Behavioral Interventions for
Addictions and Co-Occurring
Disorders
Suzette Glasner-Edwards, Ph.D.
UCLA Integrated Substance Abuse Programs
February 28th, 2013
Acknowledgements
Collaborators: Patricia Marinelli-Casey, Ph.D., Maureen
Hillhouse, Ph.D., Alfonso Ang, Ph.D., Larissa Mooney,
M.D., Richard Rawson, Ph.D.
Thanks to the treatment and research staff at the participating
community-based center sites and the study investigators in
each region.
The research presented in this talk was supported by grants
provided by NIDA (K23DA20085 and R21DA029255), the
Center for Substance Abuse Treatment (CSAT), Substance
Abuse and Mental Health Services Administration
(SAMHSA), US Department of Health and Human Services.
Disclosure Information
Continuing Medical Education committee members and those involved in the planning of this
CME Event have no financial relationships to disclose.
Suzette Glasner-Edwards
I have no financial relationships to disclose
Overview


Clinical course and outcomes of substance users
with comorbid psychiatric disorders
Behavioral interventions with promise
Integrated treatments
 CBT/MI
 Mindfulness Based Relapse Prevention

Background

Affective Disorders are among the most common Axis I disorders for
most drugs of abuse.


26% of adults with SUDs have lifetime history of affective disorder
27% of adults with unipolar depression have lifetime history of SUDs.

Depression-SUD comorbidity is associated with poorer outcomes
whether treatment targets the SUD or the depression.
(e.g., Stein et al., 2004)

Outcomes for this population appear to be optimized by:
(1) Integrating therapy content for both problems
(2) Using CBT
(3) Improving retention
Course and Outcomes of Methamphetamine
Users With Co-Occurring Disorders


Participants: a subset (N=526) of adults who were recruited
to participate in the Methamphetamine Treatment Project
(Rawson et al., 2004) participated in a longitudinal followup study.
Inclusion criteria:




Age 18 or over
MA dependence
Able to understand English and attend treatment
Exclusion criteria:



Medical impairment compromising safety to participate
Need for medical detox from alcohol/opioids/other substances
Psychiatric impairment warranting hospitalization/primary tx
Study Design (cont’d)

Assessments conducted by trained interviewers at




Inclusion criteria:




Baseline
Tx discharge
Post-treatment (M=3.1 years)
Age 18 or over
MA dependence with recent use (i.e., past 30 days)
Able to understand English and attend treatment
Exclusion criteria:




Medical impairment compromising safety to participate
Need for medical detox from alcohol/opioids/other substances
Psychiatric impairment warranting hospitalization/primary tx
Recent participation in another drug treatment program
Measures

Mini-International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998) was given at
3-year follow-up to assess DSM-IV current psychiatric disorders

Life Experiences Timeline was given at follow-up to assess substance use

Addiction Severity Index (McLellan et al., 1980) was given at all timepoints, providing
data regarding:
 MA use frequency in the 30 days prior

Composite severity scores in 7 functional domains

Beck Depression Inventory (Beck et al., 1961) was given at each assessment to measure
depression severity

Brief Symptom Inventory (Derogatis and Melisaratos, 1983) was given at each assessment
to measure psychological symptom severity across 9 domains.

Treatment adherence: continuous variable indicating the number of weeks of scheduled
treatment attended
Psychiatric Disorders in Methamphetamine
Dependent Adults
Glasner-Edwards, S., Mooney, L.J., Marinelli-Casey, P., Hillhouse, M., Ang, A., Rawson, R.A.
(2010). Psychopathology in methamphetamine dependent adults 3 years after
treatment. Drug and Alcohol Review, 29: 12-20.
Results: Psychiatric Diagnoses (N=526)
Diagnosis
Current (%)
Life (%)
34.0
34.6
15.2
***
Major Depression, Recurrent
***
9.1
Mania
3.9
8.5
Hypomania
2.4
9.3
Any Affective Disorder
22.2
24.5
Any Anxiety Disorder
23.4
***
Psychotic Disorders
4.9
12.7
Antisocial Personality Disorder
***
25.8
Any Psychiatric Disorder
Affective Disorders
Major Depression
Psychiatric Diagnoses and Outcomes

Of those who participated in the Methamphetamine Treatment project, 48% met criteria for
a current or past psychiatric disorder.

Mood disorders, anxiety disorders, and antisocial personality disorders were the most
common diagnoses.

MA use


Those with an Axis I disorder reported greater frequency of MA use during follow-up (M=15.5
months, SD=0.8) compared to those without a diagnosis (M=12.8 months, SD=0.8), t(523)= -2.0,
p=0.03.

Those with Antisocial Personality Disorders reported using less frequently than those without ASPD
(M=11.9 vs. M=14.8 months), t(523)=2.0, p=0.03.

