No evidence for a reciprocal relationship between daily self-control failures and addictive behavior in a longitudinal study.

Introduction: We all experience occasional self-control failures (SCFs) in our daily lives, where we enact behaviors that stand in conflict with our superordinate or long-term goals. Based on the assumption that SCFs share common underlying mechanisms with addictive disorders, we tested the hypothesis that a generally higher susceptibility to daily SCFs predicts more addictive behavior, or vice versa. Methods: At baseline, 338 individuals (19-27 years, 59% female) from a community sample participated in multi-component assessments. These included among others (1) a clinical interview on addictive behaviors (quantity of use, frequency of use, DSM-5 criteria; n = 338) and (2) ecological momentary assessment of SCFs (n = 329, 97%). At the 3-year and 6 year follow-up, participation rates for both assessment parts were 71% (n = 240) and 50% (n = 170), respectively. Results: Controlling for age, gender, IQ, and baseline addiction level, random-intercept cross-lagged panel models revealed that participants who reported more SCFs also showed pronounced addictive behavior at the between-person level, but we found no evidence of a predictive relationship at the within-person level over time. Discussion: A higher rate of SCFs is associated with more addictive behavior, while there is no evidence of an intraindividual predictive relationship. Novel hypotheses suggested by additional exploratory results are that (1) only addiction-related SCFs in daily life are early markers of an escalation of use and thus for addictive disorders and that (2) an explicit monitoring of SCFs increases self-reflection and thereby promotes the mobilization of cognitive control in response to goal-desire conflicts.

Individual risk factors and prediction of gambling disorder in online sports bettors - the longitudinal RIGAB study.

Introduction: While research in online sports betting is dominated by studies using objective player tracking data from providers to identify risky gambling behavior, basicresearch has identified various putative individual risk factors assumed to underlie the development of gambling disorder across all types of gambling. This study aims to examine individual risk factors and their longitudinal clinical relevance in online sports bettors. Methods: German online sports bettors (N = 607, Mage = 34, 92% male) from a provider based sample took part in an online survey. The study team randomly preselected customers to be invited. N = 325 (53,45%) of the participants also took part in an online follow-up survey one year later. Crosssectional and longitudinal associations of putative risk factors and DSM-5 gambling disorder in online sports bettors were analyzed. These risk factors include alcohol and tobacco use, impulsivity, difficulties in emotion identification, emotion regulation strategies, comorbid mental disorders and stress. Results: We found more pronounced impulsivity, difficulties in emotion identification, emotion suppression, comorbid mental disorders and stress were cross-sectionally associated with gambling disorder, and longitudinally predicted gambling disorder in online sports bettors (with the exception of emotion suppression). In an overall model only lack of premeditation and perceived helplessness remained significant as predictors for gambling disorder. Online sports bettors with gambling disorder predominantly showed more pronounced risk factors, which were also confirmed longitudinally as relevant for the maintenance of gambling disorder. Discussion: Risk factors such as impulsivity and stress and appropriate coping mechanisms should consequently be integrated not only into prevention efforts to identify individuals at risk early, but also into intervention efforts to tailor treatment.

Characteristics and prediction of risky gambling behaviour study: A study protocol.

OBJECTIVE: This study protocol describes the RIGAB study, a prospective case-control-study assessing online sports betting behaviour and underlying risk factors for the development of gambling disorder (GD). It has two aims: (1) to characterise sports bettors concerning putative risk factors and their gambling behaviour, and (2) to predict the development of GD from these factors. METHODS: At baseline, online sports bettors took part in an online survey comprising a GD screening (DSM-5), questions on gambling behaviour and on the putative risk factors emotion regulation, impulsivity, comorbidities, stress, and substance use. Participants were reinvited for a 1-year follow-up online survey. In a nested design, a subsample was invited in-person to take part in a cognitive-behavioural task battery and a clinical interview. RESULTS: Of the initial 6568 online sports bettors invited, 607 participated at baseline (rate: 9.2%), 325 took part in the 1-year follow-up and 54 participated in the nested in-person assessment. CONCLUSION: The RIGAB study combines different fields of GD studies: player tracking data and putative risk factors from self-report and behavioural tasks. The results of this study will support the development of preventive measures for participants of online gambling based on the combined findings from previously rather distinct research fields.

The relationship between executive functioning and addictive behavior: new insights from a longitudinal community study.

