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Aims: People who have experienced adverse childhood experiences (ACEs) are more susceptible to substance use disorder (SUD) and depression. The present study examined depression prevalence in hospitalized patients with SUD and examined the association of individual ACEs with major depression. Depression rates 3 months after discharge were also examined., Methods: Medical inpatients with SUD were recruited from Temple University Hospital. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9) at baseline and 3 months post-discharge. Participants were also assessed using an ACE scale at baseline., Results: Of 79 baseline participants, 48% (38) had moderate to severe major depressive disorder (MDD) with PHQ-9 scores ≥15. Among those with baseline MDD, 38% (9/24) continued to have MDD 3 months post discharge, and 42.9% (12/28) of those without MDD at baseline met criteria at 3 months. Sixty-three percent (50/79) of the participants reported 4+ ACEs at baseline. Two ACEs, Household Incarceration and Household Mental Illness, were significantly associated with having MDD at baseline and 3 months (adjusted mean PHQ-9 total score increase (SE) and p-value: 2.97 (1.35), p < .05; 5.32 (1.37), p < .005, respectively)., Conclusions: In this exploratory study, nearly half of medical inpatients with substance use disorder had moderate to severe major depression, with a similar percentage of participants having MDD as outpatients at 3 months. Approximately two thirds of participants reported four or more adverse childhood experiences at baseline. Inpatient medical hospitalization should be utilized as an opportunity to engage people with SUD in multidisciplinary treatment including psychiatric, trauma informed care, and substance abuse treatment., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Brief interventions such as Screening, a single session of Brief Intervention, and Referral to Treatment (SBIRT) have shown mixed effectiveness in primary care. However, there are indications that multi-session brief interventions may demonstrate more consistently positive outcomes, and perhaps a more intensive approach would be of benefit in addressing substance use in primary care. This study compared the effectiveness of SBIRT with a single BI session (BI/RT) to a multi-session brief-treatment intervention (BI/RT+) in primary care. We also developed easy-to-use, evidence-based materials to assist clinicians in delivering these interventions., Methods/design: This study was conducted in three Federally Qualified Healthcare Centers (FQHCs). A total of 10,935 patients were screened, and 600 individuals were recruited. The sample was primarily Black/African American (82 %) with a mean age of 40. Patients who attended a healthcare appointment were screened for substance use via the AUDIT and DAST. Patients were eligible for the study if they scored 8 or higher on the AUDIT, were using only marijuana and scored 2 or higher on the DAST, or were using other illicit drugs and scored 1 or higher on the DAST. Participants were randomly assigned to receive one-session BI/RT, or two to six sessions of brief intervention that incorporated elements of motivational enhancement therapy and cognitive-behavioral therapy (BI/RT+). Both interventions were delivered by behavioral health consultants at the FQHCs. Participants completed follow-up assessments every 3 months for 1 year. Primary outcome variables included substance use treatment sessions attended and days of substance use. Secondary outcomes included measures of health, employment, legal, and psychiatric functioning and HIV risk behaviors. Additionally, we will conduct an economic evaluation examining cost-effectiveness and will analyze outcomes from a process evaluation examining patient and provider experiences., Discussion: The ability of brief interventions to impact substance use has great potential, but research findings have been mixed. By conducting a large-scale randomized controlled trial in real-world health centers, this study will answer important questions about the effectiveness of expanded BIs for patients who screen positive for risky substance use in primary care. Trial registration NCT01751672.

