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Patients diagnosed with both substance use disorder (SUD) and posttraumatic stress disorder (PTSD) often experience hypervigilance, increased fear, and difficulties regulating emotions. This dual diagnosis increases treatment complexity. Recently, a short-term music therapy intervention for arousal and attention regulation (the SMAART intervention) was designed based on neurobiological findings. Twelve patients with SUD and PTSD (50% females) in outpatient treatment participated in six weekly one-hour sessions of the SMAART intervention. Six patients completed the study. PTSD symptom severity was evaluated with the Posttraumatic Stress Disorder Symptom Scale Interview for DSM–5 (PSSI-5) pre- and post-intervention, and sustained attention was evaluated with the Bourdon–Wiersma (BW) test. A significant difference in measurements for the PSSI-5 overall symptom severity was found pre- and post-intervention. Furthermore, participants showed significant improvement on subscales of hyperarousal, mood and cognition, and attention. The BW test completion time decreased significantly. Two participants dropped out before the end of the intervention due to craving. Concerning future research, it is recommended to define the role of the music more explicitly and to change the design to a randomized controlled trial. A risk for future larger studies is a high dropout rate (50%). Several limitations of the study are discussed.

Contains fulltext : 219019.pdf (Publisher’s version ) (Open Access) Introduction: Substance use disorders (SUD) in physicians often remain concealed for a long time. Peer monitoring and open discussions with colleagues are essential for identifying SUD. However, physicians often feel uncomfortable discussing substance use with a colleague. We explored physicians’ attitudes and norms about substance use (disorders) and their (intended) approach upon a presumption of substance use in a colleague. Materials and methods: An online cross-sectional survey concerning "Addiction in physicians" was administered by the Royal Dutch Medical Association physician panel. Overall, 1685 physicians (47%) responded. Data were analyzed by logistic regression to explore factors associated with taking action upon a substance use presumption. Results: Most physicians agreed that SUD can happen to anyone (67%), is not a sign of weakness (78%) and that it is a disease that can be treated (83%). Substance use in a working context was perceived as unacceptable (alcohol at work: 99%, alcohol during a standby duty: 91%, alcohol in the eight hours before work: 77%, and illicit drugs in the eight hours before work: 97%). Almost all respondents (97%) intend to act upon a substance use presumption in a colleague. Of the 29% who ever had this presumption, 65% took actual action. Actual action was associated with male gender and older age (OR = 1.81; 95% CI = 1.20-2.74 and OR = 1.03; 95% CI = 1.01-1.05, respectively). Conclusions: About one-third of physicians reported experience with a presumption of substance use in a colleague. Whilst most physicians intend to take action upon such a presumption, two-thirds actually do act upon a presumption. To bridge this intention-behavior gap continued medical education on signs and symptoms of SUD and instructions on how to enter a supportive dialogue with a colleague about personal issues, may enhance physicians' knowledge, confidence, and ethical responsibility to act upon a presumption of substance use or other concerns in a colleague. 14 p.

Alexithymia is common in patients with a substance use disorder (SUD) and is possibly a negative prognostic factor in their treatment. The aim of this study was twofold. First, we explored whether SUD patients with posttraumatic stress disorder (PTSD) are more alexithymic than SUD patients without PTSD. Next, we explored whether trait and state-related parts of alexithymia could be differentiated in these patients. This phenomenon was studied in 197 SUD patients with the Toronto Alexithymia Scale-20 (TAS-20); Clinician Administered PTSD Scale; Self-Report Inventory for PTSD; Traumatic Experiences Checklist; European Addiction Severity Index; and the Depression, Anxiety and Stress Scale in a cross-sectional design. SUD patients with current PTSD showed more alexithymic characteristics than patients without PTSD or with previous lifetime/not current PTSD. The severity of PTSD complaints; alcohol addiction; and the combination of depression, anxiety and stress symptoms, all of which are more related to alexithymia as a state, explained 38.1% of the TAS-20. In conclusion, we advise that SUD patients be assessed for alexithymia and that its degree is taken into account. We also tentatively assume that a considerable part of alexithymia is more state- than trait-related in these patients.

