, central, and posterior regions (decrease, p < or = .02, p < or = .01, p < or = .03, respectively), posterior beta absolute power (increase, p < or = .01), and central and posterior beta relative power (increase, p < or = .04, p < or = .04, respectively). When the two subjects with complications were removed from the analyses, these variables and also anterior alpha absolute power (increase, p < or = .02), alpha relative power over anterior, central, and posterior regions (increase, p < or = .05, p < or = .03, p < or = .04, respectively), and anterior and central theta absolute power (decrease, p < or = .05, p < or = .04, respectively) showed significant pre- to post-transplant changes. In conclusion, a combination of quantitative EEG parameters which are most affected by liver transplantation might provide an effective assessment tool for determining and quantitatively monitoring the cerebral status of post-transplant patients.

The relation between ethnicity and cognistat performance in males seeking substance use disorder treatment

This study examined the relation between ethnicity and results obtained during standard administration of the Cognistat, a screening measure of cognitive functioning, in a sample of male veterans seeking substance use disorder treatment (n = 312). Results indicated that screening items for the Naming, Calculation, and Similarities subtests were missed significantly more frequently by African American compared to Caucasian veterans, although the frequency of identification as impaired on the full metric portion of this scales did not differ based on ethnicity. The mean scores on the metric items for these three scales were very similar between groups. Additionally, African American veterans diverted to the Constructional Ability metric items had significantly lower scores on items from that subtest. Logistic regression analyses of impairment identification on the various subtests indicated that ethnicity was a significant (p < .005) predictor beyond the covariates of age and years of education for the Calculation subtest, but only accounted for 4.8% of the variance. Based on the results of the current study, it is recommended that 1) the entire Cognistat be administered regardless of screening item performance to minimize the risk of potential ethnic or cultural based performance bias and 2) a prospective study of potential demographic bias based on comparing Cognistat screening results to a battery of specific neuropsychological assessments of the same constructs be performed to maximize the potential specificity and sensitivity of this assessment for all demographic groups.

The Marijuana Check-up: reaching users who are ambivalent about change

AIMS

A brief intervention called the Marijuana Check-up (MCU) was designed to attract adult marijuana users who were experiencing adverse consequences, but who were ambivalent about change and would be unlikely to seek treatment. Our objective was to determine whether the MCU would reach the target population.

DESIGN

Comparisons were made between those who enrolled in the MCU versus those who were screened but failed to follow through with enrollment on demographic, drug use and stage of change variables. Comparisons were also made between participants in the MCU and participants in a concurrently offered treatment project that targeted marijuana users who wanted to quit.

SETTING

The study took place at the University of Washington in Seattle.

PARTICIPANTS

Participants were adult marijuana users who telephoned and expressed interest in the MCU (n = 587).

MEASUREMENT

Study variables included stage of change, frequency and duration of drug use, DSM-IV cannabis dependence and abuse diagnoses and negative consequences of marijuana use assessed via interviews and questionnaires.

FINDINGS

Callers to the MCU were near-daily marijuana users, two-thirds of whom were in the pre-contemplation or contemplation stage of change. Participants who enrolled in the MCU reported fewer problems related to marijuana use and less readiness to make changes compared to those enrolled in the treatment study, despite similar levels of drug use.

CONCLUSIONS

The MCU attracted and enrolled near-daily users of marijuana who experienced negative consequences but were ambivalent about making changes. The MCU potentially has a role in the continuum of care for substance abuse problems.

Social anxiety and drinking in college students: a social cognitive theory analysis

Evidence is reviewed that indicates that social anxiety is a significant motivation for drinking among college students. Although the link between social anxiety and alcohol consumption has been studied from a variety of perspectives, there has been little integration of data. Drawing from the alcohol and anxiety literature, the relationship between social anxiety and heavy drinking in college students is examined. Findings indicate a clear relationship between social anxiety and drinking that may be moderated by alcohol expectancies and self-efficacy beliefs specific to socially anxious situations. A social cognitive model is proposed to guide future research and intervention efforts. A better understanding of college students' reasons for drinking offers the possibility of improving prevention and treatment efforts designed to reduce excessive drinking.