RATIONALE: Although there is evidence that impaired executive functioning plays a role in addictive behavior, the longitudinal relationship between the two remains relatively unknown. OBJECTIVES: In a prospective-longitudinal community study, we tested the hypothesis that lower executive functioning is associated with more addictive behavior at one point in time and over time. METHODS: Three hundred and thirty-eight individuals (19-27 years, 59% female) from a random community sample were recruited into three groups: addictive disorders related to substances (n = 100) or to behaviors (n = 118), or healthy controls (n = 120). At baseline, participants completed nine executive function tasks from which a latent variable of general executive functioning (GEF) was derived. Addictive behavior (i.e., quantity and frequency of use, and number of DSM-5 criteria met) were assessed using standardized clinical interviews at baseline and three annual follow-ups. The trajectories of addictive behaviors were examined using latent growth curve modeling. RESULTS: At baseline, we found weak to no evidence of an associations between GEF and addictive behavior. We found evidence for an association between a lower GEF at baseline and a higher increase in the quantity of use and a smaller decrease in frequency of use over time, but no evidence for an association with an increase in the number of DSM-5 criteria met. CONCLUSIONS: Lower EFs appear to lead to a continuing loss of control over use, whereas addictive disorders may develop secondarily after a long period of risky use. Previous etiological models assuming lower EF as a direct vulnerability factor for addictive disorders need to be refined.

Comparison of self-reported alcohol consumption and ethyl glucuronide in hair in a sample of 60+ year -olds treated for DSM-5 alcohol use disorder.

There is a lack of evidence for the consistency between self-reported alcohol consumption (SRAC) and concentrations of ethyl glucuronide in hair (hEtG) among elderly patients treated exclusively for alcohol use disorder (AUD). Hence, this study assessed the consistency between these two measures in these patients. A total of 190 patients with AUD were assessed for SRAC using Form 90 and hEtG, 14 or 22 weeks after treatment conclusion. Patients were grouped according to SRAC (g/day) and corresponding hEtG concentrations (pg/mg): 0 and <5 (abstinence), 0.1-14.3 and 5.0-9.9 (low consumption), 14.4-21.4 and 10.0-15.9 (moderate consumption), 21.5-59.9 and 16.0-30 (high consumption) and ≥60 and >30 (excessive consumption). The extent of underreporting and overreporting was examined by crosstabulations, and inter-rater reliability was reported by kappa correlations. Associations and effect modification were examined by conditional logistic regression. Due to multitesting, p-values ≤0.01 were considered significant. Underreporting was found in 96 patients (50.5%) and overreporting in 41 patients (21.6%). The kappa coefficients varied between 0.19 and 0.34. HEtG was more likely to detect low, moderate and high alcohol consumption compared with SRAC (ORs between 5.1 and 12.6, all p-values <0.01), but SRAC and hEtG did not differ significantly with respect to identification of abstinence (OR = 1.9, p = 0.05). Inconsistency between the outcome measures was found in a considerable number of the patients. More studies examining the consistency between SRAC and specific direct biomarkers of alcohol in this population seem warranted.

Residual alcohol use disorder symptoms after treatment predict long-term drinking outcomes in seniors with DSM-5 alcohol use disorder.

BACKGROUND: Risk of relapse within the first months after alcohol use disorder (AUD) interventions is substantial among older adults. For this vulnerable group, little information exists on how this risk is associated with residual DSM-5 AUD symptoms after treatment. AIMS: To investigate among older adults who received short-term treatment for DSM-5 AUD (1) the prediction of drinking behaviors and quality of life 12 months after treatment initiation by 6-month DSM-5 AUD symptoms, AUD severity, and AUD remission, and (2) whether these DSM-5 AUD indicators provide prognostic information beyond that gained from 6-month alcohol use (AU) status. METHODS: The international multicenter RCT "ELDERLY-Study" enrolled adults aged 60+ with DSM-5 AUD. We used data from the subsample of 323 German and Danish participants with complete DSM-5 AUD criterion information 6 months after treatment initiation (61% male; mean age = 65.5 years). AU was assessed with Form 90, DSM-5 AUD with the M.I.N.I., and quality of life with the WHOQOL-BREF. Generalized linear models were applied to investigate the associations between 6-month AUD indicators and 12-month AU and quality of life. RESULTS: Independent of AU at 6 months, having 1 (vs. no) residual AUD symptom at 6 months predicted a 12-month "slip," defined as exceeding a blood alcohol concentration of 0.05% at least once during that time (OR: 3.7, 95% CI: 1.5 to 9.0), heavy episodic drinking, and hazardous use (p < 0.05). AUD remission was associated with a lower risk of a "slip" at 12 months (p < 0.05). Failed reduction/cessation was associated with poorer physical health (Coef.: -0.4, 95% CI -0.7 to -0.1). CONCLUSION: For older adults, residual AUD symptoms in the first months after short-term treatment predict problematic AU outcomes during the first 12 months after treatment entry. Thus, residual symptoms should be addressed in this patient population during posttreatment screenings.

