Treatment Attendance Among Veterans With Depression, Substance Use Disorder, and Trauma.

OBJECTIVE: Low attendance in psychotherapy, particularly among individuals with comorbid disorders, is a pervasive challenge. The present study examined predictors of treatment attendance in a sample of veterans with depression, substance use disorder, and trauma. METHODS: This is an analysis of data collected as part of a larger clinical trial involving outpatients at a Veterans Administration dual diagnosis clinic. Individuals were excluded if they had significant memory deficits, schizophrenia, bipolar disorder, or substantial travel constraints. Participants (N = 146) received 12 weeks of group-delivered integrated cognitive behavioral therapy for depression and substance use, followed by randomization to 12 additional weeks of individually delivered cognitive behavioral therapy (n = 62) or cognitive processing therapy (n = 61) modified to address substance use and trauma. Participants, therapists, and researchers were not blinded to group assignment. For this study, we included only the 123 participants who were randomized into the second phase, analyzing predictors of treatment attendance categorized into predisposing factors, enabling factors, and need factors. RESULTS: Participants were primarily male (89%) and Caucasian (76%) and averaged 47 years old (SD = 12). Forty-four percent had alcohol use disorder, 16% had drug use disorder, and 40% had polysubstance use disorder. Most met criteria for PTSD (82%), with 44% having combat-related trauma, 33% sexual trauma, and 28% other trauma. Treatment attendance did not differ between groups. More education was associated with increased group (r = .19, p = .04) and individual session attendance (r = .28, p = .002). Individuals with chronic housing problems attended fewer group sessions (r = -.19, p = .04), while individuals with sexual trauma, compared to those with other traumas, attended more individual sessions (r = .23, p = .01). Number of group sessions attended was positively associated with individual session attendance. CONCLUSIONS: Few variables were significantly predictive of treatment attendance, possibly due to the complex nature of comorbid disorders. Including a focus on trauma was not associated with lower attendance. Special consideration may need to be given to education level, homelessness, and trauma when trying to engage and retain patients with comorbid disorders in treatment. This clinical trial is registered at www.clinicaltrials.gov as NCT00958217.

Behavioral economic predictors of brief alcohol intervention outcomes.

OBJECTIVE: The present study attempted to determine whether behavioral economic indices of elevated alcohol reward value, measured before and immediately after a brief alcohol intervention, predict treatment response. METHOD: Participants were 133 heavy drinking college students (49.6% female, 51.4% male; 64.3% Caucasian, 29.5% African American) who were randomized to 1 of 3 conditions: motivational interviewing plus personalized feedback (brief motivational interventions; BMI), computerized personalized feedback intervention (electronic check-up to go; e-CHUG), and assessment only. RESULTS: Baseline level of alcohol demand intensity (maximum consumption) significantly predicted drinks per week and alcohol problems at 1-month follow-up and baseline relative discretionary expenditures on alcohol significantly predicted drinks per week and alcohol problems at 6-month follow-up. BMI and e-CHUG were associated with an immediate postsession reduction in alcohol demand (p < .001, ηp2 = .29) that persisted at the 1-month follow-up, with greater postsession reductions in the BMI condition (p = .02, ηp2 = .06). Reductions in demand intensity and Omax (maximum expenditure) immediately postintervention significantly predicted drinking reductions at 1-month follow up (p = .04, ΔR2 = .02, and p = .01, ΔR2 = .03, respectively). Reductions in relative discretionary expenditures on alcohol at 1-month significantly predicted drinking (p = .002, ΔR2 = .06,) and alcohol problem (p < .001, ΔR2 = .13) reductions at the 6-month follow-up. CONCLUSIONS: These results suggest that behavioral economic reward value indices may function as risk factors for poor intervention response and as clinically relevant markers of change in heavy drinkers.

Chronic physical health problems moderate changes in depression and substance use among dual diagnosed individuals during and after treatment.

