Factor structure of the Conners Adult ADHD Rating Scale (CAARS) for substance users.

Adult substance users are known to have above average rates of Attention Deficit-Hyperactivity Disorder (ADHD), but the psychometric properties of self-report measures of ADHD symptoms for adult substance users are unknown. Subjects (206 adults with a DSM-IV substance abuse disorder) were administered the Conners Adult ADHD Rating Scales (CAARS) upon enrolling in outpatient treatment. A factor structure similar to that reported for other populations was obtained and internal consistency reliabilities for the subscales and the overall index were high. Compared with CAARS norms, substance users scored significantly above average on all subscales as well as on the overall index. The CAARS may prove useful for measuring ADHD symptomatology among substance users, but additional reliability and validity evidence is needed. The CAARS should not be used by itself to diagnose individuals for ADHD.

The combined effects of treatment intensity, self-help groups and patient attributes on drinking outcomes.

Better understanding of the diverse factors that predict alcoholism treatment outcomes is essential to improving treatment strategies. Patients accepted for treatment at a multimodality program were interviewed and followed-up at three months and one year after admission. The study tested a set of hypotheses relating to the effects on drinking outcomes of treatment modality, modality matching, treatment retention, aftercare, self-help group participation and patient attributes at admission. Drinking frequency diminished substantially between baseline and the two follow-ups. Outcomes for inpatient were better than for outpatient treatment in bivariate analysis, but outcomes for these modalities were equal after adjusting for the effect of patient-treatment mismatching. Aftercare treatment, time in treatment for outpatients, community 12-Step group participation, and several patient attributes such as motivation for change and psychiatric severity significantly predicted drinking outcomes at one or both follow-ups. Clinical implications of the results are discussed.

Psychometric properties of the Toronto Alexithymia Scale (TAS-20) for substance users.

OBJECTIVE: To determine the psychometric properties of the Toronto Alexithymia Scale (TAS-20), an established self-report measure of alexithymia, for a substance user sample participating in a clinical trial of outpatient cognitive-behavioral therapies (N=230). METHODS: Confirmatory and exploratory factor analyses were used to determine the number and nature of the factors underlying the TAS-20 in a sample of substance users. Structural equation modeling was used to determine the predictive validity of the TAS-20. RESULTS: A factor structure comparable, but not identical, with TAS-20 psychometric results with other populations was found; alpha coefficients were .88 for the feelings factor, .62 for the external thinking factor, and .87 for the total score. Although, on average, the substance users did not appear to have elevated alexithymia scores compared with the undergraduate students, alexithymia predicted less treatment engagement, i.e., fewer sessions attended and weaker helping alliance. Alexithymia also predicted alcohol use outcomes but not drug use outcomes. The relation between alexithymia and drinking outcome was conditional on whether the patient was using solely alcohol at baseline. CONCLUSION: The TAS-20 has reasonably good psychometric properties in this sample, which might be improved by dropping several marginal questionnaire items. Alexithymia appears to attenuate substance abuse treatment engagement. More clinical and research experience with this construct and specific instrument in substance user samples is needed.

Moderators of effects of motivational enhancements to cognitive behavioral therapy.

Patient treatment matching hypotheses were tested for substance users randomly assigned to a group cognitive behavioral therapy (CBT; n= 114) or a group motivational intervention (GMI; n= 116). Treatment was scheduled twice weekly for 10 weeks. Using a patient attribute by treatment interaction design with a 15-week follow-up, the study predicted that alexithymia, antisocial personality disorder (ASPD), and network support for alcohol and drug use would be associated with less substance use for CBT subjects and that hostility and lower treatment motivation would be associated with less substance use for GMI subjects. Three of the hypothesized moderators were empirically supported: alexithymia, network support for alcohol, and ASPD. Results indicate the use of assessing specific patient attributes to better inform treatment recommendations.

Predictive validity of the ASAM Patient Placement Criteria for naturalistically matched vs. mismatched alcoholism patients.

