Characteristics, Services, and Outcomes of Treatment for Women

This paper analyzes the demographic and pretreatment characteristics of maleand female participants in the National Treatment Improvement Evaluation Study,including the women's treatment experiences and the outcomes of various types of substance abuse treatment. Follow-up of a multisite sample of 1,374 women and 3,037 men indicates minimal differences exist between menand women in the outcomes of five modalities of substance abuse treatment. Treatment appears to reduce women's drug and alcohol use and illegal activities and increase their levels of employment. Demographic and pretreatment characteristics are only modestly associated with differences in treatment outcomes, and differential service receipt has inconsistent effects on outcomes.     

Narcissism, Perfectionism, and Self-Termination from Treatment in Outpatient Cocaine Users

This study examines perfectionism in individuals with a Diagnostic and Statistical Manual-IV, Text Revised [American Psychiatric Association, 2000. Diagnostic and statistical manual of mental disorders (4th ed.). Text revision (DSM-TV-TR). Washington, DC: American Psychiatric Association] diagnosis of Narcissistic Personality Disorder and a coexisting diagnosis of cocaine abuse or dependence. Participating clients were treated in outpatient settings that provided cognitive-behavioral therapy. Clients were administered Hewitt and Flett's (1991b) [Journal of Personality and Social Psychology, 60, 456-470] Multidimensional Perfectionism Scale prior to treatment. Scores for dimensions of perfectionism were compared with those obtained from cocaine abusers in treatment with diagnoses of Antisocial Personality or Affective Disorder. Clients with Narcissistic Personality Disorder were characterized by relatively higher levels of other-oriented and socially prescribed perfectionism. Survival analysis suggests that self-termination from treatment by cocaine-abusing clients with a diagnosis of Narcissistic Disorder is related to high levels of other-oriented perfectionism. The clinical implications and limits of this study are discussed.     

CBT/DBT-Informed Intensive Outpatient Treatment for Anxiety and Depression: A Naturalistic Treatment Outcomes Study

Anxiety and depression are highly prevalent and disabling mental health disorders, with comorbidity often posing as a barrier to successful treatment outcomes, thus creating a need for more intensive treatment options. Outpatient clinicians are more likely to refer patients with severe symptoms of anxiety and depression to inpatient hospitalizations rather than partial hospital programs (PHPs) or intensive outpatient programs (IOPs), despite evidence that inpatient hospitalization is associated with high costs and other risks following discharge. The present study reviews two case studies of patients who received cognitive-behavioral therapy/dialectical behavior therapy (CBT/DBT)-based IOP treatment in a private New York clinic. We evaluated treatment outcomes for 73 adult patients (50.7% female) with a mean age of 29.10 years (SD = 10.30). At intake, patients averaged 2.15 diagnoses (SD = 0.94, range = 4) and the majority (80.8%) were prescribed psychotropic medication. Treatment was structured and individually tailored, with patients receiving an average of 21.77 hours (SD = 15.06) of psychotherapy over 12.63 treatment sessions (SD = 9.76), across 12.21 days (SD = 9.61). We observed a clinically and statistically significant change in symptoms of anxiety (t = 6.24, p < .001), depression (t = 5.55, p < .001), and suicidality (t = 2.32, p < .05) over the course of the IOP. After completing treatment, 68.1% of participants tapered down to once-weekly treatment. The present study highlights the clinical utility of an IOP and suggests that this approach can be effective for adult patients presenting with severe symptoms of anxiety and/or depression.     

Clients in Treatment for Alcohol Problems: Treatment Experiencesand Outcomes

This report presents an analysis of National Treatment Improvement Evaluation Study data describing the characteristics and treatment experiences of clients entering treatment for alcohol problems. Three client groups were contrasted—those entering treatment for alcohol only, for alcohol plus other drugs, or for other drugs only. Clients using alcohol only were more often white, male, and currently employed. Alcohol only clients were treated predominantly in outpatient settings. Alcohol only clients were frequently referred to treatment by the criminal justice system, and less often self-referred. In all 3 study groups, employment, general health, and mental health outcomes were improved following treatment. Illicit drug use increased marginally for the alcohol only group following treatment. No significant posttreatment reductions in reports of total abstinencefrom alcohol were found for any of the groups. Findings are discussed as they relate to research, treatment practice, and policyareas.     

