Examining changes in negative mood regulation expectancies, posttraumatic stress disorder, depression, and substance use following integrated cognitive-behavioral therapy.

BACKGROUND: The comorbidity of depression, posttraumatic stress disorder (PTSD), and substance use disorder (SUD) is common among veterans. Some research indicates that poor expectancies for negative mood regulation (NMR) may be associated with depression, trauma symptoms, and substance abuse. However, little is known about whether NMR expectancies can be changed through psychotherapy and if so, whether changes in NMR expectancies are related to changes in depression, PTSD, and SUD. METHODS: Therefore, this study examined (1) whether NMR expectancies correlate with depression, PTSD, and SUD symptoms; (2) whether NMR expectancies improve after group integrated cognitive-behavioral therapy (ICBT); and (3) whether these changes were associated with improvements in depression, PTSD, and SUD symptoms in a sample of 123 veterans (89% male, 64% non-Hispanic Caucasian) recruited from a Department of Veteran Affairs (VA) Healthcare System. RESULTS: Findings indicated that (1) NMR expectancies were significantly associated with depression and PTSD symptoms but not substance use at baseline; (2) NMR expectancies significantly improved following group ICBT treatment; (3) following treatment, improvements in NMR expectancies were associated with decreases in depression and PTSD symptoms but were unrelated to changes in substance use outcomes; and (4) baseline NMR expectancies did not predict treatment outcomes. Similarly, pre-post NMR expectancies change scores were significantly associated with changes in depression and PTSD symptoms, but not percentage days using or percentage days heavy drinking. CONCLUSIONS: In conclusion, this study suggests that group ICBT is associated with improvements in NMR expectancies among veterans with depression, PTSD, and SUD, which are associated with improvements in depression and PTSD symptoms.

Treatment Attendance Among Veterans With Depression, Substance Use Disorder, and Trauma.

OBJECTIVE: Low attendance in psychotherapy, particularly among individuals with comorbid disorders, is a pervasive challenge. The present study examined predictors of treatment attendance in a sample of veterans with depression, substance use disorder, and trauma. METHODS: This is an analysis of data collected as part of a larger clinical trial involving outpatients at a Veterans Administration dual diagnosis clinic. Individuals were excluded if they had significant memory deficits, schizophrenia, bipolar disorder, or substantial travel constraints. Participants (N = 146) received 12 weeks of group-delivered integrated cognitive behavioral therapy for depression and substance use, followed by randomization to 12 additional weeks of individually delivered cognitive behavioral therapy (n = 62) or cognitive processing therapy (n = 61) modified to address substance use and trauma. Participants, therapists, and researchers were not blinded to group assignment. For this study, we included only the 123 participants who were randomized into the second phase, analyzing predictors of treatment attendance categorized into predisposing factors, enabling factors, and need factors. RESULTS: Participants were primarily male (89%) and Caucasian (76%) and averaged 47 years old (SD = 12). Forty-four percent had alcohol use disorder, 16% had drug use disorder, and 40% had polysubstance use disorder. Most met criteria for PTSD (82%), with 44% having combat-related trauma, 33% sexual trauma, and 28% other trauma. Treatment attendance did not differ between groups. More education was associated with increased group (r = .19, p = .04) and individual session attendance (r = .28, p = .002). Individuals with chronic housing problems attended fewer group sessions (r = -.19, p = .04), while individuals with sexual trauma, compared to those with other traumas, attended more individual sessions (r = .23, p = .01). Number of group sessions attended was positively associated with individual session attendance. CONCLUSIONS: Few variables were significantly predictive of treatment attendance, possibly due to the complex nature of comorbid disorders. Including a focus on trauma was not associated with lower attendance. Special consideration may need to be given to education level, homelessness, and trauma when trying to engage and retain patients with comorbid disorders in treatment. This clinical trial is registered at www.clinicaltrials.gov as NCT00958217.

Chronic physical health problems moderate changes in depression and substance use among dual diagnosed individuals during and after treatment.