Real-Life Self-Control is Predicted by Parietal Activity During Preference Decision Making: A Brain Decoding Analysis.

Despite its relevance for health and education, the neurocognitive mechanism of real-life self-control is largely unknown. While recent research revealed a prominent role of the ventromedial prefrontal cortex in the computation of an integrative value signal, the contribution and relevance of other brain regions for real-life self-control remains unclear. To investigate neural correlates of decisions in line with long-term consequences and to assess the potential of brain decoding methods for the individual prediction of real-life self-control, we combined functional magnetic resonance imaging during preference decision making with ecological momentary assessment of daily self-control in a large community sample (N = 266). Decisions in line with long-term consequences were associated with increased activity in bilateral angular gyrus and precuneus, regions involved in different forms of perspective taking, such as imagining one's own future and the perspective of others. Applying multivariate pattern analysis to the same clusters revealed that individual patterns of activity predicted the probability of real-life self-control. Brain activations are discussed in relation to episodic future thinking and mentalizing as potential mechanisms mediating real-life self-control.

Stability of Posttreatment Reductions in World Health Organization (WHO) Drinking Risk Levels and Posttreatment Functioning in Older Adults with DSM-5 Alcohol Use Disorder: Secondary Data Analysis of the Elderly Study.

BACKGROUND: Studies have found that reductions in World Health Organization (WHO) drinking risk levels may be a stable outcome of treatment for alcohol use disorder (AUD) and associated with functional improvements. The aim of this study was to investigate whether posttreatment reductions in WHO drinking risk levels are stable over time among older adults and associated with a decrease in consequences of drinking and AUD symptoms and improved quality of life. METHODS: Participants. Individuals 60+ years old, suffering from DSM-5 AUD (n = 693), and seeking outpatient treatment. MEASUREMENTS: WHO drinking risk levels, prior to treatment and at all follow-up points up to 1 year after treatment start, were assessed with Form 90. Outcomes at follow-up included consequences of drinking (Drinker Inventory of Consequences), quality of life (WHOQOL-BREF), and DSM-5 AUD symptoms (Mini International Neuropsychiatric Interview). Logistic regression and linear mixed models were used to examine the probability of maintaining risk-level reductions at follow-up and the association between risk-level reductions and outcomes, respectively. RESULTS: Reductions in risk levels were maintained over time (at least 1 level: OR 5.39, 95% CI 3.43, 8.47; at least 2 levels: OR 9.30, 95% CI 6.14, 14.07). Reductions were associated with reduced consequences of drinking and number of AUD symptoms, and minor, but statistically significant, improvements in quality of life. CONCLUSIONS: Maintaining reductions in WHO risk levels appears achievable for older adults seeking treatment for AUD. The small reduction of AUD symptoms and improvement of quality of life indicates that these reductions may not be adequate as the only treatment goal.

Chronic stress, executive functioning, and real-life self-control: An experience sampling study.

OBJECTIVE: To test the hypothesis that chronic stress impairs the use of cognitive control for self-control, we examined how chronic stress affects the relation between individual differences in general executive functioning (GEF) and self-control in real-life situations. METHOD: About 338 young adults with varying degrees of chronic stress underwent experience sampling of real-life self-control for 7 days and completed a battery of nine executive function tasks from which a latent variable representing individual differences in GEF was derived. RESULTS: Structural equation models showed that higher levels of chronic stress were associated with stronger desires and a less negative relationship between GEF and desire strength. Chronic stress and GEF did not predict desire enactment in situations where effortful resistance was attempted. CONCLUSIONS: These findings suggest that chronic stress may impair self-control by reducing the use of cognitive control for "early" desire regulation strategies while leaving "late" resistance strategies unaffected. That relationships between executive functioning and real-life self-control can be moderated by third factors such as chronic stress may to some extent explain the common finding of weak or missing associations between laboratory measures of executive functioning and real-life self-control.

