[Proactive psychiatry in addiction]. / Proactieve psychiatrie bij verslaving.

BACKGROUND: Most substance use disorders (SUD) emerge in adolescence and early adulthood. Early interventions in young people may reduce the risk and severity of SUD and other psychiatric disorders.
AIM: To provide suggestions for proactive psychiatry in addiction.
METHOD: Literature review.
RESULTS: Comorbidity, cumulative risks and self-regulation skills each play an important role in proactive psychiatry. Early universal prevention and intervention targeted at improving self-regulation reduces the risk of a broad array of psychiatric and social problems, including addiction.
CONCLUSION: In terms of broad prevention, much can be gained by widespread, consistent implementation and normalization of universal prevention at the pre- and elementary school level. Tijdschrift voor Psychiatrie 63(2021)2, 125-128.

[The therapeutic alliance as predictor in the treatment of young people]. / De therapeutische alliantie als voorspeller in de behandeling van jongeren.

BACKGROUND: The quality of the therapeutic alliance is an important factor in the treatment of both adult and adolescent patients in psychiatry. Little is known about the importance of the therapeutic alliance among youths who seek help for their substance abuse problems in addiction treatment. AIM: We investigated the importance of first treatment session therapeutic alliance for outcome in youth mental health and addiction treatment, considering both the youths' and therapists' perspective. METHOD: 127 adolescents participated in a prospective clinical cohort study, with favorable or unfavorable treatment outcome after 4 months as primary outcome measure. At the end of the first treatment session, youths and their therapists were asked to rate the therapeutic alliance. RESULTS: Youths' and therapists' perceptions about the therapeutic alliance at the start of treatment were predictive of treatment outcome at four months follow-up. In particular, the combined perspective on first-session alliance by both youths and therapists appeared a strong predictor for treatment outcome. If both youths and therapists rated the therapeutic alliance as weak, the percentage of youths showing a favorable treatment outcome was much lower (23%), than if youths and therapists rated the alliance as strong (70%). CONCLUSION: The present study confirms the importance of a combined perspective on the therapeutic alliance for predicting treatment outcome among patients in youth mental health and addiction treatment.

[Adolescents with concurrent ADHD and substance use disorder; international consensus]. / Jongeren met een stoornis in het gebruik van middelen en ADHD: internationale consensus.

BACKGROUND: Substance use disorder (SUD) is common among youths with attention-deficit/hyperactivity disorder (ADHD). Co-morbid ADHD and SUD in youths complicates screening, diagnosis, and treatment of both disorders and is associated with worse treatment prognosis. Limited research in youths with SUD and co-morbid ADHD provides insufficient basis for firm recommendations. To offer clinicians some guidance on this topic, we present the results of an international consensus procedure. AIM: To summarize an international consensus on diagnosis and treatment of young people with comorbid ADHD and SUD. METHOD: In a modified Delphi-study, a multidisciplinary, international group of 55 experts strived to reach consensus on 37 recommendations. RESULTS: Consensus was reached on 36 recommendations. Routine screening of ADHD and/or SUD is important. For the treatment of co-morbid SUD and ADHD in youths, both psychosocial and pharmacological treatment should be considered. Psychosocial treatment should preferably consist of psychoeducation, motivational interviewing (MI), and cognitive behavioral therapy (CBT) focused on SUD or both disorders. Long-acting stimulants are recommended as first choice pharmacotherapy, preferably embedded in psychosocial treatment. Experts did not agree on the precondition that patients need to be abstinent before starting stimulant treatment. CONCLUSION: Clinicians and youths with co-morbid SUD and ADHD can use this international consensus to choose the best possible treatment.

The working alliance inventory - short version: psychometric properties of the patient and therapist form in youth mental health and addiction care.

The therapeutic alliance is considered to play an important role in youth treatment. The commonly used versions of the Working Alliance Inventory (WAI) are based on Bordin's three-dimensional alliance model. However, previous psychometric studies of the WAI did not find this three-dimensional structure in youth psychotherapy. These earlier findings may indicate different perceptions of the alliance by adolescent versus adult patients, but may also be due to methodological shortcomings. The current study aims to address previous study limitations by evaluating the factor structure of the short version of the WAI (WAI-S) in youth treatment in multilevel analysis to address the hierarchical structure of the alliance data. We examined the psychometric properties of the patient (n = 203) and therapist (n = 62) versions of the WAI-S in youth mental health and addiction care and tested four multilevel models of alliance at start of treatment and 2-month follow-up. Our results suggests a two-factor model for youth and a three-dimensional model for their therapist at both time points. Since this is the first study that finds a best fit for a two-dimensional construct of alliance in youth, more research is needed to clarify whether the differences in alliance dimensions are due to measurement differences between the WAI-S for youth and therapists or whether youth and their therapists truly differ in their perceptions of the concept of alliance.