BACKGROUND: Physical illnesses frequently co-occur with depression and substance use disorders and may impact their improvement. Physical illness symptoms may overlap with or exacerbate somatic symptoms of depression. Individuals may use substances to cope with symptoms of physical illness. OBJECTIVES: We examined whether chronic physical health problems moderated changes in depression and substance use among dual diagnosed individuals during and in the year following treatment. METHODS: Participants were recruited from a Veterans Affairs dual diagnosis outpatient program between March 2000 and November 2007 and were randomized to either Integrated Cognitive-Behavioral Therapy or Twelve-Step Facilitation Therapy. A total of 214 veterans with assessment data for the variables of interest were included in analyses. Participants completed quarterly depression, substance use, and health assessments over an 18 month period. We used linear-mixed effects models to analyze patterns of change for depression and substance use. RESULTS: Individuals with severe chronic health problems and higher intake depression showed slower improvements in both nonsomatic and somatic depression symptoms. Individuals with severe chronic health problems and higher midtreatment substance use showed less improvement in substance use. CONCLUSIONS: Assessing and addressing physical health issues during depression and substance use disorder treatment may improve outcomes.

Family history of problem drinking is associated with less sensitivity of alcohol demand to a next-day responsibility.

OBJECTIVE: Behavioral economic demand curves measure alcohol consumption as a function of price and may capture clinically relevant individual differences in alcohol-reinforcing efficacy. This study used a novel, behavioral-economic, hypothetical demand-curve paradigm to examine the association between family history of alcohol misuse and individual differences in both alcohol demand and the relative sensitivity of alcohol demand to next-day responsibilities. METHOD: Participants were 207 college students (47% male, 68.5% White, 27.4% African American, Mage = 19.5 years) who reported at least one heavy drinking episode (5/4 or more drinks on one occasion for a man/woman) in the past month and completed two versions of an alcohol purchase task (APT) that assessed hypothetical alcohol consumption across 17 drink prices. In one APT (standard), students imagined they had no next-day responsibilities, and in the other, they imagined having a 10:00 a.m. test the next day. RESULTS: A series of analyses of covariance indicated that participants with at least one biological parent or grandparent who had misused alcohol reported similar levels of alcohol demand on the standard APT but significantly less sensitivity to the next-day academic responsibility as measured by the percentage of reduction in demand intensity and breakpoint across the no-responsibility and next-day-test conditions. CONCLUSIONS: These findings provide initial evidence that APTs might clarify one potential mechanism of risk conferred by family history. Young adult heavy drinkers with a family history of problematic drinking may be less sensitive to next-day responsibilities that might modulate drinking in drinkers without a family history of alcohol problems.

Behavioral economic measures of alcohol reward value as problem severity indicators in college students.

The aims of the current study were to examine the associations among behavioral economic measures of alcohol value derived from 3 distinct measurement approaches, and to evaluate their respective relations with traditional indicators of alcohol problem severity in college drinkers. Five behavioral economic metrics were derived from hypothetical demand curves that quantify reward value by plotting consumption and expenditures as a function of price, another metric measured proportional behavioral allocation and enjoyment related to alcohol versus other activities, and a final metric measured relative discretionary expenditures on alcohol (RDEA). The sample included 207 heavy-drinking college students (53% female) who were recruited through an on-campus health center or university courses. Factor analysis revealed that the alcohol valuation construct comprises 2 factors: 1 factor that reflects participants' levels of alcohol price sensitivity (demand persistence), and a second factor that reflects participants' maximum consumption and monetary and behavioral allocation toward alcohol (amplitude of demand). The demand persistence and behavioral allocation metrics demonstrated the strongest and most consistent multivariate relations with alcohol-related problems, even when controlling for other well-established predictors. The results suggest that behavioral economic indices of reward value show meaningful relations with alcohol problem severity in young adults. Despite the presence of some gender differences, these measures appear to be useful problem indicators for men and women.

Demographic and predeparture factors associated with drinking and alcohol-related consequences for college students completing study abroad experiences.

OBJECTIVE: Study abroad students are at risk for increased and problematic drinking behavior. As few efforts have been made to examine this at-risk population, the authors predicted drinking and alcohol-related consequences abroad from predeparture and site-specific factors. PARTICIPANTS: The sample consisted of 339 students completing study abroad programs. METHODS: Participants filled out online measures at predeparture, abroad, and at postreturn. RESULTS: The authors found that drinking and consequences abroad were predicted by a number of factors, including demographics (eg, younger age, male sex, Greek affiliation, white ethnicity), student factors (eg, low GPA, major area of study), study abroad site factors (eg, apartment living abroad, study in Europe), predeparture levels of drinking and consequences, sensation seeking, and goals related to social gathering. CONCLUSIONS: Findings can be used to inform campus policies for admission to study abroad programs as well as assist in the development of interventions targeted toward preventing risk for students during abroad experiences.