An Investigation of Treatment Integrity and Outcomes in Wraparound Services

Research on wraparound services has been generally positive, but has failed to include data regarding treatment integrity. Without such data, conclusions drawn from such studies are weakened. This study followed 28 children and adolescents receiving wraparound services in rural central Pennsylvania. Treatment integrity was defined as the percentage of service hours prescribed vs. received, and behavioral outcomes were defined as Total Problem Behavior T Scores on the Child Behavior Checklist. Preliminary analyses failed to reveal significant differences in sample means between included subjects and those excluded due to missing data. Outcome behavior ratings were significantly improved over baseline ratings. Regression analyses, however, failed to find a significant effect for treatment integrity when used in an outcome prediction equation for Therapeutic Support Staff, Mobile Therapy services, or Behavioral Specialist wraparound services. These results suggest that adherence to prescribed treatment hours may not be related to behavioral outcomes in a wraparound service setting.     

Relationships Between Treatment Components, Client-Level Factors, and Positive Treatment Outcomes

How different amounts and components of treatment affect substance abuse treatment outcomes is fundamentally important to evaluating current treatment practices and recommending improvements. Through a secondary analysis of data from the National Treatment Improvement Evaluation Study (NTIES), the present study examined the relationships between treatment components, client-level factors, and positive treatment outcomes. Several components were shown tohave significant effects on the odds of a positive outcome, over and above the effects of client background characteristics. Depending on treatment modality, these included length of stay; whether or not clients reported seeing their treatment plan hours per month in group and individual counseling; utilization ofeducational, vocational, and other ancillary services; use of antianxiety and drug and alcohol medications; and client matching. Several interactions between client-level factors and treatment components were also observed. Studylimitations are discussed, followed by implications for policy and practiceand suggestions for further research.     

Interdependent Group Contingency Management for Cocaine-Dependent Methadone Maintenance Patients

Contingency management (CM) for drug abstinence has been applied to individuals independently even when delivered in groups. We developed a group CM intervention in which the behavior of a single, randomly selected, anonymous individual determined reinforcement delivery for the entire group. We also compared contingencies placed only on cocaine abstinence (CA) versus one of four behaviors (CA, treatment attendance, group CM attendance, and methadone compliance) selected randomly at each drawing. Two groups were formed with 22 cocaine-dependent community-based methadone patients and exposed to both CA and multiple behavior (MB) conditions in a reversal design counterbalanced across groups for exposure order. The group CM intervention proved feasible and safe. The MB condition improved group CM meeting attendance relative to the CA condition.     

A REVIEW OF COCAINE ABUSE: BEHAVIOR,PHARMACOLOGY, AND CLINICAL APPLICATIONS,EDITED BY S. T. HIGGINS AND J. L. KATZ

This book comprises 17 chapters that deal with a variety of topics related to cocaine and its abuse. Several of the chapters are excellent, and the book in its totality contains a wealth of information. These are major strengths. On the down side, some important topics are ignored, the relevance of several chapters to cocaine abuse is not apparent, and the various chapters are not well integrated. We recommend Cocaine Abuse as a reference volume for scientists with specific training in the areas that it covers. But we do not recommend it for cover‐to‐cover reading as an overview of cocaine abuse.     

Randomized Trial Comparing Two Treatment Strategies Using Prize-Based Reinforcement of Abstinence in Cocaine and Opiate Users

We compared two strategies of prize-based contingency management (CM) in methadone-maintained outpatients. Urine was tested thrice weekly for 5 weeks pre-CM, 12 weeks CM, and 8 weeks post-CM. Participants were randomly assigned to a cocaine contingency (four prize draws for each cocaine-negative urine, N  =  29) or an opiate-cocaine contingency (one draw for each urine negative for opiates or cocaine, four draws if negative for both, N  =  38). There were no group differences in cocaine abstinence during CM or post-CM and no differences in opiate abstinence during CM. Opiate abstinence was greater in the opiate-cocaine group post-CM, and heroin craving was reduced in this group during and post-CM. Draws earned per cocaine-negative urine (four vs. one) did not affect cocaine use.     

Financing A Voucher Program for Cocaine Abusers Through Community Donations in Spain

This study analyzed the viability of financing a voucher program for cocaine addicts in Spain through public and private donations. Of the 136 companies contacted, 52 (38%) provided donations. The difference between the benefits (15,670€/$20,371) and the costs (3,734€/$4,854) was 11,936€/$15,517. The type of reinforcer a company can offer, the size of the company, and the time elapsed before responding may be determining variables in a company''s decision whether to collaborate.     

