The influence of co-occurring axis I disorders on treatment utilization and outcome in homeless patients with substance use disorders.

The current study examined the relationship between co-occurring substance use and Axis I psychiatric disorders and treatment utilization and outcome among homeless individuals (N=365) who participated in an episode of intensive outpatient substance use treatment. Compared to patients without a co-occurring diagnosis, homeless patients with a diagnosis of major depressive disorder or PTSD participated in more substance use treatment. Diagnostic status did not predict 12-month alcohol or drug treatment outcome. Substance use treatment programs appear to successfully engage homeless individuals with major depressive disorder and PTSD in treatment. Such individuals appear to achieve similar benefits from standard substance use treatment as do homeless individuals without such disorders.

Patients' abstinence status affects the benefits of 12-step self-help group participation on substance use disorder outcomes.

BACKGROUND: Studies measuring the effectiveness of 12-step self-help group attendance have yielded mixed results but none of the prior studies have accounted for the potential impact of interim abstinence status. METHODS: Participants were 1683 patients with substance use disorders (SUD) from 88 community residential facilities. Self-report data were collected at baseline and 1- and 4-year follow-ups, and included measures of SUD severity, social resources, coping, and 12-step self-help group attendance. We tested the hypothesis that 12-step self-help group attendance is more effective for non-abstinent patients than for abstinent patients. We also controlled for self-selection effects by using propensity score analyses and we cross-validated our results in a second sample of patients (N=2173). RESULTS: Sample 1. Patients abstinent at 1-year post-treatment who attended 12-step self-help group meetings were no more likely to be abstinent at 4 years than abstinent patients who did not attend. However, for patients not abstinent at 1 year, a significant improvement in abstinence rates at 4 years emerged for those who attended 12-step self-help groups compared to those who did not (42% vs. 28.9%). A similar pattern emerged for SUD problems. There were no benefits from 12-step self-help group attendance for patients abstinent at 1 year, but non-abstinent patients who attended 12-step self-help groups had significantly fewer problems at 4 years. Sample 2. The cross-validation yielded consistent results as 12-step self-help group attendance led to higher abstinence rates and fewer SUD problems only among patients non-abstinent at interim assessment. CONCLUSIONS: Individual's abstinence status should be considered when evaluating the potential influence of 12-step self-help group attendance on SUD outcomes. In addition, increased clinical resources should focus on assessing patients after discharge and on improving linkage of non-abstinent patients to self-help groups.

Predictors of 4-year outcome of community residential treatment for patients with substance use disorders.

AIMS: This study examined systematically how predictors of substance use disorder (SUD) treatment outcome worked together over time and identified mediators and moderators of outcome. DESIGN: The MacArthur model was applied in this naturalistic study to identify how baseline, discharge and 1-year follow-up factors worked together to predict 4-year improvement in substance-related problems. SETTING: Eighty-eight community residential facilities were selected based on geographic representativeness, number of patient referrals and type of treatment orientation. PARTICIPANTS: Of 2796 male patients who completed intake assessments, 2324 were assessed at the 1-year follow-up and 2023 at the 4-year follow-up. MEASUREMENTS: Self-report measures of symptom severity, functioning, social resources and coping, treatment and involvement in Alcoholics Anonymous (AA) were collected at baseline and at 1- and 4-year follow-ups. Provider-rated treatment participation measures were obtained at discharge. FINDINGS: Greater substance use severity, more psychiatric symptoms, more prior arrests and stronger belief in AA-related philosophy at treatment entry predicted improvement significantly in substance-related problems 4 years later. At the 1-year follow-up, being employed and greater use of AA-related coping predicted outcome significantly. AA-related coping at 1 year mediated the relationship partially between belief in AA philosophy at treatment entry and 4-year outcome. CONCLUSIONS: The findings highlight the unique and positive impact of AA involvement on long-term SUD treatment outcome and extend understanding of why AA is beneficial for patients.

Acceptance and relationship context: a model of substance use disorder treatment outcome.

