Psychotherapy Effectiveness

• Grant Title: Feasibility of a Behavioral Activation Trial in Community Mental Health
• Grant Number: 5R34MH108818-02
• Principal Investigator: Paul Crits-Christoph

Abstract

Major depressive disorder (MDD) is a severe and disabling disorder afflicting 7% of individuals in the United States annually and approximately 17% of individuals across their lifetime. Despite multiple investigations demonstrating that both medications and psychotherapeutic interventions are effective in the treatment of MDD, response rates in well-done efficacy trials still reach only 40 to 60%. Response rates in the public sector are even lower. One psychosocial treatment that holds promise for use in the publicly-funded community mental health centers (CMHC) is Behavioral activation (BA). This treatment has been found to be efficacious in the treatment of MDD, particularly severe MDD, and has been used effectively by the types of non-doctoral level clinicians that often deliver treatment in CMHC settings. The purpose of the study proposed here is to examine the feasibility of conducting a study of behavioral activation when implemented in community mental health settings where many patients suffer from severe MDD. In the first phase of the project, consumers, clinicians, and staff at a CMHC will provide input on an existing BA treatment model to tailor it to the CMHC environment. In the second phase of the project, the final treatment manual will be used to train clinicians in BA at the CMHC through workshops, training cases, and a novel online training module designed for training CMHC clinicians in BA. In the third phase of the project, a total of 80 patients with MDD who score 14 or above on the 17-item Hamilton Rating Scale for Depression (HAM-D) will be randomly assigned in a 3:1 ratio to 9 sessions of BA or treatment-as-usual (TAU) at a community mental health center (CMHC). In addition to feasibility/acceptability of BA and TAU, the study is designed to test whether theoretically important targets of BA (increased activation; increased reward value of activities) change over the course of BA treatment, and whether such changes as associated with changes in depressive symptoms. Patients will also be assessed at baseline and then weekly using the BASIS-24 and at week 6 and week 12 using the HAM-D administered by independent raters. A measure of trait reward processing will be measured at baseline using the Effort- Expenditure for Rewards Task to pilot the use of this measure as a potential moderator of BA treatment effects. The ability of CMHC therapists to adequately implement BA will be assessed by rating taped sessions on BA adherence and competence scales. Successful completion of this project will lead a larger scale effectiveness study of BA in the CMHC setting.

A Feasibility Study of Behavioral Activation for Major Depressive Disorder in a Community Mental Health Setting

Behavioral activation (BA) is a well-supported treatment approach, but little research has been conducted on the effectiveness of this treatment within publicly funded community mental health settings. We examined the feasibility of conducting a randomized trial examining the effectiveness of nine sessions of BA as a treatment for major depressive disorder (MDD) in a community mental health clinic (CMHC) setting. Following adaptation of a BA manual and training of BA therapists, 80 patients seeking treatment at a CMHC were randomized with a 3:1 randomization rate of BA to nine sessions of treatment as usual (TAU). Click on the paper title above to view our findings!

• Grant Title: Comparative Effectiveness of Interventions for Depression in the Community
• Grant Number: 1K02HS022124-01
• Principal Investigator: Mary Beth Connolly Gibbons

