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Major depression in patients with substance use disorders: Relationship to 12-Step self-help involvement and substance use outcomes
Abstract
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.
... Despite increasing evidence that MHOs can be valuable treatment adjuncts (Humphreys, 2004), professional concerns have lingered regarding their fit for those with dual substance use and psychiatric diagnoses (i.e., dual diagnosis [DD]; Kelly et al., 2003, Bogenschutz et al., 2006, Timko, 2008. Such concerns include potential 12-step member opposition to psychotropic medications prescribed for the comorbid disorder (Tonigan and Kelly, 2004), which has traditionally been connected to the idea that any medication use will increase someone's risk of addiction and relapse. ...
... Some empirical comparisons of DD and SUD-only patients show that a comorbid mental illness may hinder positive outcomes. For example, patients with psychotic disorders tend to report lower levels of 12-step participation and benefit (Bogenschutz et al., 2006) while major depressive disorder (MDD) also appears to dampen 12-step effects among adult inpatients (Kelly et al., 2003). On the other hand, Kelly et al. (2006) found that 12-step attendance bolstered abstinence rates following outpatient treatment irrespective of diagnostic status and, among outpatients with concurrent SUD and MDD, 12-step attendance may improve drinking outcomes through reductions in depressive symptomatology (Worley et al., 2012). ...
... Studies examining the role of DD in mutual help-related outcomes have yielded mixed results whereby some point to reduced benefit among those with DD (Kelly et al., 2003, Bogenschutz et al., 2006, some to analogous benefit (Kelly et al., 2006, Chi et al., 2013, and others to increased benefit (Grella et al., 2004, Timko et al., 2013. Despite this emerging literature on the role of DD in mutual-help participation, to our knowledge no studies have examined DD young adults -a large segment of the treated population. ...
Background:
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.
Methods:
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.
Results:
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.
Conclusions:
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.
... These findings highlight the clinical importance of these proximal indicators, but no known study has examined longitudinal, prospective effects of self-efficacy and social networks on the outcomes of outpatient psychotherapy specifically focused on co-occurring AODD and MDD. Prior research has found that co-occurring MDD attenuates the effects of other process variables, such as 12-step affiliation (Kelly, McKellar, & Moos, 2003), demonstrating the need to investigate whether common targets of psychosocial treatment actually predict treatment outcomes within this population. ...
... Prior studies of the proximal determinants of posttreatment alcohol/drug use have not typically focused on individuals with AODD and co-occurring psychiatric disorders, despite high rates of these co-occurring disorders in many clinical settings (Chi, Satre, & Weisner, 2006;Lynskey, 1998). Co-occurring MDD is particularly common, and individuals with AODD and MDD typically have poorer outcomes after treatment (Gamble et al., 2010;Glasner-Edwards et al., 2009;Ilgen & Moos, 2005), with some evidence that therapeutic mechanisms of change are less potent for these patients (Kelly et al., 2003). Given the lack of prior research in this prevalent and high-risk population, it is critically important to determine whether common mechanisms of behavioral interventions predict posttreatment substance use in this population, as a means of validating existing clinical interventions. ...
Proximal personal and environmental factors typically predict outcomes of treatment for alcohol or drug dependence (AODD), but longitudinal treatment studies have rarely examined these factors in adults with co-occurring psychiatric disorders. In adults with AODD and major depression, the aims of this study were to: (a) disaggregate person-and time-level components of network substance use and self-efficacy, (b) examine their prospective effects on posttreatment alcohol/drug use, and (c) examine whether residential environment moderated relations between these proximal factors and substance use outcomes. Veterans (N = 201) enrolled in a trial of group psychotherapy for AODD and independent MDD completed assessments every 3 months during 1 year of posttreatment follow-up. Outcome variables were percent days drinking (PDD) and using drugs (PDDRG). Proximal variables included abstinence self-efficacy and social network drinking and drug use. Self-efficacy and network substance use at the person-level prospectively predicted PDD (ps < .05) and PDDRG (ps < .05). Within-person, time-level effects of social networks predicted future PDD (ps < .05) but not PDDRG. Controlled environments moderated person-level social network effects (ps < .05), such that greater time in controlled settings attenuated the association between a heavier drinking/using network and posttreatment drinking and drug use. Both individual differences and time-specific fluctuations in proximal targets of psychosocial interventions are related to posttreatment substance use in adults with co-occurring AODD and MDD. More structured environmental settings appear to alleviate risk associated with social network substance use, and may be especially advised for those who have greater difficulty altering social networks during outpatient treatment. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
... Using an original sample of participants from 15 Veteran's Affairs hospitals, Kelly, McKellar, and Moos (2003) sought to compare the relationship between major depression and support group participation. To this end, 3, 698 male participants Symptoms of Depression 43 diagnosed with SUD's were recruited. ...
... The hypothesized relationship between these variables was not supported; the hypothesized model suggested that greater symptoms of depression would lead to less support group attendance. This result lends support to the work of Kelly, McKellar, and Moos (2003), which found no significant difference in meeting attendance between a group of participants diagnosed with comorbid Major Depressive Disorder and a Substance Use Disorder, and a group of participants diagnosed with only a substance abuse disorder. The current study and the study by Kelly et al. differ in that participants in the current study did not necessarily carry a diagnosis of Major Depression; rather, the current study employed a scale of depressive symptoms. ...
... Varios grupos han estudiado las intervenciones grupales como método de abordaje terapéutico para los pacientes con diagnóstico dual (121)(122)(123)(124)(125)(126). James y cols., en Australia, han examinado la efectividad de una intervención grupal para disminuir el consumo en pacientes duales (121). ...
... Las tasas de asistencia al grupo por parte de pacientes y familiares arrojan resultados positivos, sólo en el contexto de un tratamiento psiquiátrico especializado, como base fundamental de la terapéutica que se va a desarrollar. A pesar de lo alentadores que pueden llegar a ser estos resultados, la mayoría de estudios que evalúan dicha intervención en pacientes con diagnóstico dual presentan grandes limitaciones metodológicas (123,124). ...
Introduction: In an effort to treat dually diagnosed patients, multiple therapeutic interventions that have shown efficacy for inpatients with major psychiatric disorders or substance abuse have been used in combination. In spite of the vast evidence of the association between drug abuse and major psychiatric disorders, most guidelines for the treatment of dually diagnosed patients are based on combinations that lack enough evidence, thus limiting their success. To date, no treatment has shown promise of long-term effectiveness. Objective: To describe briefl y the available evidence for relevant psychotherapeutic and psychopharmacological strategies in the treatment of dually diagnosed patients. At the same time, we hope to develop dynamic and fl exible algorithms to be included in the Clinical Guidelines for the Treatment of Dually Diagnosed Patients admitted to El Prado Psychiatric Institute in Armenia, Colombia. Method: We searched the Biomedical Literature on Medline, OVID, Proquest, Scielo, and EMBASE for articles matching the MeSH, dual diagnosis with treatment and prognosis, limiting results to clinical trials, systematic reviews, meta-analysis and clinical guidelines published in the last 25 years in adult population. Results: 246 articles were downloaded, of which 146 were selected after carefully reviewing all abstracts that met our established inclusion criteria in terms of methodology, safety, efficacy and effectiveness of the interventions. Conclusion: The clinical evidence available supports the nine protocols designed for the treatment of dually diagnosed patients in the addiction program of El Prado Psychiatric Institute in Armenia, Colombia.
... One study with dual diagnosis participants in the US Veterans Administration healthcare system (Lydecker et al., 2010) found a disadvantage for PDA with AA/TSF. This may be because, although participants met criteria for AUD, the primary problem was mood disorder as opposed to AUD, which may represent a poorer fit with AA (Kelly et al., 2003). That said, a recent meta-analysis by Tonigan (Tonigan et al., 2018) found consistent abstinence benefits from participation in AA by those dually diagnosed. ...
Aims:
A recently completed Cochrane review assessed the effectiveness and cost-benefits of Alcoholics Anonymous (AA) and clinically delivered 12-Step Facilitation (TSF) interventions for alcohol use disorder (AUD). This paper summarizes key findings and discusses implications for practice and policy.
Methods:
Cochrane review methods were followed. Searches were conducted across all major databases (e.g. Cochrane Drugs and Alcohol Group Specialized Register, PubMed, Embase, PsycINFO and ClinicalTrials.gov) from inception to 2 August 2019 and included non-English language studies. Randomized controlled trials (RCTs) and quasi-experiments that compared AA/TSF with other interventions, such as motivational enhancement therapy (MET) or cognitive behavioral therapy (CBT), TSF treatment variants or no treatment, were included. Healthcare cost offset studies were also included. Studies were categorized by design (RCT/quasi-experimental; nonrandomized; economic), degree of manualization (all interventions manualized versus some/none) and comparison intervention type (i.e. whether AA/TSF was compared to an intervention with a different theoretical orientation or an AA/TSF intervention that varied in style or intensity). Random-effects meta-analyses were used to pool effects where possible using standard mean differences (SMD) for continuous outcomes (e.g. percent days abstinent (PDA)) and the relative risk ratios (RRs) for dichotomous.
Results:
A total of 27 studies (21 RCTs/quasi-experiments, 5 nonrandomized and 1 purely economic study) containing 10,565 participants were included. AA/TSF interventions performed at least as well as established active comparison treatments (e.g. CBT) on all outcomes except for abstinence where it often outperformed other treatments. AA/TSF also demonstrated higher health care cost savings than other AUD treatments.
Conclusions:
AA/TSF interventions produce similar benefits to other treatments on all drinking-related outcomes except for continuous abstinence and remission, where AA/TSF is superior. AA/TSF also reduces healthcare costs. Clinically implementing one of these proven manualized AA/TSF interventions is likely to enhance outcomes for individuals with AUD while producing health economic benefits.
... Thus, mutual support groups for addictions are the main option for people with co-occurring substance use and mental health disorders. Research suggests that individuals with comorbid mental illness and substance use problems may be reluctant to attend and engage with traditional single-focus mutual support groups and do not derive as much benefit as those with substance use disorders alone (Kelly, McKellar, & Moos, 2003;Laudet, Magura, Vogel, & Knight, 2003;Noordsy, Schwab, Fox, & Drake, 1996). More broadly, while there is some research that suggests groups such as Alcoholics Anonymous (AA) can have benefits for mental health symptoms (e.g. ...
Objective: SMART Recovery provides cognitive behavior therapy based mutual support groups for addictions. The aim of the present study was to explore the impact of cognitive behavior skill use and the influence of a person's social network on psychological distress. Method: Paper based surveys were mailed out to 121 SMART Recovery groups across Australia. A sample of 75 SMART Recovery group members participated. Measures of social network size and composition, psychological distress and cognitive behavior skill use were collected. Results: There are high rates of self-reported mental illness within SMART Recovery respondents. Use of behavioral skills and social network influence was significantly associated with level of psychological distress. Discussion: The current results indicate that engaging in behavioral activation and having a social network of non-drinking or non-using people is associated with lower levels of psychological distress. Given the high rates of self-reported comorbid mental illness in this population, it is important research continues to explore the role of specific cognitive behavioral therapy components and social networks on recovery within mutual support groups.
... Considering the significant relationship between psychological health and addiction (Kelly et al. 2003), including the Internet (Lachmann et al. 2016;Young and Rodgers 1998) and smartphone addiction (Ahn 2016;Chiu 2014;Demirci et al. 2015) mothers who have psychological problems or a lower level of life-satisfaction are very likely to be addicted to smartphones. Also, a report by National Institute for Health and care Excellence stated that (a) approximately 10-15% of mothers have experienced postnatal depression, (b) up to 20% of women have suffered from depression and anxiety during the first of year of birth, and (c) that psychosis can worsen later. ...