Item does not contain fulltext Background: The Eating Disorder Questionnaire-Online (EDQ-O) is an online self-report questionnaire, which was developed specifically to provide a DSM-IV-TR classification of anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), and eating disorder not otherwise specified (EDNOS), without using a face-to-face clinical interview. Objective: The purpose of the present study was to examine the psychometric quality of the EDQ-O. Methods: The validity of the EDQ-O was determined by examining the agreement with the diagnoses obtained from the Longitudinal, Expert, and All DATA (LEAD) standard. Participants included 134 new patients of a specialist center for eating disorders located in the Netherlands. Results: Assessment of the validity of the EDQ-O yielded acceptable to good AUC (area under the receiver operating characteristic curve) values with a range from 0.72 to 0.83. Most other diagnostic efficiency statistics were also good except for a low sensitivity for AN (0.44), a low positive predictive value for BN (0.50), and a relatively low sensitivity for BED (0.66). Conclusion: The results of the present study suggest that the EDQ-O performs acceptably as a diagnostic instrument for all DSM-IV-TR eating disorder classifications. However, suggestions are made to further improve the validity of the EDQ-O. 10 p.

Contains fulltext : 175254.pdf (Publisher’s version ) (Closed access) Objective: In a sample of people with substance use disorder who had experienced psychological trauma, this study aimed to quantify differences in perceived suffering due to addiction-related problems and to trauma-related problems. Methods: The sample comprised 146 inpatients with substance use disorder: 25% had posttraumatic stress disorder (PTSD), 21% had subthreshold PTSD; and the remainder constituted the trauma-only group. PTSD, substance use disorder, and suffering were assessed using validated instruments. Suffering was measured using the Pictorial Representation of Illness and Self Measure (PRISM). Results: No differences were found among the PTSD, subthreshold PTSD, and trauma-only group in the suffering attributed to addiction-related problems. Those in the PTSD group appraised their suffering due to trauma-related problems as greater than the other groups. In the PTSD group, but not the subthreshold PTSD group, suffering due to trauma-related problems was appraised as greater than that due to addiction-related problems. Conclusions: This is the first study to demonstrate quantitative comparisons between different health problems using the "common currency" of suffering. Our results indicate that even among those in an inpatient substance use disorder treatment program, comorbid PTSD may be more personally salient and cause greater suffering, with implications for therapeutic interventions available on substance use disorder treatment programs. 8 p.

Item does not contain fulltext While guidelines advise integrated treatment of patients with substance use disorder (SUD) and posttraumatic stress disorder (PTSD), recent studies and reviews find no convincing evidence of different outcomes following treatment between non-trauma focused integrated programs and SUD treatment alone. In this study, we analyzed whether SUD patients with higher levels of PTSD symptoms receiving standard, non-integrated SUD treatment (N=145) differed in outcomes compared to patients with lower levels of PTSD symptoms (N=152). Patients with higher levels of PTSD symptoms showed no difference in days of substance use, but significantly more craving and psychiatric symptoms (depression, anxiety and stress) were measured at baseline. After 3 and 6months of SUD treatment, there was no difference between the groups in decreased days of substance use. After 6months of SUD treatment, depression, anxiety and stress were significantly diminished in both groups. However, those with higher levels of PTSD symptoms at the start of the SUD treatment still reported significantly higher scores on depression, anxiety and stress after 6 months of SUD treatment. These findings corroborate earlier studies that SUD patients with PTSD symptoms do not necessarily have poorer addiction treatment outcomes. However, as anxiety and PTSD symptoms predict relapse, future research should note the effect of higher symptom levels on long-term SUD treatment results. Additionally, more research is needed to determine which patients need additional treatment in conjunction with or following SUD treatment. 5 p.