Abstract

The goal of this independent research scientist award application is to protect the time necessary to further develop my skills as a newly independent researcher specializing in comparative effectiveness of interventions for depression in the community mental health system. This award would allow me to become a sophisticated comparative effectiveness researcher utilizing state-of-the-art methodologies and statistical approaches to study the effectiveness of interventions in alleviating mental health disorders of high public health priority. My program of research and planned career development activities are based on the definition of comparative effectiveness research elaborated by the Institute for Medicine's Committee on Comparative Effectiveness Research Prioritization. It is my goal to work with expert consultants and participate in training activities to take my comparative effectiveness research program to the next level. To complement my current program of research evaluating the effectiveness of interventions for depression in the community mental health system that inform clinical decision making at the population level, my goal is to develop expertise in methods and statistical approaches that would allow my research to address the important question of how to efficiently disseminate effective interventions to meet the needs of individual consumers of services for depression. This award would afford me the time needed to participate in classroom instruction in the newest statistical approaches, attend training seminars and institutes, work with expert consultants, and attend conferences to enhance my development as a comparative effectiveness researcher. This award would also allow me the time, expert consultation, and education needed to conduct two important studies to inform the efficient dissemination of interventions for depression in the community: a study of the patient baseline moderators of treatment effectiveness and a study of healthcare utilization and costs associated with the utilization of mental health interventions for MDD in the community mental health system. The specific aims of this investigation include 1) to assess whether patient baseline skills deficits moderate the effectiveness of dynamic therapy and cognitive therapy for patients with major depressive disorder treated in the community mental health setting, 2) to assess whether patient baseline deficits moderate the effectiveness of dynamic therapy and cognitive therapy on secondary measures of outcome, 3) to explore additional baseline patient variables that may moderate the effectiveness of these psychotherapeutic approaches for patients with major depressive disorder treated in the community mental health setting, and 4) to evaluate healthcare utilization and associated costs for patients treated with psychotherapy for depression in the community mental health system compared to patients who receive alternative treatments.

Predictors of Treatment Attendance in Cognitive and Dynamic Therapies for Major Depressive Disorder Believed in a Community Mental Health Setting

Our goals was to evaluate treatment attendance patterns, including both treatment completion and premature termination from treatment, for two evidence-based psychotherapies for major depressive disorder (MDD) delivered in a community mental health setting. We explored rates of premature termination across the course of treatment as well as the factors that predicted and moderated premature termination and treatment completion. This investigation included 237 patients with MDD who participated in a noninferiority trial comparing short-term dynamic psychotherapy (DT) to cognitive therapy (CT). Patients in both conditions were offered 16 sessions of treatmetn and had up to 5 months to complete treatment. All patients completed an extensive self-report battery at treatment baseline as well as measures of the therapeutic alliance and opinions about treatment following Session 2. Click on the paper above to view our findings!

• Grant Title: A Comparison of Cognitive and Dynamic Therapy for MDD in Community Settings
• Grant Number: 5R01HS018440-03
• Principal Investigator: Mary Beth Connolly Gibbons

Abstract

The goal of the current proposal is to conduct a randomized, comparative, non-inferiority clinical trial that tests the hypothesis that a widely used form of manualized dynamic psychotherapy (supportive expressive psychodynamic therapy) is not inferior to cognitive therapy when implemented in community mental health settings for the treatment of major depressive disorder. Major depressive disorder is a severe and disabling disorder afflicting 7% of individuals in the United States annually and approximately 17% of individuals across their lifetime (Kessler et al., 2005). Over the past 30 years, cognitive therapy (Beck et al., 1979) has become established as the most empirically-validated psychosocial treatment for major depressive disorder (Hollon, Thase, & Markowitz, 2002). At this point in time, extensive efforts are occurring to disseminate cognitive therapy to clinical practice settings. Health systems and managed care entities have begun to accelerate dissemination of cognitive therapy to existing psychotherapists working in community agencies. Despite the large number of studies that have been done on cognitive therapy, one central question relevant to mental health care systems and agencies that has never been addressed is whether or not cognitive therapy provides superior outcomes to the typical form of psychotherapy provided by many community-based psychotherapists. If a standard form of psychotherapy (i.e., psychodynamic therapy) already common in the community produces outcomes that are not inferior to those produced by cognitive therapy, then the extensive amount of funds needed to re-train community therapists in cognitive therapy would be better spent on other quality improvement initiatives including hiring new therapists to help with the understaffing that is prevalent in the community. The Specific Aims of the current proposal are 1) to conduct a randomized non-inferiority trial to compare supportive-expressive psychodynamic therapy and cognitive therapy for patients with major depressive disorder, and 2) to assess the comparative effectiveness of supportive-expressive therapy and cognitive therapy on secondary measures of patient functioning and quality of life. Therapists working in community mental health agencies will be trained in either cognitive therapy or dynamic psychotherapy during the first year of the protocol. In addition, concurrent therapist training procedures will be implemented across the study period in order to retain the appropriate number of therapists throughout the study. Consumers seeking services at two community mental health centers will be randomized to either receive 12 sessions of cognitive therapy or dynamic psychotherapy. All psychotherapy will be provided by therapists employed at the community agency and will take place at the community agency. Consumers diagnosed with major depressive disorder at the mental health agency will be offered participation in the current protocol. Interested consumers will be consented for the study and randomized to treatment. All participants will complete a baseline interview as well as monthly assessments of depressive symptoms, functioning, and quality of life. As part of normal clinic procedures, all consumers will also complete the BASIS-24 at baseline and at each treatment session. We will evaluate whether dynamic psychotherapy is not inferior to cognitive therapy on change from baseline to endpoint of acute treatment in the HAM-D total score. If psychodynamic therapy is not inferior to cognitive therapy, the cost of re-training psychotherapists in cognitive therapy may not be warranted.

