Review: Prevention of anxiety among at-risk children and adolescents - a systematic review and meta-analysis.

BACKGROUND: Anxiety disorders are common, often start in childhood and run a chronic course. As such there is a need for effective prevention. METHODS: We conducted a systematic review and meta-analyses of randomized, controlled trials to prevent the onset of anxiety disorders in 'at risk' young people. Diagnostic and symptom outcomes were examined. Putative moderators were tested as was publication bias. RESULTS: We included 16 trials (2545 young people). Two trials reported diagnostic outcomes, and significant effects were found for these at end-of-programme (RR = .09, 95%CI = .02 to .16), 6- (RR = .17, 95%CI = .06 to .27) and 12-month (RR = .31, 95%CI .17 to .45) follow-ups. Based on 16 trials, improved anxiety symptoms were significant compared to nonattention controls only, with small effect sizes reported by young people at the end-of-programmes, 6- and 12-month follow-ups; and by parents at the end of the programmes and 12-, but not 6-, month follow-ups. There was no evidence of significant moderation or publication bias. CONCLUSIONS: Fourteen studies included children and young people who presented with elevated anxiety symptoms, but anxiety disorder was not ruled out in the participants in these studies. Hence, these studies might be reporting results of mixed prevention/early intervention programmes. Prevention programmes that target developmental risk factors, not only disorder maintaining factors, appear most promising. The clinically meaningful impact of anxiety disorder prevention programmes remains unknown.

Experiences of marijuana-vaporizer users.

BACKGROUND: Using a marijuana vaporizer may have potential harm-reduction advantages on smoking marijuana, in that the user does not inhale smoke. Little research has been published on use of vaporizers. METHODS: In the first study of individuals using a vaporizer on their own initiative, 96 adults anonymously answered questions about their experiences with a vaporizer and their use of marijuana with tobacco. RESULTS: Users identified 4 advantages to using a vaporizer over smoking marijuana: perceived health benefits, better taste, no smoke smell, and more effect from the same amount of marijuana. Users identified 2 disadvantages: inconvenience of setup and cleaning and the time it takes to get the device operating for each use. Only 2 individuals combined tobacco in the vaporizer mix, whereas 15 combined tobacco with marijuana when they smoked marijuana. Almost all participants intended to continue using a vaporizer. CONCLUSIONS: Vaporizers seem to have appeal to marijuana users, who perceive them as having harm-reduction and other benefits. Vaporizers are worthy of experimental research evaluating health-related effects of using them.

Effectiveness of a self-guided web-based cannabis treatment program: randomized controlled trial.

BACKGROUND: Self-help strategies offer a promising way to address problems with access to and stigma associated with face-to-face drug and alcohol treatment, and the Internet provides an excellent delivery mode for such strategies. To date, no study has tested the effectiveness of a fully self-guided web-based treatment for cannabis use and related problems. OBJECTIVES: The current study was a two-armed randomized controlled trial aimed at testing the effectiveness of Reduce Your Use, a fully self-guided web-based treatment program for cannabis use disorder consisting of 6 modules based on cognitive, motivational, and behavioral principles. METHODS: 225 individuals who wanted to cease or reduce their cannabis use were recruited using both online and offline advertising methods and were randomly assigned to receive: (1) the web-based intervention, or (2) a control condition consisting of 6 modules of web-based educational information on cannabis. Assessments of cannabis use, dependence symptoms, and abuse symptoms were conducted through online questionnaires at baseline, and at 6-week and 3-month follow-ups. Two sets of data analyses were undertaken--complier average causal effect (CACE) modeling and intention to treat (ITT). RESULTS: Two thirds (149) of the participants completed the 6-week postintervention assessment, while 122 (54%) completed the 3-month follow-up assessment. Participants in the intervention group completed an average of 3.5 of the 6 modules. The CACE analysis revealed that at 6 weeks, the experimental group reported significantly fewer days of cannabis use during the past month (P=.02), significantly lower past-month quantity of cannabis use (P=.01), and significantly fewer symptoms of cannabis abuse (P=.047) relative to controls. Cannabis dependence symptoms (number and severity) and past-month abstinence did not differ significantly between groups (Ps>.05). Findings at 3 months were similar, except that the experimental group reported significantly fewer and less severe cannabis dependence symptoms (Ps<.05), and past-month quantity of cannabis consumed no longer differed significantly between groups (P=.16). ITT analyses yielded similar outcomes. CONCLUSION: Findings suggest that web-based interventions may be an effective means of treating uncomplicated cannabis use and related problems and reducing the public health burden of cannabis use disorders. TRIAL REGISTRATION: ACTRN12609000856213, Australian New Zealand Clinical Trials Registry.