BACKGROUND: Physical illnesses frequently co-occur with depression and substance use disorders and may impact their improvement. Physical illness symptoms may overlap with or exacerbate somatic symptoms of depression. Individuals may use substances to cope with symptoms of physical illness. OBJECTIVES: We examined whether chronic physical health problems moderated changes in depression and substance use among dual diagnosed individuals during and in the year following treatment. METHODS: Participants were recruited from a Veterans Affairs dual diagnosis outpatient program between March 2000 and November 2007 and were randomized to either Integrated Cognitive-Behavioral Therapy or Twelve-Step Facilitation Therapy. A total of 214 veterans with assessment data for the variables of interest were included in analyses. Participants completed quarterly depression, substance use, and health assessments over an 18 month period. We used linear-mixed effects models to analyze patterns of change for depression and substance use. RESULTS: Individuals with severe chronic health problems and higher intake depression showed slower improvements in both nonsomatic and somatic depression symptoms. Individuals with severe chronic health problems and higher midtreatment substance use showed less improvement in substance use. CONCLUSIONS: Assessing and addressing physical health issues during depression and substance use disorder treatment may improve outcomes.

12-step affiliation and attendance following treatment for comorbid substance dependence and depression: a latent growth curve mediation model.

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.

Impact of Physical Health on Treatment for Co-occurring Depression and Substance Dependence.

OBJECTIVE: There is a high rate of comorbidity among substance dependence, depression, and physical health problems. This study aimed to examine the impact of pre-treatment physical health stressors (acute and chronic conditions) on outcomes of treatment in a sample of veterans with dual disorders (depression and substance dependence) who were randomized to integrated cognitive behavioral therapy versus 12-Step interventions. METHODS: This study included 205 veterans (89.8% male, mean age = 49.5 years) enrolled in a clinical treatment outcomes trial. Chronic health problems (persistent, ongoing conditions lasting 2 weeks or more; e.g., arthritis, diabetes) and acute health events (occurring on a discrete date; e.g., injury, surgery, myocardial infarction) were coded dichotomously (presence versus absence) and evaluated separately. The impact of physical health stressors on abstinence (defined dichotomously), percentage of days abstinent, and depression symptoms were analyzed at the end of 12 and 24 weeks of treatment. Additionally, associations between intake motivation to change, health stressors, and substance use were examined. RESULTS: Analyses revealed that participants who had experienced a pretreatment acute health event had higher rates of abstinence at 12-weeks, higher percentage of days abstinent at 24-weeks, and higher depression symptoms at intake. Participants with chronic health difficulties had more severe depression at intake and those participants with severe chronic difficulties had greater depression symptoms across all time points. Chronic health difficulties were related to the Taking Steps factor of motivation to change substance use, but acute health events were not related to motivation to change. Motivation to change was also not related to substance outcomes in our sample. CONCLUSIONS: Physical health appears to have a complex relationship with co-occurring depression and substance dependence. Acute health problems predicted lower substance use, whereas chronic health problems were associated with higher depression levels. Explicitly addressing the connection between substance use and health events during treatment may improve addiction treatment outcomes. However, individuals with chronic health problems may benefit from extending treatment or adjunct strategies focused on addressing chronic health concerns. This is an analysis of data collected as part of a clinical trial registered at www.ClinicalTrials.gov as NCT00108407.

Predictors of treatment retention for substance-dependent adults with co-occurring depression.

Low attendance in addiction treatment, particularly in cases of comorbidity, has been identified as a pervasive challenge. We examine predictors of treatment retention in a sample of veterans (N = 253) participating in a clinical trial comparing two types of psychotherapy for co-occurring depression and substance use disorders. The study protocol included 24 weeks of outpatient group psychotherapy in either a newly developed Integrated Cognitive Behavioral Therapy (ICBT) or Twelve-Step Facilitation Therapy (TSF). Using a model of treatment utilization developed by Aday and Anderson, we analyzed predictors categorized into predisposing factors, enabling resources, need for treatment, and type of treatment received. Outcome included total number of sessions attended (maximum of 36 sessions). Treatment retention did not differ between the two study interventions. Bivariate analyses indicated that predisposing factors were most predictive, with older participants, Caucasians, and those using only alcohol in the month before treatment attending more sessions, and individuals who had recently experienced a health event remained in treatment longer. Importantly, several factors were not related to treatment retention: marital status, education, neuropsychological functioning, financial stress, chronic health problems, treatment motivation, and psychiatric severity. In the combined model of predisposing, enabling and need factors, age and ethnicity were the only significant predictors.

Neuropsychological functioning and outcomes of treatment for co-occurring depression and substance use disorders.

