behavioral interventions for addictions and co-occurring disorders suzette glasner-edwards, ph.d....
TRANSCRIPT
Behavioral Behavioral Interventions for Interventions for
Addictions and Co-Addictions and Co-Occurring DisordersOccurring Disorders
Suzette Glasner-Edwards, Ph.D. Suzette Glasner-Edwards, Ph.D. UCLA Integrated Substance Abuse ProgramsUCLA Integrated Substance Abuse Programs
February 28February 28thth, 2013, 2013
AcknowledgementsAcknowledgements
Collaborators: Patricia Marinelli-Casey, Ph.D., Collaborators: Patricia Marinelli-Casey, Ph.D., Maureen Hillhouse, Ph.D., Alfonso Ang, Ph.D., Maureen Hillhouse, Ph.D., Alfonso Ang, Ph.D., Larissa Mooney, M.D., Richard Rawson, Ph.D. Larissa Mooney, M.D., Richard Rawson, Ph.D.
Thanks to the treatment and research staff at the Thanks to the treatment and research staff at the participating community-based center sites and participating community-based center sites and the study investigators in each region. the study investigators in each region.
The research presented in this talk was supported The research presented in this talk was supported by grants provided by NIDA (K23DA20085 and by grants provided by NIDA (K23DA20085 and R21DA029255), the Center for Substance Abuse R21DA029255), the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Treatment (CSAT), Substance Abuse and Mental Health Services Administration Mental Health Services Administration (SAMHSA), US Department of Health and (SAMHSA), US Department of Health and Human Services.Human Services.
Disclosure InformationDisclosure Information
Continuing Medical Education committee members and those involved Continuing Medical Education committee members and those involved in the planning of this CME Event have no financial relationships to in the planning of this CME Event have no financial relationships to disclose.disclose.
Suzette Glasner-EdwardsSuzette Glasner-Edwards
I have no financial relationships to discloseI have no financial relationships to disclose
OverviewOverview
Clinical course and outcomes of Clinical course and outcomes of substance users with comorbid substance users with comorbid psychiatric disorderspsychiatric disorders
Behavioral interventions with Behavioral interventions with promisepromise Integrated treatmentsIntegrated treatments CBT/MICBT/MI Mindfulness Based Relapse PreventionMindfulness Based Relapse Prevention
BackgroundBackground Affective Disorders are among the most common Axis I Affective Disorders are among the most common Axis I
disorders for most drugs of abuse. disorders for most drugs of abuse. 26% of adults with SUDs have lifetime history of affective 26% of adults with SUDs have lifetime history of affective
disorderdisorder 27% of adults with unipolar depression have lifetime history of 27% of adults with unipolar depression have lifetime history of
SUDs.SUDs.
Depression-SUD comorbidity is associated with poorer Depression-SUD comorbidity is associated with poorer outcomes whether treatment targets the SUD or the outcomes whether treatment targets the SUD or the depression. (e.g., Stein et al., 2004)depression. (e.g., Stein et al., 2004)
Outcomes for this population appear to be optimized by:Outcomes for this population appear to be optimized by: (1) Integrating therapy content for both problems(1) Integrating therapy content for both problems
(2) Using CBT(2) Using CBT(3) Improving retention(3) Improving retention
Course and Outcomes of Course and Outcomes of Methamphetamine Users With Co-Methamphetamine Users With Co-
Occurring DisordersOccurring Disorders Participants: a subset (N=526) of adults who Participants: a subset (N=526) of adults who
were recruited to participate in the were recruited to participate in the Methamphetamine Treatment Project (Rawson et Methamphetamine Treatment Project (Rawson et al., 2004) participated in a longitudinal follow-up al., 2004) participated in a longitudinal follow-up study. study.
