Improving Access and Quality of Behavioral Health Services for Health Care Employees.

OBJECTIVE: To describe key features and the initial implementation of an employer-sponsored program designed to increase access to quality mental health treatment for employees of a large health care system. Methods: Retrospective data were collected on employer's efforts to develop a programmatic solution to address barriers to accessing quality mental health treatment among its employees and on initial program implementation. Results: Data from the initial cohort ( N = 1049) of program participants support the use of low threshold digital tools to enhance access to care, the importance of care navigation and a robust curated provider network in matching employees to appropriate care options, and the value of providing online, evidence-based psychotherapy to facilitate high rates of treatment engagement. Conclusions: Findings can help inform employers about approaches to improve access to quality mental health treatment for their employees.

An Implementation Approach to Translating Assessment Data into Treatment for Disorders of Addiction.

Effective translation of data to inform real-time patient care is lacking in addiction inpatient settings. The current study presents the optimization of an assessment report that is used by clinicians to individualize treatment. A multi-aim, iterative approach was taken, utilizing an implementation science perspective to arrive at a final version of the assessment report. This occurred at a small inpatient addiction treatment facility. Participants were all available clinical staff (N = 7; female = 71%). A quantitative survey was used for aims 1 and 2 to, respectively, assess motives and context around the report as well as evaluate its design. Aim 3 focused on optimization via semi-structured interviews. Descriptive and modified content analyses were utilized appropriately across aims. This resulted in five versions of the assessment report being created between February 2021 and August 2022, the most recent of which was adapted into patients' electronic medical records. We discuss each version of the report in depth, including clinicians' iterative feedback and researchers' perceived barriers to this translational process. The response rate was 64.3%. The current study highlights a replicable approach for optimizing the translation of assessment data into treatment for patients with disorders of addiction as well as an assessment report that could be utilized by similar facilities with a naturally low sample size.

Neural correlates of drinking reduction during a clinical trial of cognitive behavioral therapy for alcohol use disorder.

BACKGROUND: Cognitive behavioral therapy (CBT) is an effective treatment for alcohol use disorder (AUD). We hypothesized that the dorsolateral prefrontal cortex (DLPFC), a region implicated in cognitive control and goal-directed behavior, plays a role in behavior change during CBT by facilitating the regulation of craving (ROC). METHODS: Treatment-seeking participants with AUD (N = 22) underwent functional magnetic resonance imaging (fMRI) scanning both before and after a 12-week, single-arm trial of CBT, using an ROC task that was previously shown to engage the DLPFC. RESULTS: We found that both the percentage of heavy drinking days (PHDD) and the overall self-reported alcohol craving measured during the ROC task were significantly reduced from pre- to post-CBT. However, we did not find significant changes over time in either the ability to regulate craving or regulation-related activity in any brain region. We found a significant 3-way interaction between the effects of cue-induced craving, cue-induced brain activity and timepoint of assessment (pre- or post-CBT) on PHDD in the left DLPFC. Follow-up analysis showed that cue-induced craving was associated with cue-induced activity in the left DLPFC among participants who ceased heavy drinking during CBT, both at pre-CBT and post-CBT timepoints. No such associations were present at either timepoint among participants who continued to drink heavily. CONCLUSIONS: These results suggest that patients in whom DLPFC functioning is more strongly related to cue-induced craving may preferentially respond to CBT.

Automated, tailored adaptive mobile messaging to reduce alcohol consumption in help-seeking adults: A randomized controlled trial.