Expert-recommended warnings for medical marijuana.

Medical marijuana is legal in some countries, including in many US states. At present, there are no government-mandated warnings on packages of marijuana, even though the substance has dangers similar to those of alcohol, tobacco, and various prescribed drugs. This article reports the results of an effort to collect marijuana warnings recommended by scientific experts on marijuana. The recommended warnings, the first ever from marijuana experts, come from 13 experts. The expert-recommended warnings pertain to risks relating to (1) safety, (2) physical health, (3) fetal harm, (4) mental health, (5) withdrawal and dependence, and (6) adolescent development. The results provide initial expert recommendations for warnings to be required on packages of medical marijuana.

Effects on smokers of exposure to graphic warning images.

BACKGROUND AND OBJECTIVES: Several countries have introduced graphic warning images aimed at discouraging smoking. The objective of this study was to evaluate the impact on smokers of graphic warnings showing cosmetically important harm caused by smoking. METHODS: Fifty-six adult smokers were randomly assigned to view either written smoking warnings or the same written warnings with related graphic images. The smokers viewed the warnings at a rate of one per week for 4 weeks. The smokers were assessed before and after the warnings with regard to stage of change toward smoking cessation and level of smoking. RESULTS: The randomized control trial showed that the warnings with graphic images led to significantly more progress in stage of change toward smoking cessation than written warnings alone. However, the images did not lead to decreases in smoking rates. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: The results indicate that written smoking warnings accompanied by images of cosmetically important harm caused by smoking have more potential than warnings alone in prompting changes in the direction of quitting.

An evaluation of web-based clinical practice guidelines for managing problems associated with cannabis use.

BACKGROUND: Cannabis is the most widely used illicit substance, and multiple treatment options and avenues exist for managing its use. There has been an increase in the development of clinical practice guidelines (CPGs) to improve standards of care in this area, many of which are disseminated online. However, little is known about the quality and accessibility of these online CPGs. OBJECTIVE: The purpose of study 1 was to determine the extent to which cannabis-related CPGs disseminated online adhere to established methodological standards. The purpose of study 2 was to determine if treatment providers are familiar with these guidelines and to assess their perceived quality of these guidelines. METHODS: Study 1 involved a systematic search using the Google Scholar search engine and the National Drugs Sector Information Service (NDSIS) website of the Alcohol and Other Drugs Council of Australia (ADCA) to identify CPGs disseminated online. To be included in the current study, CPGs needed to be free of charge and provide guidance on psychological interventions for reducing cannabis use. Four trained reviewers independently assessed the quality of the 7 identified guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Study 2 assessed 166 Australian cannabis-use treatment providers' (mean age = 45.47 years, SD 12.14) familiarity with and opinions of these 7 guidelines using an online survey. Treatment providers were recruited using online advertisements that directed volunteers to a link to complete the survey, which was posted online for 6 months (January to June 2012). Primary study outcomes included quality scores and rates of guideline familiarity, guideline use, and discovery methods. RESULTS: Based on the AGREE II, the quality of CPGs varied considerably. Across different reporting domains, adherence to methodological standards ranged from 0% to 92%. Quality was lowest in the domains of rigor of development (50%), applicability (46%), and editorial independence (30%). Although examination of AGREE II domain scores demonstrated that the quality of the 7 guidelines could be divided into 3 categories (high quality, acceptable to low quality, and very low quality), review of treatment providers' quality perceptions indicated all guidelines fell into 1 category (acceptable quality). Based on treatment providers' familiarity with and usage rates of the CPGs, a combination of peer/colleagues, senior professionals, workshops, and Internet dissemination was deemed to be most effective for promoting cannabis use CPGs. Lack of time, guideline length, conflicts with theoretical orientation, and prior content knowledge were identified as barriers to guideline uptake. CONCLUSIONS: Developers of CPGs should improve their reporting of development processes, conflicts of interest, and CPGs' applicability to practice, while remaining cognizant that long guidelines may deter implementation. Treatment providers need to be aware that the quality of cannabis-related CPGs varies substantially.