Inclusion criteria:Inclusion criteria: Age 18 or overAge 18 or over MA dependenceMA dependence Able to understand English and attend treatmentAble to understand English and attend treatment
Exclusion criteria:Exclusion criteria: Medical impairment compromising safety to participateMedical impairment compromising safety to participate Need for medical detox from alcohol/opioids/other Need for medical detox from alcohol/opioids/other
substancessubstances Psychiatric impairment warranting Psychiatric impairment warranting
hospitalization/primary txhospitalization/primary tx
Study Design (cont’d)Study Design (cont’d) Assessments conducted by trained interviewers atAssessments conducted by trained interviewers at
BaselineBaseline Tx dischargeTx discharge Post-treatment (M=3.1 years)Post-treatment (M=3.1 years)
Inclusion criteria:Inclusion criteria: Age 18 or overAge 18 or over MA dependence with recent use (i.e., past 30 days)MA dependence with recent use (i.e., past 30 days) Able to understand English and attend treatmentAble to understand English and attend treatment
Exclusion criteria:Exclusion criteria: Medical impairment compromising safety to participateMedical impairment compromising safety to participate Need for medical detox from alcohol/opioids/other Need for medical detox from alcohol/opioids/other
substancessubstances Psychiatric impairment warranting Psychiatric impairment warranting
hospitalization/primary txhospitalization/primary tx Recent participation in another drug treatment programRecent participation in another drug treatment program
MeasuresMeasures Mini-International Neuropsychiatric Interview (MINI) (Sheehan et Mini-International Neuropsychiatric Interview (MINI) (Sheehan et
al., 1998) was given at 3-year follow-up to assess DSM-IV current al., 1998) was given at 3-year follow-up to assess DSM-IV current psychiatric disorderspsychiatric disorders
Life Experiences Timeline was given at follow-up to assess substance Life Experiences Timeline was given at follow-up to assess substance use use
Addiction Severity Index (McLellan et al., 1980) was given at all Addiction Severity Index (McLellan et al., 1980) was given at all timepoints, providing data regarding:timepoints, providing data regarding:
MA use frequency in the 30 days priorMA use frequency in the 30 days prior Composite severity scores in 7 functional domains Composite severity scores in 7 functional domains
Beck Depression Inventory (Beck et al., 1961) was given at each Beck Depression Inventory (Beck et al., 1961) was given at each assessment to measure depression severityassessment to measure depression severity
Brief Symptom Inventory (Derogatis and Melisaratos, 1983) was Brief Symptom Inventory (Derogatis and Melisaratos, 1983) was given at each assessment to measure psychological symptom given at each assessment to measure psychological symptom severity across 9 domains.severity across 9 domains.
Treatment adherence: continuous variable indicating the number of Treatment adherence: continuous variable indicating the number of weeks of scheduled treatment attendedweeks of scheduled treatment attended
Psychiatric Disorders in Methamphetamine Psychiatric Disorders in Methamphetamine Dependent AdultsDependent Adults
Glasner-Edwards, S., Mooney, L.J., Marinelli-Casey, P., Hillhouse, M., Glasner-Edwards, S., Mooney, L.J., Marinelli-Casey, P., Hillhouse, M., Ang, A., Rawson, R.A.Ang, A., Rawson, R.A.
(2010). Psychopathology in methamphetamine dependent (2010). Psychopathology in methamphetamine dependent adults 3 years after adults 3 years after
treatment. treatment. Drug and Alcohol Review, 29: Drug and Alcohol Review, 29: 12-20.12-20.
Results: Psychiatric Diagnoses (N=526)Results: Psychiatric Diagnoses (N=526)Diagnosis Current (%) Life (%)
Any Psychiatric Disorder 34.0 34.6
Affective Disorders Major Depression 15.2 ***
Major Depression, Recurrent *** 9.1
Mania 3.9 8.5
Hypomania 2.4 9.3
Any Affective Disorder 22.2 24.5
Any Anxiety Disorder 23.4 ***
Psychotic Disorders 4.9 12.7
Antisocial Personality Disorder *** 25.8
Psychiatric Diagnoses and OutcomesPsychiatric Diagnoses and Outcomes
Of those who participated in the Methamphetamine Treatment project, 48% met criteria for Of those who participated in the Methamphetamine Treatment project, 48% met criteria for a current or past psychiatric disorder.a current or past psychiatric disorder.
Mood disorders, anxiety disorders, and antisocial personality disorders were the most Mood disorders, anxiety disorders, and antisocial personality disorders were the most common diagnoses.common diagnoses.
MA useMA use Those with an Axis I disorder reported greater frequency of MA use during follow-up (M=15.5 Those with an Axis I disorder reported greater frequency of MA use during follow-up (M=15.5
months, SD=0.8) compared to those without a diagnosis (M=12.8 months, SD=0.8), t(523)= -2.0, months, SD=0.8) compared to those without a diagnosis (M=12.8 months, SD=0.8), t(523)= -2.0, p=0.03. p=0.03.
Those with Antisocial Personality Disorders reported using less frequently than those without Those with Antisocial Personality Disorders reported using less frequently than those without ASPD (M=11.9 vs. M=14.8 months), t(523)=2.0, p=0.03.ASPD (M=11.9 vs. M=14.8 months), t(523)=2.0, p=0.03.