Impact of Physical Health on Treatment for Co-occurring Depression and Substance Dependence.

OBJECTIVE: There is a high rate of comorbidity among substance dependence, depression, and physical health problems. This study aimed to examine the impact of pre-treatment physical health stressors (acute and chronic conditions) on outcomes of treatment in a sample of veterans with dual disorders (depression and substance dependence) who were randomized to integrated cognitive behavioral therapy versus 12-Step interventions. METHODS: This study included 205 veterans (89.8% male, mean age = 49.5 years) enrolled in a clinical treatment outcomes trial. Chronic health problems (persistent, ongoing conditions lasting 2 weeks or more; e.g., arthritis, diabetes) and acute health events (occurring on a discrete date; e.g., injury, surgery, myocardial infarction) were coded dichotomously (presence versus absence) and evaluated separately. The impact of physical health stressors on abstinence (defined dichotomously), percentage of days abstinent, and depression symptoms were analyzed at the end of 12 and 24 weeks of treatment. Additionally, associations between intake motivation to change, health stressors, and substance use were examined. RESULTS: Analyses revealed that participants who had experienced a pretreatment acute health event had higher rates of abstinence at 12-weeks, higher percentage of days abstinent at 24-weeks, and higher depression symptoms at intake. Participants with chronic health difficulties had more severe depression at intake and those participants with severe chronic difficulties had greater depression symptoms across all time points. Chronic health difficulties were related to the Taking Steps factor of motivation to change substance use, but acute health events were not related to motivation to change. Motivation to change was also not related to substance outcomes in our sample. CONCLUSIONS: Physical health appears to have a complex relationship with co-occurring depression and substance dependence. Acute health problems predicted lower substance use, whereas chronic health problems were associated with higher depression levels. Explicitly addressing the connection between substance use and health events during treatment may improve addiction treatment outcomes. However, individuals with chronic health problems may benefit from extending treatment or adjunct strategies focused on addressing chronic health concerns. This is an analysis of data collected as part of a clinical trial registered at www.ClinicalTrials.gov as NCT00108407.

Symptoms of depression and PTSD are associated with elevated alcohol demand.

BACKGROUND: Behavioral economic demand curves measure individual differences in motivation for alcohol and have been associated with problematic patterns of alcohol use, but little is known about the variables that may contribute to elevated demand. Negative visceral states have been theorized to increase demand for alcohol and to contribute to excessive drinking patterns, but little empirical research has evaluated this possibility. The present study tested the hypothesis that symptoms of depression and PTSD would be uniquely associated with elevated alcohol demand even after taking into account differences in typical drinking levels. METHOD: An Alcohol Purchase Task (APT) was used to generate a demand curve measure of alcohol reinforcement in a sample of 133 college students (50.4% male, 64.4% Caucasian, 29.5% African-American) who reported at least one heavy drinking episode (5/4 or more drinks in one occasion for a man/woman) in the past month. Participants also completed standard measures of alcohol consumption and symptoms of depression and PTSD. RESULTS: Regression analyses indicated that symptoms of depression were associated with higher demand intensity (alcohol consumption when price=0; ΔR(2)=.05, p=.002) and lower elasticity (ΔR(2)=.04, p=.03), and that PTSD symptoms were associated with all five demand curve metrics (ΔR(2)=.04-.07, ps<.05). CONCLUSIONS: These findings provide support for behavioral economic models of addiction that highlight the role of aversive visceral states in increasing the reward value of alcohol and provide an additional theoretical model to explain the association between negative affect and problematic drinking patterns.

The impact of elevated posttraumatic stress on the efficacy of brief alcohol interventions for heavy drinking college students.

