The relationship of depression and stressors to immunological assays: a meta-analytic review.

This is a broad meta-analysis of the relations of both depression and stressors to immunological assays. The number of study samples (greater than 180) and measures (greater than 40) is much more extensive than any so far. Analyses are done by both fixed and random effects. By a fixed-effects analysis, both major depression and naturally occurring acute stressors are associated with (1) an overall leukocytosis, (2) mild reductions in absolute NK-cell counts and relative T-cell proportions, (3) marginal increases in CD4/CD8 ratios, and (4) moderate decreases in T- and NK-cell function. However, the degree of heterogeneity of the studies' results raises questions about their robustness. Therefore, we also did the first random effects analysis to estimate what is likely to appear in future studies. For depression, the analysis showed the immunological correlates included (1) an overall leukocytosis, manifesting as a relative neutrophilia and lymphoenia; (2) increased CD4/CD8 ratios; (3) increased circulating haptoglobin, PGE(2), and IL-6 levels; (4) reduced NK-cell cytotoxicity; and (5) reduced lymphocyte proliferative response to mitogen. For stressors, the random effects analysis showed that future studies are likely to find the following effects: (1) an overall leukocytosis, manifesting as an absolute lymphocytosis; (2) alterations in cytotoxic lymphocyte levels, CD4/CD8 ratios, and natural killer cell cytotoxicity with the direction of change depending on the chronicity of the stressor; (3) a relative reduction of T-cell levels; (3) increased EBV antibody titers; (4) reduced lymphocyte proliferative response and proportion of IL-2r bearing cells following mitogenic stimulation; and (5) increased leukocyte adhesiveness. The random-effects analysis revealed that for both major depression and naturally occurring stressors the following effects are shared: leukocytosis, increased CD4/CD8 ratios, reduced proliferative response to mitogen, and reduced NK cell cytotoxicity. The implications for these findings for disease susceptibility and the pathophysiology of these conditions is discussed.

The role of continuing care in outpatient alcohol treatment programs.

Substance-abusing patients are frequently urged to participate in continuing care, or "after-care," following an initial phase of treatment. However, there has been relatively little research on the effectiveness of continuing care, particularly in the context of outpatient service delivery systems. Since 1988, 12 controlled studies of continuing care for alcohol use disorders have been published. Only three of these studies were conducted exclusively within outpatient service delivery systems; in the other studies, all patients (six studies) or at least half of the patients (three studies) were first treated in inpatient or residential facilities. Four of the 12 studies yielded positive findings (two of six studies with minimal/no continuing care control conditions and two of six studies with active control conditions). It is suggested that continuing care treatment might be improved by placing greater emphasis on addressing co-occurring problems and facilitating the identification and strengthening of patients' skills, interests, and talents, although additional research would be needed to evaluate the impact of these modifications. Further research is also needed to establish guidelines for when patients are ready to enter continuing care and to develop performance indicators to monitor progress.

A review of temporal effects and outcome predictors in substance abuse treatment studies with long-term follow-ups. Preliminary results and methodological issues.

This article is an initial report from a review of alcohol and drug treatment studies with follow-ups of 2 years or more. The goals of the review are to examine the stability of substance use outcomes and the factors that moderate or mediate these outcomes. Results from 12 studies that generated multiple research reports are presented, and methodological problems encountered in the review are discussed. Substance use outcomes at the group level were generally stable, although moderate within-subject variation in substance use status over time was observed. Of factors assessed at baseline, psychiatric severity was a significant predictor of outcome in the highest percentage of reports, although the nature of the relationship varied. Stronger motivation and coping at baseline also consistently predicted better drinking outcomes. Better progress while in treatment, and the performance of pro-recovery behaviors and low problem severity in associated areas following treatment, consistently predicted better substance use outcomes.

Effectiveness of continuing care interventions for substance abusers. Implications for the study of long-term treatment effects.