AIMS: To test differential outcomes between three 6-month text-messaging interventions to reduce at-risk drinking in help-seeking adults. DESIGN: A three-arm single-blind randomized controlled trial with 1-, 3-, 6- and 12-month follow-ups. SETTING: United States. A fully remote trial without human contact, with participants recruited primarily via social media outlets. PARTICIPANTS: Seven hundred and twenty-three adults (mean = 39.9 years, standard deviation = 10.0; 62.5% female) seeking to reduce their drinking were allocated to 6 months of baseline 'tailored statically' messaging (TS; n = 240), 'tailored adaptive' messaging (TA; n = 239) or 'drink tracking' messaging (DT; n = 244). INTERVENTIONS: TS consisted of daily text messages to reduce harmful drinking that were tailored to demographics and alcohol use. TA consisted of daily, tailored text messages that were also adapted based on goal achievement and proactive prompts. DT consisted of a weekly assessment for self-reported drinking over the past 7 days. MEASUREMENTS: The primary outcome measure was weekly sum of standard drinks (SSD) at 6-month follow-up. Secondary outcome measures included drinks per drinking day (DDD), number of drinking days (NDD) per week and heavy drinking days (HDD) at 1-, 3-, 6- and 12-month follow-ups. FINDINGS: At 6 months, compared with DT, TA resulted in significant SSD reductions of 16.2 (from 28.7 to 12.5) drinks [adjusted risk ratio (aRR) = 0.80, 95% confidence interval (CI) = 0.71, 0.91] using intent-to-treat analysis. TA also resulted in significant improvements in DDD (aRR = 0.84; 95% CI = 0.77-0.92) and drinking days per week (b = -0.39; 95% CI = -0.67, -0.10), but not HDD compared with DT at 6 months. TA was not significantly different from TS at any time-point, except DDD at 6 months. All groups made improvements in SSD at 12-month follow-up compared with baseline with an average reduction of 12.9 drinks per week across groups. CONCLUSIONS: Automated tailored mobile messaging interventions are scalable solutions that can reduce weekly alcohol consumption in remote help-seeking drinkers over time.

Adapting, Implementing, and Maintaining a Group Cognitive Behavioral Therapy Program at an Inpatient Addiction Treatment Facility.

Background: Quality training is an oft-cited barrier to effective implementation and ongoing delivery of high-quality evidence-based practice (EBP) across fields. This is especially true in the addiction field, but there is little cited evidence for optimal methods to improve EBP in inpatient addiction facilities with minimal resources. Objective: The current paper focuses on evaluating the state of our facility's group CBT manual and clinical training on the manual in a "realistic" (ie, non-RCT, non-grant-funded) inpatient addiction treatment setting. Methods: Five full-time clinicians volunteered to take part in the study (woman = 60%; Mage = 36.20 years). The study involved a mix of semi-structured interviews and surveys designed to measure seven outcomes (barriers, feasibility, useability, appropriateness, acceptability, burden, trialability). Results: Three themes emerged from the data that impacted the group CBT manual: training, timing, and functionality. Addressing these themes allowed for a new, optimal manual and training procedure to be put into place. Conclusion: The current study highlights that under-resourced inpatient addiction facilities can still methodically utilize implementation approaches to study their EBP, namely CBT. Such an approach will ensure that the highest quality care is being delivered to patients and actively addresses known training barriers that prevent proper EBP delivery.

Data driven mixed effects modeling of the dual process framework of addiction among individuals with alcohol use disorder.

Alcohol use disorder (AUD) comprises a continuum of symptoms and associated problems that has led AUD to be a leading cause of morbidity and mortality across the globe. Given the heterogeneity of AUD from mild to severe, consideration is being given to providing a spectrum of interventions that offer goal choice to match this heterogeneity, including helping individuals with AUD to moderate or control their drinking at low-risk levels. Because so much remains unknown about the factors that contribute to successful moderated drinking, we use dynamical systems modeling to identify mechanisms of behavior change. Daily alcohol consumption and daily desire (i.e., craving) are modeled using a system of delayed difference equations. Employing a mixed effects implementation of this system allows us to garner information about these mechanisms at both the population and individual levels. Use of this mixed effects framework first requires a parameter set reduction via identifiability analysis. The model calibration is then performed using Bayesian parameter estimation techniques. Finally, we demonstrate how conducting a parameter sensitivity analysis can assist in identifying optimal targets of intervention at the patient-specific level. This proof-of-concept analysis provides a foundation for future modeling to describe mechanisms of behavior change and determine potential treatment strategies in patients with AUD.