Brief alcohol interventions (BAIs) have been widely adopted for use with college students and are associated with significant reductions in drinking and problems. However, many students do not respond to these approaches and little is known about risk factors for poor response. The current study investigated one possible risk factor by examining the impact of posttraumatic stress (PTS) symptoms on BAI efficacy. This study presents pooled data from two randomized clinical trials that examined the efficacy of counselor-administered BAIs compared with computerized interventions. Participants were 207 college students (53.1% women, 68.1% White/Caucasian, 16.9% with elevated post-traumatic stress) who reported past-month heavy episodic drinking. Follow-up assessments were completed six months post-intervention. Analyses testing differences in frequency of past-month heavy episodic drinking revealed a significant post-traumatic stress by time interaction (F(1,165)=8.27, p=.005) such that individuals screening positive for PTS showed larger reductions in heavy episodic drinking at follow-up. A significant three-way interaction between time, PTS, and intervention condition (F(2,167)=5.76, p=.004) was found for alcohol related consequences. Specifically, among individuals screening positive for PTS, only those that received the counselor-administered BAI showed a significant reduction in consequences at follow-up. These results suggest that overall college students with PTS may respond well to BAIs and that counselor-delivered BAIs may be more efficacious than computer-delivered interventions for reducing alcohol problems for these high-risk students.

Alcohol-related consequences in African American and European American college students.

Approximately 50% of college students report a heavy drinking episode in the past 2 weeks. This pattern of heavy episodic drinking places them at risk for experiencing alcohol-related problems. In addition, important ethnic differences exist between European American and African American college students in terms of drinking. European American college students report consuming more alcohol than African American college students, but little research exists on the differences in types and rates of problems. The current study sought to examine the differences in problems among 451 African American and European American college students using a comprehensive measure of alcohol-related problems. The effect of gender was also examined as research has found consistent gender differences in drinking. European American students experienced more problems overall and greater levels of social/interpersonal problems and risky behaviors even after controlling for drinking level. In addition, women reported significantly greater levels of problems in all domains except physical dependence, risky behaviors, and self-perception when drinking was controlled for.

A randomized controlled trial of a behavioral economic supplement to brief motivational interventions for college drinking.

OBJECTIVE: Behavioral economic theory suggests that a reduction in substance use is most likely when there is an increase in rewarding substance-free activities. The goal of this randomized controlled clinical trial was to evaluate the incremental efficacy of a novel behavioral economic supplement (Substance-Free Activity Session [SFAS]) to a standard alcohol brief motivational interviewing (BMI) session for heavy-drinking college students. METHOD: Participants were 82 first-year college students (50% female; 81.7% White/European American; M age = 18.5 years, SD = 0.71) who reported 2 or more past-month heavy drinking episodes. After completing a baseline assessment and an individual alcohol-focused BMI, participants were randomized to either the SFAS or to a Relaxation Training (RT) control session. The SFAS was delivered in an MI style and attempted to increase the salience of delayed academic and career rewards and the patterns of behavior leading to those rewards. RESULTS: The combination of an alcohol BMI plus the SFAS was associated with significantly greater reductions in alcohol problems compared with an alcohol BMI plus RT at the 1-month and 6-month follow-up assessments (p = .015, ηp² = .07), an effect that was partially mediated by increases in protective behavioral strategies. BMI + SFAS was also associated with greater reductions in heavy drinking among participants who at baseline reported low levels of substance-free reinforcement or symptoms of depression. CONCLUSION: These results are consistent with behavioral economic theory and suggest that a single session focused on increasing engagement in alternatives to drinking can enhance the effects of brief alcohol interventions.

A behavioral economic supplement to brief motivational interventions for college drinking.

Basic behavioral and neurobiological research has demonstrated that deficiencies in naturally occurring substance-free rewards are both a cause and a consequence of substance abuse that are due in part to the systematic discounting of delayed substance-free rewards. Existing brief motivational interventions (BMIs) for alcohol abuse do not target this mechanism of change. The goal of this uncontrolled pilot study was to evaluate a behavioral economic Substance-Free Activity Session (SFAS) to traditional alcohol BMIs. Participants were 13 college freshmen who reported two or more heavy drinking episodes (>5/4 drinks in an occasion for men/ women) in the past month. All participants completed a baseline assessment and a BMI that addressed alcohol use. In addition, participants received the SFAS, a 50-min individual session that attempts to increase engagement in constructive alternatives to drinking by enhancing the salience of delayed rewards (academic and career success) and the patterns of behavior (academic and extracurricular engagement) leading to these outcomes. At the 1-month follow-up assessment, participants reported significant reductions in heavy drinking, and moderate to large effect size reductions in weekly drinking and peak blood alcohol levels. The results of this pilot study provide preliminary support for the efficacy of this behavioral economic intervention session as a supplement to traditional alcohol BMIs.