This study examined the relationship between maternal life satisfaction, smartphone addiction, and parenting behavior in order to protect and promote sustainable well-being of mothers as well as children throughout their lifetimes and quality of life in the family system. Self-report questionnaires were used on 328 Korean mothers with children aged 3 to 5 years. Data were analyzed using Structural Equation Modeling. Results revealed that maternal life satisfaction had a significant and direct influence on parenting behavior, and its indirect influence on parenting behavior was mediated by smartphone addiction tendency. The findings confirm that a mother’s psychological well-being (life satisfaction) and smartphone addiction tendency are preceding factors for positive maternal parenting behavior. Significant attention must be paid to parents’ psychological well-being to promote children’s healthy development from very early on in life.
... These young adult data are also consistent with findings in large, naturalistic adolescent SUD treatment studies [67]. However, the influence of chronic major depressive disorder and psychotic disorders, which may negatively impact one's ability to engage with the social milieu [68,69], has not yet been examined. Finally, engaging with meetings that have high proportions of other young adults, as well as finding a compatible sponsor early in a treatment/recovery episode, may promote subsequent recovery benefit. ...
Purpose of Review
Empirical evidence indicates that, in general, treatments which systematically engage adults with freely available twelve-step mutual-help organizations (TSMHOs), such as alcoholics anonymous (AA) and narcotics anonymous (NA) often enhance treatment outcomes while reducing healthcare costs. Also evident is that TSMHOs facilitate recovery through mechanisms similar to those mobilized by professional interventions, such as increased abstinence self-efficacy and motivation, as well changing social networks. Much less is known, however, regarding the utility of these resources specifically for young adults and whether the TSMHO mechanisms are similar or different for young adults. This article provides a narrative review of the clinical and public health utility of TSMHOs for young adults and summarizes theory and empirical research regarding how young adults benefit from TSMHOs.
Recent Findings
Results indicate that, compared to older adults, young adults are less likely to attend TSMHOs and attend less frequently but derive similar benefit. The mechanisms, however, by which TSMHOs help, differ in nature and magnitude. Also, young adults appear to derive greater benefit initially from meetings attended by similar aged peers, but this benefit diminishes over time.
Summary
Findings offer developmentally specific insights into TSMHO dynamics for young adults and inform knowledge of broader recovery needs and challenges.
... These EA data are also consistent with findings in large, naturalistic adolescent SUD treatment studies (Grella, Hser, Joshi, & Rounds-Bryant, 2001). However, the influence of chronic major depressive disorder and psychotic disorders, which may negatively impact one's ability to engage with the social milieu (Bogenschutz & Akin, 2000;Kelly, McKellar, & Moos, 2003), have not yet been examined. Finally, engaging with meetings that have high proportions of other EAs, as well as finding a compatible sponsor early in a treatment/recovery episode may promote subsequent recovery benefit. ...
A body of literature has shown that free, widely available mutual-help organizations (MHOs), such as Alcoholics Anonymous (AA), offer cost-efficient community-based sources of recovery support for individuals with substance use disorder (SUD). Emerging adults (18–29 years old) are a prevalent group of individuals in the SUD treatment system who present unique challenges and typically have poorer outcomes than those of older adults (e.g., 30+ years). Given the need to identify low-cost strategies that can help destabilize the course of SUD for emerging adults, this chapter reviews the extent to which emerging adults participate in MHOs and the degree to which they benefit from participation in MHOs. The chapter also outlines the mechanisms through which MHO participation promotes better outcomes and the factors that influence emerging adults’ MHO participation and participation-related benefit. The chapter then highlights opportunities for timely but as-of-yet untapped targets for emerging adult recovery-related research, such as the intersection between MHO participation and opioid agonist treatment.
... Studies of TSA and its mediational effects have been limited to SUD-only populations. Only one self-help affiliation investigation to date has focused on the study of substance users with comorbid MDD ( Kelly et al., 2003). In that study, indi- viduals with SUDs and comorbid MDD were compared with those with SUD-only in terms of the development of TSA in treatment and its association with substance use outcomes. ...
... 33 However, the available empirical evidence suggests that, in general, individuals with co-occurring psychiatric illnesses in addition to their SUD can benefit from participation in traditional AA or NA meetings as much or more (e.g., Timko et al. 34 ) compared to their SUD-only counterparts. An exception to these findings, however, are those with more socially impairing mental illness such as schizophrenia or severe unipolar depression, 35,36 who may be better suited for dual-diagnosis focused MHOs, such as Double Trouble in Recovery. 37,38 Research also suggests that less religiously inclined individuals are less likely to become engaged, but those that do participate Mutual-Help Groups for Addictions 9 have outcomes as good as those who are more religiously inclined. ...
Integrated Approaches to Drug and Alcohol Problems: Action on Addiction provides a pathway through the field of addiction, giving a clear description of points along that path, from the beginning of problematic use of drugs and alcohol, to treatment, support, recovery and reintegration in society.
The book illustrates the principle of integrated approaches to tackling the rise in problems with addiction. Practical applications of these approaches are demonstrated in the work of UK charity Action on Addiction, one organisation which has been influenced by, and contributed to, the research and practice of the authors. The interventions illustrated within Integrated Approaches to Drug and Alcohol Problems demonstrate how the findings of international research can be brought together to provide effective services for individuals, families and communities suffering from addiction-related problems.
Some of the foremost internationally recognized addiction researchers, clinicians and trainers from the UK, USA and Canada have contributed chapters to this book. It will be of interest to all those working in the field of drug and alcohol addiction, including counsellors and therapists, as well as GPs, nurses and public health officers. Integrated Approaches to Drug and Alcohol Problems will also have general appeal to anyone studying Psychology and Mental Health courses at undergraduate or postgraduate level, plus those affected by addiction.
Foreword Graham Beech Preface & Acknowledgements Willm Mistral List of Contributors Part One Routes to Addiction 1 From Substance Use to Addiction Willm Mistral 2 My Story of Addiction and Recovery Geri Lettle Part Two Action for Individuals 3 SHARP Intensive Day Treatment Tim Leighton 4 Residential Treatment: countering the chaos of addiction Kirby Gregory Part Three Action for Families and Young People 5 M-PACT: supporting families affected by parental substance misuse Lorna Templeton 6 FAMILIES: you don’t have to be addicted to suffer from addiction Nick Barton 7 Young People and Substance Misuse: the power of personality Maeve O’Leary-Barrett & Patricia J Conrod Part Four Action for Policy and Practice 8 Reducing Deaths from Opiate Overdose: Take-Home-Naloxone Rebecca McDonald, Rhian Hills, Carole Hunter, Kirsten Horsburgh, Andrew McAuley, Rosie Mundt-Leach, Sarah Small & John Strang 9 Management of Alcohol Use Disorders in the UK Ed Day & Mandip Jheeta 10 New Drugs, Old Responses?Willm Mistral 11 Improving Addiction Workforce Skills Devin Ashwood & Jane Rowley 12 Reducing Alcohol-related Harm among Young People Willm Mistral Part Five Routes to Recovery 13 Twelve-Step Mutual-Help Organizations and Facilitation Interventions John F Kelly & Brandon G Bergman 14 Recovery Advocacy in America William L White Part Six An Integrated Approach to Addiction 15 Action on Addiction – the Charity Nick Barton
... Conversely, MDD is among the common psychiatric disorders that have high comorbidity with all types of SUDs. 27,28 These patients report poorer response rates compared to their singly diagnosed counterparts from a 12-step program, 29 from single-medication trials, [30][31][32] and from cognitive behavioral therapy. 33 Likewise, MDD patients with nicotine dependence also have increased difficulty with smoking cessation, with antidepressants having little influence on abstinence, and these patients are more likely to develop an episode of depression post-smoking cessation. ...
Major depressive disorder (MDD) and substance use disorders (SUDs) are prevalent, disabling, and challenging illnesses for which new treatment options are needed, particularly in comorbid cases. Neuroimaging studies of the functional architecture of the brain suggest common neural substrates underlying MDD and SUDs. Intrinsic brain activity is organized into a set of functional networks, of which two are particularly relevant to psychiatry. The salience network (SN) is crucial for cognitive control and response inhibition, and deficits in SN function are implicated across a wide variety of psychiatric disorders, including MDD and SUDs. The ventromedial network (VMN) corresponds to the classic reward circuit, and pathological VMN activity for drug cues/negative stimuli is seen in SUDs/MDD. Noninvasive brain stimulation (NIBS) techniques, including rTMS and tDCS, have been used to enhance cortico-striatal-thalamic activity through the core SN nodes in the dorsal anterior cingulate cortex, dorsolateral prefrontal cortex, and anterior insula. Improvements in both MDD and SUD symptoms ensue, including in comorbid cases, via enhanced cognitive control. Inhibition of the VMN also appears promising in preclinical studies for quenching the pathological incentive salience underlying SUDs and MDD. Evolving techniques may further enhance the efficacy of NIBS for MDD and SUD cases that are unresponsive to conventional treatments.
... However, the type of co-occurring diagnoses may make a difference on outcome impact. Individuals who had depression and a substance use disorder have a weaker association between self-help involvement and abstinence than individuals with substance use disorders alone [15]. This was the impetus for the emergence of dually focused 12-Step programs, such as Double Trouble, which specifically address the needs of individuals with co-occurring disorders [16,17]. ...
There are a variety of self-help treatments which have components of sponsorship or peer support. Although there has been a recent surge in the utilization of peer support interventions within clinical settings, there is limited data on substance use outcome predictors for interventions designed solely for peer support within community treatment settings that are empirically based. We examined both treatment process and participant characteristic variables as predictors of substance use outcomes within our Stage I pilot which developed a new intervention, Mentorship for Addiction Problems (MAP). We found treatment process variables to be significantly associated with substance use outcome and no participant characteristic variables.
... Similarly, a study by Noordsy and colleagues (1996) of outpatients suffering from AU10 psychotic spectrum disorders and substance dependence did not find evidence for beneficial effects of 12-step group involvement at a 4-year follow-up, although the sample size was very small (N = 18). Kelly et al. (2003) found that compared with SUD patients without a psychiatric diagnosis, patients with major depressive disorder in addition to their SUD, did not become as socially involved in selfhelp fellowships as their noncomorbid counterparts and derived progressively less benefit from traditional 12-step groups during the 2-year follow-up, despite similar levels of self-help involvement. In contrast, Ouimette et al. (2001), using the same dataset, found that patients with comorbid SUDs and posttraumatic stress disorder (PTSD) participated in, and benefited from, 12-step participation as much as SUD-only patients. ...
This chapter describes the goals and key therapeutic processes of mutual-help groups (MHGs) presumed to facilitate improvement and/or maintenance of functioning. It reviews and evaluates available outcome data pertaining to MHGs' effectiveness in helping individuals manage or recover from their respective disorders, including any evidence in support of the key therapeutic processes. It describes the role MHGs plays in a formal treatment plan and describes how professionals facilitate and coordinate participation in these groups. It concludes by describing opportunities for further research and what might be done to help disseminate knowledge about MHGs and their potential utility. It provide information about various MHGs divided into three distinct problem areas—i.e., substance dependence (e.g., alcohol, cocaine), mental illness (e.g., schizophrenia, depression), and dual diagnosis (i.e., substance dependence in combination with mental illness). It provides summary tables containing brief descriptions of the MHGs, website and contact information, degree of evidence for the MHGs, and several other indices that facilitate easy comparisons of organizations along multiple lines. It also provides detailed MHG information in the text regarding other compulsive behaviors (e.g., gambling, sex, eating behaviors) and family-related MHGs.
... increase in use of mental health services. Those with these co-occurring disorders also benefit less from 12-Step groups than those without co-occurring disorders (Kelly, McKellar, & Moos, 2003). ...