Age as a moderator of motivational interviewing and nondirective client-centered psychotherapy for alcohol use disorder: An exploratory study.

BACKGROUND: Motivational interviewing (MI) is a widely used intervention applied to a host of health behaviors, including alcohol consumption among individuals with alcohol use disorder (AUD). Age is an underexplored moderator of MI for treating AUD, with the impact of comparing older individuals with their younger counterparts virtually unexplored. Also unexplored is whether age is associated with distinct mechanisms of change (e.g., motivation and self-efficacy) within treatment. METHODS: This secondary data analysis utilizes combined data from two previous studies (total N = 228) that both aimed to test MI's mechanisms of action in the context of a goal for moderated drinking. Both studies had three conditions: MI, nondirective listening (NDL), and a self-change condition (SC). In the current analyses, the moderating impact of continuous age and age group, <51 (younger adults, YA) versus ≥51 (older adults, OA), on the impact of MI on alcohol use compared to NDL and SC were tested using generalized linear models. Age differences in confidence and commitment to reduce heavy drinking during treatment were also explored. RESULTS: Age group by condition differences emerged, where NDL significantly reduced drinking among YA but not OA (mean -12 vs. -3 standard drinks, respectively). Among OA, MI outperformed NDL but not SC, though the effect was weak. Confidence and commitment during treatment were not significantly different across age-by-condition groups. CONCLUSION: Findings underscore the importance of understanding the impact of age on treatment effectiveness, as providing a nondirective intervention for OA with AUD could provide suboptimal treatment. Further research is needed to explore these differential effects.

A Comparison of Mathematical and Statistical Modeling with Longitudinal Data: An Application to Ecological Momentary Assessment of Behavior Change in Individuals with Alcohol Use Disorder.

Ecological momentary assessment (EMA) has been broadly used to collect real-time longitudinal data in behavioral research. Several analytic methods have been applied to EMA data to understand the changes of motivation, behavior, and emotions on a daily or within-day basis. One challenge when utilizing those methods on intensive datasets in the behavioral field is to understand when and why the methods are appropriate to investigate particular research questions. In this manuscript, we compared two widely used methods (generalized estimating equations and generalized linear mixed models) in behavioral research with three other less frequently used methods (Markov models, generalized linear mixed-effects Markov models, and differential equations) in behavioral research but widely used in other fields. The purpose of this manuscript is to illustrate the application of five distinct analytic methods to one dataset of intensive longitudinal data on drinking behavior, highlighting the utility of each method.

The Role of Daily Goal Setting Among Individuals with Alcohol Use Disorder.

Introduction: Individuals with alcohol use disorder (AUD) who seek help to reduce their drinking are expected to vary with respect to drinking goal, with some choosing abstinence and others moderation. The present research explored whether drinking goals vary day to day among individuals with AUD planning to enter treatment and the relationship of specific daily goals to actual drinking behavior in daily life. Methods: Participants were 153 individuals with AUD who enrolled in a study of stepped care brief interventions and completed smartphone momentary assessments in daily life. Drinking goals and number of standard drinks consumed were reported daily for 21 consecutive days after receiving brief advice but prior to assignment to further treatment. Daily drinking goals were coded as (a) complete abstinence (b) moderation, i.e., 2 or fewer standard drinks, or (c) other. Mixed-effects models nested daily drinking goals within individuals to consider both individual and daily patterns in daily goal setting. Results: Complete abstinence was the most common daily drinking goal and showed greater day-to-day stability than setting a moderation goal. Setting an abstinence goal in the morning was also most successful in limiting alcohol consumption later that day, relative to other goals. Those individuals who set more abstinence goals, however, were also those who drank more per drinking occasion. Conclusions: Findings support the clinical benefit of mapping daily goal setting and strategizing for specific circumstances. Future research may track the relation of daily drinking goals to successful goal achievement during treatment and compare to overall treatment goals.