BACKGROUND: We previously published findings from our clinical trial comparing treatment outcomes for substance-dependent veterans with co-occurring depression who received Integrated Cognitive Behavioral Therapy (ICBT) or Twelve-Step Facilitation (TSF) Therapy. OBJECTIVES: This study is a secondary analysis that examined whether neuropsychological functioning at baseline moderated substance use and depression outcomes in ICBT relative to TSF. METHODS: This study was a randomized clinical trial in which 164 veterans with major depressive disorder and comorbid alcohol, cannabinol, and/or stimulant dependence were randomly assigned to either ICBT or TSF group therapy. A comprehensive neuropsychological test battery was administered at baseline. RESULTS: Contrary to our hypothesis, participants with poor neuropsychological functioning had better substance use outcome in ICBT than in TSF, whereas participants with good neuropsychological functioning had comparable substance use outcomes in TSF and ICBT by 18-month follow-up. Depression outcomes, in contrast, were not moderated by neuropsychological functioning by 18-month follow-up. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: The substance use outcomes may suggest that substance-dependent depressed adults with poorer neuropsychological functioning should be offered ICBT over TSF. These individuals may be less able to develop and use novel coping skills for managing substance use and depressive symptoms on their own without formal structured training in cognitive and behavioral skills provided in ICBT.

Comorbidity of substance dependence and depression: role of life stress and self-efficacy in sustaining abstinence.

The authors examined life stress and self-efficacy as predictors of time to relapse for 113 adults with comorbid major depressive disorder and alcohol and/or substance dependence in a randomized clinical trial comparing 2 psychotherapy interventions (integrated cognitive- behavioral therapy and 12-step facilitation therapy). Life stress, self-efficacy, and substance use were assessed at treatment entry, 12 weeks (mid-treatment), and 24 weeks (end of treatment). Time to relapse was defined as the number of days from treatment initiation until first alcohol and/or drug use. Half of the sample relapsed within the study period of 24 weeks. There was no significant difference between treatment groups. Individuals experiencing life stressors were more likely to relapse early than those not experiencing life stressors. Lower self-efficacy also predicted earlier relapse. Chronic stress levels and self-efficacy were stable across time for most individuals. In contrast, acute stress events occurred at differing times, and survival analyses provided evidence of heightened relapse risk in the month following acute stressors. The interaction of self-efficacy and life stress was not significant. The results highlight the significance of life stress and self-efficacy as predictors of early relapse.

Do trauma history and PTSD symptoms influence addiction relapse context?

Exposure to traumatic events is common among individuals with substance use disorders (SUD), although not all go on to develop PTSD. We compared SUD treatment outcomes and relapse features in three groups of male veterans receiving SUD treatment: (1) those without trauma exposure (SUD-only; n=68), (2) those with PTSD (SUD-PTSD; n=32), and (3) those with trauma exposure but no PTSD (SUD-trauma; n=34). Veterans were assessed regarding psychiatric symptoms, substance use, and relapse features quarterly for 1 year. The groups did not differ on length of abstinence, relapse prevalence or severity. SUD-PTSD and SUD-trauma reported more depression, anxiety, PTSD, and total psychiatric symptoms prior to relapse than SUD-only. SUD-PTSD and SUD-trauma also endorsed more PTSD, and total symptoms following relapse than SUD-only. PTSD symptoms were associated with greater risk of relapse in intrapersonal and negative physiological contexts. Understanding relapse contexts for those experiencing PTSD symptoms can help us to understand one mechanism whereby those with both PTSD and SUD have a poorer clinical course.

Health problems of substance-dependent veterans with and those without trauma history.

Substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) are associated with an increased risk for health problems. We examined whether trauma history and PTSD were related to physical health in patients with an SUD. We compared health stressors, health service utilization, and self-rated health status in three groups of male veterans receiving SUD treatment: (1) no trauma exposure (SUD-only group), n = 55; (2) with PTSD (SUD-PTSD group), n = 32; and (3) trauma exposure without PTSD (SUD-trauma group), n = 34. The veterans were assessed quarterly for 1 year. Groups differed in their likelihood of experiencing chronic health stressors at all time points. The SUD-only group consistently had the lowest rates of chronic health stressors, the SUD-PTSD group had the highest rates, and the SUD-trauma group fell in between. In contrast, groups did not differ in rates of acute health problems. Chronic health stressors appear to be associated with trauma exposure and psychologic response to the trauma. Substance use disorder interventions may benefit from incorporation of primary care services.