... AA participation is associated with producing and maintaining salutary changes in alcohol and other drug use that are on par with professional interventions while simultaneously reducing reliance on professional services and thus lowering related health care costs Humphreys & Moos, 2007;. Despite some earlier concerns regarding AA's ability to cater effectively to women, young people, people of color, those with comorbid psychiatric illnesses, and non-religious/spiritual persons, research has found that AA confers similar benefits to women as men (Del Boca & Mattson, 2001;Kelly, Stout, Zywiak, & Schneider, 2006); to young people (Alford, Koehler, & Leonard, 1991;Chi, Kaskutas, Sterling, Campbell, & Weisner, 2009;Kelly, Brown, Abrantes, Kahler, & Myers, 2008;Kelly, Dow, Yeterian, & Kahler, 2010;Kelly, Myers, & Brown, 2000;Kennedy & Minami, 1993); to many (e.g., Ouimette et al., 2001;Timko, Sutkowi, Cronkite, Makin-Byrd, & Moos, 2011), but not all, persons with psychiatric conditions (e.g., those with severe social impairments and/or psychotic spectrum illness; Bogenschutz & Akin, 2000;Kelly, McKellar, & Moos, 2003;Noordsy, Schwab, Fox, & Drake, 1996;Tomasson & Vaglum, 1998); and to those individuals who are non-religious/spiritual or less religious/spiritual (Kelly et al., 2006;Winzelberg & Humphreys, 1999). ...
Peer-led mutual-help organizations addressing substance use disorder (SUD) and related problems have had a long history in the United States. The modern epoch of addiction mutual help began in the postprohibition era of the 1930s with the birth of Alcoholics Anonymous (AA). Growing from 2 members to 2 million members, AA's reach and influence has drawn much public health attention as well as increasingly rigorous scientific investigation into its benefits and mechanisms. In turn, AA's growth and success have spurred the development of myriad additional mutual-help organizations. These alternatives may confer similar benefits to those found in studies of AA but have received only peripheral attention. Due to the prodigious economic, social, and medical burden attributable to substance-related problems and the diverse experiences and preferences of those attempting to recover from SUD, there is potentially immense value in societies maintaining and supporting the growth of a diverse array of mutual-help options. This article presents a concise overview of the origins, size, and state of the science on several of the largest of these alternative additional mutual-help organizations in an attempt to raise further awareness and help broaden the base of addiction mutual help.
... Substance abusers with a psychotic disorder attended traditional meetings less often and did not get beneficial effects (Tomasson & Vaglum, 1998). Kelly, McKellar and Moos (2003) found that major depression was a factor in deriving progressively fewer benefits and socializing less while attending 12-Step meetings. However, overall psychiatric severity did not seem to affect abstinence (Polcin & Zenmore, 2004). ...
Self-help groups are part of a larger mutual aid movement. Found in many forms, the concept of peer-to-peer help is an effective, worldwide phenomenon. This chapter is concerned with single disorder 12-Step groups for chemical dependency, which have the largest participation of any other kind. There is evidence supporting the utility of 12-Step groups for alcohol and other drug dependence. Based on the principles of Alcoholics Anonymous (AA), there are now 12-Step groups for a wide range of addictions and other conditions. 12-Step groups best serve the chemically dependent as opposed to those with a diagnosis of clinical abuse. However, concerns have been raised about their appropriateness for chemically dependent people who have experienced trauma. In this chapter, 12-Step groups are discussed as to their conceptual and practical utility for chemically dependent victims of trauma.
... Results suggesting that higher rates of internalizing psychological symptoms were associated with higher AA affiliation were unexpected. Prior research suggested that 12step involvement is either lower (Kelly, McKellar, & Moos, 2003;Noordsy, Schwab, Fox, & Drake, 1996) or similar (Bogenschutz & Akin, 2000;Laudet et al., 2003) among individuals with dual-diagnoses. However, the present observation of higher affiliation is not necessarily counterintuitive. ...
Individuals with comorbid internalizing psychological symptoms and substance abuse issues often have more negative outcomes and evidence a relative disparity in treatment gains compared to those with only substance abuse issues. The present study examined social mechanisms over time for individuals living in self-governed recovery homes (Oxford Houses) such as 12-step group activities and social support, which likely influence both abstinence and psychological outcomes. Participants (n = 567) from a national United States sample of Oxford Houses completed baseline and multiple follow-up self-report assessments over a one-year period. A structural equation model was utilized to evaluate predicted relationships among baseline symptoms, 12-step activities, social support, and outcome variables. Results indicated that internalizing symptoms were associated with subsequent mutual help activities, but not directly with social support. Living in an Oxford House for six months and number of 12-step meetings attended were partially mediated by social support variables in predicting abstinence outcomes, but not psychological outcomes. Environments such as Oxford Houses may be viable options for recovering individuals with comorbid internalizing psychological problems, although social support mechanisms primarily promote abstinence. Implications for future research and for Oxford House policies are discussed.
... Moreover, trauma-related disorders interfere with substance abuse treatment recruitment and retention and treatment outcomes (Palacios, Urmann, Newel, & Hamilton, 1999). Psychiatric comorbidity in general also reduces the impact of 12-step groups (Kelly, McKellar, & Moos, 2003). ...
In a randomized trial of a group intervention for co-occurring substance abuse and traumatic stress disorders “Trauma Adaptive Recovery Group Education and Therapy” (TARGET) was compared to trauma-sensitive usual care (TSU) with 213 clients in three adult outpatient clinics. Improvement at 6- and 12-month assessments occurred across conditions. TARGET was superior to TSU in maintaining sobriety self-efficacy. However, ethnic differences emerged. White TARGET participants reported more improvement than non-White participants on post-traumatic cognitions, and fewer non-White men reported relapses in TSU than in TARGET. TARGET appears to enhance sustained sobriety, but may require culturally specific adaptations.
... Despite the perceived therapeutic value of MHGs, concerns have been raised about the ability of DDIs to engage in and benefit from standard MHGs, such as AA (e.g., Kelly, McKellar, & Moos, 2003;Laudet, Magura, Vogel, & Knight, 2000a;2000b). One of the most frequently cited barriers is that some 12-step members may oppose the use of general psychotropic or relapse prevention medications by other members. ...
Mutual-help groups (MHGs), such as Alcoholics Anonymous (AA), have been shown to be helpful to a broad range of individuals suffering from substance use disorders (SUD). However, for the substantial number of SUD individuals suffering from co-occurring psychiatric conditions, purely substance-focused groups, such as AA, may not be as good a fit. Consequently, MHGs have emerged that focus more explicitly on both substance use and other psychiatric concerns. In this review, we describe, compare, and discuss the four largest “dual-focused” mutual-help organizations and examine the evidence for any incremental benefit they may offer dually diagnosed individuals. We also provide evidence-based recommendations for ways in which clinicians can facilitate patients’ participation in these groups.
... Whereas AOD treatment has a long tradition of relying on self-help, particularly 12-steporiented groups, as a key therapeutic ingredient, they are much less commonly used in the psychiatric setting (Timko et al. 2005). Although the literature is mixed on whether COD patients are more or less likely than others to participate in 12-step meetings (Bogenschutz 2007;Chi et al. 2006a;Jordan et al. 2002;Kelly et al. 2003), evidence increasingly shows that when they do participate, they benefit from 12-step participation as much or more than other patients (Chi et al. 2006a;Magura et al. 2008;Timko and Sempel 2004). In the past two decades, self-help groups that are rooted in traditional 12-step programs but have been adapted to meet the special needs of people with CODs have been growing in number, and evaluations point to positive direct and indirect effects on several key components of recovery for COD patients (Magura 2008). ...
Most people with alcohol and other drug (AOD) use disorders suffer from co-occurring disorders (CODs), including mental health and medical problems, which complicate treatment and may contribute to poorer outcomes. However, care for the patients' AOD, mental health, and medical problems primarily is provided in separate treatment systems, and integrated care addressing all of a patient's CODs in a coordinated fashion is the exception in most settings. A variety of barriers impede further integration of care for patients with CODs. These include differences in education and training of providers in the different fields, organizational factors, existing financing mechanisms, and the stigma still often associated with AOD use disorders and CODs. However, many programs are recognizing the disadvantages of separate treatment systems and are attempting to increase integrative approaches. Although few studies have been done in this field, findings suggest that patients receiving integrated treatment may have improved outcomes. However, the optimal degree of integration to ensure that patients with all types and degrees of severity of CODs receive appropriate care still remains to be determined, and barriers to the implementation of integrative models, such as one proposed by the Institute of Medicine, remain.
... Greater levels of 12-step affiliation and attendance have been consistently associated with reduced alcohol and drug use in general samples (13,14), but fewer studies have examined these relations in patients with psychiatric comorbidity. Similar levels of participation (6) and degree of benefit from 12-step meetings (15) have been found for patients with psychiatric conditions, but other studies found reduced long-term benefits (16) for patients with comorbid MDD. Given the inconsistent and limited body of research, further studies are needed to clarify the importance of post-treatment 12-step affiliation and meeting attendance for patients with comorbid substance dependence and MDD. ...
ABSTRACT Among substance-dependent individuals, comorbid major depressive disorder (MDD) is associated with greater severity and poorer treatment outcomes, but little research has examined mediators of posttreatment substance use outcomes within this population. Using latent growth curve models, the authors tested relationships between individual rates of change in 12-step involvement and substance use, utilizing posttreatment follow-up data from a trial of group Twelve-Step Facilitation (TSF) and integrated cognitive-behavioral therapy (ICBT) for veterans with substance dependence and MDD. Although TSF patients were higher on 12-step affiliation and meeting attendance at end-of-treatment as compared with ICBT, they also experienced significantly greater reductions in these variables during the year following treatment, ending at similar levels as ICBT. Veterans in TSF also had significantly greater increases in drinking frequency during follow-up, and this group difference was mediated by their greater reductions in 12-step affiliation and meeting attendance. Patients with comorbid depression appear to have difficulty sustaining high levels of 12-step involvement after the conclusion of formal 12-step interventions, which predicts poorer drinking outcomes over time. Modifications to TSF and other formal 12-step protocols or continued therapeutic contact may be necessary to sustain 12-step involvement and reduced drinking for patients with substance dependence and MDD.
... These findings provide valuable information on potentially important moderators of the benefits derived from both TSF interventions and community 12-step meeting participation. Specifically, as found in prior work with individuals with psychotic spectrum illness and among other samples of military veterans (28), the presence of major depressive disorder (MDD) in addition to substance dependence may attenuate 12-step related benefits for this important population. ...
Introduction
We know little about what youth with opioid use disorders (OUD) think about outpatient substance use treatment and 12-step meetings following discharge from residential substance use treatment. This study explores youths' preferences between intensive outpatient treatment (IOP) and community-based 12-step groups.
Method
The study recruited youth (n = 35) from a larger randomized trial (N = 288) that examined the effectiveness of extended-release naltrexone versus treatment-as-usual. This study asked the youth to participate in semi-structured qualitative interviews at baseline, 3 months, and 6 months post-residential treatment discharge. Qualitative interviews probed youths' key decision points during the six-months following residential treatment for OUD, including medication and counseling, and 12-step continuation in the community.
Results
Qualitative analyses revealed three overarching themes related to youths' preferences for either IOP or 12-step meetings: structure of recovery support, mechanisms of accountability, and relationships.
Conclusion
Despite varying preferences, this analysis highlights the complexity of benefits that youth report receiving from each approach. Research has yet to determine the degree to which these approaches are complementary or supplementary for this population.
Background
Patients with cooccurring mental health and substance use disorders often find it difficult to sustain long‐term recovery. One predictor of recovery may be how depression symptoms and Alcoholics Anonymous (AA) involvement influence alcohol consumption during and after inpatient psychiatric treatment. This study utilized a parallel growth mixture model to characterize the course of alcohol use, depression, and AA involvement in patients with cooccurring diagnoses.
Methods
Participants were adults with cooccurring disorders (n = 406) receiving inpatient psychiatric care as part of a telephone monitoring clinical trial. Participants were assessed at intake, 3‐, 9‐, and 15‐month follow‐up.
Results
A 3‐class solution was the most parsimonious based upon fit indices and clinical relevance of the classes. The classes identified were high AA involvement with normative depression (27%), high stable depression with uneven AA involvement (11%), and low AA involvement with normative depression (62%). Both the low and high AA classes reduced their drinking across time and were drinking at less than half their baseline levels at all follow‐ups. The high stable depression class reported an uneven pattern of AA involvement and drank at higher daily frequencies across the study timeline. Depression symptoms and alcohol use decreased substantially from intake to 3 months and then stabilized for 90% of patients with cooccurring disorders following inpatient psychiatric treatment.
