Highly Structured Treatment Programs for Addicted Offenders: Comparing the Effects of the Reasoning & Rehabilitation Program and DBT-F.

BACKGROUND: When treating addicted offenders in a forensic psychiatric setting, a primary concern is to decrease antisocial cognitions and behaviors. The cognitive style of offenders is often characterized by impulsiveness, egocentricity, irrational thinking, and rigidity. We examined the relative efficacy of Reasoning and Rehabilitation Program (R&R) and Dialectical Behavioral Therapy- Forensic (DBT-F) on the domains of underlying psychological constructs (e.g., mental flexibility, planning, and problem-solving). MATERIALS AND METHODS: The R&R and DBT-F were introduced in a forensic-psychiatric hospital for offenders with substance addictions in Germany. We compared pre- and post-tests to measure the cognitive skills of addicted offenders having undergone R&R (N = 47), DBT-F (N = 34), or Treatment as Usual (TAU; N = 28). Participants' skills (cognitive flexibility, ability to inhibit cognitive interference, cognitive performance/mental speed, divergent and convergent reasoning/problem solving) were assessed using neuropsychological instruments. Analyses of variance were conducted to investigate whether there were significant improvements within groups and whether these differences were significant between groups. To examine the predictive power of treatment-program on outcomes, and diagnosis of personality disorder, a hierarchical regression model was used. RESULTS: Both programs were associated with improvements in nearly all of the measured constructs. The only construct on which the R&R and DBT-F groups differed significantly was word fluency, with those receiving R&R improving more than those receiving DBT-F. A regression model showed no predictive power for age, IQ, or diagnosis of personality disorder. Treatment group explained 13.8% of variance in cognitive flexibility but did not predict variance in other outcomes. CONCLUSION: Surprisingly, we did not find superiority for one intervention over TAU or differential effects between the two programs. Future research should use larger samples and additional outcomes, including recidivism, to identify possible effects of treatment programs. Additionally, qualitative methods might inform us about these programs are implemented as well as which outcomes may be relevant.

Relationships between a Dissociative Subtype of PTSD and Clinical Characteristics in Patients with Substance Use Disorders.

The increasing support for a dissociative subtype of post-traumatic stress disorder (PTSD-D) has led to its inclusion in DSM-5. We examined relationships between PTSD-D and relevant variables in patients with substance use disorders (SUD). The sample comprised N = 459 patients with SUD. The International Diagnostic Checklist and the Posttraumatic Diagnostic Scale were used to diagnose PTSD. In addition, participants completed the Childhood Trauma Questionnaire and the Dissociative Experiences Scale. The course of SUD was assessed by means of the European Addiction Severity Index. One-fourth of participants fulfilled a diagnosis of PTSD (25.3%). Patients with PTSD-D (N = 32, 27.6% of all patients with PTSD) reported significantly more current depressive symptoms, more current suicidal thoughts, more lifetime anxiety/tension, and more suicide attempts. The PTSD-D group also showed a significantly higher need for treatment due to drug problems, higher current use of opiates/analgesics, and a higher number of lifetime drug overdoses. In a regression model, symptoms of depression in the last month and lifetime suicide attempts significantly predicted PTSD-D. These findings suggest that PTSD-D is related to additional psychopathology and to a more severe course of substance-related problems in patients with SUD, indicating that this group also has additional treatment needs.

Mentally challenged patients in a forensic hospital: a feasibility study concerning the executive functions of forensic patients with organic brain disorder, learning disability, or mental retardation.

The past years have seen an increasing number of patients of lower intelligence or with organic brain disorder being committed into our forensic psychiatry. Our clinic has an ongoing scientific project to investigate the possibilities of reducing costs while at the same time guaranteeing adequate treatment and enforcement practice in forensic hospitals. This current project did not take these kinds of patients into consideration initially. This feasibility study is intended to examine if and to what extent these patients can be part of the scientific project. All patients of forensic psychiatry in Rostock (Mecklenburg-Western-Pomerania) with an IQ<80 (learning disorder) or a primary or secondary organic brain dysfunction that have been committed to the clinic since 2009 are included. These patients went through an extensive battery of neuropsychological tests. Furthermore, the treating psychotherapists had to rate the prognoses for criminal re-offending at discharge. Patients affected by lower intelligence or an organic brain dysfunction achieve lower results in neuropsychological testing than other patients participating in the main project. Nevertheless, participation in neuropsychological testing does not appear to overtax them. Future examination of the patients will be conducted to investigate to what extent certain therapeutic methods have been of noticeable benefit to this problematic group.

