Symptom networks in patients with substance use disorders.

BACKGROUND: Reciprocity between symptoms of psychiatric disorders is increasingly recognized to contribute to their chronicity. In substance use disorders (SUD) little is known on reciprocal interactions between symptoms. We applied network analyses to study these interactions. METHODS: We analyzed 11 DSM-IV / DSM-5 criteria for SUD for the most prevalent substances in addiction care (alcohol, cannabis, cocaine, stimulants, and opioids) in a sample of 10,832 SUD patients in treatment. First, we estimated an overall symptom network. Second, we compared symptom networks between the different substances. Finally, we tested differences in symptom networks between DSM-IV and DSM-5. RESULTS: In the overall symptom network for SUD patients the most central symptom was: "spending substantial amount of the day obtaining, using, or recovering from substance use". The symptoms "giving up or cutting back on important activities because of use" and "repeated usage causes or contributes to an inability to meet important obligations", were the symptoms that influenced each other the most. Networks differed between substances both in global strength and structure, especially regarding the position of "use despite health or interpersonal problems". Networks based on DSM-5 criteria differed moderately from DSM-IV, mainly because "craving" was more central in the DSM-5 network than "legal problems" in DSM-IV. CONCLUSIONS: Network analyses can identify core symptoms of SUD that could maintain the disease processes in SUD. Future studies should address whether targeting these core symptoms with precedence, might help to break through the addictive process.

Effectiveness of a brief motivation enhancing intervention on treatment initiation, treatment retention and abstinence: Results from a multi-site cluster-randomized trial.

The aim of this study was to test the effectiveness of a brief motivational enhancing intervention (MEI) as an add-on to supervision-as-usual (SAU) in reducing time to treatment initiation in offenders with substance use disorders (SUDs) under probation supervision. We also tested the effectiveness in enhancing treatment retention and abstinence of primary substance rates. The study was designed as a multi-site, cluster randomized trial (CRT) in six addiction probation offices. We randomized 73 probation officers (37 to intervention, 36 to control) and followed 220 substance-abusing repeat offenders during their supervision (111 intervention, 109 control). Individualized SAU was compared with supervision with MEI. We report time to treatment initiation, treatment retention rate during the 12 months follow-up, and primary substance abstinence rate in the 30 days before follow-up. Results show that time to treatment initiation (χ2(1) = 1.817, p = .178), and the proportion of treatment retention (OR = 1.980, p = .213) and primary substance abstinence (OR = 0.945, p = .886) did not significantly differ between offenders that received SAU plus MEI and those that received SAU at 12 months follow-up. Our findings provide no evidence that supervision plus a brief manual-base MEI is more effective than SAU.

The Predictive Value of Impulsivity and Risk-Taking Measures for Substance Use in Substance Dependent Offenders.

Impulsivity and risk-taking are known to have an important impact on problematic substance use and criminal behavior. This study examined the predictive value of baseline self-report and behavioral impulsivity and risk-taking measures [Delay Discounting Task (DDT), Balloon Analogue Risk Task (BART) and Behavioral Inhibition, Behavioral Activation Scale (BIS/BAS)] in 12-months follow-up substance use outcomes (e.g., use of alcohol, cannabis and other substances) and criminal recidivism (yes/no). Participants were 213 male offenders with a substance use disorder (SUD) under probation supervision. Bivariate regression analyses showed that BIS and BAS levels were associated (respectively) with the use of alcohol and cannabis. Multiple regression analysis showed that BIS was negatively associated with alcohol use at follow-up, whereas cannabis use at baseline and BAS predicted cannabis use at follow-up. At a trend level, interactions between delay discounting and risk-taking, and interactions between baseline cannabis use and BAS and BART predicted cannabis use at follow-up. Other substance use at follow-up was solely predicted by baseline other substance use. Overall, the findings provide marginal support for the predictive utility of impulsivity and risk-taking in accounting for variability in substance use among offenders with a SUD. This may be partly explained by the fact that only a limited number of psychological factors was assessed in this study. The studied population consists of a severe group, in which relapse into substance use or criminal behavior likely is related to complex, interacting biopsychosocial factors, of which impulsivity measures play a relatively small part.

