Parsing within & between-person dynamics of therapy homework completion and clinical symptoms in two cognitive behavioral treatments for adults with anhedonia.

OBJECTIVE: Homework is a key theoretical component of cognitive-behavioral therapies, however, the effects of homework on clinical outcomes have largely been evaluated between-persons rather than within-persons. METHODS: The effects of homework completion on treatment response were examined in a randomized trial comparing Behavioral Activation Treatment for Anhedonia (BATA, n = 38), a novel psychotherapy, to Mindfulness-Based Cognitive Therapy (MBCT, n=35). The primary endpoint was consummatory reward sensitivity, measured weekly by the Snaith Hamilton Pleasure Scale (SHAPS), up to 15 weeks. Multilevel models evaluated change in SHAPS scores over time and the effects of clinician-reported and participant-reported homework. RESULTS: BATA and MBCT resulted in significant, equivalent reductions in SHAPS scores. Unexpectedly, participants who completed greater mean total amounts of homework did not improve at a faster rate (i.e., no between-person effect). However, sessions with greater than average participant-reported homework completion were associated with greater than average reductions in SHAPS scores (i.e., a within-person effect). For clinician-reported homework, this effect was only evident within the BATA condition. CONCLUSION: This study shows psychotherapy homework completion relates to symptomatic improvement in cognitive-behavioral treatments for anhedonia when session-to-session changes are examined within-person. On the contrary, we found no evidence that total homework completion predicted greater improvements between-person. When possible, psychotherapy researchers should evaluate their constructs of interest across multiple sessions (not just pre/post) to allow more direct tests of hypotheses predicted by theoretical models of individual change processes.

Neural reward response to substance-free activity images in opiate use disorder patients with depressive symptoms.

BACKGROUND: Deficits in the ability to experience reward from natural, substance-free activities and stimuli is a common mechanism contributing to both opiate use disorder and depressive symptoms, and is a target of behavioral-focused treatments for substance use and depression. Although the neural response to monetary, positive affect-eliciting and social images has been investigated, the neural response to images representing substance-free activity engagement remains untested. The current study tested the neural response to anticipation and receipt of substance-free activity engagement images and monetary reward in opiate use disorder patients with elevated depressive symptoms compared to healthy controls. METHODS: Sixteen male opiate use disorder detoxification patients with elevated depressive symptoms (Beck Depression Inventory (BDI-II) ≥ 14) (OUDD Mage = 32.19 years, SD = 8.17 years) and seventeen male healthy controls (BDI-II < 14) (HC: Mage = 26.82 years, SD = 5.29 years) completed the Monetary Incentive Delay (MID) and newly developed Activity Incentive Delay (AID) tasks. Within- and between-group whole-brain contrasts tested activation during anticipation ([reward]-[non-reward]) and receipt ([win]-[non-win]) of substance-free activity image, monetary, and substance-free activity relative to monetary (AID-MID), reward. RESULTS: OUDD demonstrated significantly lower activation in reward regions during anticipation and significantly greater activation during receipt of substance-free activity image reward compared to HC. OUDD demonstrated significantly lower activation during anticipation of substance-free activity reward relative to monetary reward, compared to HC. CONCLUSIONS: The observed reduction in frontostriatal response to reward anticipation of substance-free activity engagement images in OUDD, yet increased neural response to reward receipt, supports theory linking reductions in reward processing with deficits in motivation for substance-free activity engagement.

Substance type moderates the longitudinal association between depression and substance use from pre-treatment through a 1-year follow-up.

