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Treatment integrity ratings (adherence and competence) are frequently used as outcome measures in clinician training studies, drawn from recorded real client or role-played client sessions. However, it is unknown whether clinician adherence and competence are similar in real client and role-played sessions or whether real and role-play clients provide similar opportunities for skill demonstration. In this study, we examined the correspondence of treatment adherence and competence ratings obtained in real client and role-played sessions for 91 clinicians trained in motivational interviewing (MI), using data from a multisite trial examining 3 methods of clinician training (Martino et al., 2011). Results indicated overall poor integrity rating correspondence across the 2 session types, as indicated by weak correlations (rs = 0.05-0.27). Clinicians were rated significantly more MI adherent overall and specifically used more advanced MI strategies in role-played than real client sessions at several assessment time points (ds = 0.36, 0.42). Real clients, in comparison to the role-play actor, demonstrated greater motivation at the beginning of the session (d = 1.09), discussion of unrelated topics (d = 0.70), and alliance with the clinician (d = 0.72). These findings suggest that MI integrity rating data obtained from real client and role-played sessions may not be interchangeable. More research is needed to improve the procedures and psychometric strength of treatment integrity assessment based on role-played sessions. (Contains 3 tables and 3 footnotes.)

Objectives. To evaluate whether adding Web-based cognitive behavioral treatment (CBT) to standard outpatient psychiatric or addiction treatment improved substance use outcomes. Methods. We conducted a randomized clinical trial in New Haven, Connecticut, between 2014 and 2017 comparing 8 weeks of standard outpatient treatment to the same treatment with access to a culturally adapted version of Web-based CBT with a 6-month follow-up. Participants were 92 treatment-seeking individuals with Spanish as their primary language and current substance use disorder, with few other restrictions. Results. Treatment completion and data availability were high (98% of the randomized sample). For the primary outcome (change in frequency of primary substance used), there was a significant effect of treatment condition by time (t 1, 718 = −2.64; 95% confidence interval = −0.61, 0.09; P =.01), indicating significantly greater reductions for those assigned to Web CBT, which were durable through the 6-month follow-up. The knowledge test indicated significantly greater increases for those assigned to Web CBT. Conclusions. Adding a culturally adapted version of Web-based CBT to standard treatment improved substance use outcomes. Public Health Implications. This approach has high potential to address health disparities by providing an easily accessible, inexpensive form of evidence-based treatment to a range of Latinos with substance use disorders. [ABSTRACT FROM AUTHOR]

Background Cognitive behavioral therapy ( CBT) is an evidence-based treatment for alcohol use disorders ( AUDs), yet is rarely implemented with high fidelity in clinical practice. Computer-based delivery of CBT offers the potential to address dissemination challenges, but to date there have been no evaluations of a web-based CBT program for alcohol use within a clinical sample. Methods This study randomized treatment-seeking individuals with a current AUD to 1 of 3 treatments at a community outpatient facility: (i) standard treatment as usual ( TAU); (ii) TAU plus on-site access to a computerized CBT targeting alcohol use ( TAU + CBT4 CBT); or (iii) CBT4 CBT plus brief weekly clinical monitoring ( CBT4 CBT + monitoring). Participant alcohol use was assessed weekly during an 8-week treatment period, as well as 1, 3, and 6 months after treatment. Results Sixty-eight individuals (65% male; 54% African American) were randomized ( TAU = 22; TAU + CBT4 CBT = 22; CBT4 CBT + monitoring = 24). There were significantly higher rates of treatment completion among participants assigned to 1 of the CBT4 CBT conditions compared to TAU (Wald = 6.86, p < 0.01). Significant reductions in alcohol use were found across all conditions within treatment, with participants assigned to TAU + CBT4 CBT demonstrating greater increases in percentage of days abstinent ( PDA) compared to TAU, t(536.4) = 2.68, p < 0.01, d = 0.71, 95% CI (0.60, 3.91), for the full sample. Preliminary findings suggest the estimated costs of all self-reported AUD-related services utilized by participants were considerably lower for those assigned to CBT4 CBT conditions compared to TAU, both within treatment and during follow-up. Conclusions This trial demonstrated the safety, feasibility, and preliminary efficacy of web-based CBT4 CBT targeting alcohol use. CBT4 CBT was superior to TAU at increasing PDA when delivered as an add-on, and it was not significantly different from TAU or TAU + CBT4 CBT when delivered with clinical monitoring only. [ABSTRACT FROM AUTHOR]