MA use frequency during FU increased as a function of the number of psychiatric diagnoses MA use frequency during FU increased as a function of the number of psychiatric diagnoses ((ββ=0.68, SE=0.29, p=0.02).=0.68, SE=0.29, p=0.02).
Other psychosocial and functional outcomesOther psychosocial and functional outcomes Those with an Axis I disorder evidenced problems of significantly greater severity from baseline to Those with an Axis I disorder evidenced problems of significantly greater severity from baseline to
follow-up on a subset of ASI composites and BSI scales:follow-up on a subset of ASI composites and BSI scales: ASI: Alcohol, drug, psychiatricASI: Alcohol, drug, psychiatric BSI: anxiety, phobic anxietyBSI: anxiety, phobic anxiety
Major Depressive Disorder in Major Depressive Disorder in Methamphetamine Dependent AdultsMethamphetamine Dependent Adults
Glasner-Edwards, S., Marinelli-Casey, P., Hillhouse, M., Ang, A., Glasner-Edwards, S., Marinelli-Casey, P., Hillhouse, M., Ang, A., Mooney, L.J., Rawson, R.A. Mooney, L.J., Rawson, R.A.
(2009). Depression among methamphetamine users: (2009). Depression among methamphetamine users: association with outcomes fromassociation with outcomes from
the Methamphetamine Treatment Project at 3-year follow-up. the Methamphetamine Treatment Project at 3-year follow-up. Journal of Nervous and Journal of Nervous and
Mental Disease, Mental Disease, 197: 225-231.197: 225-231.
Depressive Symptoms and MA UseDepressive Symptoms and MA Use
Time
Baseline Discharge
Mea
n B
DI S
core
0
5
10
15
20
Abstinent Used MA
Those who remained abstinent from MA showed a greater reduction in depressive symptoms as compared to those who used within 30 days prior to treatment discharge (β=5.1, SE=0.69, p<0.0001).
Results: Major Depressive DisorderResults: Major Depressive Disorder
No MDD
ASI Composite
med
ical
empl
oym
ent
alco
hol
drug
lega
l
fam
ily
psyc
hiat
ric
Me
an C
omp
osite
Sco
re
0.0
0.1
0.2
0.3
0.4
0.5
0.6Baseline DischargeFollow-up
Results: Major Depressive DisorderResults: Major Depressive Disorder
MDD
ASI Composite
med
ical
empl
oym
ent
alco
hol
drug
lega
l
fam
ily
psyc
hiat
ric
Mea
n C
ompo
site
Sco
re
0.0
0.1
0.2
0.3
0.4
0.5
0.6
Baseline DischargeFollow-Up
Major Depressive Disorder: cont’dMajor Depressive Disorder: cont’d
Summary of findingsSummary of findings Abstainers shifted from clinically significant depressive symptoms at Abstainers shifted from clinically significant depressive symptoms at
treatment entry to the normal/minimal symptom range at discharge.treatment entry to the normal/minimal symptom range at discharge.
Those with Major Depressive Disorder at follow-up had poorer Those with Major Depressive Disorder at follow-up had poorer methamphetamine use outcomes.methamphetamine use outcomes.
Depression severity at follow-up was greater for those who used Depression severity at follow-up was greater for those who used methamphetamine intravenously, relative to those who used other methamphetamine intravenously, relative to those who used other routes of administration. routes of administration.
Those with Major Depression had worsening depressive symptoms, Those with Major Depression had worsening depressive symptoms, overall psychiatric severity, and psychosocial outcomes from overall psychiatric severity, and psychosocial outcomes from discharge to follow-up.discharge to follow-up.
Anxiety Disorders in Methamphetamine Anxiety Disorders in Methamphetamine Dependent AdultsDependent Adults
Glasner-Edwards, S., Mooney, L.J., Marinelli-Casey, P., Hillhouse, M., Glasner-Edwards, S., Mooney, L.J., Marinelli-Casey, P., Hillhouse, M., Ang, A., Rawson, R.A.Ang, A., Rawson, R.A.
(2010). Anxiety disorders among methamphetamine dependent (2010). Anxiety disorders among methamphetamine dependent adults: adults:
association with posttreatment outcomes. association with posttreatment outcomes. American Journal on American Journal on Addictions, 19(5Addictions, 19(5): ): 385-390.385-390.
Results: Anxiety DisordersResults: Anxiety Disorders
26.2% of the sample was diagnosed with an anxiety disorder (current or 26.2% of the sample was diagnosed with an anxiety disorder (current or past).past).