Mindfulness-Based Stress Reduction for Older Adults With Stress Disorders and Neurocognitive Difficulties: A Randomized Controlled Trial.

OBJECTIVE: To determine whether neurocognitive performance and clinical outcomes can be enhanced by a mindfulness intervention in older adults with stress disorders and cognitive complaints. To explore decreased hypothalamic-pituitary-adrenal (HPA) axis activity as a possible mechanism. METHODS: 103 adults aged 65 years or older with an anxiety or depressive disorder (diagnosed according to DSM-IV criteria) and subjective neurocognitive difficulties were recruited in St. Louis, Missouri, or San Diego, California, from September 2012 through August 2013 and randomly assigned in groups of 5-8 to mindfulness-based stress reduction (MBSR) or a health education control condition matched for time, attention, and credibility. The primary outcomes were memory (assessed by immediate and delayed paragraph and list recall) and cognitive control (Delis-Kaplan Executive Function System Verbal Fluency Test and Color Word Interference Test). Other outcomes included clinical symptoms (worry, depression, anxiety, and global improvement). HPA axis activity was assessed using peak salivary cortisol. Outcomes were measured immediately post-intervention and (for clinical outcomes only) at 3- and 6-month follow up. RESULTS: On the basis of intent-to-treat principles using data from all 103 participants, the mindfulness group experienced greater improvement on a memory composite score (P = .046). Groups did not differ on change in cognitive control. Participants receiving MBSR also improved more on measures of worry (P = .042) and depression (P = .049) at posttreatment and on worry (P = .02), depression (P = .002), and anxiety (P = .002) at follow-up and were more likely to be rated as much or very much improved as rated by the Clinical Global Impressions-Improvement scale (47% vs 27%, χ² = 4.5, P = .03). Cortisol level decreased to a greater extent in the mindfulness group, but only among those participants with high baseline cortisol. CONCLUSIONS: In this population of older adults with stress disorders and neurocognitive difficulties, a mindfulness intervention improves clinical outcomes such as excessive worry and depression and may include some forms of immediate memory performance. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01693874.

An examination of self-medication and rebound effects: Psychiatric symptomatology before and after alcohol or drug relapse.

This study evaluated psychiatric symptoms preceding and following initial posttreatment substance use episodes. 125 veterans meeting DSM-IV criteria for alcohol, cannabis, and/or stimulant dependence at treatment entry were followed with quarterly interviews for one year. Approximately half of the sample met criteria for substance use disorders only (n = 65; SUD-only) and half additionally met criteria for an independent non-substance related Axis I disorder (n = 60; SUD-PSY). SUD-PSY adults reported more psychiatric symptoms preceding and following substance use compared to SUD-only adults. Depression and anxiety symptoms were commonly reported by both groups. Symptoms typically did not change or worsened after substance use, with depression worsening more than anxiety or psychotic symptoms. Findings are discussed in relation to the Self-Medication Hypothesis and the Rebound Hypothesis.

Integrated cognitive behavioral therapy versus twelve-step facilitation therapy for substance-dependent adults with depressive disorders.

In a randomized trial, this study compared the longitudinal outcome patterns of veterans (N = 66) with substance use disorders and major depressive disorder receiving standard pharmacotherapy and either 12-Step Facilitation Therapy (TSF) or disorder-specific Integrated Cognitive Behavioral Treatment (ICBT). Depression and substance use were assessed at intake, during and after treatment using the Hamilton Depression Rating Scale and the Time Line Follow Back. Reductions in depression during treatment were comparable between the two treatment groups; however, their posttreatment patterns were distinct. While ICBT participants evidenced a steady linear decline in depression through six months posttreatment, a quadratic trend characterized TSF participants, for whom depression declined during treatment, but increased throughout posttreatment follow-up. During treatment, TSF participants used substances less frequently relative to those in ICBT; however, reductions in substance use were more stable through six months posttreatment among those in ICBT relative toTSF. While both interventions produced improvement in depression and substance use during treatment, ICBT may yield more stable clinical outcomes once treatment ceases.

Integrated Cognitive Behavioral Therapy Versus Cognitive Processing Therapy for Adults With Depression, Substance Use Disorder, and Trauma.

