Suicidal behavior during economic hard times.

BACKGROUND: Most research on suicide is quantitative, and qualitative research is needed to reveal how individuals subjectively experience and account for suicidal behaviors. AIMS: The aim of this study is to learn about the circumstances, motivations and consequences of suicidal behavior among individuals hospitalized for attempted suicide and suicidal ideation during the global economic recession. METHODS: In-depth semi-structured interviews were conducted with in-patients hospitalized for suicidal behavior in a state-subsidized public mental hospital and analyzed with framework analysis. RESULTS: Interpersonal conflict in the context of severe economic hardship and inadequate mental health care preceded suicidal behavior, rescue and a subsequent respite from desperate situations. Attempted suicide led to increased attention and concern from loved ones and immediate access to mental health care. CONCLUSIONS: Government-subsidized funding for outpatient mental health care should be sustained or increased during economic recessions to protect the most vulnerable from suicidal behavior when it is the only viable path toward immediate psychiatric treatment.

Stigma predicts residential treatment length for substance use disorder.

BACKGROUND: Stigma has been suggested as a possible contributor to the high rates of treatment attrition in substance-dependent individuals, but no published empirical studies have examined this association. OBJECTIVES: The present paper assessed the relationship between baseline stigma variables and length of treatment stay in a sample of patients in a residential addictions treatment unit. METHODS: The relationship between baseline stigma variables (self-stigma, enacted stigma, and shame) and length of stay for participants (n=103) in a residential addictions treatment unit was examined. RESULTS: Higher self-stigma predicted longer stay in residential addictions treatment, even after controlling for age, marital status, race, overall mental health, social support, enacted stigma, and internalized shame. However, other stigma variables (i.e. internalized shame, stigma-related rejection) did not reliably predict length of treatment stay. CONCLUSION: These results are consistent with other findings suggesting that people with higher self-stigma may have a lowered sense of self-efficacy and heightened fear of being stigmatized and therefore retreat into more protected settings such as residential treatment, potentially resulting in higher treatment costs. Specialized clinical interventions may be necessary to help participants cope with reduced self-efficacy and fear of being stigmatized.

Self-Stigma in Substance Abuse: Development of a New Measure.

Little attention has been paid to the examination and measurement of self-stigma in substance misuse. This paper aims to fill this gap by reporting on the development of a new scale to measure self-stigma experienced by people who are misusing substances, the Substance Abuse Self-Stigma Scale. Content validity and item refinement occurred through an iterative process involving a literature search, focus groups, and expert judges. Psychometric properties were examined in a cross-sectional study of individuals (n = 352) receiving treatment for substance misuse. Factor analyses resulted in a 40-item measure with self devaluation, fear of enacted stigma, stigma avoidance, and values disengagement subscales. The measure showed a strong factor structure and good reliability and validity overall, though the values disengagement subscale showed a mixed pattern. Results are discussed in terms of their implications for studies of stigma impact and intervention.

Slow and steady wins the race: a randomized clinical trial of acceptance and commitment therapy targeting shame in substance use disorders.

OBJECTIVE: Shame has long been seen as relevant to substance use disorders, but interventions have not been tested in randomized trials. This study examined a group-based intervention for shame based on the principles of acceptance and commitment therapy (ACT) in patients (N = 133; 61% female; M = 34 years old; 86% Caucasian) in a 28-day residential addictions treatment program. METHOD: Consecutive cohort pairs were assigned in a pairwise random fashion to receive treatment as usual (TAU) or the ACT intervention in place of 6 hr of treatment that would have occurred at that same time. The ACT intervention consisted of three 2-hr group sessions scheduled during a single week. RESULTS: Intent-to-treat analyses demonstrated that the ACT intervention resulted in smaller immediate gains in shame, but larger reductions at 4-month follow-up. Those attending the ACT group also evidenced fewer days of substance use and higher treatment attendance at follow-up. Effects of the ACT intervention on treatment utilization at follow-up were statistically mediated by posttreatment levels of shame, in that those evidencing higher levels of shame at posttreatment were more likely to be attending treatment at follow-up. Intervention effects on substance use at follow-up were mediated by treatment utilization at follow-up, suggesting that the intervention may have had its effects, at least in part, through improving treatment attendance. CONCLUSIONS: These results demonstrate that an approach to shame based on mindfulness and acceptance appears to produce better treatment attendance and reduced substance use.

Does acceptance and relationship focused behavior therapy contribute to bupropion outcomes? A randomized controlled trial of functional analytic psychotherapy and acceptance and commitment therapy for smoking cessation.

This study evaluated a treatment combining bupropion with a novel acceptance and relationship focused behavioral intervention based on the acceptance and relationship context (ARC) model. Three hundred and three smokers from a community sample were randomly assigned to bupropion, a widely used smoking cessation medication, or bupropion plus functional analytic psychotherapy (FAP) and acceptance and commitment therapy (ACT). Objective measures of smoking outcomes and self-report measures of acceptance and relationship processes were taken at pretreatment, posttreatment, 6-month, and 1-year follow-up. The combined treatment was significantly better than bupropion alone at 1-year follow-up with 7-day point prevalence quit rates of 31.6% in the combined condition versus 17.5% in the medication-alone condition. Acceptance and the therapeutic relationship at posttreatment statistically mediated 12-month outcomes. Bupropion outcomes were enhanced with an acceptance and relationship focused behavioral treatment.

Burnout among the addiction counseling workforce: the differential roles of mindfulness and values-based processes and work-site factors.