ABSTRACT Aims To evaluate reciprocal enhancement (combining treatments to offset their relative weaknesses) as a strategy to improve cannabis treatment outcomes. Contingency management (CM) with reinforcement for homework completion and session attendance was used as a strategy to enhance cognitive-behavioral therapy (CBT) via greater exposure to skills training; CBT was used as a strategy to enhance durability of CM with rewards for abstinence. Setting Community-based out-patient treatment program in New Haven, Connecticut, USA. Design Twelve-week randomized clinical trial of four treatment conditions: CM for abstinence alone or combined with CBT, CBT alone or combined with CM with rewards for CBT session attendance and homework completion. Participants A total of 127 treatment-seeking young adults (84.3% male, 81.1% minority, 93.7% referred by criminal justice system, average age 25.7 years). Measurements Weekly urine specimens testing positive for cannabis, days of cannabis use via the time-line follow-back method. Findings Within treatment, reinforcing homework and attendance did not significantly improve CBT outcomes, and the addition of CBT worsened outcomes when added to CM for abstinence (75.5 versus 57.1% cannabis-free urine specimens, F = 2.25, P = 0.02). The CM for abstinence condition had the lowest percentage of cannabis-negative urine specimens and the highest mean number of consecutive cannabis-free urine specimens (3.3, F = 2.33, P = 0.02). Attrition was higher in the CBT alone condition, but random effect regression analyses indicated this condition was associated with the greatest rate of change overall. Cannabis use during the 1-year follow-up increased most rapidly for the two enhanced groups. Conclusions Combining contingency management and cognitive-behavioural therapy does not appear to improve success rates of treatment for cannabis dependence in clients involved with the criminal justice system. [ABSTRACT FROM AUTHOR]

The effectiveness of expert-led (EX) and train-the-trainer (TT) strategies was compared to a self-study approach (SS) for teaching clinicians motivational interviewing (MI). Twelve community treatment programs were assigned randomly to the three conditions. EX and TT conditions used skill-building workshops and three monthly supervision sessions guided by treatment integrity ratings, performance feedback and coaching techniques. Trainers in TT were first trained and certified in MI and then prepared carefully to deliver the workshops and supervise MI at their programs. Clinicians in SS only received the training materials. Licensed out-patient and residential addiction and mental health treatment programs in the US state of Connecticut were involved in the study. Ninety-two clinicians who provided addiction treatment within these programs and had limited experience with MI participated in the study. Primary outcomes were the clinicians' MI adherence and competence and the percentage of clinicians meeting clinical trial standards of MI performance. Assessments occurred at baseline, post-workshop, post-supervision and at 12-week follow-up. The study found EX and TT, in comparison to SS, improved clinicians' adherence and competence significantly, with higher percentages of clinicians reaching clinical trial standards of MI performance and few differences between EX and TT. This study supports the combined use of workshops and supervision to teach community program clinicians MI and suggests the train-the-trainer approach may be a feasible and effective strategy for disseminating empirically supported treatments. [ABSTRACT FROM AUTHOR]

Homeless shelters provide a unique opportunity to intervene with occupants who have substance abuse problems, as not addressing these issues may lead to continuation of problems playing a contributing role in homelessness. Attempts to implement Contingency Management (CM) with this population have often been complex, costly, and not straightforward to replicate in community settings. We conducted a randomized trial evaluating a simple, low-cost 4-week CM program for 30 individuals seeking shelter in a community-based homeless shelter who had both current substance and psychiatric disorders. Behavioral assessments were performed at baseline, weekly, and termination of the study. Overall retention in the trial was high; participants assigned to CM reduced their cocaine and alcohol use more than those in assessment-only. This pilot trial suggests that application of low-cost CM procedures is feasible within this novel setting and may decrease substance use. [ABSTRACT FROM AUTHOR]

Sixty individuals referred for a substance abuse evaluation by a child welfare worker were randomly assigned to either a standard evaluation or an evaluation enhanced by Motivational Interviewing techniques, each delivered in a single session. Participants who received the enhanced evaluation were significantly more likely to attend at least one additional treatment session after the initial evaluation (59% versus 29%). This finding suggests that comparatively inexpensive modifications of "standard" initial evaluations with substance-using parents may increase engagement of substance-abusing parents in treatment. Moreover, this study adds to an overwhelmingly positive literature supporting Motivational Interviewing with alcohol-using populations and extends prior findings to non-research community settings. [ABSTRACT FROM AUTHOR]

This study examined gender differences in demographics, psychosocial functioning, substance abuse severity, psychopathology, and 1-year outcome in cocaine-dependent patients with the goal of identifying factors important to improving treatment and identifying prognostic indicators. The sample included 298 cocaine-dependent adults (92 women). Ninety-four patients (29 women) provided 1-year follow-up assessments. Compared to men, women consumed similar quantities of cocaine by more addictive routes and experienced more rapid progression of drug dependence, thus highlighting the need to facilitate treatment entry. The substantial rates of positive treatment outcomes emphasizes the effectiveness of treatment for cocaine-dependent individuals. [ABSTRACT FROM AUTHOR]

An obituary for psychiatry professor Bruce James Rounsaville of Yale University School of Medicine is presented.

