Clinical Effectiveness of an Intensive Outpatient Program for Integrated Treatment of Comorbid Substance Abuse and Mental Health Disorders

Comorbid substance use disorders (SUDs) and mental health disorders are a pervasive problem among post-9/11 veterans and service members. Treatment of SUD and comorbid disorders has historically occurred separately and sequentially, and when treated concurrently has been primarily done in a weekly outpatient setting, which has high rates of dropout. The current study describes an integrated 2-week intensive outpatient treatment (IOP) using cognitive-behavioral therapy, including prolonged exposure for posttraumatic stress disorder (PTSD), unified protocol for anxiety and mood disorders, and relapse prevention for SUD. Forty-two patients completed the comorbid treatment program. Results indicated that self-reported substance use, PTSD, and depression symptoms significantly decreased following treatment, while satisfaction with participation in social roles increased. These preliminary effectiveness data indicate that comorbid SUD and mental health disorders can be effectively treated in a 2-week intensive outpatient program.     

An Emotion Regulation Treatment for Young People With Complex Substance Use and Mental Health Issues: A Case-Series Analysis

Individuals accessing treatment within the youth alcohol and other drug (AoD) sector represent a highly vulnerable population who present with complex patterns of substance use and mental health comorbidity. Current treatments often fail to address this complexity. Emotion regulation (ER) has been identified as a promising transdiagnostic treatment target for this population of young people. The current study aimed to investigate the acceptability and feasibility of an adjunct ER intervention, ERIC (Emotion Regulation and Impulse Control) in young people receiving AoD treatment at a residential rehabilitation service. A mixed methods case series design was utilized. Ten participants aged between 16–20 years old completed 4–6 sessions of ERIC as an adjunct to their existing residential treatment. Participants undertook a post intervention feedback session and completed a number of self-report measures of ER, depression and anxiety at baseline and 2 weeks after receiving ERIC. Qualitative feedback from young people following the delivery of ERIC was positive, and suggested that ERIC was a viable and useful intervention. Participants reported that the components of ERIC, which involved metaphors and experiential exercises, were particularly beneficial and memorable. Pre-post measures indicated that 60% of the young people had both reliable and clinically significant reductions in overall emotion dysregulation, while reliable and clinically significant reductions in depression and anxiety were observed in 50% and 60% of participants respectively. Results support the acceptability of ERIC for this cohort of young people with complex substance use and mental health needs. Furthermore, these findings support the viability of delivering flexible and adjunctive ER treatments to young people seeking AoD treatment.     

Anxiety as a Predictor of Age at First Use of Substances and Progression to Substance Use Problems Among Boys

This study examined associations of generalized and social anxiety with (1) age at first use of tobacco, alcohol, and marijuana and (2) interval from first use to first problem use of each substance. Participants were 503 males who comprised the youngest cohort (first assessed in the first grade) of the Pittsburgh Youth Study, a longitudinal community-based study of boys. Annual assessments of generalized and social anxiety, delinquency, and substance use from first grade through high school were included. Both types of anxiety predicted earlier first use of alcohol and tobacco, and generalized anxiety predicted earlier first use of marijuana. Both types of anxiety predicted the progression from first use to problems related to marijuana. The effect of generalized anxiety tended to be significant above and beyond the effect of delinquency, while the effect of social anxiety on risk for first use of substances was not. Overall, the associations between anxiety and substance use and related problems depend on the class of substance and the type of anxiety.     

Conducting Outcomes Research in a Clinical Practice Setting: The Effectiveness and Acceptability of Acceptance and Commitment Therapy (ACT) in a Partial Hospital Program

Multiple challenges exist integrating research into clinical practice, particularly in acute care settings where randomized controlled trials may be impractical or unethical. Partial or day hospitals are one such setting. As compared to outpatients and inpatients, relatively little research is conducted or reported in partial hospital program (PHP) patients, leaving providers in this setting without a solid empirical basis from which to draw. We report treatment outcomes and patient satisfaction from the first 750 patients enrolled in a clinical research PHP utilizing the acceptance and commitment therapy (ACT) treatment model. ACT is a well-established, transdiagnostic behavior therapy. However, to date no study has examined the use of ACT in acute day hospitals. We hypothesized that applying ACT with this patient group would result in significantly improved depression, anxiety, functioning, and quality of life from intake to discharge. We additionally expected that patients would report high satisfaction with ACT treatment groups. Patients (n = 750 full sample, n = 518 completed treatment) completed daily measures of symptoms, functioning, and ACT processes at intake and discharge, and postgroup satisfaction surveys. Results showed significant improvements in symptoms and impairment. ACT process variables also increased over the course of treatment. Importantly, patient satisfaction was high for all groups. Thus, ACT provides an appropriate, flexible, effective, and satisfactory model for this patient group. A comparison of our findings using ACT to the limited research using other models in PHP settings is discussed, as well as challenges in the overall process of integrating research into routine clinical care.     