Conclusions
These findings can inform future clinical interventions among patients with cooccurring mental health and substance use disorders. Specifically, patients with more severe symptoms of depression may benefit from increased AA involvement, whereas patients with less severe symptoms of depression may not.
Background
In the multi-site Prescription Opioid Addiction Treatment Study (POATS), the best predictor of successful opioid use outcome was lifetime diagnosis of major depressive disorder. The primary aim of this secondary analysis of data from POATS was to empirically assess two explanations for this counterintuitive finding.
Methods
The POATS study was a national, 10-site randomized controlled trial (N = 360 enrolled in the 12-week buprenorphine-naloxone maintenance treatment phase) sponsored by the NIDA Clinical Trials Network. We evaluated how the presence of a history of depression influences opioid use outcome (negative urine drug assays). Using adjusted logistic regression models, we tested the hypotheses that 1) a reduction in depressive symptoms and 2) greater motivation and engagement in treatment account for the association between depression history and good treatment outcome.
Results
Although depressive symptoms decreased significantly throughout treatment (p <.001), this improvement was not associated with opioid outcomes (aOR = 0.98, ns). Reporting a goal of opioid abstinence at treatment entry was also not associated with outcomes (aOR = 1.39, ns); however, mutual-help group participation was associated with good treatment outcomes (aOR = 1.67, p <.05). In each of these models, lifetime major depressive disorder remained associated with good outcomes (aORs = 1.63-1.82, ps = .01-.055).
Conclusions
Findings are consistent with the premise that greater engagement in treatment is associated with good opioid outcomes. Nevertheless, depression history continues to be associated with good opioid outcomes in adjusted models. More research is needed to understand how these factors could improve treatment outcomes for those with opioid use disorder.
Background:
Alcohol use disorder (AUD) confers a prodigious burden of disease, disability, premature mortality, and high economic costs from lost productivity, accidents, violence, incarceration, and increased healthcare utilization. For over 80 years, Alcoholics Anonymous (AA) has been a widespread AUD recovery organization, with millions of members and treatment free at the point of access, but it is only recently that rigorous research on its effectiveness has been conducted.
Objectives:
To evaluate whether peer-led AA and professionally-delivered treatments that facilitate AA involvement (Twelve-Step Facilitation (TSF) interventions) achieve important outcomes, specifically: abstinence, reduced drinking intensity, reduced alcohol-related consequences, alcohol addiction severity, and healthcare cost offsets.
Search methods:
We searched the Cochrane Drugs and Alcohol Group Specialized Register, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, CINAHL and PsycINFO from inception to 2 August 2019. We searched for ongoing and unpublished studies via ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 15 November 2018. All searches included non-English language literature. We handsearched references of topic-related systematic reviews and bibliographies of included studies.
Selection criteria:
We included randomized controlled trials (RCTs), quasi-RCTs and non-randomized studies that compared AA or TSF (AA/TSF) with other interventions, such as motivational enhancement therapy (MET) or cognitive behavioral therapy (CBT), TSF treatment variants, or no treatment. We also included healthcare cost offset studies. Participants were non-coerced adults with AUD.
Data collection and analysis:
We categorized studies by: study design (RCT/quasi-RCT; non-randomized; economic); degree of standardized manualization (all interventions manualized versus some/none); and comparison intervention type (i.e. whether AA/TSF was compared to an intervention with a different theoretical orientation or an AA/TSF intervention that varied in style or intensity). For analyses, we followed Cochrane methodology calculating the standard mean difference (SMD) for continuous variables (e.g. percent days abstinent (PDA)) or the relative risk (risk ratios (RRs)) for dichotomous variables. We conducted random-effects meta-analyses to pool effects wherever possible.
Main results:
We included 27 studies containing 10,565 participants (21 RCTs/quasi-RCTs, 5 non-randomized, and 1 purely economic study). The average age of participants within studies ranged from 34.2 to 51.0 years. AA/TSF was compared with psychological clinical interventions, such as MET and CBT, and other 12-step program variants. We rated selection bias as being at high risk in 11 of the 27 included studies, unclear in three, and as low risk in 13. We rated risk of attrition bias as high risk in nine studies, unclear in 14, and low in four, due to moderate (> 20%) attrition rates in the study overall (8 studies), or in study treatment group (1 study). Risk of bias due to inadequate researcher blinding was high in one study, unclear in 22, and low in four. Risks of bias arising from the remaining domains were predominantly low or unclear. AA/TSF (manualized) compared to treatments with a different theoretical orientation (e.g. CBT) (randomized/quasi-randomized evidence) RCTs comparing manualized AA/TSF to other clinical interventions (e.g. CBT), showed AA/TSF improves rates of continuous abstinence at 12 months (risk ratio (RR) 1.21, 95% confidence interval (CI) 1.03 to 1.42; 2 studies, 1936 participants; high-certainty evidence). This effect remained consistent at both 24 and 36 months. For percentage days abstinent (PDA), AA/TSF appears to perform as well as other clinical interventions at 12 months (mean difference (MD) 3.03, 95% CI -4.36 to 10.43; 4 studies, 1999 participants; very low-certainty evidence), and better at 24 months (MD 12.91, 95% CI 7.55 to 18.29; 2 studies, 302 participants; low-certainty evidence) and 36 months (MD 6.64, 95% CI 1.54 to 11.75; 1 study, 806 participants; low-certainty evidence). For longest period of abstinence (LPA), AA/TSF may perform as well as comparison interventions at six months (MD 0.60, 95% CI -0.30 to 1.50; 2 studies, 136 participants; low-certainty evidence). For drinking intensity, AA/TSF may perform as well as other clinical interventions at 12 months, as measured by drinks per drinking day (DDD) (MD -0.17, 95% CI -1.11 to 0.77; 1 study, 1516 participants; moderate-certainty evidence) and percentage days heavy drinking (PDHD) (MD -5.51, 95% CI -14.15 to 3.13; 1 study, 91 participants; low-certainty evidence). For alcohol-related consequences, AA/TSF probably performs as well as other clinical interventions at 12 months (MD -2.88, 95% CI -6.81 to 1.04; 3 studies, 1762 participants; moderate-certainty evidence). For alcohol addiction severity, one study found evidence of a difference in favor of AA/TSF at 12 months (P < 0.05; low-certainty evidence). AA/TSF (non-manualized) compared to treatments with a different theoretical orientation (e.g. CBT) (randomized/quasi-randomized evidence) For the proportion of participants completely abstinent, non-manualized AA/TSF may perform as well as other clinical interventions at three to nine months follow-up (RR 1.71, 95% CI 0.70 to 4.18; 1 study, 93 participants; low-certainty evidence). Non-manualized AA/TSF may also perform slightly better than other clinical interventions for PDA (MD 3.00, 95% CI 0.31 to 5.69; 1 study, 93 participants; low-certainty evidence). For drinking intensity, AA/TSF may perform as well as other clinical interventions at nine months, as measured by DDD (MD -1.76, 95% CI -2.23 to -1.29; 1 study, 93 participants; very low-certainty evidence) and PDHD (MD 2.09, 95% CI -1.24 to 5.42; 1 study, 286 participants; low-certainty evidence). None of the RCTs comparing non-manualized AA/TSF to other clinical interventions assessed LPA, alcohol-related consequences, or alcohol addiction severity. Cost-effectiveness studies In three studies, AA/TSF had higher healthcare cost savings than outpatient treatment, CBT, and no AA/TSF treatment. The fourth study found that total medical care costs decreased for participants attending CBT, MET, and AA/TSF treatment, but that among participants with worse prognostic characteristics AA/TSF had higher potential cost savings than MET (moderate-certainty evidence).
Authors' conclusions:
There is high quality evidence that manualized AA/TSF interventions are more effective than other established treatments, such as CBT, for increasing abstinence. Non-manualized AA/TSF may perform as well as these other established treatments. AA/TSF interventions, both manualized and non-manualized, may be at least as effective as other treatments for other alcohol-related outcomes. AA/TSF probably produces substantial healthcare cost savings among people with alcohol use disorder.
Background:
Even low levels of substance misuse by people with a severe mental illness can have detrimental effects.
Objectives:
To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care.
Search methods:
The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases.
Selection criteria:
We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness.
Data collection and analysis:
Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison.
Main results:
Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence).
Authors' conclusions:
We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.
Objectives:
Transcranial direct current stimulation can be effective in reducing the craving for food, alcohol, and methamphetamine. Because its effects have not been tested on patients with opium use disorder, we investigated its efficacy when it is combined with a standard methadone maintenance therapy protocol.
Methods:
We carried out a pretest-posttest control group method to evaluate the effect of transcranial direct current stimulation at the dorsolateral prefrontal cortex (right anodal/left cathodal) on opium craving, depression, and anxiety symptoms. We considered opium craving as a primary outcome as well as depression and anxiety symptoms as secondary outcomes. Sixty participants with opium use disorder were randomly assigned into 3 groups (n = 20 for each group): (1) an active transcranial direct current stimulation with methadone maintenance treatment (active tDCS group), (2) sham transcranial direct current stimulation with methadone maintenance treatment (sham tDCS group), and (3) only methadone maintenance treatment (methadone maintenance treatment group). All participants completed the Desire for Drug Questionnaire, Obsessive-Compulsive Drug Use Scale, Beck Depression Inventory II, and Beck Anxiety Inventory a week before and a week after the treatment. The outcomes were assessed by independent assessors who were blind to the treatment conditions.
Results:
The active tDCS group had a significant reduction in opium craving, depression, and anxiety symptoms compared with the other 2 groups.
Conclusions:
Our results provide a preliminary support for using the transcranial direct current stimulation along with methadone maintenance therapy in the treatment of patients with opium use disorder.
BACKGROUND AND AIMS
There is consensus that best clinical practice for dual diagnosis (DD) is integrated mental health and substance use treatment augmented with Alcoholics Anonymous (AA) attendance. This is the first quantitative review of the direction and magnitude of the association between AA attendance and alcohol abstinence for DD patients.
METHOD
A systematic literature search (1993‐2017) identified 22 studies yielding 24 effect sizes that met our inclusion criteria (8,075 patients). Inverse‐variance weighting of correlation coefficients (r) was used to aggregate sample‐level findings and study aims were addressed using random and mixed effect models. Sensitivity and publication bias analyses were conducted to assess the likelihood of bias in the overall estimate of AA‐related benefit.
RESULTS
AA exposure and abstinence for DD patients were significantly and positively associated (rw=.249; 95% CI.203‐.293; Tau=.097). There was also significant heterogeneity in the distribution of effect sizes, (Q(23)=90.714, p<.001), and high between‐sample variance (I²=74.646). Subgroup analyses indicated that the magnitude of AA‐related benefit did not differ between 6 (k=7) and 12 (k=12) month follow‐up, (Q=.068, p<.794), type of treatment received (inpatient k=9; intensive outpatient, outpatient, community k=15; Q=2.057, p<.152), and whether a majority of patients in a sample had (k=11) or did not have (k=13) major depression (Q=.563, p<.453). Sensitivity analyses indicated that the overall meta‐analytic estimate of AA benefit was not adversely or substantively impacted by pooling RCT and observational samples (Q=.763, p<.382), pooling count, binary, and ordinal‐based AA (Q=.023, p<.879) and outcome data (Q=1.906, p<.167), and reversing direction of correlations extracted from studies (Q=.006, p<.937). No support was found for publication bias.
CONCLUSIONS
Clinical referral of dual diagnosis (DD) patients to Alcoholics Anonymous (AA) is common and, in many cases, DD patients who attend AA will report higher rates of alcohol abstinence relative to DD patients who do not attend AA.