Abstract: Objective: The objective was to compare the efficacy of motivational enhancement therapy coupled with cognitive behavioral therapy (MET-CBT) to brief advice for treatment of substance use in pregnancy. Method: This was a randomized, parallel, controlled trial that was yoked to prenatal care and delivered at hospital outpatient clinics. We enrolled 168 substance-using women who had not yet completed an estimated 28 weeks of pregnancy. Obstetrical clinicians provided brief advice, and study nurses administered manualized MET-CBT. The primary outcome was percentage of days in the prior 28 days in which alcohol and/or drugs were used immediately before and 3 months postdelivery. Results: There were no significant differences across groups in terms of self-reported percentage of days in which drugs or alcohol were used prior to and 3 months postdelivery. Biological measures showed similar results. There was a trend (P=.08) for lower risk of preterm birth among those who received MET-CBT. Conclusions: The tested interventions had similar therapeutic effects. Hence, both treatments may be suitable for pregnant substance users, depending on the population, setting and provider availability. Interventions that are intensified after delivery may decrease postpartum “rebound” effects in substance misuse. [Copyright &y& Elsevier]

Cognitive-behavioral therapy (CBT), because of its comparatively high level of cognitive demand, is likely to be challenging for substance users with limitations in cognitive function. However, it is not known whether computer-assisted versions of CBT will be particularly helpful (e.g., allowing individualized pace and repetition) or difficult (e.g., via complexity of computerized delivery) for such patients. In this secondary analysis of data collected from a randomized clinical trial evaluating computer-assisted CBT, four aspects of cognitive functioning were evaluated among 77 participants. Those with higher levels of risk taking completed fewer sessions and homework assignments and had poorer substance use outcomes.

Converging evidence suggests that disulfiram is a promising treatment for cocaine dependence. We study the cost-effectiveness of providing disulfiram to methadone-maintained opioid addicts in a randomized clinical trial setting. Our economic evaluation is based on a double blind clinical trial in which 67 cocaine-dependent methadone-maintained opioid-dependent subjects were randomized to get the additional treatment of disulfiram or placebo in a 12-week trial. Outcome measures used are the number of days of cocaine use and grams of cocaine per week. Cost measures used are the cost of providing standard methadone treatment and the incremental cost of adding disulfiram to the standard treatment. Cost measures of standard and disulfiram-enhanced treatment were collected retrospectively from the provider. Results from this cost-effectiveness analysis imply that, even though disulfiram increases slightly the cost of methadone treatment, its increase in effectiveness may be important enough to warrant its addition for treating cocaine dependence in methadone-maintained opiate addicts.

Objective: This study examined the results of two previous studies that evaluated African Americans and whites who were undergoing treatment for cocaine dependence to determine whether the groups differed in pretreatment characteristics, treatment retention, compliance, and cocaine use outcome., Methods: Data were taken from two trials (N=111 in each), in which patients were randomly assigned to groups that used different behavioral treatments (cognitive-behavioral treatment and 12-step facilitation) and pharmacotherapies (desipramine and disulfiram)., Results: Few differences between African Americans and whites were found in terms of demographic characteristics, reasons for seeking treatment, or expectations of treatment. In both studies African Americans and whites did not differ significantly with respect to cocaine use outcomes, but African-American participants completed significantly fewer days of treatment than white participants. In study 2, which was not placebo controlled, African Americans who received disulfiram remained in treatment significantly longer than African Americans who did not receive disulfiram. However, in study 1, in which patients took either desipramine or a placebo, no interactions of ethnicity by medication were found. Among patients who expected improvement to take a month or longer in study 1, African Americans remained in treatment for fewer days than whites., Conclusions: The behavioral therapies evaluated did not significantly differ in effectiveness for African Americans and whites, suggesting that they are broadly applicable across these ethnic groups. Findings also suggest possible strategies for improving retention of African Americans in treatment. Such strategies might include offering treatment with a medication component and better addressing participants' treatment expectations.