BACKGROUND: Research examining directionality of the relationship between depressive symptoms and substance use following treatment entry is limited. Furthermore, substances differ in their neurobiological effects on mood. The relationship between depression and substance use following treatment entry may be moderated by dependence on specific substances. The study tested (a) lagged effects between depressive symptoms and substance use frequency following substance use treatment entry through a 1-year post-treatment follow-up and (b) if substance dependence type moderates these effects. METHODS: Participants (N = 263) entering residential treatment were assessed for DSM-IV substance dependence, depressive symptoms (Beck Depression Inventory), and percentage of substance use days at post-treatment, 1-, 3-, 6- and 12-month follow-up assessments (time t0 to t4). Linear mixed effects models tested lagged effects between depressive symptoms and substance use frequency and the impact of substance type (i.e., dependence on alcohol, cannabis, opioid, cocaine, hallucinogen/PCP) on this relationship. RESULTS: After controlling for concurrent effects, substance type moderated each longitudinal relationship. Depressive symptoms significantly predicted substance use frequency at the subsequent follow-up assessment, only among individuals with pre-treatment opioid dependence (B = 5.55, SE = 0.89, z = 6.21, p < 0.01). Substance use frequency significantly predicted depressive symptoms at the subsequent follow-up assessment, but not among individuals with cannabis dependence at pre-treatment (B = 1.01, SE = 0.22, t (524) = 4.49, p < 0.01). CONCLUSIONS: The directionality of depression-substance use comorbidity may differ based on the substance of dependence at pre-treatment. Opioid users may especially benefit from treating both depression and substance use.

Distress tolerance to auditory feedback and functional connectivity with the auditory cortex.

Distress tolerance is the capacity to withstand negative affective states in pursuit of a goal. Low distress tolerance may bias an individual to avoid or escape experiences that induce affective distress, but the neural mechanisms underlying the bottom-up generation of distress and its relationship to behavioral avoidance are poorly understood. During a neuroimaging scan, healthy participants completed a mental arithmetic task with easy and distress phases, which differed in cognitive demands and positive versus negative auditory feedback. Then, participants were given the opportunity to continue playing the distress phase for a financial bonus and were allowed to quit at any time. The persistence duration was the measure of distress tolerance. The easy and distress phases activated auditory cortices and fronto-parietal regions. A task-based functional connectivity analysis using the left secondary auditory cortex (i.e., planum temporale) as the seed region revealed stronger connectivity to fronto-parietal regions and anterior insula during the distress phase. The distress-related connectivity between the seed region and the left anterior insula was negatively correlated with distress tolerance. The results provide initial evidence of the role of the anterior insula as a mediating link between the bottom-up generation of affective distress and top-down behavioral avoidance of distress.

An examination of psychiatric comorbidities as a function of gender and substance type within an inpatient substance use treatment program.

BACKGROUND: There are elevated rates of comorbid psychiatric disorders among individuals with substance dependence; however, little research examines these rates within inpatient settings, particularly in relation to gender and type of substance. The current study aimed to fill this gap. METHOD: 465 patients (71.4% male) were recruited from an inpatient substance use treatment facility from 2006 to 2009. These patients were interviewed and diagnosed using the Structure Clinical Interview for DSM-IV and the Diagnostic Interview for Personality Disorders. RESULTS: 60.6% of patients with substance dependence had a current comorbid psychiatric disorder, and more than 30% had at least two psychiatric disorders. The most common current Axis I diagnosis was major depressive disorder (25.8%), followed by PTSD (14%). Comparable rates were found for Antisocial and Borderline Personality Disorders. Females were significantly more likely to meet diagnostic criteria for a psychiatric disorder than were males (73.7% versus 55.4%). When examining comorbidities across different substance dependences, the highest rates of comorbid psychiatric disorders were found among individuals with alcohol dependence (76.8%) and cannabis dependence (76%), although rates were above 60% for cocaine and opioid dependence. Rates of psychiatric diagnoses were significantly lower (27%) among patients who did not meet diagnostic criteria for substance dependence. CONCLUSIONS: There are particularly elevated rates of psychiatric disorders among individuals with substance dependence in inpatient treatment. These rates differ as a function of substance dependence type and gender, making these factors important to consider when researching and treating this type of population.