Those with anxiety disorders reported greater MA use frequency during 3-Those with anxiety disorders reported greater MA use frequency during 3-year follow-up compared to those without an anxiety disorder.year follow-up compared to those without an anxiety disorder.
Those with anxiety disorders were more likely to have been hospitalized Those with anxiety disorders were more likely to have been hospitalized within the year prior to FU than those without a diagnosis (OR=1.8, 95% within the year prior to FU than those without a diagnosis (OR=1.8, 95% C.I., 1.1-2.9) and to have attempted suicide in their lifetimes (C.I., 1.1-2.9) and to have attempted suicide in their lifetimes (OR=3.1, OR=3.1, 95% C.I., 2.1-4.7)95% C.I., 2.1-4.7)..
Participants with anxiety disorders had poorer treatment adherence Participants with anxiety disorders had poorer treatment adherence (M=6.2 vs. 7.6 weeks, t=2.3, df=524, p=0.02), were more likely to meet (M=6.2 vs. 7.6 weeks, t=2.3, df=524, p=0.02), were more likely to meet criteria for alcohol- (OR=1.8) or other substance dependence (OR=2.2) at criteria for alcohol- (OR=1.8) or other substance dependence (OR=2.2) at 3-year follow-up, and evidenced declining functional outcomes on the ASI 3-year follow-up, and evidenced declining functional outcomes on the ASI (drug, psychiatric) from baseline to FU.(drug, psychiatric) from baseline to FU.
PTSD Symptoms as Risk Factors for Post-PTSD Symptoms as Risk Factors for Post-Treatment Methamphetamine UseTreatment Methamphetamine Use
Glasner-Edwards, S., Mooney, L.J., Ang, A., Hillhouse, M., Rawson, R.A.Glasner-Edwards, S., Mooney, L.J., Ang, A., Hillhouse, M., Rawson, R.A. (in press). PTSD symptoms as risk factors for (in press). PTSD symptoms as risk factors for Drug and Drug and
Alcohol Review, 29: Alcohol Review, 29: 12-20.12-20.
Results: PTSDResults: PTSD
Those with PTSD reported greater MA use frequency during 3-year Those with PTSD reported greater MA use frequency during 3-year follow-up compared to those without an anxiety disorder.follow-up compared to those without an anxiety disorder.
MA use frequency was associated with specific PTSD symptom MA use frequency was associated with specific PTSD symptom clusters; higher levels of use were predicted by avoidance (clusters; higher levels of use were predicted by avoidance (β=1.58, β=1.58, SESE=0.58; =0.58; pp<0.01) <0.01) and arousal and arousal (β=1.50, (β=1.50, SESE=0.62; =0.62; pp<0.05) <0.05) symptoms.symptoms.
Participants with PTSD were more likely to have an additional Axis I Participants with PTSD were more likely to have an additional Axis I disorder (particularly, mood psychotic, and eating disorders).disorder (particularly, mood psychotic, and eating disorders).
Psychotic Disorders in Methamphetamine Psychotic Disorders in Methamphetamine Dependent AdultsDependent Adults
Glasner-Edwards, S., Mooney, L.J., Marinelli-Casey, P., Hillhouse, M., Glasner-Edwards, S., Mooney, L.J., Marinelli-Casey, P., Hillhouse, M., Ang, A., Rawson, R.A.Ang, A., Rawson, R.A.
(2008). Clinical course and outcomes of methamphetamine (2008). Clinical course and outcomes of methamphetamine dependent adults dependent adults
with psychosis. with psychosis. Journal of Substance Abuse Treatment.Journal of Substance Abuse Treatment. 35, 445-35, 445-450. 450.
Results: Psychotic DisordersResults: Psychotic Disorders
12.9% of the sample was diagnosed with a psychotic disorder 12.9% of the sample was diagnosed with a psychotic disorder (current or past).(current or past).
Those with psychotic illness were more likely to have been Those with psychotic illness were more likely to have been hospitalized within the year prior to FU than those without a diagnosis hospitalized within the year prior to FU than those without a diagnosis (OR=2.4, 95% C.I., 1.2-4.3) and reported more episodes ((OR=2.4, 95% C.I., 1.2-4.3) and reported more episodes (ββ=0.33, =0.33, SE=0.11, p<0.01)SE=0.11, p<0.01)..
Those with psychotic illness evidenced declining functional outcomes Those with psychotic illness evidenced declining functional outcomes on the ASI (medical, employment, legal) and worsening on the ASI (medical, employment, legal) and worsening psychological impairment on the BSI from baseline to FU.psychological impairment on the BSI from baseline to FU.
