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.

Multidimensional family therapy in adolescents with a cannabis use disorder: long-term effects on delinquency in a randomized controlled trial.

BACKGROUND: Substance use and delinquency are considered to be mutual risk factors. Previous studies have shown that multidimensional family therapy (MDFT) is effective in tackling both conditions on the short term. The current study examines the long-term effects of MDFT on criminal offending. METHODS: 109 adolescents with cannabis use disorder and comorbid problem behavior were randomly assigned to either MDFT or cognitive behavioral therapy (CBT). Police arrest data were collected for 6 years: 3 years prior to and 3 years after treatment entry. Using survival analysis and repeated measure General Linear Models (rmGLM), the two treatment groups were compared on number of arrests, type of offence, and severity of offence. Moderator analyses looking at age, disruptive behavior disorders, history of crimes, family functioning, and (severe) cannabis use were conducted (rmGLM). RESULTS: While police arrest rates increased in the 3 years before treatment, the rates decreased substantially after the start of both treatments. No differences were found between the treatment groups with respect to either time to first offence from the start of the treatment or changes in frequency or severity of offending over time. A treatment effect trend favoring MDFT was found for property offending in the subgroup of adolescents with high baseline-severity of cannabis use. CONCLUSIONS: Across a follow-up period of 3 years, MDFT and CBT were similarly effective in reducing delinquency in adolescents with a cannabis use disorder.Trial registration ISRCTN51014277, Registered 17 March 2010-Retrospectively registered, http://www.isrctn.com/ISRCTN51014277.

Multidimensional Family Therapy Reduces Self-Reported Criminality Among Adolescents With a Cannabis Use Disorder.

Multidimensional family therapy (MDFT) is an established treatment program for youth displaying multiproblem behavior. We examined whether MDFT decreased criminal offending among cannabis abusing adolescents, as compared with individual psychotherapy (IP). In a Western European randomized controlled trial comparing MDFT with IP, a sample of 169 adolescents with a cannabis disorder completed self-reports on criminal offending. Half indicated they had committed one or more criminal offenses in the 90 days before the baseline assessment. Follow-up assessments were at 6 and 12 months after randomization. The proportion of adolescents reporting nondelinquency increased during the study period, most so in the MDFT condition. In addition, MDFT lowered the number of violent offenses more than IP. This difference was not seen for property crimes. In cannabis abusing adolescents, MDFT is an effective treatment to prevent and reduce criminal offending. MDFT outperforms IP for violent crimes.

Multidimensional family therapy decreases the rate of externalising behavioural disorder symptoms in cannabis abusing adolescents: outcomes of the INCANT trial.

BACKGROUND: US-based trials have shown that Multidimensional Family Therapy (MDFT) not only reduces substance abuse among adolescents, but also decreases mental and behavioural disorder symptoms, most notably externalising symptoms. In the INCANT trial, MDFT decreased the rate of cannabis dependence among Western European youth. We now focus on other INCANT outcomes, i.e., lessening of co-morbidity symptoms and improvement of family functioning. METHODS: INCANT was a randomised controlled trial comparing MDFT with individual therapy (IP) at and across sites in Berlin, Brussels, Geneva, The Hague, and Paris. We recruited 450 boys and girls aged 13 up to 18 years with a cannabis use disorder, and their parent(s), and followed them for 12 months. Mental and behavioural characteristics (classified as 'externalising' or 'internalising') and family conflict and cohesion were assessed. RESULTS: From intake through 12 months, MDFT and IP groups improved on all outcome measures. Models including treatment, site, and referral source showed that MDFT outperformed IP in reducing externalising symptoms.Adolescents were either self-referred to treatment (mostly on the initiative from people close to the teen) or referred under some measure of coercion by an external authority. These two groups reacted equally well to treatment. CONCLUSIONS: Both MDFT and IP reduced the rate of externalising and internalising symptoms and improved family functioning among adolescents with a cannabis use disorder. MDFT outperformed IP in decreasing the rate of externalising symptoms. Contrary to common beliefs among therapists in parts of Western Europe, the 'coerced' adolescents did at least as well in treatment as the self-referred adolescents.MDFT shows promise as a treatment for both substance use disorders and externalising symptoms. TRIAL REGISTRATION ISRNCT: ISRCTN51014277.