The Role of Motivation in Predicting Addiction Treatment Entry Among Offenders With Substance Use Disorders Under Probation Supervision.

Many offenders with a substance use disorder (SUD) do not enter addiction treatment. The aim of this study was to examine predictors of addiction treatment entry and to get more insight in the predictive value of treatment motivation. A total of 83 male offenders with a SUD under probation supervision in the Netherlands were assessed at the start of probation supervision and at 12-month follow-up. A total of 38 offenders (45.5%) entered addiction treatment in the follow-up period. Offenders with any mandated treatment (p = .028) and higher treatment motivation (p = .005) were more likely to enter treatment. Multiple logistic regression analysis showed that treatment motivation predicts addiction treatment entry in the first year of probation (OR = 2.215, p < .01). This emphasizes the relevance of treatment motivation for addiction treatment entry among offenders with a SUD. Pretreatment motivational interventions are therefore recommended for offenders with low motivation for treatment in probation settings.

Social support in chat sessions for adolescents and young adults living with a family member with mental illness.

Children from families with a mental illness are at risk of developing negative health outcomes. Online interventions are a new way to offer support to these children. The present study utilized a website that had been developed to support Dutch youth who had a family member with a mental illness. The objective was to analyse monitored and unmonitored chatroom conversations among these young people, and specifically to compare supportive messages and self-disclosures of experiences. We electronically imported session transcripts of 34 chatroom conversations into the qualitative analysis software Atlas.ti. A content analysis was performed on 4252 messages from 22 female participants. A correlational analysis was then conducted to identify significant associations between sent and received supportive statements and disclosing statements. We found supporting comments in approximately 34% of the conversations and disclosures of problems in the home in approximately 15-18% of the messages. Participants made approximately twice as many disclosing statements and approximately half as many supportive statements in the monitored sessions compared to the unmonitored sessions. The number of disclosures that were sent was positively correlated with the amount of social support that was received. The number of disclosures sent was negatively correlated with the amount of social support that was sent, but only in the unmonitored sessions. Considering the greater reach of Internet interventions, online chatroom sessions might be provided as complementary to, or as an alternative to, face-to-face groups for supporting youth with a family member who has a mental illness.

Cue exposure therapy for the treatment of alcohol use disorders: A meta-analytic review.

Cue Exposure Therapy (CET) is a behavioristic psychological approach to treating substance use disorders (SUD). Prior systematic reviews have found CET to be ineffective when targeting SUDs. The effect of this approach on alcohol use disorders (AUD) seems more promising at trial level but has yet to be systematically reviewed and quantitatively analyzed. Therefore, we aimed to examine the effectiveness of CET targeting AUD compared to active control conditions in a meta-analytic review. Following a systematic search of the literature, a total of seven controlled trials were identified. CET showed no to small additional effects on drinking intensity and drinking frequency, a small additional effect on total drinking score and a moderate additional effect on latency to relapse. Stratification and analysis of a-priori defined trial covariates revealed that CET may have an increased effect in the longer term, and that CET combined with urge-specific coping skills may be the better option for treating AUD than conventional CET. Also, CET may prove less effective when comparing it to cognitive behaviour therapy as opposed to other active control conditions. The overall quality of evidence was graded low due to high risk of bias, inconsistency, imprecision and suspected publication bias. Sounder methodological trials are needed to derive a firm conclusion about the effectiveness of CET for treating AUD.

Self-expressed strengths and resources of children of parents with a mental illness: A systematic review.

The aim of the present study was to explore the strengths children reported to have acquired while coping with their parents illness, and the external factors these children indicated had facilitated their coping process. A systematic literature search was conducted of peer-reviewed papers that focused on self-reported experiences of children with parents who had mental illness, and revealed their strengths and resources. The search included the following databases: MEDLINE, PsycINFO, and CINAHL. Results were filtered according to whether search terms appeared in the title or abstract. Fifty-seven full-text papers were reviewed; 26 of them met the inclusion criteria and were included in the review. The statements were analysed using content analysis. The search identified 160 relevant statements, 38 (24%) of which could be described as self-reported strengths, and 122 (76%) as self-reported resources. According to these statements, the children described themselves as more mature, independent, and empathic than their peers who did not have a parent with a mental illness, and as having acquired several abilities. The statements about resources indicated that the children regarded social support, information, and particularly the support of mental health-care professionals as helpful when living with a parent with a mental illness. Recommendations for nursing actions to support children's ability to cope with their parents' illness are outlined.