Effects of vicarious punishment: a meta-analysis.

Vicarious punishment involves observing a model exhibit a behavior that leads to punishment for the model. If observers then exhibit the behavior at a lower rate than do individuals in a control group, vicarious punishment occurred. The authors report the results of a meta-analysis of studies that tested for vicarious-punishment effects. Across 21 research samples and 876 participants, the viewing of a model experiencing punishment for a behavior led to a significantly lower level of the behavior by the observers, d = 0.58. Vicarious punishment occurred consistently with (a) live and filmed models, (b) severe and nonsevere punishment for the model, (c) positive punishment alone or positive plus negative punishment, (d) various types of behavior, (e) adults and children, and (f) male and female participants. The findings have implications for the use of models in reducing undesirable behavior.

A smartphone app intervention for adult cannabis users wanting to quit or reduce their use: a pilot evaluation.

BACKGROUND: Smartphone applications (apps) offer a promising alternative to face-to-face treatment due to their ease of access and convenience. However, there is a lack of evidence-based apps for cannabis users wishing to reduce their use. OBJECTIVES: The current study evaluated the feasibility and acceptability of a smartphone app intervention (called Assess, Plan, Track, and Tips [APTT]) for cannabis users wanting to reduce their use. METHOD: The current study included 111 cannabis users (68% male, aged 18-50 yrs) who had used cannabis in the past month, were not currently in treatment, and who wanted to reduce/quit their use. Participants were given access to APTT for 1 month. Participants reported on their cannabis use and related problems, confidence in resisting use, severity of dependence, and stage of change at baseline, post-intervention (4 weeks), and at 1-month follow-up. At post-intervention, participants also reported on their usage and satisfaction with the app. RESULTS: The current study found that APTT was acceptable, with over 40% of participants using the app over 20 times over the course of a month. Participants showed a reduction in dependence and cannabis related problems over the course of the study. Further, participants' stage of change at baseline predicted changes in cannabis use. CONCLUSIONS/IMPORTANCE: These findings support the feasibility and acceptability of APTT as an engaging app for cannabis users wishing to better manage their use and support the need for future RCTs to assess the efficacy of mobile-based interventions for cannabis users.

Efficacy of written modeling and vicarious reinforcement in increasing use of problem-solving methods by distressed individuals.

The authors evaluated an application of social cognitive theory principles intended to increase adherence to a problem-solving intervention. The study included 132 adult volunteers who wanted to reduce their distress levels. All participants received group training in problem-solving methods. Before attempting to solve at least 1 distressing problem in their lives over the next 3 weeks, participants were randomly assigned to either (a) a modeling with vicarious reinforcement condition in which they received 3 personal anecdotes written by individuals who had successfully applied problem-solving methods to a real problem or (b) a control condition in which they received a fact sheet about problem solving. Word counts of problem-solving writing, self-reports of adherence, and observer ratings of adherence showed that participants in the vicarious reinforcement condition demonstrated significantly higher adherence than did those in the control condition. These results provide support for the effectiveness of symbolic modeling and vicarious reinforcement in increasing adherence to problem-solving methods by individuals who want to decrease their distress.