Substance-abusing patients are frequently urged to participate in lower intensity continuing care interventions, also known as "stepdown care" or "aftercare," following an initial phase of treatment. Since 1988, 15 controlled studies of continuing care for alcohol or drug abuse have been published, with follow-up data on substance use presented in 14 of these studies. In the studies that featured an active control condition, only 1 of 7 yielded positive findings. In the studies that featured a minimal- or no-treatment control, 3 of 7 studies yielded positive findings. The relative paucity of continuing care studies, coupled with the lack of stronger evidence of clinical effectiveness, provides a convincing rationale for conducting evaluations of continuing interventions, as well as evaluations of combinations of various primary and continuing interventions. Methodological issues in the evaluation of continuing care and potential research questions that could be addressed in long-term follow-up studies are outlined and discussed.

Factors accounting for cocaine use two years following initiation of continuing care.

AIMS: To examine the relationship between various interpersonal, intrapersonal and situational factors assessed at 6, 12 and 18 months after entrance to continuing care, and cocaine use in subsequent periods. DESIGN: A randomized clinical trial with a 2-year follow-up. SETTING: An outpatient US Veterans Administration substance abuse treatment program. PARTICIPANTS: Cocaine-dependent male veterans (N = 132) entering continuing care. INTERVENTIONS: 12-Step focused group treatment vs. individualized relapse prevention continuing care. MEASUREMENTS: Motivation, coping and mood, social support, co-morbid problem severity, treatment attendance, self-help participation and cocaine use variables were assessed at each follow-up. FINDINGS: During the 2-year follow-up, patients used cocaine on fewer than 8% of the days in each of the four 6-month periods, which represented a highly significant decrease in relation to cocaine use prior to treatment. In univariate analyses, abstinence commitment, self-efficacy, positive mood, support from family, employment, attendance in continuing care and self-help participation at two or more of the follow-ups predicted less cocaine use in subsequent 6-months periods. Readiness to change and medical, psychiatric, legal and family/social problem severities either did not predict, or were inconsistently related to, subsequent cocaine use. In multivariate analyses, degree of self-help participation emerged as the strongest and most consistent predictor of cocaine use. However, when current cocaine use at each follow-up was controlled, none of the predictors was significant at more than one follow-up point. There was little evidence of interactions between treatment condition and the predictor variables. CONCLUSIONS: Continued self-help participation and the early achievement of cocaine abstinence appear to be important factors in the maintenance of good cocaine use outcomes over extended periods. The results also highlight the importance of controlling for various post-treatment factors when evaluating the relationship between any one factor and subsequent outcome, as many of the factors that were significant predictors in the univariate analyses were no longer significant when other factors were controlled.

The relationship of psychiatric comorbidity to treatment outcomes in methadone maintained patients.

The authors examined the relationship of comorbid non-substance use psychiatric disorders to preadmission problem status and treatment outcomes in 278 methadone maintenance patients. Recent admissions were assigned DSM-III-R Axis I and II diagnoses according to structured diagnostic interviews. The Addiction Severity Index was administered at admission to assess past and current substance use and psychosocial problems and again 7 months later. Treatment retention and month 7 drug urinalysis results were also obtained. Across substance use and psychosocial domains, participants showed significant and comparable levels of improvement regardless of comorbidity. Comorbid participants received more concurrent psychiatric treatment which may have accounted for the lack of differential improvement among groups. Nevertheless, psychiatric comorbidity was associated with poorer psychosocial and medical status at admission and follow-up and participants with the combination of Axis I and II comorbidity had the most severe problems. Admission and month 7 substance use were, for the most part, not related to psychiatric comorbidity, although there was a trend indicating more treatment attrition for participants with personality disorders.

Continuous, categorical, and time to event cocaine use outcome variables: degree of intercorrelation and sensitivity to treatment group differences.