The role of inhibitory control and decision-making in the course of Internet gaming disorder.

BACKGROUND AND AIMS: Internet gaming disorder (IGD) is associated with impaired inhibitory control and more impulsive decision-making. However, it remains unclear whether these associations are cross-sectional or predictive. We aimed to test the hypotheses that lower inhibitory control and more impulsive decision-making correlate with, are predicted by and predict more time spent on gaming and higher IGD severity. METHODS: A stratified convenience sample of 70 male participants (18-21 years) was recruited to achieve broad data variability for hours spent on gaming and IGD severity. In three annual assessments (T1, T2, T3), we measured gaming behaviour and IGD severity using the Video Game Dependency Scale (CSAS-II). Both gaming-related measures were correlates (T1), predictors (T2), or outcomes (T3) of inhibitory control and decision making, which were assessed at T2 using a go/no-go task and an intertemporal-choice task, respectively. RESULTS: Higher IGD severity at T1 predicted more impulsive decision-making at T2 (ß = 0.45, 95% CI = 0.14-0.76). Lower inhibitory control at T2 predicted more hours spent on gaming at T3 (ß = -0.13, 95% CI = -0.25 to -0.02). We found weak or no evidence for the other associations. DISCUSSION AND CONCLUSIONS: Lower inhibitory control predicts more time spent gaming, possibly due to insufficient top-down regulation of the behaviour. Impulsive decision-making is rather a consequence of IGD than a predictor, which may be due to altered reward learning. One-dimensional etiological assumptions about the relationship between neurocognitive impairments and IGD seem not to be appropriate for the complexity of the disorder.

Impact of comorbid mental disorders on outcomes of brief outpatient treatment for DSM-5 alcohol use disorder in older adults.

BACKGROUND: Relatively little is known about the prognostic value of comorbid mental disorders in alcohol use disorder (AUD) treatment for older adults (OA). AIMS: This article aimed to investigate 1) the impact of current unipolar mood and anxiety disorders in AUD treatment success in OA, 2) the timing of this putative comorbidity impact over six months, and 3) the role of treatment length in comorbidity effects. METHODS: We analyzed baseline and one-, three-, and six-month follow-up data from the international multicenter RCT "ELDERLY-Study" (baseline n = 693, median age: 64.0 years) using mixed effects regression models. In adults aged 60+ with DSM-5 AUD "ELDERLY" compared outpatient motivational enhancement therapy (MET, four sessions) with outpatient MET plus community reinforcement approach for seniors (MET & CRA-S; up to 12 sessions). Aiming for abstinence or minimal alcohol use (AU), both conditions included CBT-elements. We assessed AU with Form 90, and mental disorders with the Mini International Neuropsychiatric Interview (M.I.N.I.). RESULTS: Mood-related disorders were associated with more drinks per day at baseline and greater reductions in drinks per day at one and six months (main effect mood disorder: Coef. 2.1, 95% CI 0.6-3.6; one month interaction effect: Coef. -1.9, 95% CI -3.3- -0.5; six months interaction effect: Coef. -2.1, 95% CI -3.5 - -0.6). These results were replicated within MET & CRA-S but not within MET. CONCLUSION: Comorbid mental disorders had modest effects on short-term outpatient treatment outcomes. OA with AUD and unipolar mood-related disorders may profit from short interventions based on motivational interviewing and CBT-elements. ClinicalTrials.gov:NCT02084173.

Functional connectivity in a triple-network saliency model is associated with real-life self-control.

Despite its significance for health and education, the neurocognitive mechanism of real-life self-control remains unclear. While recent studies focused on task-related brain activation patterns as predictors of self-control, the contribution and relevance of functional connectivity between large-scale brain networks mediating higher-order cognition is largely unknown. Using a saliency-based triple-network model of cognitive control, we tested the hypothesis that cross-network interactions among the salience network (SN), the central executive network (CEN), and the default mode network (DMN) are associated with real-life self-control. To this end, a large community sample (N = 294) underwent ecological momentary assessment of daily self-control as well as task-free fMRI to examine intrinsic inter-network organization and determine a SN-centered network interaction index (NII). Logistic multilevel regression analysis showed that higher NII scores were associated with increased real-life self-control. This suggests that the assumed role of the SN in initiating switching between the DMN and CEN is an important part of self-control.

