Recent advances in the psychotherapy of addictive disorders

Rigorous research has recently identified a range of behavioral therapies that have been shown to be effective across the most prevalent types of substance dependence. This review summarizes the roles of behavioral therapies as contrasted with those of pharmacotherapies for substance use disorders and then provides an overview of the major classes of behavioral therapies (clinical management, coping skills approaches, motivational interviewing, and family and interpersonal approaches), highlighting their effectiveness across cocaine, opioid, alcohol, and cannabis use disorders. Lastly, important areas of current research emphasis including combined treatments, strategies for effectively transporting empirically validated treatments into clinical practice, and increasing the efficiency of treatment are described.     

Relapse of substance use disorder and its prevention among persons with co-occurring disorders

This article summarizes the scientific literature on the relapse process, describes the basic principles of relapse prevention treatment, highlights the major empirical studies, and offers suggestions for future research and application, especially in terms of ongoing care for persons with co-occurring disorders. Relapse prevention treatments have a well-established efficacy and effectiveness for persons with substance use disorders. Key ingredients include reducing exposure to substances, fostering motivation for abstinence, self-monitoring, recognizing and coping with cravings and negative affect, identifying thought processes with relapse potential, and deploying, if necessary, a crisis plan. Relapse prevention approaches may be best suited for persons in the action of maintenance stages of treatment or recovery. Further research is needed to examine relapse prevention therapies as a key component to continuing care for persons with co-occurring substance use and psychiatric disorders.     

Bridging the gap: a hybrid model to link efficacy and effectiveness research in substance abuse treatment

Many behavioral and pharmacologic treatments for which there is strong empirical support are rarely used in clinical practice in the treatment of substance dependence. In an effort to facilitate greater emphasis on issues such as utility, practicality, and cost earlier in the evaluation of promising therapies, the authors propose a hybrid model to link efficacy and effectiveness research. A hybrid model may foster broader use of empirically validated treatments in substance abuse treatment programs and enhance the scientific yield of effectiveness research. The hybrid model retains essential features of efficacy research (randomization, use of control conditions, independent assessment of outcome, and monitoring of treatment delivery) while expanding the research questions to also address issues of importance in effectiveness studies. Such issues include diversity in settings, clinicians, and patients; cost-effectiveness of treatment; training issues; and patient and clinician satisfaction.     

Neuroimmune mechanisms of psychostimulant and opioid use disorders

Substance use disorders are global health problems with few effective treatment options. Unfortunately, most potential pharmacological treatments are hindered by abuse potential of their own, limited efficacy, or adverse side effects. As a consequence, there is a pressing need for the development of addiction treatments with limited abuse potential and fewer off target effects. Given the difficulties in developing new pharmacotherapies for substance use disorders, there has been growing interest in medications that act on non‐traditional targets. Recent evidence suggests a role for dysregulated immune signaling in the pathophysiology of multiple psychiatric diseases. While there is evidence that immune responses in the periphery and the central nervous system are altered by exposure to drugs of abuse, the contributions of neuroimmune interactions to addictive behaviors are just beginning to be appreciated. In this review, we discuss the data on immunological changes seen in clinical populations with substance use disorders, as well as in translational animal models of addiction. Importantly, we highlight those mechanistic findings showing causal roles for central or peripheral immune mediators in substance use disorder and appropriate animal models. Based on the literature reviewed here, it is clear that brain‐immune system interactions in substance use disorders are much more complex and important than previously understood. While much work remains to be done, there are tremendous potential therapeutic implications for immunomodulatory treatments in substance use disorders.     

