Accuracy of the Depression, Anxiety and Stress Scale (DASS-21) for Screening on Comorbid Internalizing Disorders among Youth in Substance Use Disorder Treatment.

INTRODUCTION: Major depression, anxiety disorders, and post-traumatic stress disorder (PTSD) are among the most prevalent comorbid mental disorders in youth addiction treatment. Hence, screening for these internalizing disorders should be part of the standard routine at intake in substance use disorder treatment. We investigated the usefulness of the Depression, Anxiety and Stress Scale (DASS-21) as a screener for this purpose. METHODS: A nationally representative sample of 421 treatment-seeking youths aged 16-22 years with a primary cannabis, alcohol, cocaine, or amphetamine use disorder participated in the study. At intake, we administered the DASS-21 and the Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998) based on the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), as "gold standard," as part of a broader baseline assessment of the Youth in transition study [Moska et al. BMC Psychiatry. 2021;21(1):1-11]. RESULTS: At comparable sensitivity (0.80-0.84), based on the optimal cut-off value, specificity was higher for the DASS-21 total score detecting any DSM-5 internalizing disorder (0.62) than for the DASS subscales specifically detecting depression, anxiety, or PTSD (0.44, 0.49, and 0.51, respectively). Receiver operating characteristic curve analyses showed an area under the curve (AUC) value of 0.80 for the DASS total score to detect any internalizing disorder ("good discrimination"), compared with AUC values of 0.70-0.75 of the DASS depression and anxiety subscales to detect DSM-5 depression, anxiety, and PTSD ("fair discrimination"). The optimal DASS total score cut-off value of ≥44 for detecting any internalizing disorder resulted in 0.81 sensitivity, 0.62 specificity, 0.80 positive predictive value, and 0.64 negative predictive value. CONCLUSION: Given the high prevalence of comorbid internalizing disorders in youth addiction care, the need to address these comorbid disorders in treatment, and the favorable accuracy of the DASS to detect these disorders, we recommend to implement the DASS-21 as routine screener in youth addiction treatment in the Netherlands.

Youth in transition: Study protocol of a prospective cohort study into the long-term course of addiction, mental health problems and social functioning in youth entering addiction treatment.

BACKGROUND: Substance use disorders (SUDs) are prevalent in the general population, tend to follow a chronic course, are associated with many individual and social problems, and often have their onset in adolescence. However, the knowledge base from prospective population surveys and treatment-outcome studies on the course of SUD in adolescents is limited at best. The present study aims to fill this gap and focuses on a subgroup that is particularly at risk for chronicity: adolescents in addiction treatment. We will investigate the rate of persistent SUD and its predictors longitudinally from adolescence to young adulthood among youth with DSM-5 SUD from the start of their addiction treatment to 2 and 4 years following treatment-entry. In addition to SUD, we will investigate the course of comorbid mental disorders, social functioning, and quality of life and their association with SUD over time. METHODS/DESIGN: In a naturalistic, multi-center prospective cohort design, we will include youths (n = 420), who consecutively enter addiction treatment at ten participating organizations in the Netherlands. Inclusion is prestratified by treatment organization, to ensure a nationally representative sample. Eligible youths are 16 to 22 years old and seek help for a primary DSM-5 cannabis, alcohol, cocaine or amphetamine use disorder. Assessments focus on lifetime and current substance use and SUD, non-SUD mental disorders, family history, life events, social functioning, treatment history, quality of life, chronic stress indicators (hair cortisol) and neuropsychological tests (computerized executive function tasks) and are conducted at baseline, end of treatment, and 2 and 4 years post-baseline. Baseline data and treatment data (type, intensity, duration) will be used to predict outcome - persistence of or desistance from SUD. DISCUSSION: There are remarkably few prospective studies worldwide that investigated the course of SUD in adolescents in addiction treatment for longer than 1 year. We are confident that the Youth in Transition study will further our understanding of determinants and consequences of persistent SUD among high-risk adolescents during the critical transition from adolescence to young adulthood. TRIAL REGISTRATION: The Netherlands National Trial Register Trial NL7928 . Date of registration January 17, 2019.

Treating posttraumatic stress disorder in substance use disorder patients with co-occurring posttraumatic stress disorder: study protocol for a randomized controlled trial to compare the effectiveness of different types and timings of treatment.

BACKGROUND: Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) have high comorbidity. Although prior research indicated that PTSD can effectively be treated with Prolonged Exposure (PE) in these patients, reported effects are small and treatment dropout rates high. Eye Movement Desensitization and Reprocessing (EMDR) and Imagery Rescripting (ImRs) are other promising treatment options for PTSD, that have not yet been examined in this patient group. Furthermore, it is unclear whether PTSD treatment is most effective when offered simultaneous to or after SUD treatment. METHODS: In this article, the Treatment Of PTSD and Addiction (TOPA) study is described: a Dutch randomized controlled trial (RCT) that studies the effectiveness of PTSD treatment as an add-on to regular SUD treatment in patients with SUD and co-occurring PTSD. Effects of PE, EMDR, ImRs, and a 3-month SUD treatment only condition will be compared, as well as simultaneous SUD/PTSD treatment to sequential SUD/PTSD treatment. The primary outcome measure is PTSD symptoms. Secondary outcomes are: treatment completion, psychological distress, substance use, interpersonal problems, emotion dysregulation, and trauma-related emotions guilt, shame, and anger. DISCUSSION: This study is the first to compare effects of PE, EMDR, and ImRs in one study and to compare simultaneous SUD/PTSD treatment to sequential SUD/PTSD treatment as well. This RCT will provide more knowledge about the effectiveness of different treatment strategies for PTSD in patients with co-occurring SUD and will ultimately improve treatment outcomes for patients with this common co-morbidity worldwide. TRIAL REGISTRATION: Netherlands Trial Register (NTR), Identifier: NL7885 . Registered 22 July 2019.