[Multidimensional family therapy and cognitive behavioral therapy in adolescents with a cannabis use disorder: a randomised controlled study]. / Multidimensionele gezinstherapie en cognitieve gedragstherapie bij adolescenten met een stoornis in het gebruik van cannabis; een gerandomiseerd onderzoek.

BACKGROUND: More and more adolescents with cannabis problems are seeking treatment at addiction clinics. There is an urgent need for new types of treatment in this field. AIM: To evaluate the effectiveness of multidimensional family therapy (MDFT) and cognitive behavioral therapy (CBT) in adolescents with a cannabis use disorder. METHOD: One hundred and nine adolescents were randomly assigned to outpatient MDFT or CBT. Both types of therapy groups had a planned treatment course lasting 5 to 6 months. After 12 months the two groups were compared in terms of changes in cannabis use and in terms of secondary outcome measures, including delinquency. RESULTS: Adolescents in both treatment groups showed significant and relevant reductions in cannabis use and delinquency over 12 months. Although the MDFT treatment lasted longer and was more intensive than the CBT treatment, there was no difference in the key outcome measures of the treatments. Secondary analyses indicated that older adolescents and those without comorbid psychiatric problems derived considerably more benefit from CBT, whereas younger adolescents and those with comorbid psychiatric problems benefited much more from MDFT. CONCLUSION: MDFT and CBT are equally effective in reducing cannabis use and delinquent behavior in adolescents with a cannabis use disorder. Age and comorbid psychiatric problems turned out to be important moderators of the treatment results of MDFT and CBT and could therefore be used as a starting point for matching adolescent substance abusers to the most appropriate type of treatment.

Cost-effectiveness of multidimensional family therapy compared to cognitive behavioral therapy for adolescents with a cannabis use disorder: Data from a randomized controlled trial.

OBJECTIVE: To evaluate the cost-effectiveness of Multidimensional Family Therapy (MDFT) for adolescents with a cannabis use disorder, compared to Cognitive Behavioural Therapy (CBT). METHODS: A parallel-group randomized controlled trial was performed. 109 adolescents with a DSM-IV cannabis use disorder (CBT n=54; MDFT n=55) were included. Assessments were conducted at baseline, and 3, 6, 9 and 12 months post-baseline, and included measures on cannabis and other substance use, delinquency, health care utilization, and general health related quality of life. RESULTS: Excluding those with missing cost-data, 96 participants (MDFT n=49; CBT n=47) were included. From a health care perspective, the average annual direct medical costs in the CBT group were €2015 (95%C.I. 1397-2714), compared to €5446 (95%C.I. 4159-7092) in the MDFT group. The average quality-adjusted life years (QALY's) gained were 0.06 QALY higher for the MDFT group, which led to an incremental cost-effectiveness ratio (ICER) of 54,308 Euro/QALY or €43,405 per recovered patient. Taking the costs of delinquency into account, the costs increased to €21,330 (95%C.I. 12,389-32,894) for the CBT group and to €21,915 (95%C.I. 16,273-28,181) for the MDFT group, which lead to an ICER of 9266 Euro/QALY or a cost per recovered patient of €7491. CONCLUSIONS: This is the first comprehensive CEA of MDFT compared to CBT and it demonstrated that when costs of delinquency were included, the ICERS were modest. The results underline the importance of adopting a broader perspective regarding cost effectiveness analyses in mental health care.

Heroin self-administration by means of 'chasing the dragon': pharmacodynamics and bioavailability of inhaled heroin.

In this controlled clinical study, the bioavailability and pharmacodynamics of inhaled heroin are evaluated and compared between 'chasing the dragon' and inhalation from a heating device, and at three dose levels, 25, 50 and 100 mg heroin, in two separate study phases. In study phase 1, no differences between the inhalation methods were detected on any of the physiological or behavioral measures, nor in bioavailability. Subjectively, the participants had a strong preference for the method of chasing, which was therefore used in study phase 2. In phase 2, heroin produced a dose-related increase in subjective drug-liking, body temperature and heart rate, and a clear, dose-related decline in reaction time. Linearly dose-related differences were found in the amount of total morphine in urine, amounting to an average of 45% of the parent heroin base received. Based on these findings, it is concluded that chasing is quite an effective route of heroin administration, producing rapid, dose-related subjective and objective effects and a sufficiently high and reproducible bioavailability.