Association between psychiatric disorders and smoking stages within a representative clinic sample of Puerto Rican adolescents

OBJECTIVE: We examined the prevalence of smoking behaviors and their association with specific psychiatric disorders in a representative sample of youth from behavioral health clinics in Puerto Rico. METHOD: A complex sampling design was used to select the sample, and analyses were conducted to account for the unequal selection probability, stratification, and clustering. All analyses were weighted back to the clinical population from which they were drawn. Psychiatric and substance use disorders were assessed using the parent and youth versions of the Diagnostic Interview Schedule for Children, Version 4.0. RESULTS: More than one third of the sample reported experience with cigarette smoking, and approximately one quarter reported smoking at least once per week (23.4%). As expected, the alcohol and drug use disorders demonstrated some of the strongest associations with individual smoking stages. These were the only disorders that remained significantly associated with nicotine dependence after controlling for comorbidity. CONCLUSIONS: Our findings confirm the need for screening of smoking behavior and nicotine dependence in treatment settings and the integration of psychiatric/substance use treatments with smoking cessation.     

Diagnosis and treatment of co-occurring affective disorders and substance use disorders.

There is growing interest in the co-occurrence of mood and substance use disorders. It is clear that co-occurrence of these disorders is common and has an impact on prognosis and course of both disorders. The diagnostic issues at the interface of substance or alcohol use disorders and affective illnesses are particularly difficult because of the substantial symptom overlap between substance intoxication and withdrawal and symptoms of affective disorders. Over the past few years, advances have been made in the treatment of co-occurring disorders. Further investigation of specifically tailored treatments for patients with co-occurring substance use and other mood disorders is underway. Because many advances have been made in pharmacotherapy of mood disorders in the past 10 years, this progress will impact individuals with co-occurring disorders, because newer agents with less toxicity and fewer adverse effects and interactions with substances of abuse will be evaluated for treating the comorbid condition. Specific considerations in choosing a pharmacologic agent for use in patients with substance use disorders include safety, toxicity, and abuse liability. Although there are few studies specifically targeting pharmacotherapy for co-occurring disorders, those that have been conducted indicate that similar pharmacotherapeutic agents work for mood disorders with or without substance use disorders. In conclusion, although the co-occurrence of substance abuse and mood disorders is an important area in which recent developments provide cause for considerable optimism, much work remains to be done.     

Comorbidity of mood and anxiety disorders

This article reviews data on the prevalence of panic, social phobia, generalized anxiety, and posttraumatic stress disorder, and research documenting the comorbidity of these disorders with major depression (MDD). These anxiety disorders are frequently comorbid with MDD, and 50-60% of individuals with MDD report a lifetime history of one or more of these anxiety disorders. The anxiety disorders are also highly correlated with one another, and approximately one-quarter to one-half of individuals with each of the anxiety disorders report a lifetime history of an alcohol or substance use disorder. Anxiety disorders rarely exist in isolation, with several studies reporting that over 90% of individuals with anxiety disorders have a lifetime history of other psychiatric problems. Implications for research are discussed, including the potential benefit of using combined categorical and dimensional rating scale approaches in future genetic, biochemical, neuroimaging, and treatment studies. The clinical implications of the findings are also discussed, and the results of recent clinical trials summarized. Available data suggests selective serotonin reuptake inhibitors are the first-line pharmacological treatment for these disorders, and that newer serotonin and norepinephrine reuptake inhibitors show significant promise, especially for comorbid cases. Comorbidity among depression and anxiety disorders is associated with greater symptom severity, and a considerably higher incidence of suicidality. Increased public awareness about these disorders and the availability of effective treatments is sorely needed.     

Drug and alcohol services in middle-income countries

PURPOSE OF REVIEW: The present review summarizes current research in middle-income countries on drug and alcohol services for prevention, screening, treatment, care and rehabilitation between June 2006 and December 2007. RECENT FINDINGS: There is a dearth of scientific literature on prevention, treatment and rehabilitation in middle-income countries and no novel effective approaches reported during the review period. The Lancet Series on Global Mental Health showed only 0.7% of all papers reviewed were on low-income and middle-income countries. Several studies in these countries confirmed the effectiveness of brief interventions in treating alcohol use disorders at a primary care level. One study on alcohol screening in Brazil produced a promising screening tool. Other studies reported the availability of pharmacological and nonpharmacological treatments for alcohol and drug use disorders. Overall, poor accessibility to services and delayed onset of treatment persist. Political and cultural environments play a crucial role in providing services to fulfill treatment needs. SUMMARY: During the review period, reports from middle-income countries on alcohol and drug services were very limited. A few studies in some countries confirm the effectiveness of brief interventions in primary care settings. There is an obvious need for more research on alcohol and drug treatment services in middle-income countries.     