Impulsive decision-making predicts the course of substance-related and addictive disorders.

BACKGROUND: This study investigated whether patterns of impulsive decision-making (i) differ between individuals with DSM-5 substance use disorders (SUD) or non-substance-related addictive disorders (ND) and healthy controls, and (ii) predict the increase of SUD and ND severity after one year. METHODS: In a prospective-longitudinal community study, 338 individuals (19-27 years, 59% female) were included in one of three groups: SUD (n = 100), ND (n = 118), or healthy controls (n = 120). Group differences in four impulsive decision-making facets were analyzed with the Bayesian priors: delay discounting (mean = 0.37, variance = 0.02), probability discounting for gains and for losses (each - 0.16, 0.02), and loss aversion (- 0.44, 0.02). SUD and ND severity were assessed at baseline and after 1 year (n = 312, 92%). Predictive associations between decision-making and SUD/ND severity changes were analyzed with the Bayesian prior: mean = 0.25, variance = 0.016. RESULTS: Compared with controls, the SUD group displayed steeper delay discounting and lower probability discounting for losses; the ND group displayed lower probability discounting for losses (posterior probabilities > 98%). SUD symptom increase after 1 year was predicted by steeper delay discounting and lower loss aversion; ND symptom increase by lower probability discounting for losses and lower loss aversion (posterior probabilities > 98%). There was low evidence for predictive relations between decision-making and the quantity-frequency of addictive behaviours. DISCUSSION: Impulsive decision-making characterizes SUD and ND and predicts the course of SUD and ND symptoms but not the engagement in addictive behaviours. Strength of evidence differed between different facets of impulsive decision-making and was mostly weaker than a priori expected.

Predicting Real-Life Self-Control From Brain Activity Encoding the Value of Anticipated Future Outcomes.

Deficient self-control leads to shortsighted decisions and incurs severe personal and societal costs. Although neuroimaging has advanced our understanding of neural mechanisms underlying self-control, the ecological validity of laboratory tasks used to assess self-control remains largely unknown. To increase ecological validity and to test a specific hypothesis about the mechanisms underlying real-life self-control, we combined functional MRI during value-based decision-making with smartphone-based assessment of real-life self-control in a large community sample (N = 194). Results showed that an increased propensity to make shortsighted decisions and commit self-control failures, both in the laboratory task as well as during real-life conflicts, was associated with a reduced modulation of neural value signals in the ventromedial prefrontal cortex in response to anticipated long-term consequences. These results constitute the first evidence that neural mechanisms mediating anticipations of future consequences not only account for self-control in laboratory tasks but also predict real-life self-control, thereby bridging the gap between laboratory research and real-life behavior.

The Alcohol Dependence Scale and DSM-5 alcohol use disorder: Severity ratings correspond insufficiently in older patients.

OBJECTIVES: To investigate the psychometric properties of the frequently used Alcohol Dependence Scale (ADS) in older adults and the associations between ADS scores and alcohol use and DSM-5 AUD symptom counts. METHODS: Using baseline data from an international multicenter RCT on outpatient AUD treatment for adults aged 60+ with DSM-5 alcohol use disorder (AUD; n = 529), we computed Cronbach's alpha (α) and applied confirmatory (CFA) and exploratory factor analysis (EFA) to determine the underlying factor structure. A structural equation model (SEM) explored the interrelationship of latent ADS factors with alcohol use and number of DSM-5 criteria endorsed. RESULTS: Internal consistency of the ADS (α = 0.81) was good. EFA revealed a three-factor structure. Factor 1 ("Severe withdrawal symptoms") consisted of severe psychoperceptual and psychophysical consequences of excessive drinking, Factor 2 ("Loss of control") consisted of acute physical reactions of intoxication, and Factor 3 ("Obsessive-compulsive drinking") described habitual drinking. The SEM suggested that only Factor 3 had large effects on DSM-5 symptom score and drinking behavior. CONCLUSION: Lowering the ADS threshold or focusing on ADS items from Factor 3 may be more suitable measures of severity of alcohol dependence in treatment-seeking older adults as ADS scores are low and not closely related to DSM-5 AUD.

A Systematic Review of Land-Based Self-Exclusion Programs: Demographics, Gambling Behavior, Gambling Problems, Mental Symptoms, and Mental Health.