Anxiety sensitivity: a unique predictor of dropout among inner-city heroin and crack/cocaine users in residential substance use treatment

The present study examined the extent to which anxiety sensitivity (AS) at treatment entry was related to prospective treatment dropout among 182 crack/cocaine and/or heroin-dependent patients in a substance use residential treatment facility in Northeast Washington, DC. Results indicated that AS incrementally and prospectively predicted treatment dropout after controlling for the variance accounted for by demographics and other drug use variables, legal obligation to treatment (i.e., court-ordered vs. self-referred), alcohol use frequency, and depressive symptoms. Findings are discussed in relation to the role of AS in treatment dropout and substance use problems more generally.     

Differentiating anxiety and depression in older adults with generalized anxiety disorder

To examine affect and cognition in differentiating anxiety and depression, 83 older participants with generalized anxiety disorder completed the Cognitive Checklist (CCL) and the Positive and Negative Affect Schedule (PANAS). A 3-factor solution was found for the PANAS: positive affect (PA), anxiety and anger (Negative Affect 1 [NA-1]), and guilt and shame (Negative Affect 2 [NA-2]). A 2-factor structure was noted for the CCL. Correlations with anxiety and depression measures suggested that the CCL Depression (CCL-D) subscale showed stronger correlations with depression, whereas the CCL Anxiety subscale did not uniquely correlate with anxiety. The NA-1 subscale correlated positively with measures of depression and anxiety, whereas the PA subscale showed negative correlations. Hierarchical regression suggested that the CCL-D subscale was a significant predictor of self-reported depression.     

Peer functioning, family dysfunction, and psychological symptoms in a risk factor model for adolescent inpatients' suicidal ideation severity

Examined models of suicidal ideation severity that include two psychosocial risk factors (i.e., peer and family functioning) and four domains of psychological symptoms (i.e., generalized anxiety, depression, conduct problems, and substance abuse/dependence). Participants were 96 psychiatric inpatients (32 boys, 64 girls), ages 12 to 17, who were hospitalized because of concerns of suicidality. Adolescents completed a structured diagnostic interview, measures of suicidal ideation, and several dimensions of family and peer functioning. Results supported a model in which greater levels of perceived peer rejection and lower levels of close friendship support were associated directly with more severe suicidal ideation. In addition, indirect pathways included deviant peer affiliation and global family dysfunction related to suicidal ideation via substance use and depression symptoms. The results are among the first to demonstrate relations between suicidal ideation and several areas of adolescent peer functioning, as well as divergent processes for peer and family predictors of suicidal ideation.     

Measuring associations between social anxiety and use of different types of social media using the Swedish Social Anxiety Scale for Social Media Users: A psychometric evaluation and cross-sectional study

Research on the association between social anxiety and social media usage remains inconclusive: despite the preference for computer-mediated communication there is currently no clear empirical support for social anxiety being associated with longer duration of social media use. Self-report measures for social anxiety that are adapted for the context of social media could facilitate further research. The current study aimed to develop a Swedish version of the recently developed Social Anxiety Scale for Social Media Users (SAS-SMU), evaluate its psychometric properties, and explore associations between different uses of social media and social anxiety. Three factors were retained for SAS-SMU with excellent internal consistency. SAS-SMU evidenced convergent validity with measures of social anxiety, negative convergent validity with satisfaction with life, and divergent validity with measures of obsessive-compulsive disorder, depression and generalized anxiety disorder. Results indicated that higher levels of social anxiety were associated with passive and active use as well as longer duration of social media use in general, which is at odds with a previous study where passive use remained the only significant predictor for social anxiety.     