Item does not contain fulltext BACKGROUND AND AIMS: Gamma-hydroxybutyrate (GHB) detoxification procedures have been insufficiently studied for effectiveness and safety. Based on case reports, benzodiazepines are generally regarded as first-choice agents in GHB detoxification. Detoxification by titration and tapering (DeTiTap) with pharmaceutical GHB in an open-label consecutive case series of 23 GHB-dependent patients showed to be feasible, effective and safe. This study further explored the feasibility, effectiveness and safety of this detoxification procedure in a large group of patients. METHOD: A large observational multicenter study was carried out in six addiction treatment centers in the Netherlands. GHB-dependent inpatients (229 unique patients, 274 admissions) were titrated on and tapered off with pharmaceutical GHB. RESULTS: Successful detoxification was achieved in 85% of cases. Detoxification was carried out in 12.5days in most patients. The DeTiTap procedure proved to be feasible and significantly reduced the experienced withdrawal symptoms and craving (p

Contains fulltext : 116474.pdf (Publisher’s version ) (Closed access) Objectives: Previous research identified alexithymia as a potential risk factor for substance use disorders (SUD). More insight into the relation between alexithymia and SUD is needed in order to treat SUD effectively. Therefore, we investigated whether a familial vulnerability to alcoholism relates to the presence and severity of alexithymia in SUD patients. Method: Hospitalized, abstinent SUD-patients (n = 187), were assessed with the Toronto Alexithymia Scale (TAS-20) and Addiction Severity Index (EuropASI). A maternal, paternal, and total continuous measure of the Family History of Alcohol (FHA) was developed. Kruskal-Wallis tests and Spearman correlations were used to relate the composite scores of FHA to alexithymia as a categorical and continuous measure. Multivariate regression models were performed to control for the effects of confounders on the relation between FHA and alexithymia. Results: Compared to moderate (33%) and low (17%) alexithymic SUD-patients, high alexithymic (50%) patients were more likely to have fathers with alcohol problems (P = 0.004). Such a difference was not found for mothers with alcohol problems. The composite FHA-score was significantly associated with alexithymia (Rs = .19, P = 0.01). However, only a paternal FHA, independent from disturbed family functioning, related to the degree of alexithymia (beta = .13, P = 0.06), especially to the Difficulty Identifying Feelings as measured by the TAS-20 (beta = .16, P = 0.02). Conclusions: The relation between a paternal FHA and a higher degree of alexithymia in SUD-patients suggests that alexithymia could mediate the familiality of alcoholism or SUD in the paternal line. 7 p.

Item does not contain fulltext BACKGROUND: The inability of individuals with Alcohol Use Disorders (AUD) to recognize and describe their feelings and cravings may be due to alexithymia. Previous researches have shown evidence for a negative influence of alexithymia on treatment outcomes in patients with AUD. Therefore, it was hypothesized that high alexithymic patients with AUD would benefit less from cognitive behavioral therapy (CBT) compared with low alexithymic patients. METHODS: One hundred alcohol-dependent inpatients (DSM IV) were assessed with the Mini International Neuropsychiatric Interview for psychiatric disorders, the Toronto Alexithymia Scale (TAS-20), and the European Addiction Severity Index (EuropASI). Baseline alexithymia, as a categorical and continuous variable, was used to compare or relate baseline demographic and addiction characteristics, time in treatment, abstinence, and differences in addiction severity at 1-year follow-up. Analyses were performed using chi(2) test, analysis of variance or Kruskal-Wallis, paired t-tests or Wilcoxon's signed rank tests, multivariate logistic, and linear regression models, as appropriate. RESULTS: The prevalence of high alexithymia (TAS-20 > 61) was 45%. The total TAS-20 score correlated negatively with years of education (r = -.21; p = .04) and positively with the psychiatry domain of the EuropASI (r = .23; p = .04). Alexithymia showed no relation to abstinence, time in treatment, or change in severity of alcohol-related problems on the EuropASI. CONCLUSION: High alexithymic patients with AUD do benefit equally from inpatient CBT-like treatment as low alexithymic patients with AUD. SCIENTIFIC SIGNIFICANCE: Multimethod alexithymia assessments with an observer scale have been advised to judge the relationship with resulting outcome in CBT. 01 juli 2012