Effects of a New York Medicaid Care Management Program on Substance Use Disorder Treatment Services and Medicaid Spending: Implications for Defining the Target Population.

AIMS: We examined the effects of a statewide New York (NY) care management (CM) program for substance use disorder (SUD), Managed Addiction Treatment Services (MATS), on SUD treatment services' utilization and spending among patients with a recent history of high Medicaid spending and among those for whom a predictive algorithm indicates a higher probability of outlier spending in the following year. METHODS: We applied difference-in-difference analyses with propensity score matching using NY Medicaid claims data and a state registry of SUD-treatment episodes from 2006 to 2009. A total of 1263 CM enrollees with high SUD treatment spending (>$10K) in the prior year and a matched comparison group were included in the analysis. Crisis care utilization for SUD (detoxification and hospitalizations), outpatient SUD treatment, and Medicaid spending were examined over 12 months among both groups. CM effects among predicted high-future-spending patients (HFS) were also analyzed. RESULTS: CM increased outpatient SUD treatment visits by approximately 10.5 days (95% CI = 0.9, 20.0). CM crisis care and spending outcomes were not statistically different from comparison since both conditions had comparable pre-post declines. Conversely, CM significantly reduced SUD treatment spending by approximately $955 (95% CI = -1518, -391) and reduced days of detox utilization by about 1.0 days (95% CI = -1.9, -0.1) among HFS. CONCLUSION: Findings suggest that CM can reduce SUD treatment spending and utilization when targeted at patients with a greater likelihood of high future spending, indicating the potential value of predictive models to select CM patients.

Effects of Medicaid Health Homes among people with substance use disorder and another chronic condition on health care utilization and spending: Lessons from New York State.

INTRODUCTION: New York State implemented a Health Homes (HH) care management program to facilitate access to health services for Medicaid enrollees with multiple chronic conditions. This study assessed the impact of HH on health care utilization outcomes among enrollees who have substance use disorder (SUD). METHODS: Using HH enrollment data and Medicaid claims data 1 year before and after enrollment, this study compared HH enrollees who enrolled between 2012 and 2014 to a statistically matched comparison group created with propensity score methods. Analyses used generalized gamma models, logistic regression models, and difference-in-differences analyses to assess the impact of HH on general (all-cause) health care and SUD-related outpatient, emergency department (ED), hospitalization, and detoxification utilization as well as total Medicaid cost. RESULTS: The sample consisted of 41,229 HH enrollees and a comparison group of 39,471 matched patients. HH-enrolled patients who had SUD utilized less SUD-related ED services (average marginal effect (AME) = -1.85; 95% CI = -2.45, -1.24), SUD-related hospitalizations (AME = -1.28; 95% CI: -1.64, -0.93), and detoxification services (AME = -1.30; 95% CI = -1.64, -0.96), relative to the comparison group during the 1 year post-HH enrollment. SUD-related outpatient visits did not change significantly (AME = -0.28; 95% CI = -0.76, 0.19) for enrollees, but general health care outpatient visits increased (AME = 1.63; 95% CI = 1.33, 1.93). CONCLUSION: These findings provide preliminary evidence that care management programs can decrease ED visits and hospitalizations among people with SUD.

"I Felt I Was Reaching a Point with My Health": Understanding Reasons for Engagement and Acceptability of Treatment Services for Unhealthy Alcohol Use in Primary Care.