Immune treatments for alcohol use disorder: A translational framework

While the immune system is essential for survival, an excessive or prolonged inflammatory response, such as that resulting from sustained heavy alcohol use, can damage the host and contribute to psychiatric disorders. A growing body of literature indicates that the immune system plays a critical role in the development and maintenance of alcohol use disorder (AUD). As such, there is enthusiasm for treatments that can restore healthy levels of inflammation as a mechanism to reduce drinking and promote recovery. In this qualitative literature review, we provide a conceptual rationale for immune therapies and discuss progress in medications development for AUD focused on the immune system as a treatment target. This review is organized into sections based on primary signaling pathways targeted by the candidate therapies, namely: (a) toll-like receptors, (b) phosphodiesterase inhibitors, (c) peroxisome proliferator-activated receptors, (d) microglia and astrocytes, (e) other immune pharmacotherapies, and (f) behavioral therapies. As relevant within each section, we examine the basic biological mechanisms of each class of therapy and evaluate preclinical research testing the role of the therapy on mitigating alcohol-related behaviors in animal models. To the extent available, translational findings are reviewed with discussion of completed and ongoing randomized clinical trials and their findings to date. An applied and clinically focused approach is taken to identify the potential clinical applications of the various treatments reviewed. We conclude by delineating the most promising candidate treatments and discussing future directions by considering opportunities for immune treatment development and personalized medicine for AUD.     

Developmental traumatology: a contributory mechanism for alcohol and substance use disorders.

Early childhood traumatic experiences, such as childhood maltreatment, are associated with an enhanced risk of adolescent and adult alcohol and substance use disorders (defined as DSM-IV alcohol or substance abuse or dependence). Maltreated children and adolescents manifest dysregulation of major biological stress response systems including adverse influences on brain development. Dysregulation of biological stress response systems may lead to an enhanced vulnerability for psychopathology, particularly posttraumatic stress disorder (PTSD) and depression. These negative affect disorders may put a child at increased risk for adolescent or young adult onset alcohol or substance use disorders. Thus, studies in developmental traumatology may prove to be critical in the effort to attempt to link the neurobiology of maltreatment-related PTSD with the neurobiology of alcohol and substance use disorders and in developing early strategies for the prevention of adolescent and adult alcohol and substance use disorders.     

Addictive disorders.

In conclusion, complex medical and psychiatric comorbidity is com-mon in individuals with substance use disorders. It is important to assess comorbidity because of the implications for prevention and treatment. Studies of the neurobiology of substance use and psychiatric disorders are accumulating rapidly and informing treatment development. Information about the prevention and treatment of infectious diseases and other medical conditions associated with substance use disorders also is growing, and it is important that patients are able to benefit from this. The articles in this issue provide state-of-the-art information about several issues related to comorbidity in substance use disorders.     

Mindfulness based interventions for addictive disorders: a review

Introduction

In substance use disorders, the lack of empirically supported treatments and the minimal utilization of available programs indicate that innovative approaches are needed. Mindfulness based therapies have been used in addictive disorders for the last 10 years. Mindfulness can be defined as the ability to focus open, non-judgmental attention to the full experience of internal and external phenomena, moment by moment. Several therapies based on mindfulness have been developed. The aim of this study is to review the existing data on the use of these programs in addictive disorders.

Methods

We have reviewed the literature published from January 1980 to January 2009, using the following keywords: mindfulness, mindfulness based stress reduction program, dialectical behavior therapy, acceptance and commitment therapy, mindfulness based cognitive therapy, addiction, substance use, alcohol and smoking.

Results

Results of six clinical trials evaluating four different programs were found. Five studies were controlled and four were randomized. Drop-out rates were relatively high (from 28 to 55%). In five cases out of six, the program significantly reduced substance use. In four comparative trials out of five, interventions based on mindfulness proved more effective than control conditions. The effectiveness of interventions based on mindfulness and the differential improvement across conditions became greater and was maintained during follow-up when it was long enough. Participants in mindfulness programs were less likely to endorse the importance of reducing emotions associated with smoking and reported significant decreases in avoidance of thoughts which partially mediated alcohol use reduction. Psychiatric symptoms and the level of perceived stress were also significantly reduced.