The Dutch instant lottery: prevalence and correlates of at-risk playing.

After a long and contentious political debate, the instant lottery was introduced in the Netherlands in 1994. One of the conditions for allowing the introduction was that an evaluation study should be conducted with regard to possible negative side effects of the instant lottery in terms of excessive playing or addiction. This article reports on the main results of this evaluation study. In a random sample of 4497 instant lottery players, at-risk players were differentiated from recreative players on the basis of level of involvement in the instant lottery, impaired control and the experienced negative consequences of playing. Of the sample, 4.1% could be classified as an at-risk player. Actual problems resulting from playing in the instant lottery were experienced by 0.7% of the players. At-risk players and recreative players did not only differ substantially in their playing behaviour, but also with regard to their socio-economic background, playing motivation, participation in other games of chance, and involvement in alcohol use and use of marijuana. To summarize, at-risk players were more likely to come from a poor socio-economic background, to play the instant lottery with a negative playing motivation, to be heavily involved in other forms of gambling, to have used marijuana and to drink alcohol excessively.

Psychiatric disorders in a Dutch addict population: rates and correlates of DSM-III diagnosis.

Lifetime and 6-month prevalence rates of DIS/DSM-III diagnoses were determined in 152 Ss in a clinical detoxification center; 80% of the sample had at least one recent psychiatric disorder in addition to substance abuse. The three most prevalent disorders, antisocial personality (ASP), depressive disorder, and anxiety-related disorder, were commonly diagnosed in combination. Nearly one half of the Ss with antisocial personality also had a depressive or an anxiety-related disorder, but only the latter two were significantly interrelated. Ss with ASP were demographically distinct and had a longer history of drug use compared with other Ss. Recent drug use was not associated with any of the diagnostic groups. Interactions between psychopathology and drug use are discussed as are strengths and limitations of the diagnostic instruments.

Early-onset of illicit substance use is associated with greater axis-II comorbidity, not with axis-I comorbidity.

In the present study the relationship between early-onset (

Types of self-reported psychopathology in Dutch and American heroin addicts.

One-hundred Dutch and 100 American heroin addicts receiving methadone were administered the Symptom Check List-90 (SCL-90), and a Modal Profile Analysis was performed to determine whether or not the mean profiles of the nine SCL-90 subscales were comparable for these two White male samples. Three profile-shape components correctly classified over 85% of both groups and reflected (1) Anxious-depressed, (2) Hostile and (3) Paranoid syndromes. The relationships of the SCL-90 profiles to selected psychosocial characteristics were also studied. For example, marijuana use was associated with the Paranoid shape component in both samples. The implications of these SCL-90 profiles for identifying common aspects of self-reported psychopathology in both Dutch and American heroin addicts were discussed.

The Addiction Severity Index: reliability and validity in a Dutch addict population.

In order to meet the need for a multidimensional diagnostic instrument in the field of drug addiction in The Netherlands, the Addiction Severity Index (ASI) has been applied to a sample of Dutch drug addicts. In this article the usefulness and psychometric characteristics of the Dutch version of the ASI are discussed. Overall, there was no evidence of a general relationship between the ASI ratings of problem severity. The severity ratings showed good concurrent validity, and subscales of selected items in each problem area of the ASI were demonstrated to have good internal consistency reliability. Regression analysis indicated that the ASI items accounted for a considerable proportion of the variance in the severity ratings, indicating a strong relationship between "subjective" rating and "objective" data. On the basis of the general concept of the ASI and the satisfactory psychometric characteristics, implementation of the instrument in The Netherlands is advocated.

Cue reactivity and effects of cue exposure in abstinent posttreatment drug users.

After 12 months of inpatient treatment, 16 opiate-addicted patients were exposed to drug-related stimuli. The results of this study indicate that cue reactivity in opiate-addicted subjects is still present after 12 months of intensive inpatient treatment. After exposing subjects to drug-related stimuli, there is an increase in craving, feelings of depression, and anger. Because posttreatment subjects are likely to be confronted with these stimuli following discharge, a reduction of this reactivity is desirable. In the present study, cue reactivity (feelings of depression, anger, tension, craving, and physical symptoms) reduced after protocolized cue exposure treatment. This effect maintained for at least 6 weeks after the last cue exposure session.