INTRODUCTION/OBJECTIVES: Despite increasing need, there are large gaps in provision of care for unhealthy alcohol use. Primary care practices have become increasingly important in providing services for unhealthy alcohol use, yet little is known about the reasons patients engage in these services and their views on acceptability of such programs. The purpose of this study was to examine primary care patients' reasons for engagement, experiences with, and acceptability of a primary care practice-based program for treating unhealthy alcohol use. METHODS: This qualitative study was conducted in a primary care practice that was developing a collaborative care model for treating unhealthy alcohol use in primary care. Semi-structured interviews were conducted with 24 primary care patients. Data were analyzed using conventional qualitative content analysis. RESULTS: Findings suggest that patients engaged for both internal (concerns about drinking and health) and external reasons (family or provider concern). Patient experiences in the program were shaped by their affective responses (enjoyable, enlightening), as well as therapeutic benefits (gaining new insights about drinking; staff/provider support). Acceptability was driven by core program elements (medication, therapy, integration) as well as positive impacts on drinking cognition and behavior and flexible, patient-centered approaches. CONCLUSIONS: Offering flexible and comprehensive programs with mutiple elements and both abstinence and moderation goals could also improve patient engagement and views on acceptability. Primary care practices will need to be thoughtful about the resources needed to implement these programs in terms of staffing, training, and program support.

An efficacy trial of adaptive interventions for alcohol use disorder.

BACKGROUND: Adaptive interventions, sometimes referred to as "stepped care", are those interventions in which the type or dosage of treatment offered to patients is tailored to baseline clinical presentation and then adjusted over time in response to patient progress or lack thereof. Currently, no adaptive brief interventions exist specifically for alcohol use disorder (AUD). METHOD: This study used a sequential multiple assignment randomized trial design with 160 individuals with AUD recruited both locally and nationally who had a goal to reduce or abstain from drinking. Participants received brief advice (BA) and then the study reassessed them three weeks later; the study randomized those who did not respond to BA, defined as reducing their drinking to low-risk guidelines, to two session of motivational interviewing (MI) or more BA. The study then reassessed participants at week 8. The study re-randomized nonresponders to receive either MI alone or MI plus behavioral self-control therapy (BSCT), also referred to as coping skills therapy, and evaluated participants at week 13. RESULTS: Overall, participants receiving any BSCT made the greatest reductions in drinking. Participants who received MI at week 4 and BSCT at week 8 outperformed all other groups. CONCLUSION: Findings reveal that prolonged treatment, more sessions, and/or a specific combination of MI and BSCT provided optimal outcomes. Future research should determine whether such an algorithm holds across heterogenous groups of individuals with AUD.

Underexamined points of vulnerability for black mothers in the child welfare system: The role of number of births, age of first use of substances and criminal justice involvement.

Black mothers and their children continue to interface with the child welfare (CW) system at unacceptably high rates. With research into traditionally understood contributing factors such as poverty, substance use, mental health and intimate partner violence abounding, this study sought to identify underexamined factors that potentially sustain very high rates of CW involvement for Black mothers. A sample of 415 Black mothers who accessed financial assistance through the Temporary Assistance for Needy Families program was analyzed for the factors associated with active CW involvement. Analytic procedures included, first, independent t-test and chi-square tests to determine significant group differences. Second, logistic regression was used to test a range of psychosocial risk factors for active CW involvement. Results from our final model indicated three factors beyond those typically associated with CW involvement, number of births, age at first use of cocaine and legal involvement. The standout impact of having a history of CW involvement is also discussed. Implications for policy and practice are explored.

Drink goal difficulty effect on outcomes in moderation-based alcohol treatment for sexual minority men.

Sexual minority men (SMM) who drink heavily are at a greater risk for developing alcohol use disorders (AUD) and associated negative consequences. Barriers to treatment prevent SMM from accessing traditional care, and moderation-based alcohol treatment is a more desirable alternative. As such, investigating effective goal setting in moderation-based alcohol treatment, particularly, which goals yield the most effective outcomes, is warranted. Applying the tenets of Goal Setting Theory, this study explored the relationship between goal difficulty and goal achievement. In a secondary data analysis of a randomized controlled trial that delivered a combination of medication (i.e., naltrexone) and behavioral (i.e., Modified Behavioral Self-Control Training) treatment for SMM with AUD (N = 178), generalized estimating equations tested the effect of goal difficulty (defined as the proposed magnitude of change from current drinking in number of drinking days and number of heavy drinking days) on goal achievement at Months 0, 3, 6, and 9. Goal importance, self-efficacy, and AUD severity were tested as moderators. Findings yielded a significant positive relationship between goal difficulty and goal achievement for number of drinking days but a negative relationship for the number of heavy drinking days. Moderators of these relationships were not found. In order to increase the likelihood of achieving their goals in moderation-based alcohol treatment, SMM should initially consider setting more difficult goals for reducing drinking days. Additionally, goals of more conservative difficulty should be set for reducing heavy drinking days.

