Development and preliminary experience with an ease of extractability rating system for prescription opioids.

One important factor in the abuse potential of an opioid product is the ease with which active drug can be extracted. There are currently no standards for testing or reporting extractability. This article describes the development of an Extractability Rating System for use by the pharmaceutical industry and regulators. Despite several limitations, this effort serves as a call for standardized testing and reporting so that products can be accurately rated, and should help establish goals for drug developers who wish to develop "abuse-resistant" opioid products.

Initial validation of a computer-administered Addiction Severity Index: the ASI-MV.

The Addiction Severity Index--Multimedia Version (ASI-MV) is a CD-ROM-based simulation of the interviewer-administered Addiction Severity Index (ASI). Clients in treatment (N = 202) self-administered the ASI-MV to examine the test-retest reliability, criterion validity, and convergent-discriminant validity of the ASI-MV. Excellent test-retest reliability was observed for composite scores and severity ratings. Criterion validity, tested against the interviewer-administered ASI, was good for the composite scores. For severity ratings, variable agreement was observed between the ASI-MV and each interviewer, suggesting poor interrater reliability among interviewers. This conclusion was bolstered by a finding of superior convergent-discriminant validity for both composite scores and severity ratings compared to the standard ASI. The ASI-MV is a viable alternative to the expensive and potentially unreliable interviewer-administered version.

Behavioral health care dot-com and beyond: computer-mediated communications in mental health and substance abuse treatment.

Computer-mediated communications (CMC) such as e-mail, websites, and CD-ROM and DVD programs, both on and off the Internet, will play an ever larger role in the future of behavioral health care. This address describes the current rapid expansion of CMC and some profound changes that are likely in the future. The reasons for using such CMC programs are addressed, and an example of a new multimedia version of the Addiction Severity Index is described. Issues and concerns about future uses of CMC are raised, as are possible implications for psychology.

Group psychotherapy and managed behavioral health care: current trends and future challenges.

The rising cost of health care within the private and public sectors has created an increased demand for the management of benefit dollars. This trend has significant implications for group psychotherapists, as group modalities offer cost-effective ways of delivering services to traditional outpatient and inpatient populations. Continued cost-containment pressures and increasing attention to outcome studies will fuel trends toward briefer, manualized group treatments and intensive group outpatient programs as alternatives to hospitalization. Quality-based demands will challenge payors to (a) address biases against group psychotherapy among providers and patients and (b) integrate recent process-and-outcome research in determining the appropriateness of group versus individual modalities for particular patients and presenting problems.

A model of time-effective group psychotherapy for patients with personality disorders: the clinical model.

This article describes a model of time-limited psychotherapy for patients with personality disorders that emphasizes the group as a social microcosm. The patient population described is relatively high functioning, although the majority of the group members meet DSM-III-R (American Psychiatric Association, 1987) criteria for an Axis II diagnosis. The clinical model's key theoretical concepts, for example, interpersonal focus; active therapist stance; emphasis on group interaction and processes; use of time limits; primary care/intermittent treatment philosophy; and emphasis on patients' strengths, goals, and resources are described. The relationships between the phases of group therapy and the key theoretical concepts are delineated.

Time-limited group psychotherapy for patients with personality disorders: outcomes and dropouts.

This study reports on the time-limited (18-month long) group therapy of 49 outpatients, most of whom were diagnosed with DSM-III-R, Axis II personality disorders (American Psychiatric Association, 1987). Although many patients did not complete the full course of treatment, those who did experienced many areas of change. Completers reported substantial changes in self-esteem, symptomatology, and diagnosability on Axis II. This type of group treatment appears to be a promising mode of intervention for those with personality disorders.

Therapist's experience, training, and skill in brief therapy: a bicoastal survey.

California and Massachusetts psychologists (N = 850, 58% response rate) returned a questionnaire to ascertain clinicians' brief-therapy experience, training, self-assessed skill, and attitude. Results indicate respondents spend a considerable portion (40%) of their clinical time doing brief therapy. A disturbing finding is that one-third of those presently doing brief therapy reported that they had received little or no training in brief-therapy theory or techniques. Self-rated skill in brief therapy was found to be best predicted by a combination of one's experience, training, and attitude. We conclude that, while the number of therapists using brief therapy has increased rapidly and apparently will continue to increase due to the expansion of managed health care, many psychologists do not have adequate training to use brief therapy successfully. Implications of this finding in terms of its potentially harmful effects and suggestions for future training are discussed.