Comparative Effectiveness of Cognitive Therapy and Dynamic Psychotherapy for Major Depressive Disorder in a Community Mental Health Setting: A Randomized Clinical Noninferiority Trial

Dynamic psychotherapy (DT) is widely practiced in the community, but few trials have established its effectiveness for specific mental health disorder relative to control conditions or other evidence-based psychotherapies. To determine whether DT is not inferior to cognitive therapy (CT) in the treatment of major depressive disorder (MDD) in a community mental health setting. From October 28, 2010 to July 2, 2014, outpatients with MDD were randomized to treatment delivered by trained therapists. Twenty therapists employed at a community mental health center (CMHC) in Pennsylvania were trained by experts in CT or DT. A total of 237 adult outpatient with MDD seeking services at this site were randomized to 16 sessions of DT or CT delivered across 5 months. Click on the paper above to view our findings!

Comparative Effectiveness of Cognitive and Dynamic Therapies for Major Depressive Disorder in a Community Mental Health Setting: Study Protocol for a Randomized Non-Inferiority Trial

There is a substantial evidence that cognitive therapy is an effective intervention for the treatment of major depressive disorder. Although dynamic psychotherapies have been widely studied and are commonly practiced worldwide, there are few randomized comparisons of cognitive therapy and dynamic therapy for major depressive disorder. We completed data collection on a randomized non-inferiority trial comparing the effectiveness of cognitive therapy and short-term dynamic psychotherapy in the treatment of major depressive disorder in the community mental health setting. Therapists employed in the community setting have been recruited for training in either short-term dynamic psychotherapy or cognitive therapy. Patients seeking services at the community site who met criteria for major depressive disorder based on a blind independent diagnostic interview were randomized to 16 sessions of treatment. All patients were assessed at baseline and months 1, 2, 4, and 5 utilizing a comprehensive battery. To read more about our study protocol, click the link above!

• Grant Title: The Mechanisms of Cognitive and Dynamic Therapy in Community Settings
• Grant Number: 5R01MH092363-03
• Principal Investigator: Paul Crits-Christoph