Drinking motives mediate the relationship between reinforcing efficacy and alcohol consumption and problems.

OBJECTIVE: Several studies have shown that demand curve indices of the reinforcing efficacy of alcohol (i.e., reports of hypothetical alcohol consumption and expenditures across a range of drink prices) are associated with alcohol-related outcomes. A next logical step in this area of research is to examine potential mediators of this direct relationship. It is possible that enhancement and coping drinking motives serve as an intermediary of the reinforcing efficacy-alcohol use relationship, such that higher reinforcing efficacy is associated with increased motivation to drink, which is then associated with greater alcohol use and problems. METHOD: Data were collected from 215 college undergraduates who reported drinking in the past 30 days. RESULTS: The demand curve reinforcing efficacy indices O(max) (maximum alcohol expenditure) and intensity (consumption level when drinks were free) demonstrated the strongest and most consistent associations with alcohol use, problems, and motives. Results from two structural equation models indicated that enhancement and coping motives mediated the relationship between reinforcing efficacy and alcohol use and alcohol-related problems. CONCLUSIONS: These results suggest that the motivational effects of the behavioral economic variable reinforcing efficacy on problematic alcohol use are in part mediated by increases in enhancement and coping motives for drinking.

The effect of drink price and next-day responsibilities on college student drinking: a behavioral economic analysis.

More than [3/4] of U.S. college students report a heavy drinking episode (HDE; 5 (for men) and 4 (for women) drinks during an occasion) in the previous 90 days. This pattern of drinking is associated with various risks and social problems for both the heavy drinkers and the larger college community. According to behavioral economics, college student drinking is a contextually bound phenomenon that is impacted by contingencies such as price and competing alternative reinforcers, including next-day responsibilities such as college classes. This study systematically examines the role of these variables by using hypothetical alcohol purchase tasks to analyze alcohol consumption and expenditures among college students who reported recent heavy drinking (N = 207, 53.1% women). The impact of gender and the personality risk factor sensation seeking (SS) were also assessed. Students were asked how many drinks they would purchase and consume across 17 drink prices and 3 next-day responsibility scenarios. Mean levels of hypothetical consumption were highly sensitive to both drink price and next-day responsibility, with the lowest drinking levels associated with high drink prices and a next-day test. Men and participants with greater levels of SS reported more demand overall (greater consumption and expenditures) than women and students with low SS personality. Contrary to our hypotheses women appeared to be less sensitive to increases in price than men. The results suggest that increasing drink prices and morning academic requirements may be useful in preventing heavy drinking among college students.

Relations between heavy drinking, gender, and substance-free reinforcement.

Behavioral economic theory and laboratory research have suggested that substance abuse may be associated with diminished engagement in enjoyable substance-free activities (substance-free reinforcement). However, college students, in particular men, have reported numerous social benefits from drinking that might mitigate the expected inverse relation between drinking and substance-free reinforcement. In this study, we examined the relations between college student heavy drinking, gender, and several categories of substance-free reinforcement (peer, dating, sexual, school, and family activities). Participants were 246 undergraduate students who were classified as a function of their reported frequency of heavy drinking during a typical week in the past month (120 heavy drinkers, 126 light drinkers). Heavy drinking was associated with significantly higher substance-free peer and sexual reinforcement. This association was gender invariant and remained significant in multiple regression models that controlled for gender, ethnicity, and fraternity or sorority membership. Substance-free reinforcement did not predict frequency of heavy drinking in models that included levels of substance-related reinforcement. The results indicate that college student heavy drinking is not associated with global deficits in substance-free reinforcement and is instead associated with increased peer and sexual activity that occurs outside the context of drinking or drug use. Prevention programs should help students to compensate for the potential loss of social reinforcement associated with reductions in drinking.