Multidimensional family therapy lowers the rate of cannabis dependence in adolescents: a randomised controlled trial in Western European outpatient settings.

BACKGROUND: Noticing a lack of evidence-based programmes for treating adolescents heavily using cannabis in Europe, government representatives from Belgium, France, Germany, The Netherlands, and Switzerland decided to have U.S.-developed multidimensional family therapy (MDFT) tested in their countries in a trans-national trial, called the International Need for Cannabis Treatment (INCANT) study. METHODS: INCANT was a 2 (treatment condition)×5 (time) repeated measures intent-to-treat randomised effectiveness trial comparing MDFT to Individual Psychotherapy (IP). Data were gathered at baseline and 3, 6, 9 and 12 months thereafter. Study participants were recruited at outpatient secondary level addiction, youth, and forensic care clinics in Brussels, Berlin, Paris, The Hague, and Geneva. Participants were adolescents from 13 through 18 years of age with a recent cannabis use disorder. 85% were boys; 40% were of foreign descent. One-third had been arrested for a criminal offence in the past 3 months. Three primary outcomes were assessed: (1) treatment retention, (2) prevalence of cannabis use disorder and (3) 90-day frequency of cannabis consumption. RESULTS: Positive outcomes were found in both the MDFT and IP conditions. MDFT outperformed IP on the measures of treatment retention (p<0.001) and prevalence of cannabis dependence (p=0.015). MDFT reduced the number of cannabis consumption days more than IP in a subgroup of adolescents reporting more frequent cannabis use (p=0.002). CONCLUSIONS: Cannabis use disorder was responsive to treatment. MDFT exceeded IP in decreasing the prevalence of cannabis dependence. MDFT is applicable in Western European outpatient settings, and may show moderately greater benefits than IP in youth with more severe substance use.

Matching adolescents with a cannabis use disorder to multidimensional family therapy or cognitive behavioral therapy: treatment effect moderators in a randomized controlled trial.

BACKGROUND: In a recent randomized controlled trial (Hendriks et al., 2011), multidimensional family therapy (MDFT) and cognitive behavioral therapy (CBT) were equally effective in reducing cannabis use in adolescents (13-18 years old) with a cannabis use disorder (n=109). In a secondary analysis of the trial data, we investigated which pretreatment patient characteristics differentially predicted treatment effect in MDFT and CBT, in order to generate hypotheses for future patient-treatment matching. METHODS: The predictive value of twenty patient characteristics, in the area of demographic background, substance use, substance-related problems, delinquency, treatment history, psychopathology, family functioning and school or work related problems, was investigated in bivariate and subsequent multivariate linear regression analyses, with baseline to month 12 reductions in cannabis use days and smoked joints as dependent variables. RESULTS: Older adolescents (17-18 years old) benefited considerably more from CBT, and younger adolescents considerably more from MDFT (p<0.01). Similarly, adolescents with a past year conduct or oppositional defiant disorder, and those with internalizing problems achieved considerably better results in MDFT, while those without these coexisting psychiatric problems benefited much more from CBT (p<0.01, and p=0.02, respectively). CONCLUSIONS: The current study strongly suggests that age, disruptive behavior disorders and internalizing problems are important treatment effect moderators of MDFT and CBT in adolescents with a cannabis use disorder. If replicated, this finding suggests directions for future patient-treatment matching in adolescent substance abuse treatment.

Treatment of adolescents with a cannabis use disorder: main findings of a randomized controlled trial comparing multidimensional family therapy and cognitive behavioral therapy in The Netherlands.