Comparison of brief versus extended personalised feedback in an online intervention for cannabis users: Short-term findings of a randomised trial.

Previous studies have shown brief online self-help interventions to be a useful method of treating cannabis use and related problems; however, no studies have compared the effects of brief versus extended feedback for online brief intervention programs. OBJECTIVES: The current study was a two arm randomised trial aimed at testing the short term effectiveness of a brief and extended feedback version of Grassessment, a brief online intervention for cannabis users that provides individualised feedback regarding use, motives, and harms. METHODS: Participants (n=287) reporting at least one symptom of DSM IV cannabis abuse or dependence were recruited using online and offline advertising methods. Participants were randomised to receive either a brief or extended feedback version of the Grassessment program and were required to complete a one month follow up questionnaire. RESULTS: One hundred and ninety four participants completed the one month follow up. Wilcoxon analyses showed a significant decrease in past month quantity and frequency of cannabis use (ps<0.001; r=-0.41 and -0.40 respectively) and lower severity of dependence scores (p=0.002; r=-0.31) among those in the brief feedback condition. Participants in the extended feedback group also demonstrated significant decreases in patterns of use (ps<0.002; r=-0.39 and -0.33) but not severity of dependence (p=0.09; r=0.18). A Generalized Estimating Equation (GEE) analysis showed no significant interaction between length of feedback received and past month cannabis use frequency (p=0.78), quantity (p=0.73), or severity of dependence (p=0.47). CONCLUSION: This study adds support for the use of brief online self-complete interventions to reduce cannabis use and related problems in the short term. The findings suggest that in the case of the brief online screening and feedback program Grassessment, extended feedback does not lead to superior outcomes over brief feedback.

The efficacy of symbolic modeling and vicarious reinforcement in increasing coping-method adherence.

The aim of this study was to test a method of increasing adherence to a coping method assignment in individuals interested in reducing stress. Eighty university students and 48 adult nonstudents were asked to write about their emotions for 15 minutes per day over 3 days. Participants were randomly assigned to experimental or control conditions, with the experimental manipulation being an adherence intervention involving symbolic modeling and vicarious reinforcement. A word count and self-report measures showed significantly higher adherence in the adherence intervention group. Additionally, the adherence intervention group showed significantly more reduction in distress than the writing instructions only group. Finally, the amount of adherence was significantly associated with amount of reduction in self-reported distress. The results provide the first evidence of the efficacy of symbolic modeling and vicarious reinforcement in increasing the use and clinical benefits of a recommended coping method.

Cannabis Users' Recommended Warnings for Packages of Legally Sold Cannabis: An Australia-Centered Study.

Introduction: Although cannabis use creates health risks, governments have recently been legalizing either medical use or leisure use. These governments can mandate health warnings on cannabis packages. Prior research examined recommended warnings of cannabis experts. The aim of this study was to obtain suggested cannabis health and safety warnings from cannabis users. Methods: We used a media release, Facebook postings, and announcements in university classes to seek individuals who had used cannabis at least once according to their own report. Using online data collection software that keeps participants anonymous, we asked the individuals to suggest a warning that governments could mandate on cannabis packages. Results: In total, 288 users suggested warnings. Categorizing the warnings into content categories led to six warning topics: (1) risk of harm to mental health and psychological functioning; (2) risk of operating machinery while under the influence; (3) short-term physical side effects; (4) responsible use; (5) long-term negative physical effects; and (6) dependence, addiction, or abuse. The user-suggested warnings overlapped with six expert-recommended warnings identified in prior survey research and included two content areas that did not feature in expert-recommended warnings: short-term physical side effects and the importance of responsible use. Conclusions: The results are consistent with prior findings that some youths perceive cannabis use as potentially harmful. The current findings provide possible new content for warnings on cannabis packages.