Discussion

Mindfulness may help substance abusers to accept unusual physical sensations that might be confused with withdrawal symptoms, decentre from a strong urge and not act impulsively. It may reduce an individual's susceptibility to act in response to a drug cue. Practice of mindfulness may develop the ability to maintain perspective in response to strong emotional states and mood fluctuations and increase the saliency of natural reinforcers. Mindfulness based programs require an intensive participation, and should therefore be proposed to highly motivated patients. In smoking cessation, they should be used in patients who were unable to quit with less intensive interventions. Some programs are specifically designed for patients with co-occurring psychiatric disorders.

Conclusion

The first clinical studies testing mindfulness based interventions in substance use disorders have shown promising results. They must be confirmed by larger controlled randomized clinical trials. By developing a better acceptance of unusual physical sensations, thoughts about drugs and distressing emotions, mindfulness may help in reducing the risk of relapse.     

Substance use disorders in patients with posttraumatic stress disorder: a review of the literature

OBJECTIVE: Alcohol use disorders and other substance use disorders are extremely common among patients with posttraumatic stress disorder (PTSD). This article reviews studies pertaining to the epidemiology, clinical phenomenology, and pathophysiology of comorbid PTSD and substance use disorders. METHOD: Studies were identified by means of computerized and manual searches. The review of research on the pathophysiology of PTSD and substance use disorders was focused on studies of the hypothalamic-pituitary-adrenal axis and the noradrenergic system. RESULTS: High rates of comorbidity suggest that PTSD and substance use disorders are functionally related to one another. Most published data support a pathway whereby PTSD precedes substance abuse or dependence. Substances are initially used to modify PTSD symptoms. With the development of dependence, physiologic arousal resulting from substance withdrawal may exacerbate PTSD symptoms, thereby contributing to a relapse of substance use. Preclinical work has led to the proposal that in PTSD, corticotropin-releasing hormone and noradrenergic systems may interact such that the stress response is progressively augmented. Patients may use sedatives, hypnotics, or alcohol in an effort to interrupt this progressive augmentation. CONCLUSIONS: Vigorous control of withdrawal and PTSD-related arousal symptoms should be sought during detoxification of patients with comorbid PTSD and substance use disorders. Inclusion of patients with comorbid PTSD and substance use disorders in neurobiologic research and in clinical trials will be critical for development of effective treatments for this severely symptomatic patient population.     

Gaps in addressing problem drinking: Overcoming primary care and alcohol treatment deficiencies

Despite the high prevalence of problem drinking among Americans, primary care physicians often fail to address this major health threat. In addition, once alcohol use disorders are identified, patients often fail to receive coordinated medical and substance abuse treatment. This article reviews four types of barriers as well as potential facilitators to improving the prevention and management of problem drinking. First, primary care physicians are poorly trained about the clinical relevance of addressing alcohol problems in their daily patient care. Second, primary care physicians are concerned about the stigma and health insurance problems encountered by patients diagnosed with alcohol use disorders. Third, primary care practices have limited organizational and financial support to identify and address alcohol problems. Fourth, primary care and alcohol treatment settings communicate and collaborate poorly in delivering patient care. Opportunities to overcome these challenges are discussed and must be initiated to reduce the myriad of adverse outcomes resulting from problem drinking.     