Predicting outcome of inpatient detoxification of substance abusers.

OBJECTIVE: Variables that have been identified as predictors of outcome of substance abuse treatment--coping style, addiction severity and addiction-related problems, psychopathology, and treatment motivation--were examined as predictors of outcome of inpatient detoxification. METHODS: A cohort of 175 drug abuse patients consecutively admitted to an inpatient detoxification clinic in the Netherlands were assessed. Baseline data were obtained on psychopathology using the Symptom Checklist-90, on severity and addiction-related problems using the Addiction Severity Index (ASI), on personal coping style using the Utrecht Coping List, on motivation using the CMRS scales, and on sociodemographic background. Positive detoxification outcome was defined as transfer to inpatient rehabilitation treatment. RESULTS: Of the 175 admissions, 81 (46 percent) had a positive outcome, and 94 (54 percent) had a negative outcome. Severe drug use and severe medical problems, as measured by the ASI, were the best predictors of a negative outcome of detoxification. Self-rated suitability of postdetoxification treatment was also a predictor of positive outcome, although to a lesser degree than the ASI variables. Established predictors of residential drug abuse treatment outcome, such as psychopathology, coping style, and sociodemographic variables, did not predict outcome of detoxification. CONCLUSIONS: Caution is necessary when applying results of inpatient treatment outcome studies to inpatient detoxification programs. Different factors may play a role in the outcome of detoxification. To improve the rate at which patients in detoxification programs are transferred to longer-term rehabilitation, more attention should be paid to medical conditions and to the direct consequences of drug use, such as withdrawal symptoms and craving during detoxification.

Influence of individual differences in craving and obsessive cocaine thoughts on attentional processes in cocaine abuse patients.

In the present pilot-study, the relation between craving, obsessive thoughts about cocaine, experienced control, and attentional bias for cocaine related words is investigated. Sixteen cocaine abuse patients participated in a reaction time (RT) experiment which was employed to measure the ability of subjects to shift their attention away from cocaine related words. Postexperiment craving was found to be positively correlated with reaction times on drug related cues, in contrast to RT on neutral cues. Furthermore, obsessive thoughts about cocaine use and the experienced cocaine use control, in the week before the experiment, were correlated in a higher degree with RTs on drug cues than postexperiment craving. Attentional bias for drug cues was evidenced in patients with higher scores on obsessive cocaine thoughts and higher craving scores. This study shows that individual differences on information processing, within a cocaine abuse patient population, are present.

[Anticipated effects of experimental heroin prescription on the method of administration and the use of other drugs]. / Te verwachten effecten van experimentele heroïneverstrekking op de toedieningswijze en het gebruik van andere middelen.

OBJECTIVE: Pending a Dutch heroin prescription trial (intended to regulate drug abuse), preliminary research was conducted into client factors that may influence the course and outcome, notably into administration patterns and changes in concomitant use of other drugs. DESIGN: Interview. SETTING: Methadone programme Baan in Rotterdam, the Netherlands. METHOD: In a Rotterdam methadone programme, 60 clients were identified matching the target group of a heroin prescription trial; 42 respondents were interviewed. Using a semistructured questionnaire, data were collected on characteristics of drug use in the preceding month. RESULTS: In addition to their methadone supply, the majority (90%) of the respondents used both heroin and cocaine. Heroin and cocaine were smoked as well as injected by 22% and 31% respectively. In the choice of a route of administration individually experienced effects played a major part, which suggests that participation in a prescription trial will not lead to shifts in employed routes of administration. Cocaine was often found to have a central position in polydrug use, while the function of heroin was mostly that of a modulator. This suggests that no direct effect on the use of cocaine can be expected from the prescription of heroin. On the contrary, the relationship between the available amount of money and the cocaine used was such that, considering that participants in a prescription trial may be left with more money, a prescription trial might lead to an increased use of cocaine. CONCLUSION: The prescription of heroin does not seem to have a direct effect on the use of cocaine. Indirectly the use of cocaine might increase.

[Dutch research on the effectiveness of medical prescription of heroin; background, research design and preliminary results]. / Het Nederlandse onderzoek naar de effectiviteit van heroïne op medisch voorschrift; achtergronden, onderzoeksopzet en eerste ervaringen.