Review about self-help groups (written in Norwegian)
This chapter provides an overview of the processes and outcomes of self-help or mutual support groups that focus primarily on substance use and associated disorders. The overview covers the role of attendance and involvement in self-help groups, primarily Alcoholics Anonymous and Narcotics Anonymous, in improving substance use and psychosocial functioning outcomes and describes the connections between self-help groups and treatment. Then, the focus turns to personal factors that affect participation in and outcomes of self-help groups, including the severity of substance-related impairment, disease model beliefs and religious/spiritual orientation, and the influence of self-help groups on individuals with substance use and psychiatric disorders, women, older adults, and individuals of racial/ethnic minority backgrounds. The concluding section focuses on the probable active ingredients of self-help groups, including abstinence-specific and general support, goal direction and structure, involvement in rewarding substance-free activities, and an emphasis on bolstering members’ self-efficacy and coping skills and helping other individuals in need.
Addictive behaviors have the potential to disrupt the life of the individual who possesses the addiction; however, these behaviors also tend to produce a negative and cascading effect on everyone who may come into contact with the individual. More specifically, not only does an addiction produce misery for the addicted, it also creates misery for those who care for the individual, those who depend on the individual, and those who may be victims of the addicted individual’s impaired judgment and behavior. As the foregoing suggests, addictive behaviors constitute a serious issue in mental health. For many addicts, their problems are chronic and complex; therefore, they have been long standing enough to produce a variety of related problems in a variety of contexts.
IntroductionThe Course of Addictive DisordersScreening and Initial Referral of PatientsDescriptions of Psychosocial Treatments for SudSelf-Help for Substance Use DisorderRole of Referring Physician During Self-Help and/or Professional Sud TreatmentContinuing CareManaging Treatment-Resistant PatientsConclusions
AcknowledgmentReferences
Self-help interventions include step-by-step instructions that enable an individual to carry out an established treatment protocol either independently (pure self-help) or with minimal professional support (guided self-help). Generally, self-help interventions provide information about a given disorder as well as tools for building skills. In contrast, support groups-including 12-step programs-are relatively unstructured, do not target the reduction of symptoms, and do not involve therapists. In this chapter, we review the literature related to self-help and support groups for eating disorders, selected substance use disorders, gambling disorder, sexual addiction, and compulsive shopping; identify and describe self-help programs and resources for these problems; and provide recommendations for research and treatment. Very little research has evaluated the effectiveness of support groups in reducing symptoms of these disorders, and no research exists of self-help for individuals with comorbid eating disorders and addictions. However, reasonably strong evidence suggests that cognitive behavioral self-help treatments reduce symptoms of recurrent binge eating and bulimia nervosa. Similarly, self-help interventions for substance use disorders and gambling disorder using motivational and cognitive behavioral approaches improve outcomes. There is some evidence that assessment alone, or with personalized feedback, may be beneficial for those with gambling disorder. Further research examining the utility of self-help for these disorders, as well as indications for the use of pure versus guided self-help, is needed.
IntroductionStress Coping and Self-Medication ModelsTreatment in the Community12-Step ApproachesCognitive and Behavioral TherapiesConclusions
AcknowledgmentReferences
Alcohol use disorder (AUD) is associated with depression. Although attendance at Alcoholics Anonymous (AA) meetings predicts reductions in drinking, results have been mixed about the salutary effects of AA on reducing depressive symptoms. In this single-group study, early AA affiliates (n = 253) were recruited, consented, and assessed at baseline, 3, 6, 9, 12, 18, and 24 months. Lagged growth models were used to investigate the predictive effect of AA attendance on depression, controlling for concurrent drinking and treatment attendance. Depression was measured using the Beck Depression Inventory (BDI) and was administered at baseline 3, 6, 12, 18, and 24 months. Additional predictors of depression tested included spiritual gains (Religious Background and Behavior questionnaire [RBB]) and completion of 12-step work (Alcoholics Anonymous Inventory [AAI]). Eighty-five percent of the original sample provided follow-up data at 24 months. Overall, depression decreased over the 24 month follow-up period. AA attendance predicted later reductions in depression (slope = -3.40, p = .01) even after controlling for concurrent drinking and formal treatment attendance. Finally, increased spiritual gains (RBB) also predicted later reductions in depression (slope = -0.10, p = .02) after controlling for concurrent drinking, treatment, and AA attendance. In summary, reductions in alcohol consumption partially explained decreases in depression in this sample of early AA affiliates, and other factors such as AA attendance and increased spiritual practices also accounted for reductions in depression beyond that explained by drinking. (PsycINFO Database Record
(c) 2015 APA, all rights reserved).
Background
The revision of the psychotherapy guidelines in 2011 broadened the options for treating substance use disorders (SUD) in outpatient psychotherapy (OP).
Aim
The aims of this study were to answer the following questions: how frequently are SUDs treated in OP? What opinions do psychotherapists (PT) hold concerning the new treatment possibilities?
Material and methods
In this study the frequency of OP for patients with SUD, e.g. harmful use and abuse of as well as dependence on psychotropic substances according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and the International Statistical Classification of Diseases and Related Health Problems (ICD-10), by private practice PTs as well as their attitude towards the treatment of patients with these diagnoses were investigated. Private practice PTs in five states in East Germany were asked to participate in a postal survey.
Results
Of the 1,382 PTs contacted, 229 (16.6 %) participated in the study. Of the respondents 94.3 % had treated at least one patient with SUD (4-week prevalence including nicotine dependence). These rates ranged from 3.1 % to 26.6 % depending on the substance and diagnosis (SUD as primary reason for treatment). The highest rates of strong affirmation for OP of approximately 20 % were found for disorders related to alcohol, tobacco and medication.
Conclusion
Most PTs treated at least one patient with SUD in OP. However, this particular type of treatment offer should be further extended. Information about the options of treating SUD in OP should be further disseminated and conducting such treatment should be supported by (e.g.) therapist training.
Is it the supportive communication received through 12-step processes that enables addicts to change their behavior, or is it that addicts who are motivated to change their behavior diligently attend to 12-step processes? A retrospective two-wave panel design was employed to address these competing perspectives. Higher levels of meeting attendance and sponsor work at an earlier period in participants’ lives were associated with lower levels of sexual compulsivity at a later period in their lives. However, time-one meeting attendance and sponsor work did not explain interindividual change in sexual compulsivity from time-one to time-two, a stricter test of the validity of cross-lagged associations. Options for methodological improvements to increase the power of future inquiries are outlined.
Purpose
– The purpose of this paper is to investigate research in the field of addictions utilising CBT and 12 step fellowship methods and to create an evidence base for an integrated treatment method utilising both approaches.
Design/methodology/approach
– Research on CBT and 12 step fellowships and their current applications in addiction treatment are presented. Models of severe mental illness are referenced and the use of directive and guided referrals are used as a basis to build the paper's hypothesis. A mode of action how the treatments may work together is presented.
Findings
– Findings indicate that guided treatment approaches for dual diagnosis are more likely to lead to long term therapeutic gains. Discussion involves the practical implications of this treatment and its ability to create a synergistic approach.
Practical implications
– Implications include the potential for streamlined treatment approaches which have the potential to increase treatment adherence and outcomes. Implications, such as the joint use of social reinforcement techniques between 12 step fellowship approaches and CBT, are also discussed.
Originality/value
– There is no previous research on the application of CBT and 12 step treatment modalities working together in a structured manner. Previous work has focussed primarily on severe mental illness. The current paper aims to provide an approach to treatment which utilises several modes of treatment to create more robust treatments for people suffering from dual diagnoses.
For nearly five decades, Rudy Moos, PhD, has been one of the giants of modern addiction research. I believe he has, more than any other research scientist, focused on questions of the greatest import to addiction counselors and the individuals and families they serve. His published studies have dramatically expanded our knowledge of addiction treatment and the processes of long-term addiction recovery. peer-reviewed scientific journals and professional books. He has served on the editorial boards of more than 30 scientific journals and has received numerous awards for his groundbreaking research, including awards from the American Psychological Association, the American Psychiatric Association, the National Institute on Alcohol Abuse and Alcoholism, the Department of Veterans Affairs, and the American Society of Addiction Medicine.
This study sought to develop a typology of individuals with substance dependence (ISD) based on a longitudinal survey (n = 2,434) and 121 ISD. The latter were divided into three groups: newly abstinent individuals, chronic dependents and acute dependents. Individuals' typology was developed by cluster analysis. Newly abstinent individuals had fewer emotional problems and mental disorders in the previous 12 months. Four classes of ISD were identified, labelled respectively "chronic multi-substance consumption and mental disorders comorbidities," "multi-substance consumption," "alcohol and marijuana consumption" and "alcohol consumption only." Strategies adapted to each of these profiles could be promoted for more effective treatment.
Over 50% of people with a severe mental illness also use illicit drugs and/or alcohol at hazardous levels. This review is
based on the findings of 32 randomized controlled trials which assessed the effectiveness of psychosocial interventions, offered
either as one-off treatments or as an integrated or nonintegrated program, to reduce substance use by people with a severe
mental illness. The findings showed that there was no consistent evidence to support any one psychosocial treatment over another.
Differences across trials with regard to outcome measures, sample characteristics, type of mental illness and substance used,
settings, levels of adherence to treatment guidelines, and standard care all made pooling results difficult. More quality
trials are required that adhere to proper randomization methods; use clinically valuable, reliable, and validated measurement
scales; and clearly report data, including retention in treatment, relapse, and abstinence rates. Future trials of this quality
will allow a more thorough assessment of the efficacy of psychosocial interventions for reducing substance use in this challenging
population.
The disease model of alcoholism was adopted by the American Medical Assoication in 1956, and the intervening 47 years have seen the development of increasingly varied and sophisticated types of evidence for the biological sources of addiction to Alcohol and other drugs of abuse (AODA) . However, a synthesis of 12-step treatment with a confrontational and moralistic version of cognitive psychology remains the modal approach to AODA treatment, despite its inability to even engage many addicts. Simultaneously, the growing evidence for therapies that teach self-regulation of biopsychological processes, which treat clients supportively while encouraging their recognition of the problems and building their desire to change, has been largely ignored by practitioners. The epitome of this self-regulation approach, neurofeedback therapy, has been all but ignored despite reports of high success rates. This paper examines the confluence historical economic and ideological factors that maintain this divergence between knowledge and practice from the perspective of Gusfield's notion of moral passage based on deviant labels.
The comparative effectiveness of 12-step and cognitive–behavioral (C-B) models of substance abuse treatment was examined among 3, 018 patients from 15 programs at U.S. Department of Veterans Affairs Medical Centers. Across program types, participants showed significant improvements in functioning from treatment admission to a 1-year follow-up. Although 12-step patients were somewhat more likely to be abstinent at the 1-year follow-up, 12-step, C-B, and combined 12-Step–C-B treatment programs were equally effective in reducing substance use and improving most other areas of functioning. The finding of equal effectiveness was consistent over several treatment subgroups: Patients attending the “purest” 12-step and C-B treatment programs, and patients who had received the “full dose” of treatment. Also, patients with only substance abuse diagnoses, those with concomitant psychiatric diagnoses, and patients who were mandated to treatment showed similar improvement at the 1-year follow-up, regardless of type of treatment received. These data provide important new evidence supporting the effectiveness of 12-step treatment.
Relatively little is known about how substance abuse treatment facilitates positive outcomes. This study examined the therapeutic effects and mechanisms of action of affiliation with Alcoholics Anonymous (AA) after treatment. Patients (N = 100) in intensive 12-step substance abuse treatment were assessed during treatment and at 1- and 6-month follow-ups. Results indicated that increased affiliation with AA predicted better outcomes. The effects of AA affiliation were mediated by a set of common change factors. Affiliation with AA after treatment was related to maintenance of self-efficacy and motivation, as well as to increased active coping efforts. These processes, in turn, were significant predictors of outcome. Findings help to illustrate the value of embedding a test of explanatory models in an evaluation study.