Online support for children of parents suffering from mental illness: a case study.

From epidemiologic research, we know that children of parents with a mental illness (COPMI) have an elevated risk of developing a serious mental disorder. Aside from studies based on risk and resilience, there has been little research on the children's own perceptions. The aim of this study was to expand our understanding of key variables influencing COPMI's seeking support and to explore whether a website targeted at COPMI could help them improve their ability to cope with their circumstances and to find professional help. This case study illustrates one visitor's use of a website that was specifically designed to help COPMI. The visitor was a young adult female whose two parents both suffered from mental illness. She participated for 3 years in an intervention delivered through the website. Several things helped to inform us about her perspective on living with parents suffering from mental illness, her use of the website and the benefits she derived from using the website. These included (a) her story as she told it in the exit interview, (b) her messages to her peers and counsellors, (c) her user data and (d) the content of her chat conversations with her peers.

Treatment outcome of alcohol use disorder outpatients with or without medically assisted detoxification.

OBJECTIVE: Little is known about the incremental effects of medically assisted detoxification on outpatient treatment for alcohol use disorders. The objective of this study was to compare drinking outcomes in a psychosocial treatment program between two groups of heavy drinking patients who had an alcohol use disorder: (a) one group with initial medically assisted detoxification and (b) a second group without initial medically assisted detoxification. METHOD: Analyses were conducted on 262 patients with a more severe alcohol use disorder who completed both an intake assessment and a 9-month follow-up assessment. The effect of medically assisted detoxification was determined using logistic regression analysis with a propensity score to control for possible baseline differences between the two groups. RESULTS: Of the 262 patients, 82 (31.3%) received medically assisted detoxification. These patients were more likely to abstain from alcohol than those without medically assisted detoxification. Abstinence rates in the month before follow-up were 32.9% and 18.9%, respectively (ORadj = 3.48, p = .01, number needed to treat = 7.1). CONCLUSIONS: Medically assisted detoxification may add to the effects of outpatient psychosocial treatment for heavy drinking patients with an alcohol use disorder.

A randomized controlled trial of a brief motivational enhancement for non-treatment-seeking adolescent cannabis users.

Evidence for negative effects of early-onset cannabis use has led to a need for effective interventions targeting adolescent cannabis users. A randomized controlled trial of an Australian two-session intervention based on motivational interviewing (the ACCU, or Weed-Check in Dutch) was replicated in a larger Dutch sample of 119 non-treatment-seeking adolescent cannabis users. Outcome measures at the 3-month follow-up were quantity and frequency of cannabis use, symptoms of dependence, stage of change, and psychosocial functioning. Changes in all measures were in the expected direction, yet not significant. In moderation analyses, heavier cannabis users at baseline receiving the Weed-Check had greater reductions in cannabis use than those in the control condition. These results suggest that the Weed-Check might be beneficial for heavier cannabis-using adolescents. Further research is needed to confirm these results in a sample of adolescent heavy cannabis users and to examine the relationship between MI skills of prevention workers and outcome.

Baseline predictors of treatment outcome in Internet-based alcohol interventions: a recursive partitioning analysis alongside a randomized trial.

