Kelly JF, McKellar JD, Moos R. Major depression in patients with substance use disorders: relationship to 12-step self-help involvement and substance use outcomes. Addiction 98: 499-508

Stanford University, Palo Alto, California, United States
Addiction (Impact Factor: 4.74). 05/2003; 98(4):499-508. DOI: 10.1046/j.1360-0443.2003.t01-1-00294.x
Source: PubMed


Many patients treated for substance use disorders (SUDs) who become involved in 12-Step self-help groups have improved treatment outcomes. However, due to high rates of psychiatric comorbidity and major depressive disorder (MDD), among SUD patients in particular, concerns have been raised over whether these benefits extend to dual diagnosis patients. This study examined the influence of comorbid MDD among patients with SUDs on 12-Step self-help group involvement and its relation to treatment outcome.
A quasi-experimental, prospective, intact group design was used with assessments completed during treatment, and 1 and 2 years postdischarge.
A total of 2161 male patients recruited during in-patient SUD treatment, of whom 110 had a comorbid MDD diagnosis (SUD-MDD) and 2051 were without psychiatric comorbidity (SUD-only).
SUD-MDD patients were initially less socially involved in and derived progressively less benefit from 12-Step groups over time compared to the SUD-only group. However, substance use outcomes did not differ by diagnostic cohort. In contrast, despite using substantially more professional out-patient services, the SUD-MDD cohort continued to suffer significant levels of depression.
Treatment providers should allocate more resources to targeting depressive symptoms in SUD-MDD patients. Furthermore, SUD-MDD patients may not assimilate as readily into, nor benefit as much from, traditional 12-Step self-help groups such as Alcoholics Anonymous, as psychiatrically non-comorbid patients. Newer, dual-diagnosis-specific, self-help groups may be a better fit for these patients, but await further study.

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    • "For example, patients with primarily less severe depressive or anxiety disorders may benefit from 12-step participation (e.g., Ouimette et al., 2000), while those with more severe variants of psychopathology may affiliate less readily and/or derive less benefit (e.g., psychotic disorders ; Bogenschutz et al., 2006). In addition, while older DD patients likely struggle with a more substantial accumulation of psychosocial impairment secondary to chronic mental illness (e.g., Kelly et al., 2003) younger DD patients (e.g., Chi et al., 2013; Grella et al., 2004) may still possess the ability to tap into AA's and NA's socially grounded mechanisms of action (Kelly et al., 2011). In fact, psychiatric distress appears to be motivating and may be a potential catalyst for both formal and informal help-seeking behaviors (Finney and Moos, 1995). "
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    ABSTRACT: Evidence indicates that 12-step mutual-help organizations (MHOs), such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), can play an important role in extending and potentiating the recovery benefits of professionally delivered addiction treatment among young adults with substance use disorders (SUD). However, concerns have lingered regarding the suitability of 12-step organizations for certain clinical subgroups, such as those with dual diagnosis (DD). This study examined the influence of diagnostic status (DD vs. SUD-only) on both attendance and active involvement (e.g., having a sponsor, verbal participation during meetings) in, and derived benefits from, 12-step MHOs following residential treatment. Young adults (N = 296; 18 to 24 years old; 26% female; 95% Caucasian; 47% DD [based on structured diagnostic interview]), enrolled in a prospective naturalistic study of SUD treatment effectiveness, were assessed at intake and 3, 6, and 12 months posttreatment on 12-step attendance/active involvement and percent days abstinent (PDA). t-Tests and lagged, hierarchical linear models (HLM) examined the extent to which diagnostic status influenced 12-step participation and any derived benefits, respectively. For DD and SUD-only patients, posttreatment attendance and active involvement in 12-step organizations were similarly high. Overall, DD patients had significantly lower PDA relative to SUD-only patients. All patients appeared to benefit significantly from attendance and active involvement on a combined 8-item index. Regarding the primary effects of interest, significant differences did not emerge in derived benefit between DD and SUD-only patients for either attendance (p = 0.436) or active involvement (p = 0.062). Subsidiary analyses showed, however, that DD patients experienced significantly greater abstinence-related benefit from having a 12-step sponsor. Despite concerns regarding the clinical utility of 12-step MHOs for DD patients, findings indicate that DD young adults participate and benefit as much as SUD-only patients, and may benefit more from high levels of active involvement, particularly having a 12-step sponsor. Future work is needed to clarify how active 12-step involvement might offset the additional recovery burden of a comorbid mental illness on substance use outcomes.
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    • "Community 12-Step involvement was higher for TSF+P participants than ICBT+P participants during treatment, but the two groups had similar rates of involvement in the year following treatment completion. However, as noted by Kelly et al. (2003), 12-Step involvement is not sufficient to address the depression symptoms of dually diagnosed patients. Future research should investigate mechanisms of change that contribute to longterm decreases in depression within ICBT+P and TSF+P. "
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    • "Although our knowledge of the neural mechanisms for fear extinction remains incomplete , fear extinction in general is considered to be an important preclinical model for behavior therapy of human anxiety disorders (Barad, 2005). Clinically, several studies have demonstrated a high prevalence of mood disorders among substance abusers, such as anxiety (De Graaf et al, 2003), major depression (Kelly et al, 2003), and bipolar disorders (Brown et al, 2001). However, its underlying neural mechanism remains unclear. "
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