No difference in MA use frequency among those with and without No difference in MA use frequency among those with and without psychotic disorders during FU (M=12.5 psychotic disorders during FU (M=12.5 ++1.6 versus 14.3 1.6 versus 14.3 ++ 0.6 0.6 months); no difference in tx adherence. months); no difference in tx adherence.
SummarySummary Rates of psychiatric disorders in MA users are Rates of psychiatric disorders in MA users are
moderate relative to that observed in cocaine moderate relative to that observed in cocaine users but notably higher than prevalence users but notably higher than prevalence estimates of such syndromes in the general estimates of such syndromes in the general population.population.
Poorer functional outcomes are associated Poorer functional outcomes are associated with psychiatric illness in MA users. with psychiatric illness in MA users.
MA use outcomes are poorer among MA users MA use outcomes are poorer among MA users with psychiatric comorbidity. with psychiatric comorbidity.
Abstinence promotes psychiatric symptom Abstinence promotes psychiatric symptom recovery.recovery.
Concurrently addressing psychiatric symptoms Concurrently addressing psychiatric symptoms and relapse susceptibility may optimize and relapse susceptibility may optimize outcomes in this population. outcomes in this population.
True or False: People who stay abstinent True or False: People who stay abstinent from methamphetamine during treatment from methamphetamine during treatment
show reductions in depression symptoms. show reductions in depression symptoms.
Integrated Interventions (CBT and MI)Integrated Interventions (CBT and MI)
Integrated InterventionsIntegrated Interventions
Gold standard approach for the treatment of Gold standard approach for the treatment of COD; demonstrated efficacy in:COD; demonstrated efficacy in: Reducing hospitalizations in substance users with Reducing hospitalizations in substance users with
comorbid affective disorders or schizophrenia comorbid affective disorders or schizophrenia (e.g., Granholm et al., 2003)(e.g., Granholm et al., 2003)
Reducing psychiatric symptoms and substance Reducing psychiatric symptoms and substance abuse among those with co-occurring SUD and abuse among those with co-occurring SUD and PTSD (Back et al., 2010)PTSD (Back et al., 2010)
Improving depressive symptoms and reducing Improving depressive symptoms and reducing substance use among adults with SUD and major substance use among adults with SUD and major depression (Brown et al., 2006)depression (Brown et al., 2006)
Changes in Depression in Twelve-Step Facilitation versus Integrated
CBT
Source: Brown et al. (2006)
PreTx Treatment Posttreatment0 1 2 3 4 5
WAVE
20
25
30
35H
am
ilto
n D
ep
r essi o
n T
ota
l Sco
re
ICBT12 step
TRT
1 2 3 420
25
30
35
1 2 3 420
25
30
35TSF
ICBT
Changes in Substance Use in Twelve-Step Facilitation versus Integrated
CBT
Source: Brown et al. (2006)
TSF
ICBT
PreTx Treatment Posttreatment0 1 2 3 4 5WAVE
50
60
70
80
90
100P
erc
en
t Da
ys A
bst
ine
nt
ICBT12 step
TRT
1 2 3 450
60
70
80
90
100
1 2 3 450
60
70
80
90
100
Continuing Care Continuing Care ApproachesApproaches
Continuing care is critical, particularly within the first 6 Continuing care is critical, particularly within the first 6 months after treatment, given the relapsing nature of months after treatment, given the relapsing nature of addictive disordersaddictive disorders
Randomized continuing care trials for substance Randomized continuing care trials for substance users to date have mostly excluded those with users to date have mostly excluded those with concomitant psychopathologyconcomitant psychopathology
12-step self-help programs are the most prevalent 12-step self-help programs are the most prevalent aftercare approaches, and outcomes appear to be aftercare approaches, and outcomes appear to be comparable to CBT and MET (Ouimette et al., 1997, comparable to CBT and MET (Ouimette et al., 1997, Brown et al., 2002) for those with SUD-only.Brown et al., 2002) for those with SUD-only.
But what about those with comorbidity? But what about those with comorbidity?
Study OverviewStudy Overview Pilot clinical trial of integrated CBT and Motivational Therapy Pilot clinical trial of integrated CBT and Motivational Therapy
(CBT-MT) for Substance Dependent adults with Major Depressive (CBT-MT) for Substance Dependent adults with Major Depressive Disorder (N=68)Disorder (N=68)
CBT-MT addresses both depression and substance dependence CBT-MT addresses both depression and substance dependence with CBT and incorporates motivational exercises in each session with CBT and incorporates motivational exercises in each session targeting engagement and retention in continuing care for both targeting engagement and retention in continuing care for both conditions.conditions.