BACKGROUND: To meet the treatment needs of the growing number of adolescents who seek help for cannabis use problems, new or supplementary types of treatment are needed. We investigated whether multidimensional family therapy (MDFT) was more effective than cognitive behavioral therapy (CBT) in treatment-seeking adolescents with a DSM-IV cannabis use disorder in The Netherlands. METHODS: One hundred and nine adolescents participated in a randomized controlled trial, with study assessments at baseline and at 3, 6, 9 and 12 months following baseline. They were randomly assigned to receive either outpatient MDFT or CBT, both with a planned treatment duration of 5-6 months. Main outcome measures were cannabis use, delinquent behavior, treatment response and recovery at one-year follow-up, and treatment intensity and retention. RESULTS: MDFT was not found to be superior to CBT on any of the outcome measures. Adolescents in both treatments did show significant and clinically meaningful reductions in cannabis use and delinquency from baseline to one-year follow-up, with treatment effects in the moderate range. A substantial percentage of adolescents in both groups met the criteria for treatment response at month 12. Treatment intensity and retention was significantly higher in MDFT than in CBT. Post hoc subgroup analyses suggested that high problem severity subgroups at baseline may benefit more from MDFT than from CBT. CONCLUSIONS: The current study indicates that MDFT and CBT are equally effective in reducing cannabis use and delinquent behavior in adolescents with a cannabis use disorder in The Netherlands.

INCANT: a transnational randomized trial of multidimensional family therapy versus treatment as usual for adolescents with cannabis use disorder.

BACKGROUND: In 2003, the governments of Belgium, France, Germany, the Netherlands and Switzerland agreed that there was a need in Europe for a treatment programme for adolescents with cannabis use disorders and other behavioural problems. Based on an exhaustive literature review of evidence-based treatments and an international experts meeting, Multidimensional Family Therapy (MDFT) was selected for a pilot study first, which was successful, and then for a joint, transnational randomized controlled trial named INCANT (INternational CAnnabis Need for Treatment). METHODS/DESIGN: INCANT is a randomized controlled trial (RCT) with an open-label, parallel group design. This study compares MDFT with treatment as usual (TAU) at and across sites in Brussels, Berlin, Paris, The Hague and Geneva. Assessments are at baseline and at 3, 6, 9 and 12 months after randomization. A minimum of 450 cases in total is required; sites will recruit 60 cases each in Belgium and Switzerland, and a maximum of 120 each in France, Germany and the Netherlands.Eligible for INCANT are adolescents from 13 through 18 years of age with a cannabis use disorder (dependence or abuse), with at least one parent willing to take part in the treatment. Randomization is concealed to, and therefore beyond control by, the researcher/site requesting it. Randomization is stratified as to gender, age and level of cannabis consumption.Assessments focus on substance use; mental function; behavioural problems; and functioning regarding family, school, peers and leisure time.For outcome analyses, the study will use state of the art latent growth curve modelling techniques, including all randomized participants according to the intention-to-treat principle.INCANT has been approved by the appropriate ethical boards in Belgium, France, Germany, the Netherlands, Switzerland, and the University of Miami Miller School of Medicine. INCANT is funded by the (federal) Ministries of Health of Belgium, Germany, the Netherlands, Switzerland, and by MILDT: the Mission Interministerielle de Lutte Contra la Drogue et de Toximanie, France. DISCUSSION: Until recently, cannabis use disorders in adolescents were not viewed in Europe as requiring treatment, and the co-occurrence of such disorders with other mental and behavioural problems was underestimated. This has changed now.Initially, there was doubt that a RCT would be feasible in treatment sectors and countries with no experience in this type of study. INCANT has proven that such doubts are unjustified. Governments and treatment sites from the five participating countries agreed on a sound study protocol, and the INCANT trial is now underway as planned. TRIAL REGISTRATION: ISRCTN51014277.