This study examined the predictive validity of the ASAM Patient Placement Criteria for matching alcoholism patients to recommended levels of care. A cohort of 248 patients newly admitted to inpatient rehabilitation, intensive outpatient, or regular outpatient care was evaluated using both a computerized algorithm and a clinical evaluation protocol to determine whether they were naturalistically matched or mismatched to care. Outcomes were assessed three months after intake. One common type of undertreatment (ie, receiving regular outpatient care when intensive outpatient care was recommended) predicted poorer drinking outcomes as compared with matched treatment, independent of actual level of care received. Overtreatment did not improve outcomes. There also was a trend for better outcomes with residential vs. intensive outpatient treatment, independent of matching. Results were robust for both methods of assessment. Corroboration by more research is needed, but the ASAM Criteria show promise for reducing both detrimental undertreatment and cost-inefficient overtreatment.

Predictors of drinking outcomes among alcoholics.

Predicting outcomes for individual patients entering substance abuse treatment has long been a clinical goal in the addictions field. Intake data from the Addiction Severity Index and other standardized scales were collected on 248 alcohol dependent/abusing patients entering an urban hospital treatment program. The outcome measure was frequency of drinking days in the past 30 days. Baseline data were used to identify predictors of posttreatment drinking frequency at two follow-up interviews (3 and 12 months postbaseline). Stepwise multiple regressions indicated that a set of baseline predictors accounted for similar and substantial proportions of outcome variance at the two follow-ups. When psychosocial predictors were combined with an index of alcohol use severity (which included drinking frequency), the proportions of variance explained were 31% and 28% at 3 and 12 months, respectively. Two psychosocial predictors were significant at both time periods, and thus most likely to be replicated in future research: a treatment motivation index (a combination of measures of commitment to treatment success and internal motivation to seek treatment) and an index of 12-step (self-help) participation (a combination of measures of frequency of 12-step meeting attendance and perceived helpfulness of 12-step participation). While the predictability of short-term (3 month) outcomes could help clinicians tailor treatment strategies to maximize patient motivation and reduce drinking behavior, the predictability of longer term (12 month) outcomes could help counselors plan aftercare programs, encourage self-help participation, and promote recovery-oriented activities to sustain initial treatment-induced gains.

Convergent validity of the ASAM Patient Placement Criteria using a standardized computer algorithm.

The study examined the convergent validity of the ASAM Patient Placement Criteria (PPC) by comparing Level of Care (LOC) recommendations produced by two alternative methods: a computerdriven algorithm and a "standard" clinical assessment. A cohort of 248 applicants for alcoholism treatment were evaluated at a multi-modality treatment center. The two methods disagreed (58% of cases) more often than they agreed (42%). The algorithm recommended a more intense LOC than the clinician protocol in 81% of the discrepant cases. Four categories of disagreement accounted for 97% of the discrepant cases. Several major sources of disagreement were identified and examined in detail: clinicians' reasoned departures from the PPC rules, conservatism in algorithm LOC recommendations, and measurement overlap between two specific dimensions. In order for the ASAM PPC and its associated algorithm to be embraced by treatment programs, the observed differences in LOC recommendations between the algorithm and "standard" clinical assessment should be resolved.

Feasibility of matching alcohol patients to ASAM levels of care.

The study examined the feasibility of implementing treatment recommendations derived from the American Society of Addiction Medicine (ASAM) Patient Placement Criteria in an urban addiction treatment program that offered a continuum of levels of care (LOC). A cohort of 281 applicants for alcoholism treatment were evaluated and the reasons for observed differences ("mismatches") between recommended and actual LOC placements were determined. Overall, 88% of the applicants entered treatment, and 72% of these were matched to LOC vs. 28% who were mismatched. Presumptive overtreatment (59%) was more common than undertreatment (41%) among the mismatched patients. The reasons for overtreatment were availability of Medicaid coverage for inpatient rehabilitation (93%), referral sources' treatment philosophy of gradually "stepping down" from inpatient detoxification (59%), social pressures on patients (28%), and mandated treatment (8%). The reasons for presumptive undertreatment were work schedule conflicts (72%), patient reluctance (48%), insurance coverage (15%), and interference with family or personal responsibilities (9%). These results indicate multiple barriers that need to be overcome to enable full implementation of the ASAM Criteria in real world program settings, even when a continuum of care is available.