CBT-MT is expected to facilitate retention in treatment and to CBT-MT is expected to facilitate retention in treatment and to improve depression and substance use outcomes, relative to improve depression and substance use outcomes, relative to treatment as usual, a dual recovery anonymous self-help group treatment as usual, a dual recovery anonymous self-help group (DRA).(DRA).
Study Design: Participants receiving treatment in a day hospital Study Design: Participants receiving treatment in a day hospital program at UCLA were randomly assigned at discharge to either: program at UCLA were randomly assigned at discharge to either: Integrated CBT and Motivational Therapy (CBT-MT)Integrated CBT and Motivational Therapy (CBT-MT) Treatment As Usual (Dual Recovery Anonymous) (DRA)Treatment As Usual (Dual Recovery Anonymous) (DRA)
Inclusion CriteriaInclusion Criteria
Participants qualified for the study if they:Participants qualified for the study if they: Were at least 18 years old Were at least 18 years old Had a diagnosis of current substance dependence Had a diagnosis of current substance dependence
(alcohol, cannabis, stimulant, or opioid) (alcohol, cannabis, stimulant, or opioid) Had a diagnosis of lifetime Major Depressive Had a diagnosis of lifetime Major Depressive
Disorder (independent of substance use)Disorder (independent of substance use) Had current depressive symptoms >13 on the BDIHad current depressive symptoms >13 on the BDI
Potential participants were excluded for psychosis and Potential participants were excluded for psychosis and bipolar disorder, or suicidality warranting bipolar disorder, or suicidality warranting hospitalization. hospitalization.
Study DesignStudy Design Group CBT-MT, a weekly, 12-week group intervention draws Group CBT-MT, a weekly, 12-week group intervention draws
from group CBT and MI manualized treatments: from group CBT and MI manualized treatments: Integrated CBT for depression and SUDs (Brown et al., 2006)Integrated CBT for depression and SUDs (Brown et al., 2006) Group Motivational Interviewing (Santa Ana, 2005)Group Motivational Interviewing (Santa Ana, 2005)
Participants were assessed for depression and substance use Participants were assessed for depression and substance use at baseline, weekly during treatment, and 12 and 24 weeks at baseline, weekly during treatment, and 12 and 24 weeks post-treatment. Measures included:post-treatment. Measures included: BDIBDI HAM-DHAM-D Addiction Severity IndexAddiction Severity Index Psychiatric Research Interview for Substance and Mental Disorders Psychiatric Research Interview for Substance and Mental Disorders
(PRISM) (Hasin et al., 2006)(PRISM) (Hasin et al., 2006)
We hypothesized that CBT-MT would produce superior We hypothesized that CBT-MT would produce superior treatment retention, depression and substance use outcomes. treatment retention, depression and substance use outcomes.
DemographicsDemographics Overall CBT DRA
N % N % N %
68 35 33
Age 35 -- 36 -- 34 --
Gender
Male 33 49 17 49 16 48
Female 35 51 18 51 17 52
Ethnicity
Caucasian 52 76 28 80 24 73
Marital Status
Married 12 18 5 14 7 21
Never Married 38 56 20 57 18 55
Baseline BDI scores 30.55 -- 30.5 -- 30.6 --
The sample comprised mostly cannabis (40%) and alcohol (25%) users, followed by prescription drug (19%) and stimulant users.
Percent Attending Sessions Each Week, By Group
.
Percentage of Participants With Improvement in Depression, By
Attendance to >10 Sessions
In the overall sample, a significantly greater % of those who attended more than 10 sessions experienced improvements in depressive symptoms, (100%) chi-square=4.8, p=0.02, relative to those who attended 10 sessions or fewer (67%).
Percentage of Participants Attending >10 Sessions, by Group
Compared to those who received DRA, the proportion of those in CBT-MT who completed most or all of the sessions was significantly greater, chi square=4.48, p=.03.
Percentage of Participants With Improvement in Depressive Symptom
Severity Over Baseline
A significantly greater proportion of those in the CBT-MT condition (67%) showed a reduction from baseline to their last available assessment in total BDI scores, as compared to controls (37%); chi-square=5.9, p=0.01).