A Cognitive-Behavioral Family-Based Protocol for the Primary Presentations of Avoidant/Restrictive Food Intake Disorder (ARFID): Case Examples and Clinical Research Findings

Avoidant/restrictive food intake disorder (ARFID) is a feeding and eating disorder with evidence for distinct but overlapping presentations characterized by avoidance of eating or narrow dietary range related to poor appetite, selective eating, or fear of aversive consequences of eating. The current paper describes a flexible, cognitive-behavioral, family-oriented treatment approach that has been applied to each of these ARFID presentations within a larger partial hospitalization program (PHP) for eating disorders. We provide composite case examples for the presentations and retrospective outcome data on a sample of 81 patients treated with the protocol. Overall, patients with ARFID exhibited significant increases in body weight and the number of foods accepted, and significant decreases on measures assessing food fears, oral control behavior, anxiety, and depression. At baseline, patients with co-occurring poor appetite and selective eating exhibited significantly lower body weight than those with fear of aversive consequences, while the latter group of patients were eating significantly fewer foods and feared a larger number of foods according to parent report. Patients with the fear of aversive consequences presentation also experienced greater increases in the number of foods they were willing to eat and greater decreases in the number of foods they feared over the course of treatment relative to the other two groups. Our findings provide preliminary support for the effectiveness of our family-centered, cognitive-behavioral PHP for children and adolescents with ARFID. Future studies with more sophisticated methods, including randomized controlled designs and ARFID-specific measures, are recommended to help establish evidence-based psychosocial interventions for this clinical population.     

Group Treatment in Psychotherapy by Robert G. Hinckley and Lydia Hermann

A recently completed clinical trial that investigated the effectiveness of a group-oriented, day treatment program provided an opportunity to pursue a multidimensional approach to the prediction of treatment outcome. The sample consisted of 99 psychiatric outpatients, most of whom had received diagnoses of affective and personality disorders. The predictor variables included a patient personality characteristic (psychological mindedness), a group process variable (patient work), and their interaction. Univariate analyses revealed significant direct relationships between psychological mindedness and both work and favorable outcome, and between work and favorable outcome. Multivariate analyses indicated that psychological mindedness and work had independent significant relationships (additive or interactive) with several of the outcome variables. In combination they accounted for up to a quarter of the outcome variance. The results demonstrate the benefit of using a theoretically consistent multidimensional approach. The time-efficient nature of the predictor measures used in the study make them particularly amenable for use by clinicians and researchers.     

Prolonged exposure in patients with chronic PTSD: predictors of treatment outcome and dropout

The present study investigated predictors of treatment outcome and dropout in two samples of PTSD-patients with mixed traumas treated using prolonged imaginal exposure. Possible predictors were analysed in both samples separately, in order to replicate in one sample findings found in the other. The only stable finding across the two groups was that patients who showed more PTSD-symptoms at pre-treatment, showed more PTSD-symptoms at post-treatment and follow-up. Indications were found that benzodiazepine use was related to both treatment outcome and dropout, and alcohol use to dropout. Demographic variables, depression and general anxiety, personality, trauma characteristics, feelings of anger, guilt, and shame and nonspecific variables regarding therapy were not related to either treatment outcome or dropout, disconfirming generally held beliefs about these factors as contra-indications for exposure therapy. It is concluded that it is difficult to use pre-treatment variables as a powerful and reliable tool for predicting treatment outcome or dropout. Clinically seen, it is therefore argued that exclusion of PTSD-patients from prolonged exposure treatment on the basis of pre-treatment characteristics is not justified.     

Changes in Distress Intolerance and Treatment Outcome in a Partial Hospital Setting

Despite the well-established role of distress intolerance (DI) in a wide range of psychological disorders, few studies have examined whether DI improves during treatment and whether these changes are associated with symptom outcomes. Patients (N = 626) enrolled in a brief cognitive-behavioral partial hospital program completed pre- and posttreatment measures of DI. Results indicated that DI decreased significantly during treatment, with more than 30% of the sample exhibiting a reduction of more than 2 standard deviations from the sample mean. Women reported higher DI than men at baseline; however, there were no gender differences in changes in DI over time. Participants also completed a pre- and posttreatment measure of depression and a subset completed a measure of anxiety (n = 167). DI was associated with more severe depression and anxiety at pre- and posttreatment, with participants who reported a decrease in DI also reporting lower depression and anxiety symptoms at post-treatment. These results further highlight the transdiagnostic relevance of DI and suggest that DI may be a relevant factor in treatment outcome for depression and anxiety.     