Introduction: The need to integrate behavioral health care within medical settings is widely recognized, and integrative care approaches are associated with improved outcomes for a range of disorders. As substance use treatment integration efforts expand within primary care settings, training behavioral health providers in evidence-based brief treatment models that are cost-effective and easily fit within the medical flow is essential., Methods: Guided by principles drawn from Diffusion of Innovations theory (Rogers, 2003) and the Consolidated Framework of Implementation Research (Damschroder et al., 2009), we adapted elements of Motivational Enhancement Therapy, cognitive-behavioral therapy, and 12-step facilitation into a brief counseling toolkit. The toolkit is a menu driven assortment of 35 separate structured clinical interventions that each include client takeaway resources to reinforce brief clinical contacts. We then implemented this toolkit in the context of a randomized clinical trial in three Federally Qualified Healthcare Centers. Behavioral Health Consultants (BHCs) used a pre-screening model wherein 10,935 patients received a brief initial screener, and 2011 received more in-depth substance use screening. Six hundred patients were assigned to either a single session brief intervention or an expanded brief treatment encompassing up to five additional sessions. We conducted structured interviews with patients, medical providers, and BHCs to obtain feedback on toolkit implementation., Results: On average, patients assigned to brief treatment attended 3.29 sessions. Fifty eight percent of patients reported using most or all of the educational materials provided to them. Patients assigned to brief treatment reported that the BHC sessions were somewhat more helpful than did patients assigned to a single session brief intervention (p=.072). BHCs generally reported that the addition of the toolkit was helpful to their work in delivering screening and brief treatment., Discussion: This work is significant because it provides support to clinicians in delivering evidence-based brief interventions and has been formatted into presentation styles that can be presented flexibly depending on patient need., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Training counselors in empirically supported treatments (ESTs) far exceeds the ever decreasing resources of community-based treatment agencies. The purpose of this study was to examine outpatient substance abuse group counselors' (n=19) adherence and competence in communicating and utilizing concepts associated with empirically-supported relapse prevention treatment following a brief multimedia toolkit (RoadMAP Toolkit™) training. Moderate or large baseline to post-training effect sizes for counselor adherence to toolkit content were identified for 13 of 21 targeted behaviors (overall d range=.06-2.85) with the largest gains on items measuring active skill practice. Post-training adherence gains were largely maintained at the 6-month follow-up, although no statistically significant improvements were identified over time for counselor competence. This study provides important preliminary support for using a multi-media curriculum approach to increase empirically-supported relapse prevention skills among group counselors. Future research should focus on finding ways to improve counselor skill level and to determine the impact of the Toolkit on client outcomes., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Training community-based addiction counselors in empirically supported treatments (ESTs) far exceeds the ever-decreasing resources of publicly funded treatment agencies. This feasibility study describes the development and pilot testing of a group counseling toolkit (an approach adapted from the education field) focused on relapse prevention (RP). When counselors (N = 17) used the RP toolkit after 3 hours of training, their content adherence scores on "coping with craving" and "drug refusal skills" showed significant improvement, as indicated by very large effect sizes (Cohen's d = 1.49 and 1.34, respectively). Counselor skillfulness, in the "adequate-to-average" range at baseline, did not change. Although this feasibility study indicates some benefit to counselor EST acquisition, it is important to note that the impact of the curriculum on client outcomes is unknown. Because a majority of addiction treatment is delivered in group format, a multimedia curriculum approach may assist counselors in applying ESTs in the context of actual service delivery., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: The relationships between the occupational, educational, and verbal-cognitive characteristics of health care professionals and their motivational interviewing (MI) skills before, during, and after training were investigated., Method: Fifty-eight community-based addiction clinicians (M = 42.1 years, SD = 10.0; 66% Female) were assessed prior to enrolling in a 2-day MI training workshop and being randomized to one of three post-workshop supervision programs: live supervision via tele-conferencing (TCS), standard tape-based supervision (Tape), or workshop training alone. Audiotaped sessions with clients were rated for MI skillfulness with the Motivational Interviewing Treatment Integrity (MITI) coding system v 2.0 at pre-workshop and 1, 8, and 20 weeks post-workshop. Correlation coefficients and generalized linear models were used to test the relationships between clinician characteristics and MI skill at each assessment point., Results: Baseline MI skill levels were the most robust predictors of pre- and post-supervision performances. Clinician characteristics were associated with MI Spirit and reflective listening skill throughout training and moderated the effect of post-workshop supervision method on MI skill. TCS, which provided immediate feedback during practice sessions, was most effective for increasing MI Spirit and reflective listening among clinicians with no graduate degree and stronger vocabulary performances. Tape supervision was more effective for increasing these skills among clinicians with a graduate degree. Further, TCS and Tape were most likely to enhance MI Spirit among clinicians with low average to average verbal and abstract reasoning performances., Conclusions: Clinician attributes influence the effectiveness of methods used to promote the acquisition of evidence-based practices among community-based practitioners., (© 2012 American Psychological Association)

Objective: Training through traditional workshops is relatively ineffective for changing counseling practices. Teleconferencing supervision (TCS) was developed to provide remote, live supervision for training motivational interviewing (MI)., Method: Ninety-seven drug treatment counselors completed a 2-day MI workshop and were randomized to live supervision via teleconferencing (TCS; n = 32), standard tape-based supervision (tape; n = 32), or workshop alone (workshop; n = 33). Supervision conditions received 5 weekly supervision sessions at their sites using actors as standard patients. Sessions with clients were rated for MI skill with the Motivational Interviewing Treatment Integrity (MITI) Coding System pre-workshop and 1, 8, and 20 weeks post-workshop. Mixed-effects linear models were used to test training condition on MI skill at 8 and 20 weeks., Results: TCS scored better than workshop on the MITI for spirit (mean difference = 0.76; p < .0001; d = 1.01) and empathy (mean difference = 0.68; p < .001; d = 0.74). TCS was superior to workshop in reducing MI non-adherence and was superior to workshop and tape in increasing reflection to question ratio. Tape was superior to TCS in increasing complex reflections. Percentage of counselors meeting proficiency differed significantly between training conditions for the most stringent threshold (spirit and empathy scores ≥ 6)., Conclusions: TCS shows promise for promoting new counseling behaviors following participation in workshop training. However, further work is needed to improve supervision methods to bring more clinicians to high levels of proficiency and facilitate dissemination of evidence-based practices.