Comparisons of patients with comorbid psychiatric and substance use disorders: implications for treatment and service delivery

OBJECTIVE: Individuals with co-occurring psychiatric and substance use disorders are treated in mental health and substance abuse treatment systems, yet research on comorbid disorders rarely includes comparisons across systems. Knowledge about patients who share the label "comorbid" but are found in different treatment sectors should illuminate service issues and inform policy development. Differences across systems should provide support for separate treatments; similarities should indicate the value of the integration of services. The hypothesis that there are meaningful clinical differences between patients with comorbid mental health disorders and patients in drug treatment was tested. METHOD: As part of a larger longitudinal study, 106 patients with comorbid illness from mental health (N=106) and drug treatment (N=120) settings were compared regarding diagnosis, drug use, and problem severity. Data were obtained by using the Diagnostic Interview Schedule for DSM-IV and the Addiction Severity Index. RESULTS: Few differences between groups emerged. There were no diagnostic differences except that schizophrenia spectrum disorders were more common among mental health (43%) than drug treatment (31%) patients. Although more drug abuse than mental health subjects reported drug use in the 30 days before treatment entry, the average number of days of drug use in this period was not different. CONCLUSIONS: These findings document the high prevalence of severe mental illness in drug treatment clients and of serious drug problems in mental health patients. Only minimal differences emerged between the groups and none that indicated need for specialized treatments in separate systems of care.     

Use of complementary and alternative medicine among women with depression: results of a national survey

OBJECTIVE: This study examined patterns of and reasons for use of complementary and alternative therapies among women with depression, focusing in particular on three popular types of complementary and alternative therapies-manual therapies (for example, chiropractic treatments, massage, and acupressure), herbs, and vitamins. METHODS: The multiethnic sample consisted of 220 women with depression who were assessed as part of a nationally representative telephone survey of 3,068 women. RESULTS: Fifty-four percent of these women with depression reported past-year use of complementary and alternative medicine. African-American women were less likely to use complementary and alternative therapies in general, compared with non-Hispanic white women. Other factors significantly associated with use of complementary and alternative medicine in general included being employed, being single, and having self-perceived poor health. The relationships between the sociodemographic factors and use of each of the three individually examined types of therapies differed from their relationships with use of complementary and alternative medicine in general. Participants' most commonly cited reasons for use of these therapies were wanting treatments to be based on a "natural approach," wanting treatments to be congruent with their own values and beliefs, and past experiences in which conventional medical therapies had caused unpleasant side effects or had seemed ineffective. CONCLUSIONS: It is important for mental health and other health professionals to increase their own awareness of the types of complementary and alternative therapies that their patients may be using and to improve communication with their patients about the benefits and potential risks of these therapies.     

Alcohol and drug treatment systems in public health perspective: mediators and moderators of population effects

This article describes a public health approach to the study of service systems for people with substance use disorders. Such an approach is broadly conceived to include the consideration not only of specialized services for alcohol and drug dependence, but also of medical care and social welfare services that interact with and complement specialized drug and alcohol services. After describing a conceptual model of the substance abuse service system, we discuss how systems of care may contribute to population health and social welfare by reducing the societal burden of substance use disorders. The article then summarizes key systems issues pertaining to mediators and moderators of effective treatment systems. The potential benefits of systems thinking in relation to the management of substance use disorders are described. It is suggested that systems concepts and research may help to improve access, efficiency, economy, continuity of care, and effectiveness, thereby improving the population impact of treatment services.     

GABA systems,benzodiazepines, and substance dependence

Alterations in the gamma-aminobutyric acid (GABA) receptor complex and GABA neurotransmission influence the reinforcing and intoxicating effects of alcohol and benzodiazepines. Chronic modulation of the GABA(A)-benzodiazepine receptor complex plays a major role in central nervous system dysregulation during alcohol abstinence. Withdrawal symptoms stem in part from a decreased GABAergic inhibitory function and an increase in glutamatergic excitatory function. GABA(A) receptors play a role in both reward and withdrawal phenomena from alcohol and sedative-hypnotics. Although less well understood, GABA(B) receptor complexes appear to play a role in inhibition of motivation and diminish relapse potential to reinforcing drugs. Evidence suggests that long-term alcohol use and concomitant serial withdrawals permanently alter GABAergic function, down-regulate benzodiazepine binding sites, and in preclinical models lead to cell death. Benzodiazepines have substantial drawbacks in the treatment of substance use-related disorders that include interactions with alcohol, rebound effects, alcohol priming, and the risk of supplanting alcohol dependency with addiction to both alcohol and benzodiazepines. Polysubstance-dependent individuals frequently self-medicate with benzodiazepines. Selective GABA agents with novel mechanisms of action have anxiolytic, anticonvulsant, and reward inhibition profiles that have potential in treating substance use and withdrawal and enhancing relapse prevention with less liability than benzodiazepines. The GABA(B) receptor agonist baclofen has promise in relapse prevention in a number of substance dependence disorders. The GABA(A) and GABA(B) pump reuptake inhibitor tiagabine has potential for managing alcohol and sedative-hypnotic withdrawal and also possibly a role in relapse prevention.     