The comorbidity of substance use disorder (SUD), depression, and PTSD is common among veterans. Prior research has shown that among veterans with SUD and depression, those with PTSD did not maintain cognitive-behavioral treatment gains as well as those without PTSD. Thus, the current study was designed to evaluate whether adding trauma-focused treatment following an initial group-based integrated cognitive behavioral treatment (ICBT) for SUD and depression improved treatment outcomes. Participants were 123 veterans (89% male) recruited from the VA San Diego Healthcare System. All participants received ICBT in twice weekly, group-delivered sessions for 12 weeks (Phase 1). Participants were then randomized to receive 12 sessions of individual follow-up sessions (Phase 2) utilizing either ICBT or cognitive processing therapy that was modified to integrate SUD treatment (CPT-M). Results indicated that PTSD and depression symptoms slightly improved at the end of Phase 1 group ICBT and further improved through Phase 2 individual treatment (except for participants without PTSD who received CPT-M), with treatment gains maintained one year later. Substance use significantly improved at the end of Phase 1 group ICBT and these improvements were maintained through Phase 2 and the one year follow-up. Participants in the trauma-focused Phase 2 treatment (CPT-M) exhibited similar levels of symptom reduction and maintenance of treatment gains as those in the non-trauma-focused Phase 2 treatment (ICBT). However, there was a slight advantage for Phase 2 CPT-M over Phase 2 ICBT with respect to heavy drinking outcomes for individuals with PTSD. Overall, the combination of group ICBT followed by either CPT-M or ICBT individual therapy appears to be effective for veterans with depression, SUD, and trauma history.

Characteristics of life stressors predictive of substance treatment outcomes.

Most research and treatment focusing on the relationship between life stress and substance use have considered stress as a unitary construct despite the fact that stressors vary in terms of temporal characteristics (short-term vs. long-term) and domains (work, health). In contrast to most stressor domains, increasing evidence suggests that health stressors may reduce the risk of initiating substance use after treatment. We separately evaluated the effect of short-term stress events (discrete date of occurrence), long-term stressors (ongoing stressors lasting 2 weeks or longer), and health stressors on posttreatment alcohol and drug use. Veterans (N=195) were assessed while receiving addiction treatment and quarterly for 1 year. The odds of initiating posttreatment substance use were 2.5 times greater for participants experiencing severe (nonhealth) long-term stressors. In contrast, participants experiencing short-term health events or severe (nonhealth) short-term events were less likely to initiate posttreatment substance use (odds ratio=.28 and .44, respectively).

Characteristics of relapse to substance use in comorbid adolescents.

UNLABELLED: This study examined the factors associated with the relapse process for substance use disordered (SUD) youth with comorbid psychiatric disorders. Temporal and situational characteristics as well as psychiatric symptoms, self-efficacy, and developmentally relevant experiences preceding first relapse after treatment were evaluated as part of a youth focused addiction relapse model. METHOD: Adolescents (N = 81) with a DSM-III-R substance use disorder (SUD) and another Axis I psychiatric disorder were recruited from inpatient substance abuse and psychiatric treatment. Face-to-face interviews were conducted while youth were in treatment and monthly telephone interviews were conducted in the six months following treatment to ascertain length of time to first substance use episode and characteristics of the episode. RESULTS: Youth who relapsed within the first month were more likely to report use of drugs other than alcohol or marijuana in their first use, while use among late relapsers was more often preceded by direct social pressure to use. Those relapsing in the first 3 days after treatment were less likely to view substance use as a problem and less likely to report passive emotional states (e.g., boredom) prior to use. Psychiatric symptoms were associated with relapse in conflict/life stress, negative emotional states and active emotional states. Self-efficacy was related to relapse among youth with conflict/life stress, and when youth were experiencing a desire to use in the two weeks prior to relapsing. CONCLUSIONS: Findings highlight some of the factors that are most important in understanding the process of relapse in comorbid adolescents. Research and treatment implications are discussed.

Context of relapse for substance-dependent adults with and without comorbid psychiatric disorders.