BACKGROUND: Internet-based interventions are seen as attractive for harmful users of alcohol and lead to desirable clinical outcomes. Some participants will however not achieve the desired results. In this study, harmful users of alcohol have been partitioned in subgroups with low, intermediate or high probability of positive treatment outcome, using recursive partitioning classification tree analysis. METHODS: Data were obtained from a randomized controlled trial assessing the effectiveness of two Internet-based alcohol interventions. The main outcome variable was treatment response, a dichotomous outcome measure for treatment success. Candidate predictors for the classification analysis were first selected using univariate regression. Next, a tree decision model to classify participants in categories with a low, medium and high probability of treatment response was constructed using recursive partitioning software. RESULTS: Based on literature review, 46 potentially relevant baseline predictors were identified. Five variables were selected using univariate regression as candidate predictors for the classification analysis. Two variables were found most relevant for classification and selected for the decision tree model: 'living alone', and 'interpersonal sensitivity'. Using sensitivity analysis, the robustness of the decision tree model was supported. CONCLUSIONS: Harmful alcohol users in a shared living situation, with high interpersonal sensitivity, have a significantly higher probability of positive treatment outcome. The resulting decision tree model may be used as part of a decision support system but is on its own insufficient as a screening algorithm with satisfactory clinical utility. TRIAL REGISTRATION: Netherlands Trial Register (Cochrane Collaboration): NTR-TC1155.

Predictive validity of treatment allocation guidelines on drinking outcome in alcohol-dependent patients.

The purpose of this study was to establish the predictive validity of guidelines for allocating patients to outpatient or inpatient treatment for an alcohol-use disorder. It was hypothesized that patients who were matched to the recommended level of care would have (a) better outcomes than patients treated at a less intensive level of care, and (b) outcomes equivalent to those of patients treated at a more intensive level of care. Matched patients were allocated according to an algorithm based on their treatment history, addiction severity, psychiatric impairment, and social stability at baseline. Outcome was measured in terms of self-reported alcohol use 30days prior to follow-up and changes in number of abstinent and heavy drinking days between intake and follow up. Of the 2,310 patients, 65.4% were successfully followed up 9.67months after intake. Only 22% of the patients were treated according to the level of care prescribed by the guidelines; 49% were undertreated; and 29% were overtreated. The results were not in line with our hypotheses. Patients treated at a more intensive level of care than recommended had favorable outcomes compared to patients treated at the recommended level of care (55.5% vs. 43.9% success). Patients allocated to the recommended level of care did not have better outcomes than those treated at a less intensive level of care (43.9% vs. 38.3% success). Based on these results, we suggest ways to improve the algorithm for allocating patients to treatment.

Economic evaluation of internet-based interventions for harmful alcohol use alongside a pragmatic randomized controlled trial.

BACKGROUND: Internet interventions with and without therapist support have been found to be effective treatment options for harmful alcohol users. Internet-based therapy (IT) leads to larger and longer-lasting positive effects than Internet-based self-help (IS), but it is also more costly to provide. OBJECTIVE: To evaluate the cost effectiveness and cost utility of Internet-based interventions for harmful use of alcohol through the assessment of the incremental cost effectiveness of IT compared with IS. METHODS: This study was performed in a substance abuse treatment center in Amsterdam, the Netherlands. We collected data over the years 2008-2009. A total of 136 participants were included, 70 (51%) were female, and mean age was 41.5 (SD 9.83) years. Reported alcohol consumption and Alcohol Use Disorders Identification Test (AUDIT) scores indicated harmful drinking behavior at baseline. We collected self-reported outcome data prospectively at baseline and 6 months after randomization. Cost data were extracted from the treatment center's cost records, and sex- and age-specific mean productivity cost data for the Netherlands. RESULTS: The median incremental cost-effectiveness ratio was estimated at €3683 per additional treatment responder and €14,710 per quality-adjusted life-year (QALY) gained. At a willingness to pay €20,000 for 1 additional QALY, IT had a 60% likelihood of being more cost effective than IS. Sensitivity analyses attested to the robustness of the findings. CONCLUSIONS: IT offers better value for money than IS and might therefore be considered as a treatment option, either as first-line treatment in a matched-care approach or as a second-line treatment in the context of a stepped-care approach. TRIAL REGISTRATION: Netherlands Trial Register NTR-TC1155; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1155 (Archived by WebCite at http://www.webcitation.org/6AqnV4eTU).

Internet therapy versus internet self-help versus no treatment for problematic alcohol use: A randomized controlled trial.