Systematic and quantitative reviews on the effects of land-based self-exclusion are scarce. Therefore, the current review aimed to provide a comprehensive summary of (1) the demographic characteristics of land-based self-excluders and changes after exclusion, including (2) gambling behavior, (3) gambling problems, (4) mental symptoms, and (5) mental health. A systematic database and literature search was performed following PRISMA guidelines. Nineteen naturalistic studies met the eligibility criteria. The quality of all included records was rated via adaption of the Newcastle-Ottawa Scale. Results from higher-quality records were more heavily weighted. Self-excluders were predominantly men in their early or middle forties. Changes after exclusion revealed wide ranges in the rates of abstinence (13-81%), rates of gambling reduction (29-92%), and rates of exclusion breaches (8-59%). The records consistently demonstrated significant changes in pathological gambling from before exclusion (61-95%) to after exclusion (13-26%). Up to 73% of self-excluders exhibited symptoms of anxiety, depression, and substance use disorders at program enrollment. Several aspects of mental health improved after exclusion, e.g., quality of life. Problem and pathological gambling are most prevalent in young men, but self-exclusion was most prominent in middle-aged men. The magnitude of effects widely differed between studies despite overall benefits of self-exclusion, and many individuals continued gambling after exclusion. This shortcoming could be minimized using improved access controls and the extension of exclusion to other gambling segments. High rates of pathological gambling and other mental disorders in self-excluders highlight the need for improved early detection and treatment accessibility.

Decision-making and inhibitory control after smoking-related priming in nicotine dependent smokers and never-smokers.

Impaired decision-making and inhibitory control are important characteristics of nicotine dependence (ND). We aimed to test 1) the effects of smoking-related priming cues on subsequent decision-making and inhibitory control in ND and 2) how these priming effects are related to valence ratings, nicotine deprivation and craving. A sample of 27 smokers with ND according to DSM-IV and a control group of 33 never-smokers performed an intertemporal choice task and a go/no-go task. Before each trial of the tasks, a priming cue appeared that was either smoking-related or neutral. Valence ratings, nicotine deprivation and craving were assessed with self-reports. After smoking-related compared to neutral primes, the ND group exhibited increased delay discounting (ß = 0.07, 95% confidence-interval (CI): 0.01-0.14) and shorter go reaction times (ß = -0.13, CI: -0.32 to -0.01) compared to the never-smoker group. The speed-up in go trials after smoking-related compared to neutral cues was significantly related to more pleasant valence ratings (ß = 0.07, CI:0.01-0.13), a longer time since last cigarette (ß = -0.17, CI:-0.30 to -0.03), and increased craving (ß = -0.19, CI: -0.33 to -0.06) within the ND group. We found evidence for small group effects indicating that individuals with ND compared to never-smokers decide more dysfunctional and react faster after smoking-related compared to neutral cues. Faster reactions after smoking-related cues within the ND group, especially in states of increased nicotine deprivation and craving, without more errors could be explained by an increased attentional focus. Cue-induced alterations in decision-making and inhibitory control in ND highly depend on the temporal sequence of cue presentation.

Is Cannabis Use Treatment Also Indicated for Patients with Low to Moderate Polysubstance Use.

BACKGROUND: Polysubstance use (PSU) is common among patients with cannabis use (CU) and is related to more severe CU problems. However, it is unclear how PSU predicts CU treatment outcomes beyond CU patterns. We examined the frequency, amount, and class of additionally used substances as predictors for primary and secondary outcomes. METHODS: We conducted crude and adjusted regression analyses for PSU variables as predictors of remission, abstinence, -reduction, and secondary outcomes in 166 help-seeking -patients from a randomized clinical trial of CANDIS, a -cognitive behavioral treatment program. RESULTS: Patients with recent illegal PSU experienced more difficulties in reducing their CU (B = -1.22, p < 0.001). In contrast, remission rates were slightly higher in patients with a wide variety of -last-year-PSU (RD = 0.04, p < 0.001). Amphetamine use -predicted poorer outcomes regarding CU-related problems (B = -4.22, p = 0.019), and the use of opiates, inhalants, and dissociative substances predicted poorer physical health outcomes (B = -0.62, p = 0.009; B = -0.96, p = 0.039; B = -1.18, p = 0.007). CONCLUSIONS: CU treatment is also effective for patients with moderate PSU. However, treatment effects may be enhanced by addressing specific PSU characteristics as part of a modularized program.