Abstract

This is a proposal to conduct a study of theoretically-relevant mediators of cognitive therapy (CT) and supportive-expressive psychodynamic therapy (SE) implemented in community mental health centers. The study will be appended to a recently funded comparative effectiveness study of these two psychotherapies. Theories of the mechanism of change in CT have proposed that CT works by changing (1) dysfunctional attitudes, (2) underlying schemas, and/or (3) compensatory skills. SE therapy theoretically works by changing self-understanding in regard to interpersonal patterns. However, no fully adequate and comprehensive test of these potential mediators has been done to date. In particular, studies of the mechanism of CT have rarely used an alternative psychotherapy as a comparison group. In the parent effectiveness study, patients are randomly assigned to receive 12 weeks of CT or SE therapy, with measures of depressive symptoms, functioning, and quality of life completed monthly. We propose to administer a self-report measure of self-understanding of interpersonal patterns, a self-report measure of dysfunctional attitudes, a rater-scored measure of compensatory skills, and a computerized task that assesses underlying cognitive schemas. These measures will be conducted at baseline, month 1, and month 2 for 210 patients in the parent study. Analyses of mediation will be guided by both Baron & Kenny and MacArthur models, with change in the mediators predicting subsequent change in depressive symptoms and functioning in a longitudinal model, so that results are consistent with a model of change in the mediator causing subsequent improvements on outcome measures. The significance of this work is the potential identification of how both CT and SE therapy work in community settings. Results will have implications for the training of therapists in community settings, potential revisions of the CT and SE models of therapy, and decisions about dissemination of evidence-based treatments to community mental health centers.

Mechanisms of Change in Cognitive Therapy for Major Depressive Disorder in the Community Mental Health Setting

This study examined the relation of change in theory-relevant cognitive variables to depressive symptom change over the course of cognitive therapy, as well as the specificity of change mechanisms to cognitive therapy as compared with dynamic therapy. there were 237 adult outpatients who were randomized to either cognitive or dynamic therapy for major depressive disorder in a community mental health setting. Assessments of compensatory skills, dysfunctional attitudes, and depressogenic schemas were obtained at baseline and months 1, 2, and 5 following baseline. Primary outcome was measured using the Hamilton Rating Scale for Depression. Click on the paper above to view our findings!

Insight as a Mechanism of Change in Dynamic Psychotherapy for Major Depressive Disorder

This study aimed to investigate the change in insight into maladaptive interpersonal patterns over the course of psychotherapy, as well as the specificity of insight as a change mechanism in dynamic treatments. A total of 100 patients received up to 16 sessions of either cognitive or dynamic therapy for major depressive disorder in a randomized controlled trial. Assessments of insight and depression severity took place at the beginning of treatment, at month 2, and month 5. Click on the paper above to view our findings!

• Grant Title: Training in Services-Informed Interventions Research
• Grant Number: 5K01MH063149-05
• Principal Investigator: Mary Beth Connolly Gibbons

Abstract

This is an application for a mentored research scientist development award for Mary Beth Connolly, Ph.D. at the University of Pennsylvania. The specific aims are to gain a) knowledge of an evolving health care market, b) knowledge of methodologies needed to evaluate the effectiveness model of psychotherapy, and c) skills in grant preparation, in order to develop into an sophisticated and independent psychotherapy effectiveness researcher. The aims of this award will be accomplished through a structured program consisting of: a) formal course work in health care quality, epidemiology, outcomes research, and cost effectiveness; b) attendance at a series of grand rounds presentations focused on issues related to public health-oriented intervention research; c) tutorials with experts in cost effectiveness, mental health policy, health outcomes in mental health services, and the implementation of multi-site effectiveness trials; and d) conducting 3 investigations under the mentorship of Drs. Paul Crits-Christoph, Aileen Rothbard, and Joseph Gallo. Three pilot studies have been chosen as part of this program in order to integrate services and effectiveness research methods to investigate psychotherapy within a public health model. First, a longitudinal database will be evaluated to examine the patient predisposing factors, need factors, enabling factors, and environmental factors that influence the delivery of mental health treatment in the community. The second project will consist of a patient survey designed to evaluate further the factors that influence treatment delivery in community mental health agencies. Finally, a small pilot intervention trial will be conducted integrating the results of the first two services-oriented investigations.

Supportive-Expressive Dynamic Psychotherapy in the Community Mental Health System: A Pilot Effectiveness Trial for the Treatment of Depression

The goal of the current article is to present the results of a randomized pilot investigation of a brief dynamic psychotherapy compared with treatment-as-usual (TAU) in the treatment of moderate-to-severe depression in the community mental health system. Forty patients seeking services for moderate-to-severe depression in the community mental health system were randomized to 12 weeks of psychotherapy, with either a community therapist trained in brief dynamic psychotherapy or a TAU therapist. Click on the paper above to view our findings!

