Impact of psychosocial treatments on associated problems of cocaine-dependent patients.

A previous report from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study (P. Crits-Christoph et al., 1999) found relatively superior cocaine and drug use outcomes for individual drug counseling plus group drug counseling compared with other treatments. Using data from that study, the authors examined the relative efficacy of 4 treatments for cocaine dependence on psychosocial and other addiction-associated problems. The 487 patients were randomly assigned to 6 months of treatment with cognitive therapy, supportive-expressive therapy, or individual drug counseling (each with additional group drug counseling), or to group drug counseling alone. Assessments were made at baseline and monthly for 6 months during the acute treatment phase, with follow-up visits at 9 and 12 months. No significant differences between treatments were found on measures of psychiatric symptoms, employment, medical, legal, family-social, interpersonal, or alcohol use problems. The authors concluded that the superiority of individual drug counseling in modifying cocaine use does not extend broadly to other addiction-associated problems.

Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study.

BACKGROUND: This was a multicenter investigation examining the efficacy of 4 psychosocial treatments for cocaine-dependent patients. METHODS: Four hundred eighty-seven patients were randomly assigned to 1 of 4 manual-guided treatments: individual drug counseling plus group drug counseling (GDC), cognitive therapy plus GDC, supportive-expressive therapy plus GDC, or GDC alone. Treatment was intensive, including 36 possible individual sessions and 24 group sessions for 6 months. Patients were assessed monthly during active treatment and at 9 and 12 months after baseline. Primary outcome measures were the Addiction Severity Index-Drug Use Composite score and the number of days of cocaine use in the past month. RESULTS: Compared with the 2 psychotherapies and with GDC alone, individual drug counseling plus GDC showed the greatest improvement on the Addiction Severity Index-Drug Use Composite score. Individual group counseling plus GDC was also superior to the 2 psychotherapies on the number of days of cocaine use in the past month. Hypotheses regarding the superiority of psychotherapy to GDC for patients with greater psychiatric severity and the superiority of cognitive therapy plus GDC compared with supportive-expressive therapy plus GDC for patients with antisocial personality traits or external coping style were not confirmed. CONCLUSION: Compared with professional psychotherapy, a manual-guided combination of intensive individual drug counseling and GDC has promise for the treatment of cocaine dependence.

Cocaine-induced mood disorder: prevalence rates and psychiatric symptoms in an outpatient cocaine-dependent sample.

This paper attempts to examine and compare prevalence rates and symptom patterns of DSM substance-induced and other mood disorders. 243 cocaine-dependent outpatients with cocaine-induced mood disorder (CIMD), other mood disorders, or no mood disorder were compared on measures of psychiatric symptoms. The prevalence rate for CIMD was 12% at baseline. Introduction of the DSM-IV diagnosis of CIMD did not substantially affect rates of the other depressive disorders. Patients with CIMD had symptom severity levels between those of patients with and without a mood disorder. These findings suggest some validity for the new DSM-IV diagnosis of CIMD, but also suggest that it requires further specification and replication.

Empirically supported treatments: implications for training.

This article discusses the role of empirically supported treatments (ESTs) in the training of clinical psychologists. Training in ESTs can be integrated in ways that vary depending on the level of training and setting. Predoctoral programs, internships, postdoctoral programs, and continuing education are discussed in regard to special challenges and sequencing of training. A preliminary set of guidelines for training in ESTs is suggested.

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Rationale and methods.

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study is a large, multisite psychotherapy clinical trial for outpatients who meet the DSM-IV criteria for cocaine dependence. For 480 randomized patients, the outcomes of 4 treatments are compared for an 18-month period. All treatments include group drug counseling. One treatment also adds cognitive therapy, one adds supportive-expressive psychodynamic therapy, and one adds individual drug counseling; one consists of group drug counseling alone. In addition, 2 specific interaction hypotheses, one involving psychiatric severity and the other involving degree of antisocial personality characteristics, are being tested. This article describes the main aims of the project, the background and rationale for the study design, the rationale for the choice of treatments and patient population, and a brief description of the research plan.

Evaluation of psychotherapy. Efficacy, effectiveness, and patient progress.

Treatment-focused research is concerned with the establishment of the comparative efficacy and effectiveness of clinical interventions, aggregated over groups of patients. The authors introduce and illustrate a new paradigm-patient-focused research-that is concerned with the monitoring of an individual's progress over the course of treatment and the feedback of this information to the practitioner, supervisor, or case manager.

Factors in Outcomes of Short-Term Dynamic Psychotherapy for Chronic vs. Nonchronic Major Depression.

The benefits, and variables influencing the benefits, of short-term dynamic psychotherapy for chronic major depression versus nonchronic major depression were examined for 49 patients. The two diagnostic groups started at the same level on the Beck Depression Inventory (BDI) and Global Assessment of Functioning Scale (GAF) and benefited similarly. The bases for the benefits were examined by linear models explaining 35% of termination BDI variance and 47% of termination GAF scores. By far the largest contributor to outcome was initial GAF, followed by presence of more than one comorbid Axis I diagnosis. Initial level of depression on the BDI was not a significant predictor of termination BDI. The chronic/ nonchronic distinction accounted for less than 1% of explained variance, and little was added by personality disorder, age, or gender.

Intimate relationships and depression: is there a causal connection?