OBJECTIVE: Problematic alcohol use is the third leading contributor to the global burden of disease, partly because the majority of problem drinkers are not receiving treatment. Internet-based alcohol interventions attract an otherwise untreated population, but their effectiveness has not yet been established. The current study examined the effectiveness of Internet-based therapy (therapy alcohol online; TAO) and Internet-based self-help (self-help alcohol online; SAO) for problematic alcohol users. METHOD: Adult problem drinkers (n = 205; 51% female; mean age = 42 years; mean Alcohol Use Disorders Identification Test score = 20) were randomly assigned to TAO, SAO, or an untreated waiting-list control group (WL). Participants in the TAO arm received 7 individual text-based chat-therapy sessions. The TAO and SAO interventions were based on cognitive-behavioral therapy and motivational interviewing techniques. Assessments were given at baseline and 3 and 6 months after randomization. Primary outcome measures were alcohol consumption and treatment response. Secondary outcome measures included measures of quality-of-life. RESULTS: Using generalized estimating equation regression models, intention-to-treat analyses demonstrated significant effects for TAO versus WL (p = .002) and for SAO versus WL (p = .03) on alcohol consumption at 3 months postrandomization. Differences between TAO and SAO were not significant at 3 months postrandomization (p = .11) but were significant at 6 months postrandomization (p = .03), with larger effects obtained for TAO. There was a similar pattern of results for treatment response and quality-of-life outcome measures. CONCLUSIONS: Results support the effectiveness of cognitive-behavioral therapy/motivational interviewing Internet-based therapy and Internet-based self-help for problematic alcohol users. At 6 months postrandomization, Internet-based therapy led to better results than Internet-based self-help.

Guidelines for allocating outpatient alcohol abusers to levels of care: Predictive validity.

The purpose of this study was to assess the predictive validity of guidelines for allocating outpatients with an alcohol-use disorder to different levels of care in routine alcohol outpatient treatment facilities. It was hypothesized that patients matched to the recommended level of care would have (a) better outcomes than patients treated at a less intensive level of care, and (b) outcomes equivalent to patients treated at a more intensive level of care. Patients at two Dutch substance-abuse treatment centers who completed intake and were allocated at either a brief or standard outpatient treatment (n=471) were followed prospectively to determine differential outcomes for those who were and were not treated at the recommended level of car. The former patients were allocated according to an algorithm based on their treatment history, addiction severity, psychiatric impairment and social stability at baseline. 52.9% of the original sample was successfully contacted for follow-up 11 months after intake. Outcome was measured in terms of self-reported alcohol use 30 days prior to follow up and changes in number of excessive and nonexcessive drinking days between intake and follow up. Only 21% of the patients were matched to the level of care according to the guidelines. Patients allocated to the recommended level of care did not have better outcomes than those treated at a less intensive level of care, but they had outcomes comparable to patients treated at a more intensive level of care. The a priori allocation guidelines were followed for only a minority of the patients, and using them did not improve treatment outcome. Further work is needed to improve the content of the treatment allocation guidelines.

Developing an interactive website for adolescents with a mentally ill family member.

Adolescents with a mentally ill parent are at high risk for developing a disorder themselves. It is widely recommended that these adolescents be provided with preventive interventions designed especially for them, but their avoidance of professional help is a common problem. Because most teenagers in Western societies use the World Wide Web as a means of social interaction, use of the Internet for reaching these young people would appear to be a promising option. In this article, the authors describe the development of Survivalkid.nl, an interactive, Internet-delivered, preventive intervention for supporting adolescents with a mentally ill family member. Usage statistics with regard to frequency and duration of visits and amount of activity during visits suggest that: (a) the target group has been better served than before the site was launched; and (b) we have accomplished our goal of expanding the range of support.

Effectiveness of Nurse Based Motivational Interviewing for smoking cessation in high risk cardiovascular outpatients: a randomized trial.