AIMS: This study presented and tested a model of behavior change in long-term substance use disorder recovery, the acceptance and relationship context (ARC) model. The model specifies that acceptance-based behavior and constructive social relationships lead to recovery, and that treatment programs with supportive, involved relationships facilitate the development of these factors. DESIGN: This study used a prospective longitudinal naturalistic design and controlled for baseline levels of study variables. SETTING AND PARTICIPANTS: The model was tested on a sample of 2549 patients in 15 residential substance use disorder treatment programs. MEASUREMENTS: Acceptance-based responding (ABR), social relationship quality (SRQ), treatment program alliance (TPA) and substance use-related impairment were assessed using interviews and self-report questionnaires. FINDINGS: TPA predicted ABR and SRQ and, in turn, ABR predicted better 2-year and 5-year treatment outcomes. The baseline-controlled model accounted for 41% of the variance in outcome at 2-year follow-up and 28% of the variance in outcome at 5-year follow-up. CONCLUSIONS Patients from treatment programs with an affiliative relationship network are more likely to respond adaptively to internal states associated previously with substance use, develop constructive social relationships and achieve long-term treatment benefits.

Predictors of outcome for patients with substance-use disorders five years after treatment dropout.

OBJECTIVE: Few studies focus on the outcome of patients after they drop out of substance-use disorder (SUD) treatment, and there appear to be no prior studies of the long-term outcomes of these patients. The aim of this study is to determine how well such patients do after dropping out of treatment and to identify predictors of differential outcomes. METHOD: Patients in 15 residential SUD treatment programs were assessed at treatment entry and at 5-year follow-up on their frequency and severity of substance use, expectancies and beliefs about substance use, and social resources and stressors. Patients who dropped out and stayed out of treatment (n = 193) were compared with those who completed treatment (n = 3,204). Predictors of 5-year SUD problems among dropouts were identified. RESULTS: In general, dropouts and treatment completers did not differ significantly on their levels of SUD problems at 5 years. At baseline, patients who dropped out reported more involvement in 12-step organizations and greater cognitive impairment and more closely identified with the label "drug addict" than "alcoholic." Lower severity of SUD, lower self-efficacy, fewer positive substance- use expectancies, and less stress from social networks predicted fewer SUD problems at 5 years among dropouts. CONCLUSIONS: In addition to focusing on substance use, providers should address the adequacy of patients' social support and counter positive substance-use expectancies at the earliest stages of treatment before patients drop out.

Predictors of engagement in continuing care following residential substance use disorder treatment.

BACKGROUND: Patients in intensive SUD programs who subsequently participate in continuing care for a longer interval have better outcomes than those who participate for a shorter interval. We sought to identify patient and program factors associated with duration of engagement in SUD continuing care after residential/inpatient treatment. METHODS: Patients (n=3032) at 15 geographically diverse SUD residential treatment programs provided data on demographics, symptom patterns, recovery resources, and perceptions of treatment environment. We identified patient characteristics associated with the number of consecutive months of engagement in continuing care. We then consolidated and classified risk factors into an integrated model. RESULTS: Being African American, having more SUD and psychiatric symptoms, more resources for recovery, and perceiving the treatment staff as being supportive were associated with longer engagement in continuing care. African Americans' engagement in continuing care was 17% longer than Caucasians'. The positive effect of being African American was partially mediated by having taken actions toward changing use, and by the presence of psychotic symptoms. CONCLUSION: These results extend previous research on the predictors of continuing care engagement after residential SUD programs. Clinicians can use information about characteristics that put patients at risk for shorter engagement in continuing care to target patients who might benefit from interventions to increase engagement in continuing care.

Predictors of retention in methadone programs: a signal detection analysis.

Retention in Opioid Agonist Therapy (OAT) is associated with reductions in substance use, HIV risk behavior, and criminal activities in opioid dependent patients. To improve the effectiveness of treatment for opioid dependence, it is important to identify predisposing characteristics and provider-related variables that predict retention in OAT. Participants include 258 veterans enrolled in 8 outpatient methadone/l-alpha-acetylmethadol (LAAM) treatment programs. Signal detection analysis was utilized to identify variables predictive of 1-year retention and to identify the optimal cut-offs for significant predictors. Provider-related variables play a vital role in predicting retention in OAT programs, as higher methadone dose (> or =59 mg/day) and greater treatment satisfaction were among the strongest predictors of retention at 1-year follow-up.

Depression increases diabetes symptoms by complicating patients' self-care adherence.