• Grant Title: Psychotherapy for Major Depression in the Community
• Grant Number: 5R24MH070698-03
• Principal Investigator: Paul Crits-Christoph

Abstract

Although an extensive literature exists on the efficacy of psychotherapy treatments for major depressive disorder (MDD), there is limited data on the effectiveness of such treatments in diverse, community-based real-world practice settings. MDD is of public health concern because it is a common psychiatric disorder that is associated with significant levels of functional impairment, increased health care utilization, and suicide attempts. The purpose of this proposal is to develop an infrastructure within a community mental health center in Philadelphia to support the conduct of effectiveness research on manual-based psychotherapies that have proven efficacious in previous studies. The collaborative venture described in this application will bring together academic intervention and services researchers with administrators, clinicians, and staff working at two clinics that are part of Northwestern Human Services of Philadelphia (NHSP). NHSP is the largest publicly funded provider of mental health services in Philadelphia. Nearly all of the target consumers at NHSP are low-income individuals receiving some form of public assistance or other support and Medicaid for medical and behavioral health services. MDD is the second most common disorder found at these clinics, and the most common of the non-chronic population. Preliminary studies have indicated that while psychotherapy is delivered to many consumers with major depressive disorder in these settings, clinicians at NHSP have not been trained in empirically-supported psychotherapies for MDD. Thus, there is a great need to export empirically-supported psychotherapies for MDD to such settings and to evaluate their effectiveness in the community. Initial work, however, must focus on engaging and retaining consumers because staff at NHSP, as well as our preliminary studies, have identified lack of engagement/attrition as a major problem at these clinics. Specifically, the infrastructure will support (1) collaborative research planning/review meetings between academics and clinical service providers/ administrators, (2) implementation of a systems-wide outcomes assessment program at NHSP, (3) computer/ data analysis expertise within NHSP that will integrate outcomes assessment with clinical information databases, (4) pilot studies focusing initially upon engagement/attrition, and subsequently on the effectiveness of empirically supported psychotherapies for major depressive disorder. The infrastructure support created will work synergistically with existing programs at Penn that focuses on psychotherapy research (Center for the Study of Psychotherapy) and mental health services research (Center for Mental Health Policy and Services Research).

Purpose

This grant was a National Institutes of Mental Health (NIMH) R-24 Interventions and Practice Research Infrastructure Program (IP-RISP). The overall purpose of the program was to bridge the huge gap between academic based psychotherapy research and the practice of psychotherapy in community settings. In the past, research on various types of psychotherapy has been limited to academic settings, which do not always capture the unique challenges of serving clients in the community.

Evidence-based psychotherapies had not been widely tested in publicly funded community mental health settings with typical patients, and are not commonly delivered in such settings. The goal of the R24 award was to establish infrastructure to examine whether treatments proven efficacious in academic contexts were effective in the community when delivered by community-based providers and adapted to meet the practical constraints of service delivery in the community.

Over five years, this project sought to establish clinic-wide outcome assessment and conduct pilot studies of evidence-based treatments for depressive disorders in order to see how well these treatments adapt to the community.

Overview

The program of research was carried out in collaboration with a large non-profit, publicly funded Philadelphia community mental health agency, Northwestern Human Services of Philadelphia (NHSP). Paul Crits-Christoph, PhD, was the Principal Investigator from Penn.

Investigators from the Center for Psychotherapy Research and the administrators and providers from NHSP served as equal partners in the conceptualization of research questions, the modification of evidence-based treatments, the implementation of studies, and interpretation and dissemination of findings. Activities focused on building a successful partnership among all relevant stakeholders, including the City of Philadelphia behavioral health administration, community administrators, therapists, staff, consumers, and researchers.