Predictors of high rates of suicidal ideation among drug users

Several studies have attempted to understand the link among substance abuse, depression, and suicidal ideation (SI). Assessment of this link is important to develop specific interventions for persons in substance abuse treatment. This association was tested among 990 drug users in and out of treatment with significant criminal justice histories from two National Institute on Drug Abuse studies. The Diagnostic Interview Schedule and Substance Abuse Module assessed DSM-III-R depression, number of depression criteria met, antisocial personality disorder (ASPD), and substance use disorders. Compared with men, women were twice as likely to report depression (24% vs. 12%), whereas men were nearly twice as likely to report ASPD (42% vs. 24%). High rates of SI were found, with women more likely than men to report thoughts of death (50% vs. 31%), wanting to die (39% vs. 21%), thoughts of committing suicide (47% vs. 33%), or attempting suicide (33% vs. 11%); 63% of women and 47% of men reported at least one of these suicidal thoughts or behaviors. Male and female ideators were more likely than nonideators to report depressed mood and to meet criteria for depression, ASPD, and alcohol use disorders. Male ideators were more likely than male nonideators to meet criteria for cocaine use disorders. Using logistic regression, SI among men was predicted by alcohol use disorder (OR = 1.60), ASPD (OR = 1.59), and number of depression criteria (OR = 9.38 for five criteria). Among women, SI was predicted by older age, marital status, alcohol use disorder (OR = 2.77), and number of depression criteria (OR = 9.12 for five criteria). These original findings point out the need to discuss suicidal thoughts among depressed drug users for early treatment and prevention.     

Scientific background of psycho-oncology]

We discussed the future direction of studies on psycho-oncology by reviewing relevant previous findings regarding treatment, early detection, and prevention of psychiatric disorders experienced by cancer patients. PSYCHIATRIC DISORDERS IN CANCER PATIENTS: It is reported that the common psychiatric disorders among cancer patients are adjustment disorder, major depression, and delirium. In addition, prevalence of adjustment disorder and major depression is higher among advanced cancer patients than that among patients with early stage cancer, and that delirium is the most common disorder among patients with terminally ill cancer. TREATMENT: Some meta-analytical studies reveal an effectiveness of psychotherapy for anxiety and depression among cancer patients however, several systematic reviews do not. Three randomized clinical trials indicate the efficacy of pharmacological treatments, anti-depressants, for major depression in cancer patients. It is suggested that delirium in advanced/terminally ill cancer patients can be ameliorated by detection and management of underlying causes of delirium and concurrent symptomatic treatment such as pharmacotherapy. EARLY DETECTION: Several brief screening instruments have been developed to detect adjustment disorder, major depression, and delirium among cancer patients. PREVENTION: One randomized clinical trial indicates the efficacy of SSRI for preventing depression occurring after interferon therapy among patients with malignant melanoma. No other effective strategy for prevention of psychiatric disorders among cancer patients has been clarified. CONCLUSION: There are not enough findings for effective treatments for ameliorating the common psychiatric disorders experienced by cancer patients, and very few studies for prevention while there are several available findings regarding early detection of their psychiatric disorders. Thus future studies on developing novel treatments including prevention and studies on mechanism should be encouraged. Psycho-oncology group in National Cancer Center are now conducting several clinical studies such as biological studies (neuro-imaging studies), studies to establish novel treatment strategy (n-3 poly unsaturated fatty acid), and multi-faceted intervention study (screening and individually tailored psychotherapy and pharmacotherapy).