PURPOSE: This study evaluated whether diabetes patients with depressive symptoms are more likely than other diabetes patients to report symptoms of glucose dysregulation, and whether this relationship is mediated by the impact of depressive symptoms on patients' adherence to their diabetes self-care regimen. METHODS: Participants were English- and Spanish-speaking adults with type 2 diabetes. Interviewers assessed participants' depressive symptoms and diabetes-related symptoms at baseline. Self-care behaviors and diabetes symptoms were measured at a 1-year follow-up. Structural equation models were used to determine whether depression affected diabetes symptoms by limiting patients' ability to adhere to self-care recommendations. RESULTS: An initial model identified direct effects of baseline depressive symptoms on self-care and diabetes symptoms at follow-up. The relationship between self-care behaviors and physical symptoms of poor glycemic control were assessed using a second model. Results explained the relationship between depressive symptoms at baseline and diabetes symptoms at 1 year. CONCLUSIONS: Depressive symptoms impact subsequent physical symptoms of poor glucose control by influencing patients' ability to adhere to their self-care regimen. More aggressive management of depression among patients with diabetes may improve their physical health as well as their mental health.

The cognitive specificity of associative responses in patients with chronic pain.

OBJECTIVE: Previous studies have found evidence of an associative response bias for patients with chronic pain. This body of research is not clear, however, on whether this bias is specific to patients with chronic pain, or whether the bias is specific to pain stimuli or illness/disability stimuli. DESIGN: This is a cross-sectional study involving the comparison of selected groups (chronic pain, acute pain, and medical-staff controls). METHOD: This study included 80 male participants with chronic pain, 50 male participants with acute pain, and 49 male participants who served as medical staff controls. All participants completed the Beck Depression Inventory, the State-Trait Anxiety Inventory, a pain intensity VAS, and the single-word associate homographic response task. RESULTS: Evidence was found for the specificity of pain responses to homographic pain stimuli as the chronic pain group produced more of these responses than the two comparison groups. CONCLUSIONS: These findings were seen as providing evidence for an associative response bias. This bias appears specific to pain-related stimuli and reflects the cumulative effects of pain over a period of time.

Major depression in patients with substance use disorders: relationship to 12-Step self-help involvement and substance use outcomes.

AIMS: Many patients treated for substance use disorders (SUDs) who become involved in 12-Step self-help groups have improved treatment outcomes. However, due to high rates of psychiatric comorbidity and major depressive disorder (MDD), among SUD patients in particular, concerns have been raised over whether these benefits extend to dual diagnosis patients. This study examined the influence of comorbid MDD among patients with SUDs on 12-Step self-help group involvement and its relation to treatment outcome. DESIGN: A quasi-experimental, prospective, intact group design was used with assessments completed during treatment, and 1 and 2 years postdischarge. PARTICIPANTS: A total of 2161 male patients recruited during in-patient SUD treatment, of whom 110 had a comorbid MDD diagnosis (SUD-MDD) and 2051 were without psychiatric comorbidity (SUD-only). FINDINGS: SUD-MDD patients were initially less socially involved in and derived progressively less benefit from 12-Step groups over time compared to the SUD-only group. However, substance use outcomes did not differ by diagnostic cohort. In contrast, despite using substantially more professional out-patient services, the SUD-MDD cohort continued to suffer significant levels of depression. CONCLUSIONS: Treatment providers should allocate more resources to targeting depressive symptoms in SUD-MDD patients. Furthermore, SUD-MDD patients may not assimilate as readily into, nor benefit as much from, traditional 12-Step self-help groups such as Alcoholics Anonymous, as psychiatrically non-comorbid patients. Newer, dual-diagnosis-specific, self-help groups may be a better fit for these patients, but await further study.

Psychiatric comorbidity, continuing care and mutual help as predictors of five-year remission from substance use disorders.

OBJECTIVE: In a cohort of 2,595 male patients in VA intensive treatment programs for substance use disorders (SUD), we tested whether psychiatric comorbidity, outpatient care and mutual help group attendance during the first two follow-up years predicted remission status at Year 5, controlling for covariates. METHOD: Logistic regression modeling of longitudinal data was used to test the hypotheses. RESULTS: Dual diagnosis patients were less likely to be in remission at Year 5 than SUD-only patients. Outpatient care was at best only weakly related to Year 5 remission status. By contrast, mutual help involvement substantially improved the chances of substance use remission at Year 5 for both SUD-only and dual diagnosis patients. Mutual help involvement did not, however, offset the poorer prognosis for dual diagnosis patients. CONCLUSIONS: Because mutual help groups specifically targeted to individuals with comorbid substance use and psychiatric disorders are currently rare, further research is recommended to investigate whether they are more effective than standard SUD mutual help groups in facilitating the recovery of persons with dual diagnoses.