Generalized Anxiety Disorder in Hispanics: Symptom Characteristics and Prediction of Severity

Literature suggests that an increasing number of Hispanic people suffer with GAD, and possible associated problems include high costs for treatment and elevated risk of severe impairment. The current study examined components of anxiety, as measured by currently available assessment instruments in both English and Spanish languages, among bilingual Hispanic individuals with GAD. Participants completed all instruments in both languages. Relations between these self-report measures and clinician-rated GAD severity were also studied. In factor analyses, the Spanish measures yielded two factors, the first of which included all instruments assessing physiological components of anxiety and one content specific measure of worry. The second factor included one worry scale and one trait anxiety scale. The English measures yielded a single factor solution. Regression analyses revealed that for the English measures, the BAI and PSWQ were statistically significant predictors of GAD severity. For the Spanish measures, the BAI was the only statistically significant predictor.     

Unpacking Social Avoidance and Substance Use in Social Anxiety: Does Extraversion Explain Behavior Variability?

Social anxiety is characterized by heightened fear and anxiety associated with social situations, resulting in the use of avoidance behaviors. Contemporary models suggest that some individuals with social anxiety may choose to completely avoid social situations, while others may seek social connections and interactions and utilize avoidance behaviors such as substance use as a means of distress tolerance, while engaging in these situations. Our aim is to test a theoretical model whereby extraversion could help to explain the heterogenous nature of social anxiety in relation to these behaviors. Lower levels of extraversion have been commonly associated with withdrawal behaviors and higher levels of extraversion have been associated with behaviors commonly enacted in social situations. Understanding factors which predict the use of one behavior over another is imperative to the conceptualization and successful treatment of patients with social anxiety. A sample of 195 college students completed self-report measures and a 10-day experience sampling diary with five diary signals each day. Participants were asked to rate their current negative emotions and behaviors during each diary signal. Using a multilevel modeling approach, we tested the association between social anxiety symptoms and negative affect predicting engagement in substance use or social avoidance and tested whether extraversion moderated this association. Negative affect was included as a covariate given the established associations between elevations in negative affect predicting both behaviors. Results indicated that higher levels of social anxiety symptoms and negative affectivity increased the probability of social avoidance and substance use, and extraversion was a significant predictor for only substance use. Moderation analysis indicated that extraversion moderated the relationship between social anxiety and substance use, suggesting a stronger positive relationship between substance use and social anxiety for individuals higher in extraversion. However, extraversion was not a significant moderator between social anxiety and social avoidance. Overall, the findings suggest that extraversion could be a key factor predicting the use of substances amongst individuals with social anxiety and may need further consideration in treatment.

     

Distress tolerance as a predictor of early treatment dropout in a residential substance abuse treatment facility

A large percentage of individuals who enter residential substance abuse treatment drop out before completing treatment. Given that early treatment dropout places individuals at an increased risk for relapse, identifying the mechanisms underlying treatment dropout would have several important theoretical and clinical implications. In the current study, the authors examined levels of psychological and physical distress tolerance as a predictor of early treatment dropout in a residential substance abuse treatment facility. In a sample of 122 individuals entering a residential substance abuse treatment facility, level of psychological distress tolerance was predictive of early treatment dropout above and beyond relevant self-report variables. There was no relationship between physical distress tolerance and early treatment dropout. Implications for future studies and treatment development or modification are discussed.     

Usability and Utility of a Computerized Cognitive-Behavioral Self-Help Program for Public Speaking Anxiety

This study describes the use of a cognitive-behavioral computer-administered self-help program with minimal therapist contact for public speaking anxiety. Participants (N = 10) with social phobia, as measured by a structured clinical interview, completed the self-help program in an open clinical trial. The program was delivered via a CD-ROM during individual sessions at an outpatient clinic, including 4 sessions of psychoeducation/cognitive therapy and 4 sessions of exposure therapy using a virtual audience presented on a computer screen. A therapist was available in another room to answer questions and to debrief for up to 10 minutes after each session. Participants completed standardized self-report questionnaires assessing social anxiety at pretreatment, posttreatment, and 3-month follow-up. Participants also completed measures of computer usability. Results showed decreases on all self-report measures of social anxiety from pre- to posttreatment, which were maintained at follow-up (n = 8). Participants also reported that they were satisfied with treatment, that they felt improved after treatment, and that the computer program was user-friendly. This study provides preliminary evidence that a computer-administered cognitive-behavioral-based program that includes minimal therapist contact may reduce public speaking anxiety and suggests that further research with a controlled design is needed.     