The causal pathways that link depression and dissatisfaction in intimate relationships were estimated in 115 patients during the first 12 weeks of treatment with cognitive-behavioral therapy for depression. Depression severity, as measured by the Beck Depression Inventory, was negatively correlated with relationship satisfaction at intake and at 12 weeks. However, structural equation modeling was not consistent with the hypothesis that depression severity has a causal effect on relationship satisfaction levels and suggested that relationship satisfaction may have only a weak reciprocal effect on depression severity. As predicted, married patients were substantially less depressed 12 weeks after the beginning of treatment, when controlling for initial depression severity. Contrary to expectations, marital status predicted improvement even when relationship satisfaction was controlled. Unexpectedly, dysthymia at intake was associated with low relationship satisfaction after 12 weeks, when initial relationship satisfaction was controlled, suggesting that chronic, low-level depression may have a stronger association with interpersonal problems than other forms of depression, such as major depressive episodes. The theoretical and clinical implications of the findings are discussed.

Efficacy and specific effects data on new treatments: a case study strategy with mixed anxiety-depression.

The case study research strategy presented here can be used to develop new psychotherapeutic treatments, test theorized mechanisms of action, and obtain initial outcome data of the type needed to support treatment outcome grant applications. The strategy is illustrated by 2 case studies of a new psychotherapeutic intervention for patients with coexisting generalized anxiety disorder and major depression as described in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev; American Psychiatric Association, 1987). The treatment is a modification and integration of existing treatments for panic disorder (Barlow & Craske, 1989) and for major depression (Klerman, Weissman, Rounsaville, & Chevron, 1984).

Reliability of DSM-III-R anxiety disorder categories. Using the Anxiety Disorders Interview Schedule-Revised (ADIS-R).

A large reliability study of DSM-III-R anxiety disorders is reported in which outpatients (n = 267) received two independent structured interviews (Anxiety Disorders Interview Schedule-Revised). It is the only reliability study to date in which the final DSM-III-R criteria are used throughout the study. Reliability was assessed for each diagnosis when it was assigned as a principal diagnosis and when it was assigned as either a principal or an additional diagnosis. Excellent reliability was obtained for current principal diagnoses of simple phobia, social phobia, and obsessive-compulsive disorder. Agreement was good for panic disorder when all severity levels of agoraphobic avoidance were combined. Reliability was fair for generalized anxiety disorder. Remaining diagnostic difficulties, particularly in identifying levels of agoraphobic avoidance and in reliably diagnosing generalized anxiety disorder, are discussed in the context of changes in diagnostic criteria that are under consideration for DSM-IV.

Definitions of secondary depression: effects on comorbidity and outcome in anxiety disorders.

The impact of different definitions of secondary depression on comorbidity and treatment outcome findings in anxiety disorder patients was examined by reviewing existing studies. Few data were found specifically on alternative definitions of secondary depression. However, other relevant findings yielded several conclusions: (a) different definitions of depression dramatically affect comorbidity findings, (b) widely divergent comorbidity findings are obtained in studies that use the same (temporal) definition of secondary depression, (c) few data exist on how different definitions of depression affect treatment outcome findings for anxiety disorders, and (d) some data show that patients' reports of whether or not their depressive symptoms temporally followed their anxiety symptoms are unreliable, suggesting that investigators who want to study secondary depression need to first determine that they have a reliable way to assess it.

Effect of time-limited psychotherapy on patient dropout rates.

The authors conducted an archival study of 149 new clinic patients at a large community mental health center. The dropout rate for patients in brief psychotherapy in which the length of therapy was specified at the outset of treatment (time-limited psychotherapy) (32%) was about one-half the dropout rate for patients in brief (67%) and long-term (61%) individual psychotherapy. The difference in dropout rates could not be explained by patient demographic or diagnostic variables or by therapist characteristics measured in the study. The results suggest that setting a specific time limit on individual psychotherapy at the outset of treatment can reduce the patient dropout rate in a public mental health clinic.

Pretherapy interpersonal relations, patients' alliance, and outcome in brief therapy.

This study examined the relationship between pretherapy clinical assessments of interpersonal relations and (1) patients' therapeutic alliance and (2) outcome in time-limited psychotherapy (up to 25 sessions). For 33 college men with symptoms of depression, anxiety, and social introversion, clinical judgments of interpersonal relations predicted patients' level of collaborative, positively toned participation in a therapeutic relationship, accounting for up to a quarter of the variance in observers' ratings of audiotaped segments from therapy sessions. Pretherapy assessments of overall psychological health were highly comparable with assessments of interpersonal relations as predictors of a patient's alliance; however, when the redundancy between the two types of clinical judgments was controlled, interpersonal relations were the better predictor. Assessments of interpersonal relations were found to correlate with outcome measures at a modest level.

Ego development and sociometrically evaluated maturity: an investigation of the validity of the Washington University Sentence Completion Test of Ego Development.

The reported study was an attempt to validate the Washington University Sentence Completion Test of Ego Development (WU-SCT), using a broad, sociometric index of maturity as the criterion variable. Sixty college women living in a sorority house completed the WU-SCT and evaluated one another's readiness for mature functioning in each of four adult social roles: career, marriage, parenthood, and community involvement. The reliabilities and the intercorrelations of the ratings suggested that peers distinguished two facets of maturity. While results support the hypothesized relationship between WU-SCT scores and a global sociometric index of maturity, the test's substantial correlations with indices relating to relatively impersonal roles (career and community) and apparent lack of correlation with indices relating to intimate interpersonal roles (marital and parental) suggests that the validity of the WU-SCT may be less broad than Loevinger's theory would imply. Several alternative interpretations of the data are suggested.