Item does not contain fulltext The construct of alexithymia as a vulnerability factor for substance use disorders (SUD) is under debate, because of conflicting research results regarding alexithymia as a state or trait phenomenon. The absolute and relative stability of alexithymia were evaluated in a pre-post design as part of a randomised controlled trial, controlling for several co-variates. Assessments were done with the Toronto Alexithymia Scale (TAS-20) and the Addiction Severity Index (EuropASI) at baseline and follow-up of a 3-month trial of inpatient Cognitive Behavioural Therapy (CBT) with or without a Shared Decision Making intervention for 187 SUD patients. Paired sample t-tests and analyses of variance were performed to assess absolute stability, intraclass correlation coefficients were calculated for relative stability and multivariate linear regression models were used to evaluate the relation between co-variates and change in alexithymia. Mean level reduction of total TAS-20 and two subfactors demonstrated no absolute stability, but change in alexithymia differed for patients with low, moderate and high alexithymia scores. Relative stability of alexithymia was moderate to high for the total population, but differed according to low, moderate and high alexithymia scores. The EuropASI "psychiatry" domain, covering anxiety and depression, was related to alexithymia, but CBT-related variables were not. In conclusion, alexithymia is partly a state-dependent phenomenon, but not a stable personality trait in this SUD population.

Background: Several instruments have been developed and validated as screens for post-traumatic stress disorder (PTSD) in substance use disorder (SUD) patients. Unfortunately, many of these instruments have one or several disadvantages (e.g. low specificity, low sensitivity or high costs). No research has been conducted on instruments that screen simultaneously for other psychiatric disorders, which would be a potentially time-saving and cost-effective approach. In the current study we tested the psychometric properties of the Depression, Anxiety and Stress Scale (DASS) as a screen for PTSD. Methods: The DASS was assessed in an inpatient facility during intake with 58 patients and again 4 weeks after admission. Another 138 patients were assessed 4 weeks after admission only. The results were compared to the Clinician-Administered PTSD Scale (CAPS) that was also administered after 4 weeks of abstinence. Results: ROC curve analyses showed an area under the curve of 0.84 for the DASS at intake and 0.78 for the DASS after 4 weeks' abstinence. Conclusion: The DASS is therefore a reliable and convenient measure to use as a screen for PTSD in SUD patients.

Item does not contain fulltext Traumatic experiences have been linked with substance use disorders (SUD) and may be an important factor in the perpetuation of SUD, even in the absence of posttraumatic stress disorder (PTSD) symptoms. The purpose of the current study was to examine the relationship between childhood trauma and substance use severity in 192 SUD inpatients. Childhood trauma was assessed using the Traumatic Experiences Checklist (TEC). With variables derived from this measure in addition to PTSD symptoms, two regression models were created with alcohol use or drug use severity as dependent variables. Alcohol severity was explained by PTSD symptoms as well as the age of trauma. Drug severity was explained solely by PTSD symptoms. The clinical value of assessing childhood trauma in determining the addiction severity appears to be limited in comparison with PTSD symptoms. 5 p.

Item does not contain fulltext Previous research on substance use disorders (SUD) has yielded conflicting results concerning whether alexithymia is a state or trait, raising the question of how alexithymia should be addressed in the treatment of SUD-patients. The absolute and relative stabilities of alexithymia were assessed using the Toronto Alexithymia Scale (TAS-20) and its subscales. In total, 101 patients with SUD were assessed twice during a 3-week inpatient detoxification period while controlling for withdrawal symptoms and personality disorder traits. The relative stability of the total TAS-20 and subscales was moderate to high but showed remarkable differences between baseline low, moderate, and high alexithymic patients. A small reduction in the mean levels of the total TAS-20 scores and those of one subscale revealed the absence of absolute stability. The levels of alexithymia were unrelated to changes in withdrawal symptoms, including anxiety- and depression-like symptoms. The differences between low, moderate, and high alexithymic patients in terms of the change in alexithymia scores between baseline and follow-up indicated a strong regression to the mean. The findings suggest that alexithymia in SUD patients as measured using the TAS-20 is both a state and trait phenomenon and does not appear to be related to changes in anxiety- and depression-like symptoms. 9 p.