Research was carried out at two NHSP facilities - the E. Mt. Airy Avenue (Northwest Philadelphia) and Knights Road (Northeast Philadelphia) locations.

Early Withdrawal from Mental Health Treatment: Implications for Psychotherapy Practice

Despite more than 50 years of research on client attrition from therapy, obstacles to the delivery and success of treatments remain poorly understood, and effective methods to engage and retain clients in therapy are lacking. This article offers a review of the literature on attrition, highlighting the methodological challenges in effectively addressing the complex nature of this problem. Current interventions for reducing attrition are reviewed, and recommendations for implementing these interventions into psychotherapy practice are discussed.

Developing Research and Recruitment While Fostering Stakeholder Engagement in a National Institutes of Mental Health-Funded Interventions and Practice Research Infrastructure Programs Grant for Depression

Background: In the context of a National Institutes of Mental Health-funded interventions Practice Research Infrastructure Programs (IP-RISP) grant for the treatment of depression, a partnership was developed between a community mental health organization and a team of researchers. Objectives: This paper describes the collaborative process, key challenges, and strategies employed to meet the goals of the first phase of the grant, which included development of a working and sustainable partnership and building capacity for recruitment and research. Methods: This paper was developed through the use of qualitative interviews and discussion with a variety of IP-RISP partners. Lessons Learned: Communication with multiple stakeholders through varied channels, feedback from stakeholders on research procedures, and employing a research liaison at the clinic have been key strategies in the first phase of the grant. Conclusion: The strategies we employed allowed multiple stakeholders to contribute to the larger mission of the IP-RISP and helped to establish an ongoing research program within the mental health organization.

• Grant Title: Combined Treatment for GAD
• Grant Number: 5R34MH072678-02
• Principal Investigator: Paul Crits-Christoph

Abstract

This is an application for an R34 grant to conduct a preliminary efficacy study of combined medication and psychotherapy for generalized anxiety disorder (GAD). Of all the major mood and anxiety disorders, GAD represents one of the most common, but least studied. Although medications and cognitive-behavioral therapies (CBT) have demonstrated efficacy in the treatment of GAD, a substantial number of patients fail to achieve adequate improvements in anxiety symptoms during acute phase treatment. Thus, it is important to attempt to augment acute phase treatment outcomes for GAD. Selective serotonin reuptake inhibitors (SSRI) and serotonin norepinephrine reuptake inhibitor (SNRI) antidepressants have recently been approved by the FDA for the treatment of GAD. However, no studies have examined the efficacy of combining these medications with psychotherapy for diagnosed GAD patients. We therefore propose a preliminary randomized clinical trial to assess whether combined treatment is superior to medication alone in the acute phase treatment of GAD. The proposed study will randomly assign 160 patients with a primary diagnosis of GAD to either 12 weeks of CBT plus venlafaxine XR (N=40) or venlafaxine XR alone (N=120). Responders during the initial 12 week period will be continued on medication and assessed for 6-months to collect preliminary data on relapse. Venlafaxine will be flexibly dosed between 75 and 225 mg/day. The primary efficacy measure will be the Hamilton Anxiety Rating Scale assessed at baseline and treatment weeks 2, 4, 6, 8, and 12. Secondary outcomes will include measures of depressive symptoms, quality of life, and functional impairment. Data analysis will focus on differential rate of change (mixed model analyses) for the two groups. If promising results are obtained for combined treatment, a larger more definitive trial will be planned.

Combined Medication and Cognitive Psychotherapy for Generalized Anxiety Disorder

The current study assessed efficacy of combined cognitive behavioral therapy (CBT) and venlafaxine XR compared to venlafaxine XR alone in the treatment of generalized anxiety disorder (GAD) within settings where medication is typically offered as the treatment for this disorder. Patients with DSM-IV-diagnosed GAD who were recently enrolled in a long-term venlafaxine XR study were randomly offered or not offered the option of adding 12 sessions of CBT. Click the paper above to view our findings!