Brief therapy for managed mental health companies: becoming a learning organization.

Nearly all of the services offered through managed behavioral health care companies are brief or time effective in nature. It is often the view of these companies that many of their providers have insufficient backgrounds in doing such treatment and have been trained in longer, less efficient modes of service delivery. Although this is often the case, what is frequently not recognized is that most managed behavioral health care companies themselves lack knowledge and clarity about such therapies. We address the critical need for behavioral health care companies to become learning organizations focused on research and development and internal as well as external training in time-efficient therapies. Such activities will allow for creativity and enhancement of the substance abuse and mental health care areas.

Cohesion, alliance and outcome in group psychotherapy.

Cohesiveness has been viewed as the group psychotherapy equivalent of the therapeutic alliance in individual treatment. Although researchers have attempted to study the concept of cohesion in group treatment, understanding of this so-called "curative" group factor remains quite primitive. In this study of 12 time-limited psychotherapy groups, with a total of 90 nonpsychotic outpatients, we explore the relationships between cohesion, alliance and treatment outcome. Our cohesion measure is a new instrument, the Harvard Community Health Plan Group Cohesiveness Scale, developed for use with group therapy videotapes. To measure alliance we have modified the Penn Helping Alliance Scale (Group Alliance Scale) to be scored from videotapes of group sessions. Both of these instruments use trained observers to make ratings for the group-as-a-whole. The outcome battery for patients in these groups included a widely varied set of measures, enabling us to view change from a number of perspectives. Our findings indicate that cohesion and alliance as measured here are related concepts. We also find that both cohesion and alliance appear to have strong relationships with improved self-esteem and reduced symptomatology for patients in these groups. In addition, it appears that outcome is most related to cohesion in the first 30 minutes of a group session. Implications of these and other findings are discussed.

Performance of screening and diagnostic tests. Application of receiver operating characteristic analysis.

Evaluation of psychiatric screening and diagnostic tests has benefited from the application of sensitivity, specificity, the kappa-statistic, and predictive values. These measures derive their meaning from a single criterion threshold. Receiver operating characteristic (ROC) analysis extends assessment of test performance by providing information about all possible pairs of achievable sensitivity and specificity values. The ROC analysis offers a comprehensive means for comparing different tests or different scoring procedures for one test. As a demonstration we used the ROC analysis to evaluate three types of scoring rules for one psychiatric test, the Health Opinion Survey. The demonstration indicated that ROC analysis can profitably take a place among the standard methods for test evaluation in psychiatric research. In addition, ROC analysis can assist clinicians in selecting appropriate test procedures for particular patient populations.

A controlled study of the impact of mental health treatment on medical care utilization.

The authors report on a controlled examination of the effects of mental health intervention on the use of medical services in a health maintenance organization. Thirty-six patients were randomly assigned, after initial evaluation, either to begin immediately short-term (15 weekly session) group therapy or for those same 15 weeks to remain on a waiting list. The results seemed to indicate that both patients treated immediately and patients who were wait-listed reduced their medical utilization. Wait-list patients, however, appeared to reduce health care use more than immediate-treatment patients. Further, examination of the patterns of health care use showed that wait-listed patients were more likely to have changed their patterns of utilization than immediate-treatment patients. These findings, which must be interpreted cautiously because of the small number of subjects, appear to support the results of other studies that indicate that those patients with the least mental health intervention appear to have the greatest reductions in medical utilization.

Advances in brief psychotherapy: a review of recent literature.

Clinicians, theorists, and researchers have for many years debated the issue of if, and how, psychotherapy can be abbreviated. It is only in recent years, however, that economic, social, and political factors have converged in a manner that makes it urgent for most psychotherapists to consider doing treatment quickly, efficiently, and cost-effectively. This review examines recent and significant trends in the literature on brief psychotherapy. Some of the important directions in short-term therapy that the authors examine are the broadening of criteria for patient selection, increasing attention to life-stage developmental issues, more flexible and creative allocation of time in therapy, new approaches to short-term group psychotherapy, and use of diverse intervention techniques. Outlooks for the future of brief treatment are also discussed.

Adult mental health services in a health maintenance organization.

The authors describe an adult mental health service within a health maintenance organization and present information on the department's setting, staffing patterns, programs, and philosophy. They believe that the emphasis on brief focal psychotherapy, the staff of mental health care providers who are committed to this type of setting, and the thorough integration of the program into the larger HMO system all contribute to the provision of high-quality services at a reasonable cost.