In this article, we attempt to distinguish between the properties of moderator and mediator variables at a number of levels. First, we seek to make theorists and researchers aware of the importance of not using the terms moderator and mediator interchangeably by carefully elaborating, both conceptually and strategically, the many ways in which moderators and mediators differ. We then go beyond this largely pedagogical function and delineate the conceptual and strategic implications of making use of such distinctions with regard to a wide range of phenomena, including control and stress, attitudes, and personality traits. We also provide a specific compendium of analytic procedures appropriate for making the most effective use of the moderator and mediator distinction, both separately and in terms of a broader causal system that includes both moderators and mediators. (46 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The prevalence of comorbid alcohol, other drug, and mental disorders in the US total community and institutional population was determined from 20,291 persons interviewed in the National Institute of Mental Health Epidemiologic Catchment Area Program. Estimated US population lifetime prevalence rates were 22.5% for any non-substance abuse mental disorder, 13.5% for alcohol dependence-abuse, and 6.1% for other drug dependence-abuse. Among those with a mental disorder, the odds ratio of having some addictive disorder was 2.7, with a lifetime prevalence of about 29% (including an overlapping 22% with an alcohol and 15% with another drug disorder). For those with either an alcohol or other drug disorder, the odds of having the other addictive disorder were seven times greater than in the rest of the population. Among those with an alcohol disorder, 37% had a comorbid mental disorder. The highest mental-addictive disorder comorbidity rate was found for those with drug (other than alcohol) disorders, among whom more than half (53%) were found to have a mental disorder with an odds ratio of 4.5. Individuals treated in specialty mental health and addictive disorder clinical settings have significantly higher odds of having comorbid disorders. Among the institutional settings, comorbidity of addictive and severe mental disorders was highest in the prison population, most notably with antisocial personality, schizophrenia, and bipolar disorders.
The 2-year posttreatment course of substance abuse patients with posttraumatic stress disorder (PTSD) was examined in a multisite evaluation of Veterans Affairs substance abuse treatment. Substance abuse patients with PTSD (SUD-PTSD) were compared with patients with only substance use disorder (SUD only) and patients with other comorbid psychiatric diagnoses (SUD-PSY) on outcomes during the 2 years after treatment. SUD-PTSD patients had a poorer long-term course on substance use, psychological symptom, and psychosocial outcomes than SUD-only and SUD-PSY patients. Coping methods were examined as mediators of the effect of PTSD on substance use outcomes. Greater use of avoidance coping styles and less use of approach coping at 1 year partially accounted for the association of PTSD with 2-year substance use. Treatments that address multiple domains of functioning and focus on alternative coping strategies are recommended for this population. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
General population data from the National Comorbidity Survey are presented on co-occurring DSM-III-R addictive and mental disorders. Co-occurrence is highly prevalent in the general population and usually due to the association of a primary mental disorder with a secondary addictive disorder. It is associated with a significantly increased probability of treatment, although the finding that fewer than half of cases with 12-month co-occurrence received any treatment in the year prior to interview suggests the need for greater outreach efforts.
The prevalence of comorbid alcohol, other drug, and mental disorders in the US total community and institutional population was determined from 20,291 persons interviewed in the National Institute of Mental Health Epidemiologic Catchment Area Program. Estimated US population lifetime prevalence rates were 22.5% for any non-substance abuse mental disorder, 13.5% for alcohol dependence-abuse, and 6.1% for other drug dependence-abuse. Among those with a mental disorder, the odds ratio of having some addictive disorder was 2.7, with a lifetime prevalence of about 29% (including an overlapping 22% with an alcohol and 15% with another drug disorder). For those with either an alcohol or other drug disorder, the odds of having the other addictive disorder were seven times greater than in the rest of the population. Among those with an alcohol disorder, 37% had a comorbid mental disorder. The highest mental-addictive disorder comorbidity rate was found for those with drug (other than alcohol) disorders, among whom more than half (53%) were found to have a mental disorder with an odds ratio of 4.5. Individuals treated in specialty mental health and addictive disorder clinical settings have significantly higher odds of having comorbid disorders. Among the institutional settings, comorbidity of addictive and severe mental disorders was highest in the prison population, most notably with antisocial personality, schizophrenia, and bipolar disorders.
In this article, we attempt to distinguish between the properties of moderator and mediator variables at a number of levels. First, we seek to make theorists and researchers aware of the importance of not using the terms moderator and mediator interchangeably by carefully elaborating, both conceptually and strategically, the many ways in which moderators and mediators differ. We then go beyond this largely pedagogical function and delineate the conceptual and strategic implications of making use of such distinctions with regard to a wide range of phenomena, including control and stress, attitudes, and personality traits. We also provide a specific compendium of analytic procedures appropriate for making the most effective use of the moderator and mediator distinction, both separately and in terms of a broader causal system that includes both moderators and mediators.
A sample of 515 initially untreated problem drinkers was followed for one year after contacting alcohol information and referral or detoxification services. At a one-year follow-up, participants had self-selected into one of four groups: no treatment (24%), Alcoholics Anonymous (AA) only (18%), outpatient treatment (25%), and residential or inpatient treatment (32%); some outpatients also attended AA, and some inpatients also attended AA and/or outpatient programs. These four groups were compared on changes in drinking-related variables, other aspects of functioning, and stressors and resources over the follow-up year. Also examined were associations between amount of treatment and outcomes at one year. All four groups improved on drinking and functioning outcomes but changed less on stressors and resources. Although individuals who received no help improved, persons in the two treatment and the AA-only groups improved more, particularly on drinking-related outcomes. Inpatients were more likely than outpatients or AA-only participants to be abstinent; otherwise, type of intervention had few differential effects. More AA attendance was associated with abstinence among AA-only, outpatient, and inpatient group members. Among outpatients and inpatients, more formal treatment was associated with abstinence and improvement on other drinking-related outcomes.
The authors examined whether continuing outpatient mental health care, the orientation of the treatment program (12-step, cognitive-behavioral, or eclectic), and involvement in self-help groups were linked to substance abuse patients' remission status two years after discharge.
The data were from a cohort of 2,805 male patients who were treated through one of 15 Department of Veterans Affairs substance abuse programs. Remission was defined as abstinence from illicit drug use and abstinence from or nonproblem use of alcohol during the previous three months. The relationships of the three variables to remission were tested with regression models that controlled for baseline characteristics.
About a quarter of the study participants (28 percent) were in remission two years after discharge. Intake characteristics that predicted remission at two years included less severe substance use and psychiatric problems, lower expected disadvantages and costs of discontinuing substance use, and having abstinence as a treatment goal. No significant relationship emerged between treatment orientation and remission status two years later. Involvement in outpatient mental health care during the first follow-up year and participation in self-help groups during the last three months of that year were associated with a greater likelihood of remission at the two-year follow-up.
The results extend previously published one-year outcome findings showing that cognitive-behavioral and 12-step treatment programs result in similar remission rates. Patients who enter intensive substance abuse treatment with polysubstance use, psychiatric symptoms, or significant emotional distress have more difficulty achieving remission. Routinely engaging patients in continuing outpatient care is likely to yield better outcomes. The duration of such care is probably more important than the number of sessions.
Self-help is gaining increased acceptance among treatment professionals as the advent of managed care warrants the use of cost-effective modalities. Traditional "one disease-one recovery" self-help groups cannot serve adequately the needs of the dually diagnosed. This article discusses Double Trouble in Recovery (DTR), a 12-step self-help group designed to meet the special needs of those diagnosed with both a psychiatric disability and a chemical addiction, DTR differs from traditional self-help groups by offering people a safe forum to discuss their psychiatric disabilities, medication, and substance abuse. Preliminary data collected at four DTR sites in NYC indicate that DTR members have a long history of psychiatric disabilities and of substance abuse, and extensive experience with treatment programs in both areas. They are actively working on their recovery, as evidenced by their fairly intensive attendance at DTR. Recent substance use is limited, suggesting that participation in DTR (in conjunction with format treatment when needed) is having a positive effect. Most members require medication to control their psychiatric disabilities, and that alone may make attendance at "conventional" 12-step groups uncomfortable. Ratings of statements comparing DTR to other 12-step meetings suggest that DTR is a setting where members can feel comfortable and safe discussing their dual recovery needs.
Drawing on ecological and narrative theories of self‐help groups, this study tests a multilevel model predicting self‐help group involvement among male veterans who received inpatient substance abuse treatment. Following K. Maton (1993), the study moves beyond the individual‐level of analysis to encompass variables in the treatment and post‐treatment social ecology. Surveys administered to patients (N = 3,018) and treatment staff (N = 329) assessed these predictor domains and self‐help group involvement 1 year after discharge. A hierarchical linear model fit to the data indicates that greater involvement in 12‐step groups after discharge is predicted by the compatibility between personal and treatment belief systems. The implications of these findings for efforts to facilitate transitions between inpatient professional treatment and community‐based self‐help groups are discussed.
Background: The effect of depression on return to drinking among individuals with alcohol dependence is controversial. From February 1, 1993, to April 15, 1996, we consecutively recruited 40 women and 61 men hospitalized for alcohol dependence and followed them up monthly for I year to assess the effect of depression on drinking outcomes. Methods: We conducted structured interviews during hospitalization and monthly following discharge for l year to determine whether depression at treatment entry affected the likelihood of return to drinking and whether this effect differed between sexes. Using survival analysis, we examined the effect of depressive symptoms and a diagnosis of current major depression at treatment entry on times to first drink and relapse during follow-up. Results: A diagnosis of current major depression at the time of hospitalization was associated with shorter times to first drink (hazard ratio, 2.03; 95% confidence interval [CI], 1.28-3.21; P=.003) and relapse (hazard ratio, 2.12; 95% CI, 1.32-3.39; P=.002). There was no significant difference between women and men in this effect. Depressive symptoms as measured by the Beck Depression Inventory did not predict time to first drink or relapse in women or men. Conclusions: A diagnosis of current major depression at entry into inpatient treatment for alcohol dependence predicted shorter times to first drink and relapse in women and men. Our results differ from earlier reports that men and women differ in the effect of depression on return to drinking.
Objective:
To assess the benefits of matching alcohol dependent clients to three different treatments with reference to a variety of client attributes.
Methods:
Two parallel but independent randomized clinical trials were conducted, one with alcohol dependent clients receiving outpatient therapy (N = 952; 72% male) and one with clients receiving aftercare therapy following inpatient or day hospital treatment (N = 774; 80% male). Clients were randomly assigned to one of three 12-week, manual-guided, individually delivered treatments: Cognitive Behavioral Coping Skills Therapy, Motivational Enhancement Therapy or Twelve-Step Facilitation Therapy. Clients were then monitored over a 1-year posttreatment period. Individual differences in response to treatment were modeled as a latent growth process and evaluated for 10 primary matching variables and 16 contrasts specified a priori. The primary outcome measures were percent days abstinent and drinks per drinking day during the 1-year posttreatment period.
Results:
Clients attended on average two-thirds of treatment sessions offered, indicating that substantial amounts of treatment were delivered, and research follow-up rates exceeded 90% of living subjects interviewed at the 1-year posttreatment assessment. Significant and sustained improvements in drinking outcomes were achieved from baseline to 1-year posttreatment by the clients assigned to each of these well-defined and individually delivered psychosocial treatments. There was little difference in outcomes by type of treatment. Only one attribute, psychiatric severity, demonstrated a significant attribute by treatment interaction: In the outpatient study, clients low in psychiatric severity had more abstinent days after 12-step facilitation treatment than after cognitive behavioral therapy. Neither treatment was clearly superior for clients with higher levels of psychiatric severity. Two other attributes showed time-dependent matching effects: motivation among outpatients and meaning-seeking among aftercare clients. Client attributes of motivational readiness, network support for drinking, alcohol involvement, gender, psychiatric severity and sociopathy were prognostic of drinking outcomes over time.
Conclusions:
The findings suggest that psychiatric severity should be considered when assigning clients to outpatient therapies. The lack of other robust matching effects suggests that, aside from psychiatric severity, providers need not take these client characteristics into account when triaging clients to one or the other of these three individually delivered treatment approaches, despite their different treatment philosophies.