Percentage of Participants Who Used Drug of Choice in the Past 30 Days
ConclusionsConclusions In our pilot study of CBT-MT as a continuing In our pilot study of CBT-MT as a continuing
care approach for depressed substance care approach for depressed substance users, preliminary results suggest that :users, preliminary results suggest that : This approach effectively facilitates treatment This approach effectively facilitates treatment
retention.retention. Treatment retention is associated with Treatment retention is associated with
reductions in depressive symptoms.reductions in depressive symptoms. Preliminary drug use outcomes do not differ Preliminary drug use outcomes do not differ
between groups.between groups. Areas we are currently evaluating include: Areas we are currently evaluating include:
mechanisms of therapeutic change, effects of mechanisms of therapeutic change, effects of the intervention on time to relapse, and the intervention on time to relapse, and evaluation of the impact of baseline cognitive evaluation of the impact of baseline cognitive functioning on treatment response. functioning on treatment response.
ReferenceReferencess
Brown, S.A., Glasner, S.V., Tate, S.R., McQuaid, J.R., Chalekian, J., & Granholm, E.Brown, S.A., Glasner, S.V., Tate, S.R., McQuaid, J.R., Chalekian, J., & Granholm, E.
(2006). Integrated cognitive behavioral therapy versus twelve-step facilitation for(2006). Integrated cognitive behavioral therapy versus twelve-step facilitation for
substance dependent adults with depressive disorders. substance dependent adults with depressive disorders. Journal of Psychoactive Drugs.Journal of Psychoactive Drugs., 38(4): , 38(4): 449-460.449-460.
Brown, T.G., Seraganian, P., Tremblay, J., & Annis, H. (2002). Process and outcome changes with Brown, T.G., Seraganian, P., Tremblay, J., & Annis, H. (2002). Process and outcome changes with
relapse prevention versus 12-step aftercare programs for substance abusers. relapse prevention versus 12-step aftercare programs for substance abusers. Addiction, 97Addiction, 97: :
677-689.677-689.
Hasin, D., Samet, S., Nunes, E., Meydan, J., Matseoane, K., & Waxman, R. (2006). Diagnosis of Hasin, D., Samet, S., Nunes, E., Meydan, J., Matseoane, K., & Waxman, R. (2006). Diagnosis of
comorbid disorders in substance users: Psychiatric Research Interview for Substance and comorbid disorders in substance users: Psychiatric Research Interview for Substance and
Mental Disorders (PRISM-IV). Mental Disorders (PRISM-IV). American Journal of Psychiatry., American Journal of Psychiatry., 163(4), 689-696.163(4), 689-696.
Ouimette, P.D., Finney, J.W., & Moos, R.H. (1997). Twelve-step and cognitive-behavioral Ouimette, P.D., Finney, J.W., & Moos, R.H. (1997). Twelve-step and cognitive-behavioral treatment for treatment for
substance abuse: a comparison of treatment effectiveness. substance abuse: a comparison of treatment effectiveness. Journal of Consulting and Clinical Journal of Consulting and Clinical
Psychology, 65Psychology, 65: 230-240.: 230-240.
Santa Ana, E. (2005). Group Motivational Interviewing Treatment ManualSanta Ana, E. (2005). Group Motivational Interviewing Treatment Manual
(GMI) for Individuals with Psychiatric and Comorbid Substance Use Problems (pp. 1-25): Yale (GMI) for Individuals with Psychiatric and Comorbid Substance Use Problems (pp. 1-25): Yale University School of Medicine and VA CT Healthcare System.University School of Medicine and VA CT Healthcare System.
Stein, M.D., Herman, D.S., Solomon, D.A., Anthony, J.L., et al. (2004). Adherence to treatment of Stein, M.D., Herman, D.S., Solomon, D.A., Anthony, J.L., et al. (2004). Adherence to treatment of depression depression
in active injection drug users: the Minerva study. in active injection drug users: the Minerva study. Journal of Substance Abuse Treatment, Journal of Substance Abuse Treatment, 26(2):26(2): 87-93. 87-93.
True or False: Outcomes of integrated True or False: Outcomes of integrated treatments for continuing care are no better treatments for continuing care are no better
than those of standard, 12-step self-help than those of standard, 12-step self-help based continuing care for those with co-based continuing care for those with co-
occurring disorders.occurring disorders.
Mindfulness Based Relapse Prevention Mindfulness Based Relapse Prevention
Study OverviewStudy Overview Pilot RCT of Mindfulness Based Relapse Prevention (MBRP) Pilot RCT of Mindfulness Based Relapse Prevention (MBRP)
for Stimulant Users (N=62)for Stimulant Users (N=62)
Mindfulness involves cultivating awareness of one’s Mindfulness involves cultivating awareness of one’s moment-to-moment experience in a non-judgmental way.moment-to-moment experience in a non-judgmental way.