Although a number of cocaine use variables are available for use in treatment outcome studies, there is little information on how strongly these variables are related or their relative sensitivity for detecting treatment group differences. Eight continuous and categorical variables of cocaine use obtained at 6-, 12-, 18-, and 24-month follow-ups, four event history variables, and one summary measure of cocaine use over the 24-month follow-up period were examined. The variables were generally correlated 0.30--0.50 or greater. An exploratory factor analysis in which the repeated measures were averaged across follow-up points yielded two factors, one made up of incidence of use variables (e.g. percent days cocaine use, monetary value of cocaine, abstinence status, time to relapse, urine toxicology) and a second consisting of perceived severity of use variables (e.g. drug and cocaine composites, craving). This factor solution was supported by confirmatory factor analyses conducted at each follow-up point. None of the variables yielded significant differences between the two treatment conditions in the study, standard group and individualized relapse prevention continuing care. However, monetary value of cocaine used and urine toxicology variables yielded the largest effect sizes (eta(2)=0.020 and 0.010, respectively).

The effectiveness of two intensities of psychosocial treatment for cocaine dependence.

Structured treatments for cocaine dependence have been shown to be effective despite high attrition rates. What is unclear is what level of treatment intensity is needed to improve and sustain patient outcomes, especially among low SES urban residents. This study evaluated whether there were differences between two levels of treatment intensities for cocaine dependence in reducing substance use and improving health and social indicators. Ninety-four cocaine dependent predominantly African-American male veterans were randomly assigned to either a 12 h/week day hospital program (DH12) or a 6 h/week outpatient program (OP6) and were evaluated at baseline, during treatment and at 4 and 7 months post-treatment. Both treatments stressed abstinence, behavior change and prosocial adjustment and only differed in level of treatment intensity. During treatment measures included urine toxicologies, program attendance, treatment completion and aftercare attendance. Participants reported a 52% reduction in days of cocaine use and experienced significant improvements in employment and psychiatric functioning at seven months post-treatment. However, there was no significant difference between the DH12 and OP6 programs in terms of abstinence during treatment, treatment completion, treatment or aftercare attendance or any Addiction Severity Index (ASI)-related variable assessing level of functioning at 4 and 7 months. While future research with a larger community-based sample that includes female clients is necessary, the current findings demonstrate that a 6 h/week program is just as effective and thus has a significant cost savings compared to a 12 h/week treatment modality for cocaine dependence.

Generalizability of the clinical dimensions of the Addiction Severity Index to nonopioid-dependent patients.

Clinical dimensions (CDs) for the Addiction Severity Index recently have been established for application among opioid-dependent patients in methadone treatment (P. A. McDermott et al., 1996). This article examines the generalizability of the CDs to other substance-dependent patients. A sample of 2,027 adult nonopioid-dependent patients was identified; it comprised 581 primarily cocaine-dependent, 544 primarily alcohol-dependent, and 803 polydrug-dependent patients and 99 patients who were dependent on other varied drugs. Generality of dimensions was assessed through confirmatory components analysis, structural congruence, internal consistency, and variance partitioning in higher order factoring. The CDs were found generalizable overall and to specific nonopioid-dependent subgroups, and across patient gender and age, and to African American and White patients. Preliminary concurrent and predictive validity data supported the CD structure.

Prognostic significance of antisocial personality disorder in cocaine-dependent patients entering continuing care.

This study examined the relationship of antisocial personality disorder (APD) to response to continuing care treatments in a sample of cocaine-dependent patients. Patients (N = 127) were randomly assigned to 20-week standard group or individualized relapse prevention continuing care interventions after the completion of an initial treatment episode and followed up at 3, 6, and 12 months. APD and non-APD patients did not differ on retention in continuing care, substance use outcomes, social function outcomes, or experiences before or during cocaine relapse episodes. A diagnosis of APD was also not a predictor of differential response to the two continuing care interventions in the study. However, APD patients had worse medical and psychiatric problem severity than non-APD patients at entrance to continuing care and during follow-up. These results suggest that cocaine patients with APD who are in the continuing care phase of outpatient rehabilitation might benefit from additional medical and psychiatric treatment services.