Striatal alcohol cue-reactivity is stronger in male than female problem drinkers.

Despite apparent sex differences in the development and treatment of alcohol use disorder, relatively little is known about the underlying neural mechanisms. In this study, we therefore investigated neural cue-reactivity in a sample of male (n = 28) and female (n = 27) problem drinkers (matched on age and alcohol use severity) with an average alcohol use disorder identification test score of 12 which is indicative of a likely alcohol use disorder. Neural cue-reactivity data were extracted from four regions of interest: the ventral and dorsal striatum and the ventral and dorsal anterior cingulate cortex, with a significance level set at p < 0.05. While the cue-reactivity paradigm induced similar levels of self-reported craving in men and women, visual alcohol cues induced significantly stronger striatal activation in men compared to drinkers. While sex differences in ventral striatal cue-reactivity were partly explained by sex differences in alcohol intake, cannabis use, negative affect and anxiety, this was not the case for sex differences in dorsal striatal cue-reactivity. These results suggest that alcohol cues are differentially processed by men and women and that the neurobiological mechanisms behind cue-reactivity differ between the sexes. Consequently, paradigms using alcohol-related pictures may not be optimal to induce cue-reactivity in female drinkers and may not be optimal to measure neurobiological markers of alcohol use severity and relapse. Future alcohol cue-reactivity studies should, in addition to including both men and women, include different types of cues (e.g., stressors and imagery in addition to pictures) to assess sex differences in alcohol cue-reactivity.

Recovery of neurocognitive functions following sustained abstinence after substance dependence and implications for treatment.

BACKGROUND: Substance Use Disorders (SUDs) have been associated with impaired neurocognitive functioning, which may (partly) improve with sustained abstinence. New treatments are emerging, aimed at improving cognitive functions, and being tested. However, no integrated review is available regarding neurocognitive recovery following sustained abstinence. OBJECTIVES: In this review, results from prospective studies on neurocognitive recovery using neuropsychological assessments before and after sustained abstinence from SUDs are summarized and discussed. RESULTS: Thirty-five prospective studies were selected for this review, including twenty-two alcohol, three cannabis, four cocaine, three (meth)amphetamine, and three opioid studies. Results suggest that some cognitive functions (partially) recover after sustained abstinence, and that there are predictors of an unfavorable course such as poly-substance use and number of previous detoxifications. CONCLUSIONS: Prospective studies indicate that sustained abstinence after SUDs generally results in (partial) neurocognitive recovery. However, a final answer regarding full recovery awaits prospective studies with neurocognitive assessments before, during, and after sustained abstinence from SUDs. New interventions that might enhance neurocognitive recovery after abstinence are discussed, including neurocognitive training, medication and neuromodulation.

Effects of non-invasive neurostimulation on craving: a meta-analysis.

This meta-analysis was conducted to evaluate the available evidence regarding the effects of non-invasive neurostimulation of the dorsolateral prefrontal cortex (DLPFC), on craving in substance dependence and craving for high palatable food. Non-invasive neurostimulation techniques were restricted to repetitive Transcranial Magnetic Stimulation (rTMS) and transcranial Direct Current Stimulation (tDCS). A total of 17 eligible studies were identified. Random effects analysis revealed a pooled standardized effect size (Hedge's g) of 0.476 (CI: 0.316-0.636), indicating a medium effect size favouring active non-invasive neurostimulation over sham stimulation in the reduction of craving (z=5.832, p<0.001). No significant differences were found between rTMS and tDCS, between the various substances of abuse and between substances of abuse and food, or between left and right DLPFC stimulation. In conclusion, this meta-analysis provides the first clear evidence that non-invasive neurostimulation of the DLPFC decreases craving levels in substance dependence.

Psychophysiological determinants and concomitants of deficient decision making in pathological gamblers.

Psychophysiological responses are considered to be a mediating factor in the development of pathological gambling (PG) and PG has been associated with differential arousal levels during gambling. Yet little is known about the specific psychophysiological responses to wins and losses in PG. This study investigated heart rate (HR) and skin conductance responses (SCRs) during the Iowa Gambling Task (IGT) in an adult PG group (n=46) and a normal control (NC) group (n=47). Anticipatory psychophysiological reactions to disadvantageous and advantageous choices during the IGT and psychophysiological responses to wins and losses were measured. The PG group performed worse than the NC group on the IGT and exhibited lower anticipatory SCRs and HR decreases when pondering choices of disadvantageous card decks during the IGT. The PG group showed a decrease in HR after losses and wins, whereas the NC group showed a decrease in HR after losses, but an increase in HR after wins. Reward and punishment sensitivity as measured by the self-report BIS/BAS scale influenced IGT performance and psychophysiological responses, but in general these effects were similar for the PG group and the NC group. Lower anticipatory psychophysiological responses to disadvantageous choices in PG suggest impaired risk assessment in this group. Absence of a HR increase after wins possibly implies that reward sensitivity is decreased in PG. Because levels of reward and punishment sensitivity were associated with differential anticipatory HR responses to advantageous and disadvantageous decks, it would be advisable to include this taxonomy in studies on psychophysiological responses to rewards and losses.