The 2-year posttreatment course of substance abuse patients with posttraumatic stress disorder (PTSD) was examined in a multisite evaluation of Veterans Affairs substance abuse treatment. Substance abuse patients with PTSD (SUD-PTSD) were compared with patients with only substance use disorder (SUD only) and patients with other comorbid psychiatric diagnoses (SUD-PSY) on outcomes during the 2 years after treatment. SUD-PTSD patients had a poorer long-term course on substance use, psychological symptom, and psychosocial outcomes than SUD-only and SUD-PSY patients. Coping methods were examined as mediators of the effect of PTSD on substance use outcomes. Greater use of avoidance coping styles and less use of approach coping at 1 year partially accounted for the association of PTSD with 2-year substance use. Treatments that address multiple domains of functioning and focus on alternative coping strategies are recommended for this population.
• In order to estimate the concurrent validity of a structured psychiatric interview, we compared interview diagnoses obtained for 101 psychiatric inpatients to those recorded in the same patients' hospital charts. For most diagnoses considered, concordance was found to be high. For those in which concordance was low, we examined the reasons for the diagnostic discrepancy. Diagnostic errors that were judged to have occurred on the basis of the structured interview often seemed to have resulted from a lack of longitudinal clinical observation. However, more errors were judged to have occurred in the hospital charts, apparently because of physician oversight. We conclude that the concurrent validity of this structured interview is high and that such examinations might be useful not only for research but also for the routine initial evaluation of psychiatric patients.
This year marks the 50th anniversary of the original publication of Alcoholics Anonymous, the basic text for that mutual self-help organization devoted to helping alcoholics recover. The first edition was greeted with skepticism by the medical community1,2 based on the optimistic and spiritual writing style and the medical community's poor track record for alcoholism treatment.The ensuing 50 years have witnessed the development of Alcoholics Anonymous (AA) into the largest treatment program for alcoholics in the world. Health care providers now routinely turn to AA for help, referring alcoholics for the round-the-clock, round-the-calendar support and outreach that has helped them recover for brief and extended periods. Alcoholics Anonymous has proved itself to be a major feature of the diverse alcoholism treatment network that has emerged following the 1971 Hughes Act. We have incorporated it into our treatment planning, yet most of us (including specialists in alcoholism and addiction) have
This study examined participation in 12-step programs and attitudes toward 12-step meetings in an outpatient sample of 81 severely mentally ill patients with comorbid substance use disorders. The study found that dual diagnosis patients attended 12-step programs at rates comparable to those reported for patients in primary addiction treatment settings. Diagnosis and attitudes toward 12-step meetings each had independent effects on 12-step participation. The difficulties that some dual diagnosis patients report experiencing at 12-step meetings may need to be addressed to maximize 12-step attendance and potential to benefit from 12-step programs.
This article first explains the conceptual framework and plan of a naturalistic, multisite evaluation of Department of Veterans Affairs (VA) substance abuse treatment programs. It then examines the effectiveness of an index episode of inpatient treatment and the effectiveness of continuing outpatient care and participation in self-help groups. The study was conducted among 3018 patients from 15 VA programs that emphasized 12-Step, cognitive-behavioral (CB), or eclectic treatment. Casemix-adjusted 1-year outcomes showed that patients in 12-Step programs were the most likely to be abstinent, free of substance abuse problems, and employed at the 1-year follow-up. Patients who obtained more regular and more intensive outpatient mental health care, and those who participated more in 12-Step self-help groups, were more likely to be abstinent and free of substance use problems at the 1-year follow-up. These findings support the effectiveness of 12-Step treatment and show that patients with substance use disorders who become more involved in outpatient care and self-help groups tend to experience better short-term substance use outcomes. Subsequent papers in this section focus on the proximal outcomes of treatment, patients with psychiatric as well as substance use disorders, patient-treatment matching effects, and the link between program treatment orientation and patients’ involvement in and the influence of 12-Step self-help groups.
disciplines encountered [in this review] included anthropology, sociology, psychology, medicine, theology, and philosophy / participant-observational studies, epidemiological surveys, public opinion surveys, ethnographic investigations, and psychotherapy outcome studies were among the research strategies used in the sources (PsycINFO Database Record (c) 2012 APA, all rights reserved)
A bstract A im s. To study prospectively the type and extent of aftercare sought by patients following their admission for alcohol and other substance abuse treatment as a function of psychiatric co-morbidity . D esign. Prospective cohort study with follow-up after 16 months . Setting and participants. A nationwide sample of alcoholics discharged from inpatient treatment ( N = 351) in Iceland . M easurem ents. The Diagnostic Interview Schedule was used to assign psychiatric diagnoses at the time of index admission. A questionnaire on the type and number of aftercare attendances was mailed to all participants to obtain information about aftercare . Findings. A combination of attendance at Alcoholics Anonymous (AA) and professional care was the most common aftercare (49%); while only 8% received no aftercare whatsoever. The mean number of AA attendances was over 24 while it was less than 3 for the various professional appointments. Patients with a diagnosis of schizophrenia had a lower rate of attendance at AA. Other types of co-morbidity did not affect AA attendance but did increase rates of professional help-seeking . C onclusions. Better professional treatment attendance might be gained by integrating AA concepts while AA might benefit from professional input to address the prevalent co-morbid psychiatric disorders.
The effect of depression on return to drinking among individuals with alcohol dependence is controversial. From February 1, 1993, to April 15, 1996, we consecutively recruited 40 women and 61 men hospitalized for alcohol dependence and followed them up monthly for 1 year to assess the effect of depression on drinking outcomes.
We conducted structured interviews during hospitalization and monthly following discharge for 1 year to determine whether depression at treatment entry affected the likelihood of return to drinking and whether this effect differed between sexes. Using survival analysis, we examined the effect of depressive symptoms and a diagnosis of current major depression at treatment entry on times to first drink and relapse during follow-up.
A diagnosis of current major depression at the time of hospitalization was associated with shorter times to first drink (hazard ratio, 2.03; 95% confidence interval [CI], 1.28-3.21; P=.003) and relapse (hazard ratio, 2.12; 95% CI, 1.32-3.39; P=.002). There was no significant difference between women and men in this effect. Depressive symptoms as measured by the Beck Depression Inventory did not predict time to first drink or relapse in women or men.
A diagnosis of current major depression at entry into inpatient treatment for alcohol dependence predicted shorter times to first drink and relapse in women and men. Our results differ from earlier reports that men and women differ in the effect of depression on return to drinking.
In order to estimate the concurrent validity of a structured psychiatric interview, we compared interview diagnoses obtained for 101 psychiatric inpatients to those recorded in the same patients' hospital charts. For most diagnoses considered, concordance was found to be high. For those in which concordance was low, we examined the reasons for the diagnostic discrepancy. Diagnostic errors that were judged to have occurred on the basis of the structural interview often seemed to have resulted from a lack of longitudinal clinical observation. However, more errors were judged to have occurred in the hospital charts, apparently because of physician oversight. We conclude that the concurrent validity of this structured interview is high and that such examinations might be useful not only for research but also for the routine initial evaluation of psychiatric patients.
Synopsis
This is an introductory report for the Brief Symptom Inventory (BSI), a brief psychological self-report symptom scale. The BSI was developed from its longer parent instrument, the SCL-90-R, and psychometric evaluation reveals it to be an acceptable short alternative to the complete scale. Both test-retest and internal consistency reliabilities are shown to be very good for the primary symptom dimensions of the BSI, and its correlations with the comparable dimensions of the SCL-90-R are quite high. In terms of validation, high convergence between BSI scales and like dimensions of the MMPI provide good evidence of convergent validity, and factor analytic studies of the internal structure of the scale contribute evidence of construct validity. Several criterion-oriented validity studies have also been completed with this instrument
In structured clinical interviews of 43 adolescents hospitalized for alcohol abuse or dependence, 17 subjects met criteria for an anxiety disorder, with social phobia (N = 9) and posttraumatic stress disorder (N = 7) most common. Of these 17 subjects, only four were identified in hospital records as having an anxiety disorder. In a comparison of 30 hospitalized adolescents with a matched control group of 30 adolescents from the community, the hospitalized adolescents had a higher rate of anxiety disorders, psychoactive substance use disorders, disruptive behavior disorders, and mood disorders.
This study compared the severity of and the change in depressive symptoms among men with alcohol dependence, affective disorder, or both disorders during 4 weeks of inpatient treatment.
After their primary and secondary psychiatric disorders were defined with the use of criteria based on chronology of symptoms, 54 unmedicated men entering treatment for alcohol dependence or affective disorder were assessed for 4 consecutive weeks with the Hamilton Depression Rating Scale.
The findings indicate that the rate of remission of depressive symptoms was consistent with the primary diagnosis. Depressive symptoms remitted more rapidly among the men with primary alcoholism than among those with primary affective disorder. However, a minimum of 3 weeks of abstinence from alcohol appeared to be necessary to consistently differentiate the groups with dual diagnoses on the basis of their current depressive symptoms. Alcohol dependence occurring in conjunction with primary affective disorder did not intensify presenting depressive symptoms or retard the resolution of such symptoms.
Diagnoses of alcohol dependence and affective disorder based on symptom chronology appear to have prognostic significance with respect to remission of depressive symptoms in men with both diagnoses. Depressive symptoms of dysphoric mood, dysfunctional cognitions, vegetative symptoms, and anxiety/agitation showed different rates and levels of remission across the primary diagnostic groups.
Substance abuse treatment programs in the United States frequently incorporate self-help approaches, but little is known about the use of self-help groups by individuals with dual disorders. This paper brings together several current studies on the role of self-help programs in treating substance use disorders among individuals with severe mental illness. These studies indicate that only a minority of individuals with dual disorders become closely linked to self-help. Psychiatric diagnosis and possibly social skills are correlates of participation. Dually disorders consumers often experience the use of 12-step philosophy and jargon by mental health professionals as alienating and unempathic. The authors propose suggestions for incorporating self-help approaches into the comprehensive community care of individuals with dual disorders.
Reviews of research on Alcoholics Anonymous (AA) have speculated how findings may differ when grouped by client and study characteristics. A meta-analytic review by Emrick et al. in 1993 provided empirical support for this concern but did not explore its implications. This review divided results of AA affiliation and outcome research by sample origin and global rating of study quality. The review also examined the statistical power of studies on AA.
Meta-analytic procedures were used to summarize the findings of 74 studies that examined AA affiliation and outcome. Results were divided by whether samples were drawn from outpatient or inpatient settings and a global rating of study quality that jointly considered use of subject selection and assignment, reliability of measurement and corroboration of self-report. Efficacy of dividing study results was examined by changes in magnitude of correlations and unexplained variance.
AA participation and drinking outcomes were more strongly related in outpatient samples, and better designed studies were more likely to report positive psychosocial outcomes related to AA attendance. In general, AA studies lacked sufficient statistical power to detect relationships of interest.
AA experiences and outcomes are heterogeneous, and it makes little sense to seek omnibus profiles of AA affiliates or outcomes. Well-designed studies with large outpatient samples may afford the best opportunity to detect predictors and effects of AA involvement.
The comparative effectiveness of 12-step and cognitive-behavioral (C-B) models of substance abuse treatment was examined among 3,018 patients from 15 programs at U.S. Department of Veterans Affairs Medical Centers. Across program types, participants showed significant improvements in functioning from treatment admission to a 1-year follow-up. Although 12-step patients were somewhat more likely to be abstinent at the 1-year follow-up, 12-step, C-B, and combined 12-Step-C-B treatment programs were equally effective in reducing substance use and improving most other areas of functioning. The finding of equal effectiveness was consistent over several treatment subgroups: Patients attending the "purest" 12-step and C-B treatment programs, and patients who had received the "full dose" of treatment. Also, patients with only substance abuse diagnoses, those with concomitant psychiatric diagnoses, and patients who were mandated to treatment showed similar improvement at the 1-year follow-up, regardless of type of treatment received. These data provide important new evidence supporting the effectiveness of 12-step treatment.