In the Netherlands the total number of heroin addicts amounts to approximately 25,000. Of these about 70% is in contact with the treatment system. The remaining 30% have not been seeking help, believes that no help is needed or has lost faith in a better future altogether. Of those who are in treatment, 30% attempt to stop the use of opiates through participation in drug free abstinence oriented outpatient or inpatient treatment programs. The remaining 70% have given up the outlook of a drug free existence at least temporarily, and they participate in a methadone maintenance program directed at stabilizing drug use, harm minimization and social integration. In two-thirds these goals are not or only partially achieved. For these patients additional treatment options are needed. Medical prescription of heroin is such an option. However, currently no data are available on the effectiveness of this option. The Dutch study on the effectiveness of medical prescription of heroin is an attempt to obtain these data. In the study, simultaneously two randomized trials are being executed: one with inhalable and one with injectable heroin. In these trials, 625 (375 inhalers and 250 injectors) chronic treatment-resistant heroin addicts who are currently enrolled in a methadone maintenance program are offered heroin (in combination with oral methadone) seven days per week, three times per day for a period of six to twelve months. It is a multi-center study with eight treatment units in six cities in the Netherlands (Amsterdam, The Hague, Groningen, Heerlen, Rotterdam, Utrecht). At this moment 180 patients have been randomized. During the treatment no medical complications have been observed and no serious public order or safety problems have occurred. Study participants have been very compliant both with the treatment regimen and the research requirements. The latter is indicated by the fact that 85% of all the two-monthly assessments have been completed.

Screening and diagnosis of anxiety and mood disorders in substance abuse patients.

The aims of this study are (1) to study the prevalence of anxiety and mood disorders in a clinical substance abuse population, (2) to asses the pre- and post-detoxification change in SCL-90 score in this population for subjects with psychopathology compared to subjects without psychopathology, and (3) to asses the value of the SCL-90 and the Addiction Severity Index-psychiatric problems scale as clinical diagnostic screening instrument for psychopathology. The design was a longitudinal prospective cohort study with pre-detoxification ASI and SCL-90 data and post-detoxification CIDI and SCL-90 data on a clinical sample of 116 substance abuse patients. The present results indicate that the ASI-Psychiatric problems score is a limited indicator of psychiatric comorbidity. When a pre-detoxification screening for psychopathology is warranted, the present results show that the use of the SCL-90 is preferable above the ASI-PSY scale. Of the screening scores under study, the post-detoxification SCL-90 score is found to be the most valid screening instrument for diagnosis of anxiety and mood disorders in a clinical substance abuse population. Although the post-detoxification SCL-90 score holds moderate specificity combined with high sensitivity, applying this instrument in clinical substance abuse practice will result in a substantial reduction of patients unnecessarily referred for further psychiatric diagnostic evaluation. Further studies aimed at improvement of screening instruments in this population are needed.

Psychopathology in Dutch and American heroin addicts.

The Beck Depression Inventory (BDI) and the Symptom Check List-90 (SCL-90) were administered to 47 Dutch and 121 American White male heroin addicts receiving methadone. A one-way MANOVA indicated that the Dutch and American samples displayed comparable SCL-90 profiles, but that the Dutch had more symptom complaints than the Americans. The mean BDI total score of the Dutch was higher than that of the Americans, and this mean difference reflected more severe cognitive and affective symptoms in the Dutch than in the Americans. There was no difference between the samples with respect to somatic and performance symptoms. Furthermore, the mean levels of symptoms distress for the nine SCL-90 subscales reported by both the Dutch and the American heroin addicts were comparable to those of American psychiatric outpatients.

The Addiction Severity Index: reliability and validity in a Dutch alcoholic population.

The Addiction Severity Index (ASI) was evaluated for its psychometric qualities in a Dutch alcoholic population admitted to an addiction treatment center in The Netherlands. Its factorial structure in this population was found to be consistent with the established six factor structure of the ASI. Reliability analysis revealed that the homogeneity of the subscales was acceptable with the exception of the Alcohol Scale. The six subscales were not highly intercorrelated. The results of this study indicate that the ASI is a useful instrument for the assessment of several problems associated with alcoholism. However, the Alcohol Scale appears to be limited as a diagnostic and research instrument in the field of inpatient treatment of alcohol dependence in The Netherlands.