OBJECTIVE: This study examined the context of initial posttreatment substance use episodes and 1-year treatment outcomes among substance abusers in relation to Axis I psychiatric diagnoses. METHOD: Of the 210 adults meeting DSM-III-R diagnostic criteria for a substance use disorder (SUD), 102 also met criteria for mood disorder, posttraumatic stress disorder (PTSD), or both (SUD-PSY). Quarterly face-to-face interviews and monthly telephone contacts were conducted following treatment to ascertain outcomes. RESULTS: Antecedents of initial posttreatment substance use differed for SUD adults compared to SUD-PSY. Negative affective states preceded posttreatment use episodes more frequently among SUD-PSY participants. The majority of SUD-PSY adults reported intrapersonal/environmental antecedents whereas the majority of SUD adults reported interpersonal antecedents. Compared to SUD adults without an Axis I disorder, the SUD-PSY group was more likely to resume substance use when alone. Participants drank more than twice as much alcohol when relapsing alone compared to those who resumed use with others. Negative affective state prior to initial use was predictive of more subsequent using days for comorbid adults but not SUD adults. CONCLUSIONS: These findings highlight differences in the process of resuming substance use for substance abusers with concomitant psychiatric disorders compared to SUD adults. Treatment implications are discussed.

Mediated and moderated effects of neurocognitive impairment on outcomes of treatment for substance dependence and major depression.

OBJECTIVE: Neurocognitive impairment has not consistently predicted substance use treatment outcomes but has been linked to proximal mediators of outcome. These indirect effects have not been examined in adults with substance dependence and co-occurring psychiatric disorders. We examined mediators and moderators of the effects of neurocognitive impairment on substance use among adults in treatment for alcohol or drug dependence and major depression (MDD). METHOD: Participants were veterans (N = 197, mean age = 49.3 years, 90% male, 75% Caucasian) in a trial of 2 group interventions for alcohol/drug dependence and MDD. Measures examined here included intake neurocognitive assessments and percent days drinking (PDD), percent days using drugs (PDDRG), self-efficacy, 12-step affiliation, and depressive symptoms measured every 3 months from intake to the 18-month follow-up. RESULTS: Greater intake neurocognitive impairment predicted lower self-efficacy, lower 12-step affiliation, and greater depression severity, and these time-varying variables mediated the effects of impairment on future PDD and PDDRG. The prospective effects of 12-step affiliation on future PDD were greater for those with greater neurocognitive impairment. Impairment also interacted with depression to moderate the effects of 12-step affiliation and self-efficacy on PDD. Adults with greater impairment and currently severe depression had the strongest associations between 12-step affiliation/self-efficacy and future drinking. CONCLUSIONS: Greater neurocognitive impairment may lead to poorer outcomes from group therapy for alcohol/drug dependence and MDD due to compromised change in therapeutic processes. Distal factors such as neurocognitive impairment can interact with dynamic risk factors to modulate the association between therapeutic processes and future drinking outcomes.

Self-efficacy and social networks after treatment for alcohol or drug dependence and major depression: disentangling person and time-level effects.

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.

Mediational relations between 12-Step attendance, depression and substance use in patients with comorbid substance dependence and major depression.

AIMS: Among patients with substance dependence and comorbid major depressive disorder (MDD) receiving treatment in a controlled trial, we examined if group differences in depression were mediated by 12-Step involvement, and if the effects of 12-Step involvement on future alcohol and drug use were mediated by reductions in depression. DESIGN: Controlled trial of Twelve-Step facilitation (TSF) and integrated cognitive-behavioral therapy (ICBT), delivered in out-patient groups for 6 months with adjunct pharmacotherapy. SETTING: Out-patient dual diagnosis clinic in Veteran's Affairs Healthcare Center. PARTICIPANTS: Veterans (n = 209) diagnosed with alcohol, stimulant or marijuana dependence and substance-independent MDD. MEASUREMENTS: Twelve-Step attendance and affiliation, depression severity, percentage of days drinking and percentage of days using drugs assessed at baseline and months 3, 6 and 9. FINDINGS: In multi-level analyses greater 12-Step meeting attendance predicted lower depression and mediated the superior depression outcomes of the TSF group, explaining 24.3% of the group difference in depression. Independent of treatment group, lower depression severity predicted lower future alcohol use and mediated the effects of 12-Step meetings, explaining 15.7% of their effects on future drinking. Controlled, lagged models indicated these effects were not confounded by current substance use, suggesting that depression had unique associations with 12-Step meeting attendance and future drinking. CONCLUSIONS: For patients with substance dependence and major depressive disorder, attendance at 12-Step meetings is associated with mental health benefits that extend beyond substance use, and reduced depression could be a key mechanism whereby 12-Step meetings reduce future drinking in this population.