Applying technology to the treatment of cannabis use disorder: comparing telephone versus Internet delivery using data from two completed trials.

Technology-based interventions such as those delivered by telephone or online may assist in removing significant barriers to treatment seeking for cannabis use disorder. Little research, however, has addressed differing technology-based treatments regarding their comparative effectiveness, and how user profiles may affect compliance and treatment satisfaction. This study addressed this issue by examining these factors in online (N=225) versus telephone (N=160) delivered interventions for cannabis use, using data obtained from two previously published randomized controlled trials conducted by the current authors. Several differences emerged including stronger treatment effects (medium to large effect sizes in the telephone study versus small effect sizes in the Web study) and lower dropout in the telephone intervention (38% vs. 46%). Additionally, around half of the telephone study participants sought concurrent treatment, compared with 2% of participants in the Web study. Demographics and predictors of treatment engagement, retention and satisfaction also varied between the studies. Findings indicate that both telephone and Web-based treatments can be effective in assisting cannabis users to quit or reduce their use; however, participant characteristics may have important implications for treatment preference and outcome, with those who elect telephone-based treatment experiencing stronger outcomes. Thus, participant preference may shape study populations, adherence, and outcome.

Changes in cannabis use among young people: impact on mental health.

PURPOSE OF REVIEW: The aim of this review was to examine current trends in cannabis use and cannabis use disorder (CUD) among youth, and to investigate recent findings concerning the relationship between cannabis use and mental health concerns, with a focus on how use during adolescence may interact with related mental health disorders. RECENT FINDINGS: Current data indicate that cannabis use among adolescents has shown both marginal increases and decreases, depending on global location; however, the profile of cannabinoids in cannabis may now be biased toward those that promote psychotogenic and memory-impairing effects. CUD has been found most prevalent among youth. After controlling for multiple confounders, longitudinal research suggests that cannabis use predicts the development of anxiety disorders, depression, suicidal ideation, certain personality disorders, and interpersonal violence. Further, associations have been found stronger in adolescents relative to adults, and younger age of initiation increases the risk of developing mental health disorders. SUMMARY: Cannabis use among youth remains prevalent, and recent studies are consolidating previous findings that adolescents are especially vulnerable to mental health disorders associated with cannabis. This suggests that cannabis involvement requires increased prominence in research, prevention initiatives, routine screening, and interventions to improve adolescent mental health.

Health outcomes associated with long-term regular cannabis and tobacco smoking.

This study aimed to identify patterns of health concerns associated with long-term use of cannabis and tobacco individually, as well as in combination. We recruited 350 adults aged 40 or over who smoked cannabis but not tobacco (cannabis-only group, n=59), smoked both cannabis and tobacco (cannabis/tobacco group, n=88), smoked tobacco but not cannabis (tobacco-only group, n=80), or used neither substance (control group, n=123). Participants completed a survey addressing substance use, diagnosed medical conditions, health concerns relating to smoking cannabis/tobacco, and general health (measured using the Physical Health Questionnaire and the Short Form 36). Several significant differences were found among the four groups. With regard to diagnosed medical conditions, the three smoking groups reported significantly higher rates of emphysema than did the control group (ps<.001). However, all members of the cannabis-only group diagnosed with emphysema were former regular tobacco smokers. Total general health scores, general health subscales, and items addressing smoking-related health concerns also revealed several significant group differences, and these tended to show worse outcomes for the two tobacco smoking groups. Findings suggest that using tobacco on its own and mixing it with cannabis may lead to worse physical health outcomes than using cannabis alone.

A dual process account of adolescent and adult binge drinking.