Coping and psychological distress for men with substance use disorders

Coping with stress is a major focus for chemically dependent persons in relapse prevention programs. The relationships among coping and psychological distress were investigated in 71 men with substance use disorders, at both pre—and post-treatment. It was predicted that low task-oriented coping, high emotion-oriented coping, and high avoidance-oriented coping would predict psychological distress (e.g., anxiety and depression). It was also expected that use of task-oriented coping would increase following treatment and that use of emotion-oriented coping and avoidance-oriented coping, and reported levels of psychological distress would all decrease following treatment. Participants completed the Coping Inventory for Stressful Situations and the General Health Questionnaire, took part in an intensive treatment program (e.g., relaxation, drug education, stress management) and completed these questionnaires again following treatment. Results indicated that high emotion-oriented coping predicted hypochondriasis, anxiety and depression. Task-oriented and avoidance-oriented coping did not predict psychological distress, although task-oriented coping was negatively related to hypochondriasis, anxiety and depression. The results regarding change in coping styles and levels of psychological distress were as hypothesized, except that avoidance-oriented coping did not significantly change following treatment. Theoretical and practical implications of the research are discussed.     

Coping and psychological distress for men with substance use disorders

Coping with stress is a major focus for chemically dependent persons in relapse prevention programs. The relationships among coping and psychological distress were investigated in 71 men with substance use disorders, at both pre—and post-treatment. It was predicted that low task-oriented coping, high emotion-oriented coping, and high avoidance-oriented coping would predict psychological distress (e.g., anxiety and depression). It was also expected that use of task-oriented coping would increase following treatment and that use of emotion-oriented coping and avoidance-oriented coping, and reported levels of psychological distress would all decrease following treatment. Participants completed the Coping Inventory for Stressful Situations and the General Health Questionnaire, took part in an intensive treatment program (e.g., relaxation, drug education, stress management) and completed these questionnaires again following treatment. Results indicated that high emotion-oriented coping predicted hypochondriasis, anxiety and depression. Task-oriented and avoidance-oriented coping did not predict psychological distress, although task-oriented coping was negatively related to hypochondriasis, anxiety and depression. The results regarding change in coping styles and levels of psychological distress were as hypothesized, except that avoidance-oriented coping did not significantly change following treatment. Theoretical and practical implications of the research are discussed.     

Using the Millon Behavioral Medicine Diagnostic to Delineate Treatment Outcomes in Rehabilitation

Patients undergoing rehabilitation have been evidenced to improve in different ways depending on their coping styles. Amplifiers, Repressors, and Social Copers are examples of patients who present differently in rehabilitation settings and tend to have differing levels of success in their response to treatment. The current study examined the differential treatment outcomes of three coping style groups undergoing multidisciplinary rehabilitation. A sample of 59 patients suffering from injuries associated with chronic pain were assessed using the Multidimensional Pain Inventory, Beck Depression Inventory, and Beck Anxiety Inventory before, during, and after multidisciplinary pain management treatment. Coping style groups derived from the Millon Behavioral Medicine Diagnostic consisting of Amplifiers, Repressors, and Social Copers were compared with regard to reductions in depression, anxiety, pain, functional impairment, and associated outcomes. Repeated measures ANOVA revealed that Amplifiers, Repressors, and Social Copers had varying levels of success in the treatment program. Hierarchical linear modeling analyses revealed the coping style groups to have significantly different change curves from pre to post-treatment in depression, anxiety, pain severity, functional impairment, affective distress, life control, social support, and soliciting help from others. These findings support prior research emphasizing the value of tailoring treatments in rehabilitation settings toward patients’ coping styles in order to maximize outcomes. A program (provided in either SAS or SPSS syntax) that will compute MBMD coping style group membership will be provided upon request. Request by e-mail to: dcipher@hsc.unt.edu or by fax to: +1-817-7352270.     

An Uncontrolled Clinical Trial of Guided Respiration Mindfulness Therapy (GRMT) in the Treatment of Depression and Anxiety

Guided respiration mindfulness therapy (GRMT) is a manualized intervention that synthesizes a sustained focus on self-regulation of respiration, mindfulness, and relaxation. In our previous publication (in Lalande et al. J Contemp Psychother 46(2):107–116, 2016) we reported an evaluation of a manual-based GRMT therapist training program for the treatment of depression and anxiety. Here we report the outcomes of the manualized treatment program for depression and anxiety with clients. Forty-two participants with a primary diagnosis of depression or anxiety disorder participated in an uncontrolled clinical trial evaluating treatment response using standardised outcome measures with data collected on a session-by-session basis. For the majority of participants, treatment led to statistically and clinically significant reduction in symptoms of depression, anxiety and stress, along with reduced anxiety sensitivity and increases in overall wellbeing. Results suggested GRMT shows promise as an effective brief treatment option that does not rely on cognitive or behavioural techniques.