Combined Medication and CBT for Generalized Anxiety Disorder with African American Participants: Reliability and Validity of Assessments and Preliminary Outcomes

Using data from the previous study, this article examines the reliability and convergent validity of scales, and preliminary outcomes, for African American patients compared to European American patients. Click the paper above to view our findings!

• Grant Title: Coordinating Center for Treatment of Cocaine Abuse Study
• Grant Number: 1U01DA007090-01
• Principal Investigator: Paul Crits-Christoph

Abstract

This application is for the Coordinating Center of the NIDA multi-site collaborative treatment of cocaine abuse project. The Coordinating Center has three main function: (1) administrative support for the study, including coordination of Steering Committee meetings, (2) training and supervision of therapists, and (3) data management and analysis. The Coordinating Center will make use of the expertise in training of therapists and data management and analysis present in the Clinical Research Center for the Study of Psychotherapy at the University of Pennsylvania. Dr. Aaron Beck will be in charge of training, monitoring, and supervision of psychotherapists for a cognitive therapy condition in the collaborative study. Dr. Lester Luborsky will do the same for psychodynamic therapy and Dr. George Woody for drug counseling. A Data Management and Statistics Unit will process all incoming data from clinical sites for entry on computer and analysis. Relevant experience and resources of the investigators for conducting large scale psychotherapy and addiction research are delineated.

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study: Rationale and Methods

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study is a large, multisie psychotherapy clinical trial for outpatients who meet the DSM-IV criteria for cocaine dependence. For 490 randomized patients, the outcomes of four treatments are compared for an 18-month period. All treatments include group drug counseling. One treatment also adds cognitive therapy, one adds supportive-expressive psychodynamic therapy, and one adds individual drug counseling; one consists of group drug counseling alone. In addition, 2 specific interaction hypotheses, one involving psychiatric severity and the other involving degree of antisocial personality characteristics, are being tested. Click the paper above to learn more!

Psychosocial Treatments for Cocaine Dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study

This was a multicenter investigation examining the efficacy of four psychosocial treatments for cocaine-dependent patients. Four hundred eight-seven patients were randomly assigned to 1 of 4 manual-guided treatments: individual drug counseling plus group drug counseling (GDC), cognitive therapy plus GDC, supportive-expressive therapy plus GDC, or GDC alone. Treatment was intensive, including 36 possible individual sessions and 24 group sessions for 6 months. Patients were assessed monthly during active treatment and at 9 and 12 months after baseline. Click on the paper above to view our findings!

Impact of Psychosocial Treatments on Associated Problems of Cocaine-Dependent Patients

Using data from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study, we examined the relative efficacy of four treatments for cocaine dependence on psychosocial and other addiction-associated problems. The 487 patients were randomly assigned to 6 months of treatment with cognitive therapy, supportive-expressive therapy, or individual drug counseling (each with additional group drug counseling), or to group drug counseling alone. Assessments were made at baseline and monthly for 6 months during the acute treatment phase, with follow-up visits at 9 and 12 months. Click on the paper above to view our findings!

• Grant Title: Community-Friendly Manual Guided Drug Counseling
• Grant Number: 5R21DA016002-03
• Principal Investigator: Paul Crits-Christoph