Help-seeking for alcohol-related problems in college students: correlates and preferred resources.

Despite the development of a variety of efficacious alcohol intervention approaches for college students, few student drinkers seek help. The present study assessed students' history of help-seeking for alcohol problems, as well as their estimates of how likely they would be to use various help-seeking resources, should they wish to change their drinking. Participants were 197 college students who reported recent heavy drinking (46% male, 68.5% White, 27.4% African-American). Participants completed measures related to their drinking and their use (both past use and likelihood of future use) of 14 different alcohol help-seeking options. Repeated-measures analyses of variance revealed that students preferred informal help-seeking (e.g., talking to friends and family) over formal (e.g., talking with a counselor or medical provider) and anonymous resources (e.g., internet- or computer-based programs). Higher self-ideal discrepancy, greater depressive symptoms, and more alcohol-related consequences were positively associated with actual past help-seeking. Alcohol-related problems and normative discrepancy were negatively associated with hypothetical likelihood of utilizing all three help-seeking resources. These results suggest that heavy drinking college students prefer low-threshold intervention options including peer, family, computerized, and brief motivational interventions. Only 36 participants (18.3% of the sample) reported that they had utilized any of the help-seeking options queried, suggesting that campus prevention efforts should include both promoting low-threshold interventions and attempting to increase the salience of alcohol-related risk and the potential utility of changing drinking patterns.

Computerized versus motivational interviewing alcohol interventions: impact on discrepancy, motivation, and drinking.

The authors conducted two randomized clinical trials with ethnically diverse samples of college student drinkers in order to determine (a) the relative efficacy of two popular computerized interventions versus a more comprehensive motivational interview approach (BASICS) and (b) the mechanisms of change associated with these interventions. In Study 1, heavy drinking participants recruited from a student health center (N = 74, 59% women, 23% African American) were randomly assigned to receive BASICS or the Alcohol 101 CD-ROM program. BASICS was associated with greater post-session motivation to change and self-ideal and normative discrepancy relative to Alcohol 101, but there were no group differences in the primary drinking outcomes at 1-month follow-up. Pre to post session increases in motivation predicted lower follow-up drinking across both conditions. In Study 2, heavy drinking freshman recruited from a core university course (N = 133, 50% women, 30% African American) were randomly assigned to BASICS, a web-based feedback program (e-CHUG), or assessment-only. BASICS was associated with greater post-session self-ideal discrepancy than e-CHUG, but there were no differences in motivation or normative discrepancy. There was a significant treatment effect on typical weekly and heavy drinking, with participants in BASICS reporting significantly lower follow-up drinking relative to assessment only participants. In Study 2, change in the motivation or discrepancy did not predict drinking outcomes. Across both studies, African American students assigned to BASICS reported medium effect size reductions in drinking whereas African American students assigned to Alcohol 101, e-CHUG, or assessment did not reduce their drinking.

Reliability and validity of a demand curve measure of alcohol reinforcement.

Recent clinical research suggests that several self-report behavioral economic measures of relative reinforcing efficacy (RRE) may show utility as indices of substance abuse problem severity. The goal of the present study was to evaluate the reliability and validity of the Alcohol Purchase Task (APT), a RRE measure that uses hypothetical choices regarding alcohol purchases at varying prices (demand curves) to generate several indices of alcohol-related reinforcement. Participants were 38 college students who reported recent alcohol consumption. Both the raw alcohol purchase/consumption values and several of the computed reinforcement parameters (intensity & Omax) showed good to excellent 2-week test-retest reliability. Reinforcement parameters derived from both a linear-elasticity (Hursh, Raslear, Bauman, & Black, 1989) and an exponential (Hursh & Silberberg, 2008) demand curve equation were generally less reliable, despite the fact that both equations provided a good fit to participants' reported consumption data. The APT measures of demand intensity (number of drinks consumed when price = 0), Omax (maximum expenditure), and elasticity (alpha) were correlated with weekly drinking, alcohol-related problems, and other self-report RRE measures (relative discretionary monetary expenditures toward alcohol and/or relative substance-related activity participation and enjoyment). Demand intensity was uniquely associated with problem drinking in a regression model that controlled for weekly consumption. These results provide support for the reliability and validity of the RRE indices generated with the APT.