Family Treatment of Child Anxiety: Outcomes,Limitations and Future Directions

Anxiety of childhood is a common and serious condition. The past decade has seen an increase in treatment-focussed research, with recent trials tending to give greater attention to parents in the treatment process. This review examines the efficacy of family-based cognitive behaviour therapy and attempts to delineate some of the factors that might have an impact on its efficacy. The choice and timing of outcome measure, age and gender of the child, level of parental anxiety, severity and type of child anxiety and treatment format and content are scrutinised. The main conclusions are necessarily tentative, but it seems likely that Family Cognitive Behaviour Therapy (FCBT) is superior to no treatment, and, for some outcome measures, also superior to Child Cognitive Behaviour Therapy (CCBT). Where FCBT is successful, the results are consistently maintained at follow-up. It appears that where a parent is anxious, and this is not addressed, outcomes are less good. However, for children of anxious parents, FCBT is probably more effective than CCBT. What is most clear is that large, well-designed studies, examining these factors alone and in combination, are now needed.     

Substance Abuse Treatment Outcomes: Treatment Practice and Policy Implications

Treatment professionals, whether clinicians, scientists, or policy makers, are interested in developing methods to improve behavioral health treatment outcomes. Clinicians are interested in knowing what treatment practices to incorporate into the services they offer clients. Policymakers request guidance regarding which decisions are most likely to lead to effective treatment approaches and structures. Scientists are eager to contribute knowledge pertinent to building and evaluating effective treatment practices and policies. The papers in this special series provide information on substance abuse treatment practices andpresent findings relevant to clinical practice, policy decisions, and scientific inquiry. This paper provides a brief overview of the National Treatment Improvement Evaluation Study (NTIES) and briefly summarizes the other research papers included in this issue, all of which exemplify practice and policy issues in the substance abuse treatment field and bolster approaches applied to address these issues.     

Novelty Seeking and Reward: Implications for the Study of High-Risk Behaviors

Novelty seeking and sensation seeking are constructs useful in predicting human risk-taking behaviors. This predictive relation purportedly reflects some rewarding aspect of experiencing novelty. Research has confirmed this assumption. Rats display an increase in preference for an environment that has been differentially paired with novel stimuli. The physiological mechanisms mediating this rewarding effect of novelty involve the neurotransmitter dopamine, whereas those controlling novelty seeking do not. The mechanisms involved in drug seeking and reward show parallel dissociations. This concordance between novelty and drug-abuse research suggests that novelty and drug stimuli may interact in biologically and behaviorally meaningful ways. Indeed, preliminary research examining cocaine and novelty and published work with amphetamines support this suggestion. There is clear need for further systematic research on novelty reward and related processes at all levels of analysis: genetic, biological, behavioral, and social.     

Influence of Time in Treatment and Follow-Up Duration on Methadone Treatment Outcomes

Data for 422 methadone treatment clients in the National Treatment Improvement Evaluation Study (NTIES) were analyzed. Clients maintained continuously in methadone treatment for longer than 12 months and clients who leftbetween 3–12 months were compared with clients treated for less than 3 months. Additionally, clients treated for 3–12 months who had short follow-up periods (6-month average) were compared with 3–12-month clients with long follow-up periods (11-month average). Positive treatment outcomes includinglower drug use, reduced risk of viral infectionand sexually transmitted disease (through needle sharing and multiple sex partners), and less criminality wereassociated with both longer duration treatment and shorter follow-up periods. The findings suggested that continuous methadone treatment of 12 or more months is optimal, whereas stays of less than3 months may be ineffective. Furthermore, stays of 3–12 months are likelyto be beneficial over a relatively short time span, for example 6 months.     

心力衰竭的药物及非药物治疗

神经内分泌激活、心室重构是收缩性心力衰竭进展的关键机制,针对上述机制的生物学治疗包括血管紧张素转换酶抑制剂、β受体阻滞剂、盐皮质激素受体拮抗剂等可显著改善心力衰竭患者预后,利尿剂、洋地黄等常规药物治疗可改善心力衰竭症状、降低心力衰竭住院风险,为神经内分泌拮抗剂的应用奠定基础;近年来,从阻断心力衰竭发生机制方面研发了很多新药,但尚没有一种能对长期生存率有显著改善.器械治疗(植入型心脏复律除颤器、心室再同步和心室再同步心脏复律除颤器)可降低特定心力衰竭患者病死风险,预防猝死发生,显著改善预后;心室辅助装置及干细胞治疗则为心力衰竭治疗带来新的曙光.     