Context and craving among individuals with alcohol use disorder attempting to moderate their drinking.

Many individuals with alcohol use disorder (AUD) prefer a goal of moderation, because they do not see their drinking as causing severe enough consequences to merit abstinence. Given that individuals attempting to moderate will continue to put themselves in contexts where drinking occurs, understanding how distinct external alcohol cues prompt craving is important for implementing the optimal treatments for individuals with AUD. Using data from a randomized controlled trial of stepped care brief interventions for AUD, this study explored the relationship between drinking contexts and craving in individuals attempting to moderate their drinking using ecological momentary assessment (EMA). At baseline, participants were asked to prospectively identify drinking contexts that were particularly likely to elicit intense craving and heavy drinking, called highly valued drinking contexts (HVCs). During EMA, participants were asked to report three times a day (morning, afternoon, evening) on their non-mutually exclusive contexts and their level of craving. Using multilevel modeling, all drinking contexts were tested as concurrent predictors of craving across the 84 days of the study. Next, AUD severity was tested as a moderator of HVC on craving. Results demonstrated that being in an HVC corresponded to greater reports of any craving and intensity of craving, over and above the influences of several other contextual factors (e.g., negative affect and already drinking). AUD severity significantly moderated HVC's impact on any craving, such that greater AUD severity potentiated HVC's already high odds of any craving. Implications for treatments for individuals with AUD are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Examining motivational interviewing's effect on confidence and commitment using daily data.

Mechanisms of behavior change (MOBC) within Motivational Interviewing (MI) are thought to operate via both relational and technical elements. These elements are hypothesized to increase client motivation and self-efficacy for change and subsequently decrease drinking. Only partial support for this causal chain exists, particularly when using within-session change talk as the primary intervening variable. This study explored whether commitment to moderate or abstain from drinking and confidence to moderate drinking in the next day measured via ecological momentary assessment (EMA) provided alternative support for the theory. Data were from a pilot randomized controlled trial testing active ingredients of MI. Problem drinkers (N = 89) seeking to moderate their drinking were randomly assigned to one of the three conditions: 1) MI; 2) Spirit only MI (SOMI), consisting of non-directive elements of MI, e.g., reflective listening; and 3) a non-therapy control. Participants completed daily EMA that measured confidence, both types of commitment, and drinks per day for a week prior to and during seven weeks of treatment. Hypotheses were not supported, and results were unexpected. Participants in SOMI were more likely to have higher daily confidence than those in MI; there were no condition differences for either type of commitment. All daily measures significantly predicted drinking; however, the MI group did not demonstrate a stronger relationship between the intervening variables and drinking, as hypothesized. Instead, participants in SOMI yielded the strongest relationship between daily commitment to abstain and drinking compared to the other two conditions. Multiple possible explanations for the unexpected findings are discussed.

Mental Contrasting With Implementation Intentions Reduces Drinking When Drinking Is Hazardous: An Online Self-Regulation Intervention.