Baseline prediction of 7-month cocaine abstinence for cocaine dependence patients.

A broad range of baseline subject variables was evaluated to identify predictors of 7-month cocaine use for 160 lower socioeconomic cocaine dependent male veteran patients participating in either an intensive 1-month day hospital (DH; n=90) or a 1-month inpatient (INP; n=70) treatment program. The baseline measures included sociodemographic variables, the seven Addiction Severity Index composite scores, cocaine urine toxicology, craving, the SCL-90 total score, and lifetime psychiatric diagnoses. Since a proportion of subjects who reported no use at follow-up had positive urines, both liberal and conservative data estimation strategies were employed for subjects without urine toxicology data at follow-up who had reported no use (21% of subjects). Analyses were done separately for the DH and INP subjects. Under the conservative definition of cocaine abstinence/use, univariate correlations of predictor variables with 7-month cocaine use revealed no statistically significant relationships. Under the liberal definition of cocaine abstinence/use, only one variable, greater severity of alcohol problems at intake predicted cocaine abstinence at outcome. Because of the inability to predict treatment success, originally planned logistic regression analyses were not undertaken. The findings point to the difficulty of predicting long-term outcomes in cocaine dependent patients based on baseline information and to the importance of obtaining objective data on cocaine use.

Contrasts between admitters and deniers of drug use.

This study evaluated the agreement between self-reported drug use and urinalysis results in 232 men and 27 women opiate-dependent patients at 2, 7, and 24 months following admission to methadone maintenance treatment. Differences between deniers, those who stated that they had not used drugs, but whose urinalysis results were positive, and admitters of drug use on several psychosocial variables, Axis I and II pathology and degree of psychopathy were examined. Generally, more drug use was acknowledged by self-report than found in urinalyses. Evidence was limited that deniers were consistently different than admitters. Deniers had a significantly greater increase from initial psychopathy ratings made using interview only information to final psychopathy ratings made utilizing interview and collateral information.

Treatment services received by supplemental security income drug and alcoholic clients.

This study examined self reported problems and treatment services received by 237 recipients of Supplemental Security Income (SSI) benefits for "drug abusers and alcoholics" who had been assigned and entered into substance abuse treatment. All were administered the Treatment Services Review (TSR), a brief interview in which patients describe treatment services they have received during the past month and substance-related problems they are currently experiencing. In addition to describing serious alcohol and drug problems, SSI recipients reported a need for treatment for medical and psychiatric problems. The TSR data revealed that these clients primarily received drug and alcohol services and more limited medical, psychiatric, and employment services during treatment. There was relatively little indication of the provision of legal or family/social treatment services. The data are consistent with other findings that indicate that treatment for substance dependence provides only limited services other than those for alcohol and drug abuse.

Benefit-cost analysis of residential and outpatient addiction treatment in the State of Washington.

A benefit-cost analysis of full continuum (FC) and partial continuum (PC) care was conducted on a sample of substance abusers from the State of Washington. Economic benefits were derived from client self-reported information at treatment entry and at 9 months postadmission using an augmented version of the Addiction Severity Index (ASI). Average (i.e., per client) economic benefits of treatment from baseline to follow-up for both FC and PC were statistically significant for most variables and in the aggregate. The overall difference in average economic benefit between FC and PC was positive ($8,053) and statistically significant, favoring FC over PC. The average cost of treatment amounted to $2,530 for FC and $1,138 for PC (p < .01). Average net benefits were estimated to be $17,833 (9.70) for FC and $11,173 (23.33) for PC, with values showing statistical significance (p < .05). Results strongly indicate that both treatment options generated positive and significant net benefits to society.

Studies of factors in relapse to alcohol, drug and nicotine use: a critical review of methodologies and findings.