Relatively little is known about how substance abuse treatment facilitates positive outcomes. This study examined the therapeutic effects and mechanisms of action of affiliation with Alcoholics Anonymous (AA) after treatment. Patients (N = 100) in intensive 12-step substance abuse treatment were assessed during treatment and at 1- and 6-month follow-ups. Results indicated that increased affiliation with AA predicted better outcomes. The effects of AA affiliation were mediated by a set of common change factors. Affiliation with AA after treatment was related to maintenance of self-efficacy and motivation, as well as to increased active coping efforts. These processes, in turn, were significant predictors of outcome. Findings help to illustrate the value of embedding a test of explanatory models in an evaluation study.
This study examined whether substance abuse patients self-selecting into one of three aftercare groups (outpatient treatment only, 12-step groups only, and outpatient treatment and 12-step groups) and patients who did not participate in aftercare differed on 1-year substance use and psychosocial outcomes.
A total of 3,018 male patients filled out a questionnaire at intake and 1 year following discharge from treatment. Patients were classified into aftercare groups at follow-up using information from VA databases and self-reports.
Patients who participated in both outpatient treatment and 12-step groups fared the best on 1-year outcomes. Patients who did not obtain aftercare had the poorest outcomes. In terms of the amount of intervention received, patients who had more outpatient mental health treatment, who more frequently attended 12-step groups or were more involved in 12-step activities had better 1-year outcomes. In addition, patients who kept regular outpatient appointments over a longer time period fared better than those who did not.
Encouraging substance abuse patients to regularly attend both outpatient aftercare and self-help groups may improve long-term outcomes.
Recent surveys of the substance abuse patient population have shown a striking increase in the proportion of patients with a comorbid psychiatric disorder. In this study, patients with substance abuse and psychotic, anxiety/depressive, or personality disorders were compared with patients with only substance use disorders on treatment experiences and outcomes. Regardless of dual diagnosis status, patients generally improved on both substance use and social functioning outcomes after substance abuse treatment. At the 1-year follow-up, dually diagnosed patients, and patients with only substance use disorders, had comparable substance use outcomes. However, patients with major psychiatric disorders, specifically psychotic and anxiety/depressive disorders, fared worse on psychological symptoms and employment outcomes than did patients with personality disorders and only substance use disorders. Although there were some group differences on the amount of index treatment received and continuing care, the overall pattern of relationships between treatment variables and outcomes was comparable for the patient groups. In addition, there was no diagnostic group by treatment orientation matching effects, which indicated that the dual diagnosis patient groups improved as much in 12-Step as in cognitive-behavioral substance abuse programs.
This article first explains the conceptual framework and plan of a naturalistic, multisite evaluation of Department of Veterans Affairs (VA) substance abuse treatment programs. It then examines the effectiveness of an index episode of inpatient treatment and the effectiveness of continuing outpatient care and participation in self-help groups. The study was conducted among 3018 patients from 15 VA programs that emphasized 12-Step, cognitive-behavioral (CB), or eclectic treatment. Casemix-adjusted 1-year outcomes showed that patients in 12-Step programs were the most likely to be abstinent, free of substance abuse problems, and employed at the 1-year follow-up. Patients who obtained more regular and more intensive outpatient mental health care, and those who participated more in 12-Step self-help groups, were more likely to be abstinent and free of substance use problems at the 1-year follow-up. These findings support the effectiveness of 12-Step treatment and show that patients with substance use disorders who become more involved in outpatient care and self-help groups tend to experience better short-term substance use outcomes. Subsequent papers in this section focus on the proximal outcomes of treatment, patients with psychiatric as well as substance use disorders, patient-treatment matching effects, and the link between program treatment orientation and patients' involvement in and the influence of 12-Step self-help groups.
To study prospectively the type and extent of aftercare sought by patients following their admission for alcohol and other substance abuse treatment as a function of psychiatric co-morbidity.
Prospective cohort study with follow-up after 16 months.
A nationwide sample of alcoholics discharged from inpatient treatment (N = 351) in Iceland.
The Diagnostic Interview Schedule was used to assign psychiatric diagnoses at the time of index admission. A questionnaire on the type and number of aftercare attendances was mailed to all participants to obtain information about aftercare.
A combination of attendance at Alcoholics Anonymous (AA) and professional care was the most common aftercare (49%); while only 8% received no aftercare whatsoever. The mean number of AA attendances was over 24 while it was less than 3 for the various professional appointments. Patients with a diagnosis of schizophrenia had a lower rate of attendance at AA. Other types of co-morbidity did not affect AA attendance but did increase rates of professional help-seeking.
Better professional treatment attendance might be gained by integrating AA concepts while AA might benefit from professional input to address the prevalent co-morbid psychiatric disorders.
Alcoholics Anonymous groups are underused by persons with the dual diagnoses of mental illness and substance use disorder, and mental health professionals are cautious about referring them to AA because of fears that the AA group will discourage them from taking prescribed medication. The study assessed the attitudes of 125 AA contact persons about the participation of persons with mental illness. The majority had positive attitudes toward such persons, and 93 percent indicated that they should continue taking their medication. Fifty-four percent felt that participation in a group especially for persons with a dual diagnosis would be more desirable than in a traditional AA group. However, such groups are often not available.
Self-help programs such as Alcoholics Anonymous (AA) have been viewed as beneficial adjuncts to comprehensive treatment programs for the treatment of alcohol use disorders. The usefulness of such programs for individuals with dual psychiatric disorders has not been established. This study examined the alcohol and psychiatric treatment histories of 60 psychiatric inpatients with concomitant alcohol use or abuse with attention to the frequency and correlates with past AA attendance. Most subjects reported feeling comfortable with the basic tenets of AA; neither diagnosis nor gender was related to AA participation, belief in its basic tenets, or willingness to attend AA in the future. Regular, past attendance at AA was surprisingly high (37%) and was not different for individuals with schizophrenic spectrum disorders compared to those with other psychiatric disorders. The majority reported plans to attend AA as part of their outpatient treatment program. The potential benefits of AA for dual diagnosis individuals deserve further attention.
The purpose of this study was to systematically assess the attitudes of Alcoholics Anonymous (AA) members toward the newer medications used to prevent relapse (e.g., naltrexone) and to assess their experiences with medication use, of any type, in AA.
Using media solicitations and snowball sampling techniques, 277 AA members were surveyed anonymously about their attitudes toward use of medication for preventing relapse and their experiences with medication use of any type in AA.
Over half the sample believed the use of relapse-preventing medication either was a good idea or might be a good idea. Only 17% believed an individual should not take it and only 12% would tell another member to stop taking it. Members attending relatively more meetings in the past 3 months had less favorable attitudes toward the medication. Almost a third (29%) reported personally experiencing some pressure to stop a medication (of any type). However, 69% of these continued taking the medication.
The study did not find strong, widespread negative attitudes toward medication for preventing relapse among AA members. Nevertheless, some discouragement of medication use does occur in AA. Though most AA members apparently resist pressure to stop a medication, when medication is prescribed a need exists to integrate it within the philosophy of 12-step treatment programs.
To evaluate the correspondence among measures of self-reported drinking, standard biological indicators and the reports of collateral informants, and to identify patient characteristics associated with observed discrepancies among these three sources of research data.
Using data collected from a large-scale clinical trial of treatment matching with alcoholics (N = 1,726), these three alternative outcome measures were compared at the time of admission to treatment and at 12 months after the end of treatment.
Patient self-reports and collateral reports agreed most (97.1%) at treatment admission when heavy drinking was unlikely to be denied. In contrast, liver function tests were relatively insensitive, with positive serum gamma-glutamyl transpeptidase (GGTP) values obtained from only 39.7% of those who admitted to heavy drinking. At 15-month follow-up the correspondence between client self-report and collateral report decreased to 84.7%, but agreement with blood chemistry values increased to 51.6%. When discrepancies occurred, they still indicated that the client' s self-report is more sensitive to the amount of drinking than the biochemical measures. Patients who presented discrepant results tended to have more severe drinking problems, more previous treatments, higher levels of pretreatment drinking and significantly greater levels of cognitive impairment, all of which could potentially interfere with accurate recall.
In clinical trials using self-selected research volunteers, biochemical tests and collateral informant reports do not add sufficiently to self-report measurement accuracy to warrant their routine use. Resources devoted to collecting these alternative sources of outcome data might be better invested in interview procedures designed to increase the validity of self-report information.
Debate has ensued about whether substance use disorder (SUD) patients with comorbid posttraumatic stress disorder (PTSD) participate in and benefit from 12-step groups. One hundred fifty-nine SUD-PTSD and 1,429 SUD-only male patients were compared on participation in 12-step activities following an index episode of treatment. Twelve-step participation was similar for SUD patients with and without PTSD. PTSD patients with worldviews (e.g., holding disease model beliefs) that more closely matched 12-step philosophy participated more in 12-step activities. Although greater participation was associated with better concurrent functioning, participation did not prospectively predict outcomes after case mix adjustment. An exception was that greater participation predicted decreased distress among PTSD patients whose identity was more consistent with 12-step philosophy. In summary, PTSD patients participate in and benefit from 12-step participation; continuing involvement may be necessary to maintain positive benefits.
Drawing on ecological and narrative theories of self-help groups, this study tests a multilevel model predicting self-help group involvement among male veterans who received inpatient substance abuse treatment. Following K. Maton (1993), the study moves beyond the individual-level of analysis to encompass variables in the treatment and post-treatment social ecology. Surveys administered to patients (N = 3,018) and treatment staff (N = 329) assessed these predictor domains and self-help group involvement 1 year after discharge. A hierarchical linear model fit to the data indicates that greater involvement in 12-step groups after discharge is predicted by the compatibility between personal and treatment belief systems. The implications of these findings for efforts to facilitate transitions between inpatient professional treatment and community-based self-help groups are discussed.
Self-help groups are the most commonly sought source of help for substance abuse problems, but few studies have evaluated the mechanisms through which they exert their effects on members. The present project evaluates mediators of the effects of self-help groups in a sample of 2,337 male veterans who were treated for substance abuse. The majority of participants became involved in self-help groups after inpatient treatment, and this involvement predicted reduced substance use at 1-year follow-up. Both enhanced friendship networks and increased active coping responses appeared to mediate these effects. Implications for self-help groups and professional treatments are discussed.
Matching alcohol treatment to patient social support and the effects of participation in Alcoholics Anonymous Individ-ual and contextual predictors of involvement in twelve-step self-help groups after substance abuse treatment
- R Longabaugh
- E S Mankowski
- K Humphreys
- R H Moos
Longabaugh, R. (1999) Matching alcohol treatment to patient social support and the effects of participation in Alcoholics Anonymous. Medical Health Research, 82, 122. Mankowski, E. S., Humphreys, K. & Moos, R. H. (2001) Individ-ual and contextual predictors of involvement in twelve-step self-help groups after substance abuse treatment. American Journal of Community Psychology, 29, 537–563.
Health and Daily Living Form
- R H Moos
- R C Cronkite
- J W Finney
Moos, R. H., Cronkite, R. C. & Finney, J. W. (1990) Health and Daily Living Form, 2nd edn. Palo Alto, CA: Mind Garden.
Drug Abuse Treatmen: a National Study of Effectiveness
- John F Kelly
John F. Kelly et al. (1989) Drug Abuse Treatmen: a National Study of Effectiveness. Chapel Hill, NC: University of North Carolina Press.
Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes
- Project MATCH, Research Group
Project MATCH Research Group (1997) Matching alcoholism treatments to client heterogeneity: Project MATCH post-treatment drinking outcomes. Journal of Studies on Alcohol, 58, 7–29.
Practice guideline for psychiatric evaluation of adults. American Psychiatric Association
American Psychiatric Association (APA) (1995) Practice guideline for psychiatric evaluation of adults. American Psychiatric
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