Item does not contain fulltext Posttraumatic stress disorder (PTSD) is highly prevalent in substance use disorder (SUD) populations. Because resources for extensive and thorough diagnostic assessment are often limited, reliable screening instruments for PTSD are needed. The aim of the current study was to test two short PTSD measures for diagnostic efficiency in predicting PTSD compared to the Clinician-Administered PTSD Scale (CAPS). The sample consisted of 197 SUD patients receiving residential substance use treatment who completed questionnaires regarding substance use and trauma-related symptoms, all abstinent from substance for 4 weeks. The PTSD section of the Mini International Neuropsychiatric Interview plus (MINIplus) and the Self-Report Inventory for PTSD (SRIP) are compared to the CAPS. Results showed low sensitivity (.58) and high specificity (.91) for the PTSD section of the MINIplus. The SRIP showed high sensitivity (.80) and moderately high specificity (.73) at a cut-off score of 48. The prevalence of PTSD as measured with the CAPS was 25.4% current and 46.2% lifetime. Results indicate that the MINIplus, a short clinical interview, has insufficient quality as a screener for PTSD. The SRIP, however, is a reliable instrument in detecting PTSD in a SUD inpatient population in The Netherlands. Screening for PTSD is time efficient and increases detection of PTSD in SUD treatment settings. 5 p.

Traumatic experiences and, more specifically, posttraumatic stress disorder (PTSD) are highly prevalent among substance use disorder (SUD) patients. This comorbidity is associated with worse treatment outcomes in substance use treatment programs and more crisis interventions. International guidelines advise an integrated approach to the treatment of trauma related problems and SUD. Seeking Safety is an integrated treatment program that was developed in the United States. The aim of the current study is to test the efficacy of this program in the Netherlands in an outpatient SUD population. A randomized controlled trial (RCT) will be used to test the efficacy of Seeking Safety compared to Cognitive Behavioral Therapy (CBT) in a population of SUD outpatients. Each treatment will consist of 12 group sessions. The primary outcome measure will be substance use severity. Secondary outcome measures are PTSD and trauma symptoms, coping skills, functioning, and cognitions. Questionnaires will be administered at the start of treatment, at the end of treatment (three months after the start of treatment) and at follow-up (six months after the start of treatment). This study protocol presents a RCT in which the efficacy of an integrated treatment for comorbid PTSD and SUD, Seeking Safety, is evaluated in a SUD outpatient population compared to CBT. It is expected that the intervention group will show significantly more improvement in substance use severity compared to the control group at end-of-treatment and at follow-up. Furthermore, a lower drop-out rate is expected for the intervention group. If the intervention proves to be effective, it can be implemented. A cost-effectiveness analysis will be conducted to evaluate the two treatments. The protocol for this study is registered with the Netherlands Trial Register with number NTR3084 and approved by the local medical ethical committee (METC\11270.haa).

Objective: To determine the effectiveness and safety of a new detoxification procedure in γ-hydroxybutyrate (GHB)-dependent patients. GHB is an endogenous inhibitory neurotransmitter and anesthetic agent that is being abused as a club drug. In many GHB-dependent patients a severe withdrawal syndrome develops that does not respond to treatment with high dosages of benzodiazepines and often requires an admission to an intensive care unit. Methods: Based on the knowledge of detoxification procedures in opioid and benzodiazepine dependence, we developed a titration and tapering procedure. A consecutive series of 23 GHB-dependent inpatients were transferred from illegal GHB (mostly self-produced) in various concentrations to pharmaceutical GHB. They were given initial doses that resulted in a balance between sedation and withdrawal symptoms. After this titration period, patients were placed on a 1-week taper. Results: We have found that after titration the patients experienced a low level of withdrawal symptoms. During tapering these symptoms decreased significantly and no patient developed a delirium or a psychosis. None of the patients had to be transferred to a medium or intensive care unit. Conclusions: This detoxification procedure proved to be safe and convenient in patients with moderate to severe GHB dependence.