OBJECTIVE: To critically review the methodologies used to study relapse in substance abusers and compare some of the findings these methodologies have produced. METHOD: Representative studies that have used retrospective, prospective, or near real time methodologies to study antecedents or consequences of relapse are presented and the strengths and weaknesses of each methodology are reviewed. Limitations in the ability of substance abusers to accurately report internal states are considered. Degree of convergence in findings across methodologies is examined. RESULTS: Retrospective reports can provide perhaps the most detailed accounts of circumstances and experiences leading up to relapse, but are also more likely to be inaccurate due to the limitations of memory. Prospective studies are less likely to be affected by memory problems, but may not capture factors that immediately precede relapse. The near real time methodology, which uses palm-top computers to gather data, has many advantages over other methodologies, but a number of limitations as well. The two studies in which retrospective reports were directly compared to either prospective or near real time reports yielded mixed results regarding degree of agreement. Findings from several areas of research suggest that some substance abusers may have difficulty recognizing and reporting internal states. CONCLUSIONS: Despite memory problems and other limitations of self-report, all three methodologies have produced findings that implicate negative affect states, increased craving, cognitive factors, interpersonal problems, and lack of coping as factors in relapse. Future relapse studies should make use of all three methodologies to obtain data on relapse and consequences, and steps should be taken to enhance the accuracy of the self-reports that are gathered with each method.

Predicting proximal factors in cocaine relapse and near miss episodes: clinical and theoretical implications.

This study examined the degree of correspondence between relapse vulnerability factors assessed at intake to aftercare in 100 cocaine dependent patients and proximal factors in their first cocaine relapse and near miss episodes during a 1-year follow-up. Proximal factors in relapse and near miss episodes were also compared. Correspondence between experiences associated with prior use and experiences in the week prior to relapse and near miss episodes was generally poor. Psychiatric and family/social problem severity and coping factors at intake to aftercare predicted experiences in the week prior to near misses, and to a lesser degree, experiences in the week prior to relapse episodes. However, relapse vulnerability factors were also associated with psychiatric and family/social problem severity and mood during abstinent periods. Therefore, there was little evidence of specificity in relationships between relapse vulnerability factors and experiences prior to relapse. Proximal measures of coping, sensation seeking, positive experiences, and unpleasant affect differentiated relapses from near misses in a within-subjects analysis.

Comparability of telephone and In-person structured clinical interview for DSM-III-R (SCID) diagnoses.

The SCID was administered twice, once by telephone and once in person (1 week later) to 41 college age men. For major depression (lifetime k =.64, current k =.66), results indicated good agreement. The lifetime occurrence estimate based on the telephone SCID diagnosis was lower than the in-person SCID estimate. Kappas for specific diagnoses were calculable for simple phobia (lifetime k =. 47, current k = .03) and social phobia (lifetime k =.29). Base rates were less than 10% for all individual diagnoses except lifetime major depression; therefore, the kappas may be unstable. For all diagnoses where there were any positive cases, percentages of negative agreement and specificity were high, whereas percentages of positive agreement and sensitivity were lower. Overall agreement was fair for specific lifetime diagnoses but poor for current diagnoses. These results suggest caution in assuming comparability of in-person and telephone SCID diagnoses. Circumstances under which a telephone SCID may be useful and ways to improve reliability are discussed.

The 2-year test-retest reliability of the Psychopathy Checklist Revised in methadone patients.

The 2-year test-retest reliability of the Psychopathy Checklist-Revised (PCL-R) was examined in 200 men and 25 women methadone patients. Stability of the PCL-R was generally good whether it was evaluated as a dichotomous or dimensional measure. Utilizing a diagnostic cutoff score of 25 or more the intraclass correlation coefficients (ICCs) were.48 for men and.67 for women. For the Total PCL-R score ICCs were.60 and.65 for men and women, respectively. Factor 1 was more reliably measured in women compared to men (.63 vs.43). For men, Factor 1 was significantly less reliable than Factor 2 or the Total score. For women, Factor 2 was significantly less reliable than the Total PCL-R score or Factor 1.