This study adopted a dual process perspective to investigate the relative contributions of implicit and explicit cognitions to predicting binge drinking in adolescents and adults. Two hundred and seventy-two participants (136 teen-parent pairs) completed measures of alcohol memory associations (reflecting implicit cognition), expectancies about potential costs and benefits of alcohol use (reflecting explicit cognition), and self-reported binge drinking. Adolescents had stronger alcohol memory associations and perceived drinking benefits to be more probable than did adults. In turn, higher scores on the memory association and expected benefit measures were both associated with significantly higher levels of binge drinking. Moderation analyses revealed that alcohol memory associations and expected benefits of drinking were stronger predictors of binge drinking for adolescents than for adults. The findings suggest that both implicit and explicit cognitions may play important roles in alcohol use decisions, and these roles may differ for adolescents and adults.

Successful and unsuccessful cannabis quitters: comparing group characteristics and quitting strategies.

BACKGROUND: In order to improve treatments for cannabis use disorder, a better understanding of factors associated with successful quitting is required. METHOD: This study examined differences between successful (n=87) and unsuccessful (n=78) cannabis quitters. Participants completed a questionnaire addressing demographic, mental health, and cannabis-related variables, as well as quitting strategies during their most recent quit attempt. RESULTS: Eighteen strategies derived from cognitive behavioral therapy were entered into a principal components analysis. The analysis yielded four components, representing (1) Stimulus Removal, (2) Motivation Enhancement, (3) (lack of) Distraction, and (4) (lack of) Coping. Between groups comparisons showed that unsuccessful quitters scored significantly higher on Motivation Enhancement and (lack of) Coping. This may indicate that unsuccessful quitters focus on the desire to quit, but do not sufficiently plan strategies for coping. Unsuccessful quitters also had significantly more symptoms of depression and stress; less education; lower exposure to formal treatment; higher day-to-day exposure to other cannabis users; and higher cannabis dependence scores. CONCLUSIONS: The findings suggest that coping, environmental modification, and co-morbid mental health problems may be important factors to emphasize in treatments for cannabis use disorder.

Computer-delivered interventions for alcohol and tobacco use: a meta-analysis.

AIMS: To quantify the overall effectiveness of computer-delivered interventions for alcohol and tobacco use. METHODS: Meta-analysis of 42 effect sizes from randomized controlled trials, based on the responses of 10 632 individuals. RESULTS: The weighted average effect size (d) was 0.20, P < 0.001. While lower effect sizes were associated with studies addressing tobacco use (d = 0.14) this may well reflect differences in the types of outcome measure used. Effect sizes did not vary significantly as a function of treatment location, inclusion of entertaining elements, provision of normative feedback, availability of a discussion feature, number of treatment sessions, emphasis on relapse prevention, level of therapist involvement or follow-up period. CONCLUSION: Findings of the meta-analysis suggest that minimal contact computer-delivered treatments that can be accessed via the internet may represent a cost-effective means of treating uncomplicated substance use and related problems.

Professional development perceptions and activities of psychiatrists and mental health nurses in New Zealand.

AIMS: Psychiatrists (n=26) and mental health nurses (n=18) engaged in the practice of psychotherapy were surveyed regarding their perceptions and engagement in professional development activities. METHODS: Collaborative Research Network's (CRN) methodology was followed, and comparisons with CRN samples from Canada and the United States of America (USA) were undertaken. RESULTS: New Zealand psychiatrists reported perceived development across their careers, but their ratings were lower than those of nurses. Both professional groups rated their overall development lower their Canadian counterparts. However, New Zealand nurses reported more involvement in supervision than psychiatrists, and both groups reported rates that exceeded those reported in Canadian and USA samples. New Zealand subgroups reported low involvement in personal therapy in comparison to overseas samples. Supervision and personal therapy were highly regarded by New Zealand practitioners, but didactic training was rated as less important. CONCLUSIONS: New Zealand mental health professionals reported attainment of therapeutic mastery and skill acquisition. New Zealand psychiatrists reported less involvement in case supervision, but rated supervision as having the greatest influence to their development. The results highlight areas of need for continuing professional development for these professions.