Item does not contain fulltext Background: The availability of online treatment programs offers the potential to reach more problem drinkers. This study compared the client populations of an e-therapy program (asynchronous client–therapist communication via the Internet) and a face-to-face treatment program. Objective: To determine whether e-therapy and face-to-face groups differed from each other and changed over time. Methods: We compared the baseline characteristics of four naturalistic groups (N = 4593): two e-therapy groups (2005–2006 and 2008–2009) and two consecutive series of ambulant face-to-face clients admitted for treatment as usual. The characteristics we were interested in were gender, age, education level, working situation, and earlier treatment for drinking problems. Results: The results showed that the baseline characteristics of e-therapy and face-to-face clients differed by gender, education level, work situation, prior alcohol treatment, and age. We also found that both e-therapy groups differed over time by gender, work situation, and prior alcohol treatment. Conclusions: The e-therapy program successfully attracted clients who were different from those who were represented in regular face-to-face alcohol treatment services. This indicates that e-therapy decreases the barriers to treatment facilities and enhances the accessibility. However, the e-therapy population changed over time. Although the e-therapy program still reached an important new group of clients in 2008–2009, this group showed more overlap with the traditional face-to-face group of clients probably as a result of improved acceptance of e-therapy in the general population. Scientific Significance: Although e-therapy seems to be better accepted in the general population, anonymous treatment seems necessary to reach a broader range of problem drinkers. Read More: http://informahealthcare.com/doi/abs/10.3109/00952990.2011.600388 6 p.

Contains fulltext : 103113.pdf (Publisher’s version ) (Closed access) Background: Web-based interventions for problem drinking are effective but characterized by high rates of attrition. There is a need to better understand attrition rates in order to improve the completion rates and the success of Web-based treatment programs. Objective: The objectives of our study were to (1) examine attrition prevalence and pretreatment predictors of attrition in a sample of open-access users of a Web-based program for problem drinkers, and (2) to further explore attrition data from our randomized controlled trial (RCT) of the Web-based program. Methods: Attrition data from two groups of Dutch-speaking problem drinkers were collected: (1) open-access participants enrolled in the program in 2009 (n = 885), and (2) RCT participants (n = 156). Participants were classified as noncompleters if they did not complete all 12 treatment sessions (9 assignments and 3 assessments). In both samples we assessed prevalence of attrition and pretreatment predictors of treatment completion. Logistic regression analysis was used to explore predictors of treatment completion. In the RCT sample, we additionally measured reasons for noncompletion and participants’ suggestions to enhance treatment adherence. The qualitative data were analyzed using thematic analysis. Results: The open-access and RCT group differed significantly in the percentage of treatment completers (273/780, 35.0% vs 65/144, 45%, χ21 = 5.4, P = .02). Logistic regression analysis revealed a significant contribution of treatment readiness, gender, education level, age, baseline alcohol consumption, and readiness to change to predict treatment completion. The key reasons for noncompletion were personal reasons, dissatisfaction with the intervention, and satisfaction with their own improvement. The main suggestions for boosting strategies involved email notification and more flexibility in the intervention. Conclusions: The challenge of Web-based alcohol treatment programs no longer seems to be their effectiveness but keeping participants involved until the end of the treatment program. Further research should investigate whether the suggested strategies to improve adherence decrease attrition rates in Web-based interventions. If we can succeed in improving attrition rates, the success of Web-based alcohol interventions will also improve and, as a consequence, their public health impact will increase. Trial: International Standard Randomized Controlled Trial Number (ISRCTN): 39104853; http://www.controlled-trials.com/ISRCTN39104853 (Archived by WebCite at http://www.webcitation.org/63IKDul1T)