The modification of criminogenic factors on addicted offenders. The effectiveness of the Reasoning and Rehabilitation Program.

At the Clinic of Forensic Psychiatry in Rostock, Germany, we treat addicted offenders in a closed psychiatric setting. In 2009 we implemented the "Reasoning and Rehabilitation Program" (R & R, Ross & Fabiano, 1986), a cognitive skills program, in our clinic. There are several international studies confirming the efficacy of this training in diminishing recidivism. We examined a sample of 31 inpatients randomly distributed among the experimental (R & R) and the control group. Most of the study participants had committed homicide or other serious violent offenses. Prisoners with schizophrenia, organic mental disorders and mental retardation were excluded from the study. The target skills were assessed by treating psychotherapists, primary nurses and by the patients themselves. Our findings indicated that problem-solving, awareness of consequences, social perspective-taking, cognitive style, the ability to learn by experience, and persistence in the experimental group were significantly improved. The awareness of consequences has changed significantly in the assessment of the treating psychotherapists, the primary nurses, and the offenders themselves. Our current data are similar to our recent work, where we found significant changes in mental flexibility, planning, and problem-solving and positively assessed tendencies in some skills (Wettermann et al., 2012, 2011). Verification of these findings in a larger sample would strengthen the research foundation for this important training to diminish prisoner recidivism.

Combination treatment with nefazodone and cognitive-behavioral therapy for relapse prevention in alcohol-dependent men: a randomized controlled study.

BACKGROUND: This study evaluated the serotonergic antidepressant nefazodone versus placebo and specific cognitive-behavioral therapy (CBT) versus nondirective group counseling (GC) for relapse prevention in alcohol dependence in a large prospective, randomized, and placebo-controlled double-blind study at 3 German university centers. METHOD: 242 male patients fulfilling at least 5 criteria for alcohol dependence according to DSM-IV and ICD-10 were eligible, after detoxification, for one of the following treatment combinations: nefazodone + CBT, nefazodone + GC, placebo + CBT, and placebo + GC. Either nefazodone or placebo was administered throughout the evaluation period of 15 months. Either CBT or GC was applied during the first 12 weeks as group therapy according to operationalized manuals. The main outcome measures (assessed at 3 and 12 months of treatment) were the cumulative number of abstinent days, the amount of ethanol consumed during specified evaluation periods of 3 and 12 months, the number of relapses, and the duration of time until first relapse. RESULTS: After 12 weeks of treatment, no statistically significant differences were observed between the 4 treatment combinations in any outcome measure. After 52 weeks, the only significant difference was observed in the amount of ethanol consumed, with the nefazodone + GC group showing higher alcohol intake than the other 3 groups. CONCLUSIONS: The results from this carefully designed clinical trial suggest that the 4 treatment combinations do not differ substantially in their efficacy for relapse prevention in nondepressed, severely alcohol-dependent patients. Nefazodone might even increase the risk of consuming a larger amount of ethanol per relapse in a subset of patients. CBT as performed in this study was associated with little additional benefit compared with structured GC.

Antidepressant efficacy of two different rTMS procedures. High frequency over left versus low frequency over right prefrontal cortex compared with sham stimulation.

BACKGROUND: This placebo-controlled study was designed to investigate the influence of two different stimulation procedures of repetitive transcranial magnetic stimulation (rTMS) on depressive symptoms in patients with depressive disorders. Furthermore, effects on cognitive functions and psychomotor functioning were tested. METHODS: Thirty patients with depression (22 females and 8 males; mean age of 56.4 years) were included. They were treated with a stable dosage of antidepressant medication. They received either high frequency rTMS (20 Hz) over the left dorsolateral prefrontal cortex (LDLPFC), low frequency rTMS (1 Hz) over the right dorsolateral prefrontal cortex (RDLPFC) or sham stimulations (10 patients in each group) as add on treatment at 10 days within 2 weeks. Depressive symptoms were registered by means of observer ratings (Hamilton Depression Rating Scale - HDRS) and self reports (Beck Depression Inventory - BDI). Psychomotor retardation was investigated by the Motor Agitation and Retardation Scale and cognitive function by d2 test. RESULTS AND CONCLUSIONS: Differences between the rTMS procedures regarding depressive symptoms could not be found. Motor abnormalities, however, significantly improved exclusively after real stimulation procedures. Patients with less severe deficits in psychomotor speed and concentration responded more intensively than patients with severe deficits.