Introduction. Drinking alcohol has detrimental health consequences, and effective interventions to reduce hazardous drinking are needed. The self-regulation intervention of Mental Contrasting with Implementation Intentions (MCII) promotes behavior change across a variety of health behaviors. In this study, we tested if online delivery of MCII reduced hazardous drinking in people who were worried about their drinking. Method. Participants (N = 200, female = 107) were recruited online. They were randomized to learn MCII or solve simple math problems (control). Results. Immediately after the intervention, participants in the MCII condition (vs. control) reported an increased commitment to reduce drinking. After 1 month, they reported having taken action measured by the Readiness to Change drinking scale. When drinking was hazardous (Alcohol Use Disorders Identification Test ≥ 8, n = 85), participants in the MCII condition indicated a decreased number of drinking days, exp(ß) = 0.47, CI (confidence interval) [-1.322, -.207], p = .02, and drinks per week, exp(ß) = 0.57, CI [0.94, 5.514], p = .007, compared with the control condition. Discussion. These findings demonstrate that a brief, self-guided online intervention (Mdn = 28 minutes) can reduce drinking in people who worry about their drinking. Our findings show a higher impact in people at risk for hazardous drinking. Conclusion. MCII is scalable as an online intervention. Future studies should test the cost-effectiveness of the intervention in real-world settings.

Substance use screening and brief intervention: Evaluation of patient and implementation differences between primary care and emergency department settings.

RATIONALE, AIMS, AND OBJECTIVES: There are well-documented barriers that have limited widespread, sustained adoption of screening and brief intervention for risky substance use in health care settings. In order to better inform implementation efforts, this study evaluates whether patient characteristics, screening results, and implementation success indicators differed between two clinical setting types: primary care and emergency. METHODS: Patients presenting to an emergency or primary care setting were screened for risky substance use (n = 41 567). Patients with a positive screen were further assessed for psychosocial, health, and substance use problems (n = 1604). Differences in patient characteristics between primary care and emergency settings were examined using chi-square and t tests. Multilevel logistic regression was used to examine whether setting type predicted screening results. Site-level indicators of implementation success were calculated (percentage prescreens completed, percentage full screens completed, and percentage refused services) for all patient visits (n = 78 656). RESULTS: As compared with primary care patients, emergency patients had more severe substance use patterns and screening scores, were more likely to use a variety of illicit drugs, and reported more psychosocial issues. In logistic regression models, setting type did not predict whether patients screened positive; however, it did predict screening into a higher vs lower risk category such that emergency patients were more likely to be in a higher risk category. Emergency settings had lower indicators of implementation success (eg, 14% lower prescreen completion rate) as compared with primary care settings on some implementation measures. CONCLUSIONS: This evaluation found important differences in patient characteristics and screening and implementation results between primary care and emergency settings. Health care organizations and administrators implementing screening and brief intervention should attend to setting differences that could affect implementation and clinical care.

The relationship between in-session commitment language and daily self-reported commitment to reduce or abstain from drinking.

BACKGROUND: Motivational interviewing is hypothesized to operate by enhancing a client's internal motivation to change. Past research operationalizes this process by measuring in-session statements for change (i.e., change talk), yet relationships between change talk and other measures of motivation have yet to be substantiated. This study tested whether in-session change talk predicted subsequent reports of commitment to abstain or moderate drinking assessed via ecological momentary assessment (EMA), and explored each of their contributions to drinking outcomes. METHOD: Secondary data analysis was performed on data from 48 study participants who received therapy within a randomized controlled trial testing mechanisms of actions of MI. Multilevel models were used to test whether in-session commitment statements (strength, frequency, and slope of strength) made in two therapy sessions predicted subsequent daily reports of commitment to abstain or not drink heavily and drinking (21 days of data) in the weeks following each respective session. RESULTS: A weak, negative relationship between in-session commitment and average daily commitment to abstain emerged. No relationship between in-session statements and average daily commitment to not drink heavily emerged. Only EMA commitment predicted drinking outcome. Post hoc analyses demonstrate a moderating impact of EMA commitment to abstain on in-session commitment strength: low pre-treatment commitment to abstain and increasing commitment strength across a session yielded the greatest drink reduction. CONCLUSION: In-session change talk and EMA commitment may represent distinct aspects of motivation, yet their interaction appears important to treatment prognoses. Commitment to abstain may be important for treatment selection and successful drink reduction.