Objective: This study documented the number of people seeking help for mental health problems after a fireworks disaster in Enschede, the Netherlands. It describes their diagnostic characteristics, interventions provided, and their results. Methods: Researchers coded data from in- takes and medical charts of all patients who sought help (N=1,659) and entered treatment (N=663) at a disaster relief service between May 13, 2000 (day of the disaster), and June 1, 2004. Patients who received more than eight treatment sessions (N=394) and were in treatment one year after the disaster were interviewed with the Composite International Diagnostic Interview (CIDI) (N=228, response rate, 58%) and other questionnaires (N=271, response rate, 69%). Results: In the population probably exposed, the cumulative referral-incidence for disaster-relat- ed mental health problems over four years was approximately 10%; in terms of referrals to the mental health facility over five years, the pro- portion of disaster-related referrals was 5.7%. Among adults, posttrau- matic stress disorder (PTSD) was the most common clinical diagnosis (53%, chart sample). However, depression was the most common CIDI diagnosis (58%, CIDI interview sample). The recovery rate was about 50% on the basis of clinical judgment (chart sample), between 69% and 76% on the basis of "healthy" scores on symptoms, and between 39% and 60% in social and physical functioning (interview sample). Conclusions: Apart from persons seeking support during the first weeks postdisaster, the largest influx occurred after about one year and was limited in size. Clinicians in specialized services should be aware that conditions other than PTSD, such as depression, anxiety, substance abuse, and somatoform disorders, are also quite common after disas- ters. (Psychiatric Services 61:1138-1143, 2010)

After 12 months of inpatient treatment, 16 opiate-addicted patients were exposed to drug-related stimuli. The results of this study indicate that cue reactivity in opiate-addicted subjects is still present after 12 months of intensive inpatient treatment. After exposing subjects to drug-related stimuli, there is an increase in craving, feelings of depression, and anger. Because posttreatment subjects are likely to be confronted with these stimuli following discharge, a reduction of this reactivity is desirable. In the present study, cue reactivity (feelings of depression, anger, tension, craving, and physical symptoms) reduced after protocolized cue exposure treatment. This effect maintained for at least 6 weeks after the last cue exposure session.

Background Online self-help interventions for problem drinkers show promising results, but the effectiveness of online therapy with active involvement of a therapist via the Internet only has not been examined. Objective The objective of our study was to evaluate an e-therapy program with active therapeutic involvement for problem drinkers, with the hypotheses that e-therapy would (1) reduce weekly alcohol consumption, and (2) improve health status. Reasons for dropout were also systematically investigated. Method In an open randomized controlled trial, Dutch-speaking problem drinkers in the general population were randomly assigned (in blocks of 8, according to a computer-generated random list) to the 3-month e-therapy program (n = 78) or the waiting list control group (n = 78). The e-therapy program consisted of a structured 2-part online treatment program in which the participant and the therapist communicated asynchronously, via the Internet only. Participants in the waiting list control group received “no-reply” email messages once every 2 weeks. The primary outcome measures were (1) the difference in the score on weekly alcohol consumption, and (2) the proportion of participants drinking under the problem drinking limit. Intention-to-treat analyses were performed using multiple imputations to deal with loss to follow-up. A dropout questionnaire was sent to anyone who did not complete the 3-month assessment. Reasons for dropout were independently assessed by the first and third author. Results Of the 156 individuals who were randomly assigned, 102 (65%) completed assessment at 3 months. In the intention-to-treat analyses, the e-therapy group (n = 78) showed a significantly greater decrease in alcohol consumption than those in the control group (n = 78) at 3 months. The e-therapy group decreased their mean weekly alcohol consumption by 28.8 units compared with 3.1 units in the control group, a difference in means of 25.6 units on a weekly basis (95% confidence interval 15.69-35.80, P < .001). The between-group effect size (pooled SD) was large (d = 1.21). The results also showed that 68% (53/78) of the e-therapy group was drinking less than 15 (females) or 22 (males) units a week, compared with 15% (12/78) in the control group (OR 12.0, number needed to treat 1.9, P < .001). Dropout analysis showed that the main reasons for dropouts (n = 54) were personal reasons unrelated to the e-therapy program, discomfort with the treatment protocol, and satisfaction with the positive results achieved. Conclusions E-therapy for problem drinking is an effective intervention that can be delivered to a large population who otherwise do not seek help for their drinking problem. Insight into reasons for dropout can help improve e-therapy programs to decrease the number of dropouts. Additional research is needed to directly compare the effectiveness of the e-therapy program with a face-to-face treatment program. Trial registration ISRCTN39104853; http://controlled-trials.com/ISRCTN39104853/ISRCTN39104853 (Archived by WebCite at http://www.webcitation.org/5uX1R5xfW)