OBJECTIVE: To evaluate the feasibility and effectiveness of Nurse Based Motivational Interviewing (NBMI) on top of a routine patient based Lifestyle Inventory with Feedback (LIFE) in a cardiovascular outpatient secondary prevention setting. METHODS: All current smokers (n=112), identified in 619 successive patients with cardiovascular disease, were randomized for either care as usual (LIFE), or LIFE plus NBMI (intervention group). Cumulative time investment was recorded. RESULTS: After 3 months of follow-up, the abstinence rate in the control group was 7%, and another 15% diminished the number of cigarettes, whereas 26% of intervention patients quit smoking (p<0.017) and another 31% diminished smoking. On average, each completed motivational interviewing session took 63.5 min. Per quitter, time investment was 3.8 h and NNT appeared 5.9. CONCLUSION: NBMI strategy on top of routinely administrated lifestyle self evaluation with professional feedback, significantly increases smoking cessation in an outpatient secondary prevention setting. Although cost effectiveness needs to be addressed, time investment per quitter in this approach appears low.

Smoking cessation quitlines in Europe: matching services to callers' characteristics.

BACKGROUND: Telephone quitlines offer a wide range of services to callers, including advice and counsel, and information on pharmacotherapy for smoking cessation. But, little is known about what specific quitline services are offered to smokers and whether these services are appropriately matched to characteristics of smokers. This study examines how quitline services are matched to callers' level of addiction, educational level, stage-of-change with quitting, and whether they are referred by a doctor or other health professional. METHODS: Between February 2005 and April 2006, 3,585 callers to seven European quitlines responded to our survey. During the course of and immediately after the call, quitline counsellors collected descriptive data on callers' characteristics and the services they used. We then conducted four logistic regression analyses to examine the relationship between quitline services and the four caller characteristics. RESULTS: Forty three percent of all callers received information on pharmacotherapy--most often nicotine patches and nicotine gum--from the counsellor. As we predicted, these callers were the heavy smokers. There was a direct correlation between the length of the conversations between the counsellor and the educational level of the smoker: the lower the education of the smoker, the shorter the call. However, we found no significant association between any other type of service and the educational level of caller. We also found a correlation between the smoker's stage of quitting and the type of advice a counsellor gives. Smokers in the action stage of quitting were more likely to receive advice (in two quitlines) or counselling (in two quitlines) than those in the preparation stage, who were less likely to be referred (in three quitlines). Very few of the total number of calls (10.7%) were from referrals by health professionals. Referred callers were more likely to receive counselling, but this was found only in four of seven quitlines. CONCLUSION: Most of the services quitlines offer to smokers favour heavy smokers and those at a more advanced stage of cessation, but not based on their educational level. Thus, we recommend that European quitlines extend and tailor their services to include less-educated smokers.

Missing data approaches in eHealth research: simulation study and a tutorial for nonmathematically inclined researchers.

BACKGROUND: Missing data is a common nuisance in eHealth research: it is hard to prevent and may invalidate research findings. OBJECTIVE: In this paper several statistical approaches to data "missingness" are discussed and tested in a simulation study. Basic approaches (complete case analysis, mean imputation, and last observation carried forward) and advanced methods (expectation maximization, regression imputation, and multiple imputation) are included in this analysis, and strengths and weaknesses are discussed. METHODS: The dataset used for the simulation was obtained from a prospective cohort study following participants in an online self-help program for problem drinkers. It contained 124 nonnormally distributed endpoints, that is, daily alcohol consumption counts of the study respondents. Missingness at random (MAR) was induced in a selected variable for 50% of the cases. Validity, reliability, and coverage of the estimates obtained using the different imputation methods were calculated by performing a bootstrapping simulation study. RESULTS: In the performed simulation study, the use of multiple imputation techniques led to accurate results. Differences were found between the 4 tested multiple imputation programs: NORM, MICE, Amelia II, and SPSS MI. Among the tested approaches, Amelia II outperformed the others, led to the smallest deviation from the reference value (Cohen's d = 0.06), and had the largest coverage percentage of the reference confidence interval (96%). CONCLUSIONS: The use of multiple imputation improves the validity of the results when analyzing datasets with missing observations. Some of the often-used approaches (LOCF, complete cases analysis) did not perform well, and, hence, we recommend not using these. Accumulating support for the analysis of multiple imputed datasets is seen in more recent versions of some of the widely used statistical software programs making the use of multiple imputation more readily available to less mathematically inclined researchers.