Abstract

We propose here treatment development work to create and test a "community-friendly" manual-based individual plus group drug counseling package. The NIDA Collaborative Cocaine Treatment Study (Crits-Christoph et at., 1999) recently reported that manual-based individual drug counseling (IDC) plus group drug counseling (GDC) has superior drug use outcomes compared to cognitive-behavior therapy plus GDC, psychodynamic therapy plus GDC, and GDC alone. Proposed changes to IDC and GDC to make them more "community-friendly" include changes to both the duration and content of the treatment models. The proposed treatment development work will include (1) obtaining feedback on the new treatment manuals by a sample of 15 community-based drug counselors, (2) evaluating whether a group of drug counselors can successfully learn to implement the new manuals, (3) evaluating counselors' experiences in learning and conducting the new treatments, (4) conducting a pilot randomized evaluation of the outcomes of the new package of individual plus group drug counseling compared to group drug counseling alone, (5) obtaining ratings of treatment fidelity to assess whether the new individual and group drug counseling approaches can be differentiated from the original therapies, (6) assessing patient reactions to the new treatment, and (7) conducting a preliminary investigation of potential mediators of change of the new treatments. The pilot randomized trial will involve assignment of 40 patients meeting DSM-IV criteria for cocaine dependence to either new versions of individual plus group drug counseling or group drug counseling alone. Assessments will be done at time of intake and weekly (for urines and self-report of cocaine use) or monthly (for other outcome measures) during a 3-month treatment phase. The primary efficacy measures will be the ASI Drug Use Composite scale and a composite cocaine use measure that incorporates urine data, Addiction Severity Index Interview data, and weekly self-report of cocaine use. Mediation of drug use change will be examined by assessing beliefs about substance use, endorsement of 12-step behaviors and beliefs, and attendance/ participation in 12-step meetings at baseline, weekly for the first month and monthly thereafter. The data gathered from this treatment development project will inform the design of a subsequent larger study.

• Grant Title: The Process of Group Therapy for Cocaine Dependence
• Grant Number: 1R01DA018935-01
• Principal Investigator: Paul Crits-Christoph

Abstract

Group drug counseling is the primary treatment modality used in community settings for the treatment of cocaine dependence, as well as alcohol and most other substances of abuse. Despite the prevalence of this modality, and data on the efficacy of group approaches to the treatment of substance use disorders, little is known about how the treatment works to achieve positive outcomes. Thus, as described in the RFA, research is needed on the mechanism of action of group treatments for substance abuse. Drawing upon research on individual drug counseling and on group therapy for non-substance abuse problems, we propose to examine several theoretically important therapy process variables as predictors of the outcome of group drug counseling for cocaine dependence. Specifically, we propose to examine degree of patient participation, quality of participation, quality of the therapeutic alliance, and frequency of feedback (and positive feedback), as assessed in group drug counseling sessions, as predictors of treatment outcome. Furthermore, the relation of these process variables to two potential mediators of changes in drug use (changes in beliefs about drug use and endorsement of 12-step philosophy) will be examined. Group drug counseling sessions will be drawn from an archival tape collection from the NIDA Cocaine Collaborative Treatment Study (NIDA CCTS, Crits-Christoph et al., 1999). A second aim of the current proposal is to develop a novel approach to the analysis of group therapy data. Research on the mechanism of group counseling has been hindered by a variety of difficulties in studying treatments delivered in group formats. In particular, statistical analyses of studies using group therapy/counseling needs to address the inherent clustering within the data (i.e., there is an issue of non-independence of observations within a group). While statistical techniques such as mixed-effects models and generalized estimating equations exist for handling clustered data arising in group therapy studies with traditional static group designs, in the real world drug counseling groups typically have a "rolling" or "dynamic" structure, meaning that new members are added on an ongoing basis and existing members dropout over time. Statistical solutions for addressing such "rolling" groups have yet to be developed. Our second aim is to develop a new statistical approach to the analysis of data from "rolling" groups.

Process Predictors of the Outcome of Group Drug Counseling

This study examined the relation of process variables to the outcome of group drug counseling, a commonly used community treatmetn, for cocaine dependence. Videotaped drug counseling sessions from 440 adult patients were rated for member alliance, group cohesion, participation, self-disclosure, as well as positive and non-positive feedback and advice during the 6-month treatment of cocaine dependence. Average, session-level, and slopes of process scores were evaluated. Primary outcomes were monthly cocaine use, next session cocaine use, and duration of sustained abstinence from cocaine. Secondary outcomes were endorsement of 12-step philosophy and beliefs about substance abuse. Click on the paper above to view our findings!