Background: A large proportion of people attending residential alcohol and other substance abuse treatment have a co-occurring mental illness. Empirical evidence suggests that it is important to treat both the substance abuse problem and co-occurring mental illness concurrently and in an integrated fashion. However, the majority of residential alcohol and other substance abuse services do not address mental illness in a systematic way. It is likely that computer delivered interventions could improve the ability of substance abuse services to address co-occurring mental illness. This protocol describes a study in which we will assess the effectiveness of adding a computer delivered depression and substance abuse intervention for people who are attending residential alcohol and other substance abuse treatment., Methods/design: Participants will be recruited from residential rehabilitation programs operated by the Australian Salvation Army. All participants who satisfy the diagnostic criteria for an alcohol or other substance dependence disorder will be asked to participate in the study. After completion of a baseline assessment, participants will be randomly assigned to either a computer delivered substance abuse and depression intervention (treatment condition) or to a computer-delivered typing tutorial (active control condition). All participants will continue to complete The Salvation Army residential program, a predominantly 12-step based treatment facility. Randomisation will be stratified by gender (Male, Female), length of time the participant has been in the program at the commencement of the study (4 weeks or less, 4 weeks or more), and use of anti-depressant medication (currently prescribed medication, not prescribed medication). Participants in both conditions will complete computer sessions twice per week, over a five-week period. Research staff blind to treatment allocation will complete the assessments at baseline, and then 3, 6, 9, and 12 months post intervention. Participants will also complete weekly self-report measures during the treatment period., Discussion: This study will provide comprehensive data on the effect of introducing a computer delivered, cognitive behavioral therapy based co-morbidity treatment program within a residential substance abuse setting. If shown to be effective, this intervention can be disseminated within other residential substance abuse programs., Trial Registration: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12611000618954.

Computerized therapy approaches may expand the reach of evidence-based treatment; however, it is unclear how to integrate these therapies into community-based treatment. We conducted a two-phase pilot study to explore (a) whether clients' use of the Therapeutic Education System (TES), a Web-based community reinforcement approach (CRA) learning program, would benefit them in the absence of counselor support and (b) whether counselors and clients would use the TES in the absence of tangible research-based reinforcement. In Phase 1, clients in the TES condition (n = 14) demonstrated large improvements in knowledge, F(1, 20) = 8.90, p = .007, d = 1.05, and were significantly more likely to select CRA style coping responses, F (1, 20) = 11.95, p = .002, d = 1.16, relative to the treatment-as-usual group (n = 14). We also detected small, nonsignificant, between-group effects indicating TES decreased cocaine use during treatment. In Phase 2, counselors referred only around 10% of their caseload to the TES, and the modal number of completed modules in the absence of tangible reinforcement was three. Computer-based therapy approaches are viable in community-based treatment but must be integrated with incentive systems to ensure engagement., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

In fiscal 2002, Delaware replaced traditional cost-reimbursement contracts with performance-based contracts for all outpatient addiction treatment programs. Incentives included 90% capacity utilization and active patient participation in treatment. One of the programs failed to meet requirements. Strategies adopted by successful programs included extended hours of operation, facility enhancements, salary incentives for counselors, and two evidence-based therapies (MI and CBT). Average capacity utilization from 2001 to 2006 went from 54% to 95%; and the average proportion of patients' meeting participation requirements went from 53% to 70%--with no notable changes in the patient population. We conclude that properly designed, program-based contract incentives are feasible to apply, welcomed by programs and may help set the financial conditions necessary to implement other evidence-based clinical efforts; toward the overall goal of improving addiction treatment.

Psychiatric comorbidity, particularly depressive disorders, is associated with continued substance use and poor social functioning among methadone maintained patients. Evidence suggests similar neurochemical and environmental pathways may link the two disorders and it is reasonable to hypothesize that pharmacological and environmental factors play important roles in the treating comorbid depression and substance use. The present study tested the efficacy of sertraline for treating syndromally defined depressive disorders among non-abstinent methadone maintained opiate dependent patients. The moderating effects of environmental context on treatment outcome were also examined. Ninety-five patients were randomized in a 12-week, double-blind, placebo-controlled trial of sertraline, a serotonin-selective re-uptake inhibitor. There was no main effect of sertraline on either depression or substance use outcomes. However, sertraline demonstrated significant ameliorative effects on depression among patients with a more positive environment or less negative environment. The odds of being abstinent from heroin and cocaine were greater for patients on sertraline in environments with relatively less adversity. The findings support the hypothesis that contextual factors moderate the efficacy of pharmacological treatment for depression among methadone patients. They also suggest future research should examine a pharmacological treatment that is combined with a behavioral intervention targeting the accessibility of reinforcement or reducing the impact of aversive environmental interactions.