CONTINGENT REINFORCEMENT OF ABSTINENCE WITH INDIVIDUALS ABUSING COCAINE AND MARIJUANA

Two males diagnosed with cocaine dependence received a behavioral intervention comprised of contingency management and the community reinforcement approach. During the initial phase of treatment, reinforcement was delivered contingent on submitting cocaine-free urine specimens. The community reinforcement approach involved two behavior therapy sessions each week. Almost complete cocaine abstinence was achieved, but regular marijuana use continued. During a second phase, reinforcement magnitude was reduced, but remained contingent on submitting cocaine-free specimens. Behavior therapy was reduced to once per week. Cocaine abstinence and regular marijuana use continued. Next, reinforcement was delivered contingent on submitting cocaine- and marijuana-free specimens. This modified contingency resulted in an abrupt increase in marijuana abstinence and maintenance of cocaine abstinence. One- and 5-month follow-ups indicated that cocaine abstinence continued, but marijuana smoking resumed. These results indicate that the behavioral intervention was efficacious in achieving abstinence from cocaine and marijuana; maintenance, however, was achieved for cocaine only.     

Cocaine and food deprivation: effects on food-reinforced fixed-ratio performance in pigeons.

Key pecking by 6 pigeons was maintained by a fixed-ratio 30 schedule of food presentation while body weights were 80% of free-feeding weights. Acute administration of cocaine (0.3 to 13.0 mg/kg, i.m.) dose-dependently decreased response rates. Dose-effect curves were shifted to the right when 3 of the 6 pigeons were maintained at 70% of free-feeding weights and were shifted to the left when the other 3 pigeons were maintained at 90% of free-feeding weights. Then a dose of cocaine that initially decreased response rates by more than 95% of control rates was administered before each daily session. Comparable degrees of tolerance to these rate-decreasing effects developed in the two groups. The rate at which responding recovered was relatively rapid for pigeons in the 70% free-feeding-weight group and was slower for 2 of the 3 pigeons in the 90% free-feeding-weight group. When body weights were then increased from 70% to 80% or were decreased from 90% to 80% of free-feeding weight, performance was disrupted initially only for pigeons whose weight went from 70% to 80% of free feeding. In the present experiment the degree of deprivation may have indirectly influenced the degree of tolerance that developed to cocaine's response rate-decreasing effects because it directly influenced the dose chosen to be administered chronically. The degree of deprivation appeared to have a more direct influence on the rate at which tolerance developed.     

The Influence of Retention,Turnover, and Alliance on Process and Outcomes in Rolling Group Psychotherapy for Cocaine Disorder

A longitudinal repeated measures design was used to investigate the influence of treatment retention, and membership turnover on individual outcomes, and the relationship between individual-level and group-level therapeutic alliance in rolling group psychotherapy for individuals with cocaine abuse disorder. Eighteen patients were studied; data were collected prior to therapy and then monthly for 24 months. Patient outcomes and process were assessed. Improvements in symptoms and psychological functioning were associated with retention in psychotherapy. Membership turnover had a negative influence on symptoms. Development of an individual alliance was affected by the development of group-level therapeutic alliance, but not by time spent in therapy.     

The Economic Benefits of Increased Treatment Duration and Intensity in Residential and Outpatient Substance Abuse Treatment Settings

This study presents estimates of the economic benefits to society from community-based substance abuse treatment. The analysis focused on the impact of length of stay and frequency of counseling on clients' crime-related and health care costs, welfare receipts, and income taxes. The results indicate that the benefits from an additional day of treatment were on average $21 for short-term residential treatment (or 29% the cost of a day of care), $13 for outpatient drug-free treatment (or 94% the cost of a day of care), and $5 for long-term residential treatment (or 9% the cost of a day of care). No benefits were found from additional counseling provided by a client's primary therapist. Withthe exception of short-term residential care, estimated increases in client earnings from longer lengths of stayexceeded the benefits to society. Our estimates do not include benefits realized during treatment or beyond the year after treatment.