Mindfulness is expected to improve affect regulation as well Mindfulness is expected to improve affect regulation as well as stress reactivity, thereby reducing relapse susceptibilityas stress reactivity, thereby reducing relapse susceptibility
Study Design: All participants receive contingency Study Design: All participants receive contingency management for 12 weeks and are concurrently randomly management for 12 weeks and are concurrently randomly assigned to either assigned to either Mindfulness Based Relapse Prevention (MBRP) orMindfulness Based Relapse Prevention (MBRP) or Health Education Health Education
0
5
10
15
20
0 1 2 3 4 5* 6 7 8* 9* 10 11 12 16*
Mindf
Control
Beck Depression Inventory
Those in the MBRP condition showed a greater reduction in depressive symptoms through 1 month post-treatment , relative to controls (p<0.03; Effect Size=0.58).
Beck Anxiety Inventory
0
5
10
15
20
0 1 2 3 4 5 6 7 8 9 10 11 12 16*
Mindf
Control
Those in the MBRP condition showed a greater reduction in anxiety symptoms through 1 month post-treatment, relative to controls (p<0.02; Effect Size=0.72).
Addiction Severity Index: Psychiatric Composite
0
0.1
0.2
0.3
0.4
0 12 16*
Mindf
Control
Those in the MBRP condition showed a greater reduction in overall psychiatric severity through 1 month post-treatment as compared to controls (p<0.02; Effect Size=0.61).
Short Inventory of Problems
0
5
10
15
20
25
0 12 16
Mindf
Control
Those in the MBRP condition showed a greater reduction from baseline to 1 month post-treatment in problems related to stimulant dependence, as compared to controls (p<0.10; Effect Size=0.06).
0
5
10
15
20
25
CM Lead-In Intv phase
Mindf
Control
Stimulant Use Outcomes
Number of stimulant-free UA
% UA that were stimulant-free
Those in the MBRP condition showed comparable reductions in stimulant use during both the 4-week Contingency Management Lead-In and the subsequent 8-week Mindfulness Intervention Phase, compared to controls.
Stress Reactivity Before and After Treatment With Mindfulness or Health
Education Control
After treatment ended (right panel), cortisol levels during the hour following exposure to a laboratory stressor were elevated in a substantially larger proportion of control group participants, relative to MBRP participants, for whom post-stressor cortisol levels returned to baseline or lower.
Post-TreatmentPre-Treatment
Difficulty in Emotional Regulation Scale
50
60
70
80
90
100
0 12* 16*
Mindf
Control
Five Factor Mindfulness Scale
100
110
120
130
140
150
5 6 7 8* 9 10 11 12
Mindf
Control
SummarySummary In our pilot study of mindfulness based In our pilot study of mindfulness based
relapse prevention for stimulant users, relapse prevention for stimulant users, preliminary results suggest that :preliminary results suggest that : This approach effectively reduces negative This approach effectively reduces negative
affect, stress reactivity, psychiatric affect, stress reactivity, psychiatric impairment, and may reduce stimulant impairment, and may reduce stimulant dependence severity.dependence severity.
Changes in putative psychological Changes in putative psychological mechanisms underlying the effectiveness of mechanisms underlying the effectiveness of mindfulness (e.g., emotion regulation, mindfulness (e.g., emotion regulation, adoption of a mindful approach to living) are adoption of a mindful approach to living) are observed in this population.observed in this population.
True or False: Mindfulness interventions True or False: Mindfulness interventions were originally developed as a means of were originally developed as a means of
reducing stress.reducing stress.
ConclusionsConclusions Clinical course and outcomes of substance Clinical course and outcomes of substance
users with COD are poorer across multiple users with COD are poorer across multiple domains compared to those with SUD alone.domains compared to those with SUD alone.
Integrated interventions effectively improve Integrated interventions effectively improve outcomes, both as a primary treatment outcomes, both as a primary treatment strategy, and for continuing care for those strategy, and for continuing care for those with affective disorders and SUDs.with affective disorders and SUDs.
Mindfulness based interventions are a Mindfulness based interventions are a promising new target for COD, with efficacy promising new target for COD, with efficacy in reducing stress reactivity, negative affect, in reducing stress reactivity, negative affect, and overall psychiatric severity among and overall psychiatric severity among substance users.substance users.