Although work-site factors have been shown to be a consistent predictor of burnout, the importance of mindfulness and values-based processes among addiction counselors has been little examined. In this study, we explored how strongly experiential avoidance, cognitive fusion, and values commitment related to burnout after controlling for well-established work-site factors (job control, coworker support, supervisor support, salary, workload, and tenure). We conducted a cross-sectional survey among 699 addiction counselors working for urban substance abuse treatment providers in six states of the United States. Results corroborated the importance of work-site factors for burnout reduction in this specific population, but we found that mindfulness and values-based processes had a stronger and more consistent relationship with burnout as compared with work-site factors. We conclude that interventions that target experiential avoidance, cognitive fusion, and values commitment may provide a possible new direction for the reduction of burnout among addiction counselors.

The development and psychometric properties of a new measure of perceived stigma toward substance users.

A self-report measure of perceived stigma toward substance users was developed and studied. An initial measure was created based on a previously developed scale that was rated by experts for content validity and quality of items. The scale, along with other measures, was administered to 252 people in treatment for substance problems in the United States during 2006-2007. Refinement efforts resulted in an eight-item scale with good face validity, construct validity, and adequate levels of internal consistency. Most relationships with other constructs were as expected. Findings suggest that perceived stigma is distinct from other forms of stigma.

Reducing self-stigma in substance abuse through acceptance and commitment therapy: Model, manual development, and pilot outcomes.

Little is known about the assessment and treatment of self-stigma in substance abusing populations. This article describes the development of an acceptance based treatment (Acceptance and Commitment Therapy - ACT) for self-stigma in individuals in treatment for substance use disorder. We report initial outcomes from a study with 88 participants in a residential treatment program. The treatment involves 6 h of a group workshop focused on mindfulness, acceptance, and values work in relation to self-stigma. Preliminary outcomes showed medium to large effects across a number of variables at post-treatment. Results were as expected with one potential process of change, experiential avoidance, but results with other potential mediators were mixed.

An examination of the Motivational Interviewing Treatment Integrity code.

This study examines the reliability of the Motivational Interviewing Treatment Integrity (MITI) code, a brief scale designed to evaluate the integrity of the use of motivational interviewing (MI). Interactions between substance abuse counselors with one person role-playing a client were audiotaped and scored by trained teams of graduate and undergraduate students. Segments of 10 minutes and 20 minutes were compared and found to yield the same reliability and integrity results. Interrater reliability showed good-to-excellent results for each MITI item even with undergraduate raters. Correlations between items showed a coherent pattern of interitem correlations. The MITI is a good measure of treatment integrity for MI and seems superior to existing measures when indicators of client behavior are not needed.

Augmenting continuing education with psychologically focused group consultation: Effects on adoption of group drug counseling.

This study examines whether adding psychologically focused group consultation to a standard 1-day continuing-education workshop on Group Drug Counseling (GDC), a group therapy with evidence of effectiveness in the treatment of substance abuse problems, improves GDC adoption. Counselors who had taken a 1-day workshop were randomly assigned to an 8-week course of group consultation that met for 1.5 hr per session (n = 16) or to no additional contact (n = 14). The group consultation used Relapse Prevention and Acceptance and Commitment Therapy principles to help participants overcome psychological barriers to the adoption of GDC. Results showed that the 1-day workshop resulted in attempts by trainees to implement the new therapy, but that the consultation condition maintained significantly higher levels of adoption and 2- and 4-month followups. Additionally, those in the group consultation condition reported a higher sense of personal accomplishment at the 4-month followup. These findings suggest that empirically supported psychotherapy models can be used to decrease clinicians' psychological barriers to adoption of evidence-based psychotherapy methods. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Suitability of bupropion SR for nicotine-dependent smokers: problems in a practice setting.

BACKGROUND: Bupropion SR (Zyban) has been shown in randomized controlled trials to be an efficacious pharmacological aid for smoking cessation; however, recent reports have raised serious concerns about the breadth of its applicability without complications or contraindications. METHODS: We examined this issue in a well-documented medical population, i.e. veterans volunteering to participate in a smoking cessation treatment research program involving the use of bupropion SR. RESULTS: Overall, 22% of the 78 subjects who met the study criteria were appropriate for and completed the course of medication. CONCLUSIONS: Thus, bupropion SR in nicotine-dependent veterans may not be broadly applicable when conservative prescribing guidelines are carefully followed.

Penetrating the blind in a study of an SSRI.

We assessed blind integrity in a double-blinded study comparing paroxetine 20 mg with inert placebo in 20 volunteer subjects who were attempting to stop using methamphetamines. At the end of the study, the blinded clinicians reviewed subject charts and attempted to identify the assigned conditions for the 13 subjects who completed two or more weeks of the study. The three subjects who completed the entire study also attempted to identify their conditions on a questionnaire. We conclude that the blind may unwittingly be broken when the treatments under study are placebo and the selective serotonin reuptake inhibitor (SSRI) paroxetine. The integrity of the blind should be tested in all double-blind SSRI studies.

An exploratory study: the use of paroxetine for methamphetamine craving.

Methamphetamine abuse and dependence are growing problems nationally and worldwide. There are currently no effective pharmocologic treatments. Animal studies with SSRI's suggest that serotonergic modulation alters methamphetamine's behavioral effects. This exploratory study is a trial of the effects of the SSRI paroxetine versus placebo (in a double blind design) on craving and use in a population of methamphetamine users. Many subjects dropped out of the study, but those in active treatment who completed the eight week trial had a decrease in methamphetamine craving compared to the placebo treatment as measured by the OCDS modified for use in this population. Statistical analyses were not performed due to the low number of subjects. The preliminary data suggest that serotonergic agents may play a role in the effective treatment of methamphetamine abuse and dependence within the context of other effective behavioral interventions.