MA use frequency during FU increased as a function of the number of psychiatric diagnoses
(β=0.68, SE=0.29, p=0.02).
Other psychosocial and functional outcomes

Those with an Axis I disorder evidenced problems of significantly greater severity from baseline to
follow-up on a subset of ASI composites and BSI scales:


ASI: Alcohol, drug, psychiatric
BSI: anxiety, phobic anxiety
Major Depressive Disorder in
Methamphetamine Dependent Adults
Glasner-Edwards, S., Marinelli-Casey, P., Hillhouse, M., Ang, A., Mooney, L.J., Rawson, R.A.
(2009). Depression among methamphetamine users: association with outcomes from
the Methamphetamine Treatment Project at 3-year follow-up. Journal of Nervous and
Mental Disease, 197: 225-231.
Depressive Symptoms and MA Use
20
M e a n B D I S c o re
15
10
5
A b s tin e n t
U sed M A
0
B a s e lin e
D is c h a rg e
T im e
Those who remained abstinent from MA showed a greater reduction in depressive
symptoms as compared to those who used within 30 days prior to treatment
discharge (β=5.1, SE=0.69, p<0.0001).
Results: Major Depressive Disorder
0 .6
B a s e lin e
D is c h a rg e
F o llo w -u p
No MDD
0 .4
0 .3
0 .2
0 .1
A S I C o m p o s ite
p sych ia tric
fa m ily
le g a l
d ru g
a lco h o l
e m p lo ym e n t
0 .0
m e d ica l
M e a n C o m p o s ite S c o re
0 .5
Results: Major Depressive Disorder
0 .6
MDD
B a s e lin e
D is c h a rg e
F o llo w -U p
0 .4
0 .3
0 .2
0 .1
A S I C o m p o s ite
p s yc h ia tric
fa m ily
le g a l
d ru g
a lc o h o l
e m p lo ym e n t
0 .0
m e d ic a l
M e a n C o m p o s ite S c o re
0 .5
Major Depressive Disorder: cont’d

Summary of findings

Abstainers shifted from clinically significant depressive symptoms at
treatment entry to the normal/minimal symptom range at discharge.

Those with Major Depressive Disorder at follow-up had poorer
methamphetamine use outcomes.

Depression severity at follow-up was greater for those who used
methamphetamine intravenously, relative to those who used other
routes of administration.

Those with Major Depression had worsening depressive symptoms,
overall psychiatric severity, and psychosocial outcomes from
discharge to follow-up.
Anxiety Disorders in Methamphetamine
Dependent Adults
Glasner-Edwards, S., Mooney, L.J., Marinelli-Casey, P., Hillhouse, M., Ang, A., Rawson, R.A.
(2010). Anxiety disorders among methamphetamine dependent adults:
association with posttreatment outcomes. American Journal on Addictions, 19(5):
385-390.
Results: Anxiety Disorders

26.2% of the sample was diagnosed with an anxiety disorder (current
or past).

Those with anxiety disorders reported greater MA use frequency
during 3-year follow-up compared to those without an anxiety
disorder.

Those with anxiety disorders were more likely to have been
hospitalized within the year prior to FU than those without a diagnosis
(OR=1.8, 95% C.I., 1.1-2.9) and to have attempted suicide in their
lifetimes (OR=3.1, 95% C.I., 2.1-4.7).

Participants with anxiety disorders had poorer treatment adherence
(M=6.2 vs. 7.6 weeks, t=2.3, df=524, p=0.02), were more likely to
meet criteria for alcohol- (OR=1.8) or other substance dependence
(OR=2.2) at 3-year follow-up, and evidenced declining functional
outcomes on the ASI (drug, psychiatric) from baseline to FU.
PTSD Symptoms as Risk Factors for PostTreatment Methamphetamine Use
Glasner-Edwards, S., Mooney, L.J., Ang, A., Hillhouse, M., Rawson, R.A.
(in press). PTSD symptoms as risk factors for Drug and Alcohol Review, 29: 12-20.
Results: PTSD

Those with PTSD reported greater MA use frequency during 3-year
follow-up compared to those without an anxiety disorder.

MA use frequency was associated with specific PTSD symptom
clusters; higher levels of use were predicted by avoidance (β=1.58,
SE=0.58; p<0.01) and arousal (β=1.50, SE=0.62; p<0.05) symptoms.

Participants with PTSD were more likely to have an additional Axis I
disorder (particularly, mood psychotic, and eating disorders).
Psychotic Disorders in Methamphetamine
Dependent Adults
Glasner-Edwards, S., Mooney, L.J., Marinelli-Casey, P., Hillhouse, M., Ang, A., Rawson, R.A.
(2008). Clinical course and outcomes of methamphetamine dependent adults
with psychosis. Journal of Substance Abuse Treatment. 35, 445-450.
Results: Psychotic Disorders

12.9% of the sample was diagnosed with a psychotic disorder
(current or past).

Those with psychotic illness were more likely to have been
hospitalized within the year prior to FU than those without a diagnosis
(OR=2.4, 95% C.I., 1.2-4.3) and reported more episodes (β=0.33,
SE=0.11, p<0.01).

Those with psychotic illness evidenced declining functional outcomes
on the ASI (medical, employment, legal) and worsening psychological
impairment on the BSI from baseline to FU.

No difference in MA use frequency among those with and without
psychotic disorders during FU (M=12.5 +1.6 versus 14.3 + 0.6
months); no difference in tx adherence.
Summary





Rates of psychiatric disorders in MA users are
moderate relative to that observed in cocaine users
but notably higher than prevalence estimates of such
syndromes in the general population.
Poorer functional outcomes are associated with
psychiatric illness in MA users.
MA use outcomes are poorer among MA users with
psychiatric comorbidity.
Abstinence promotes psychiatric symptom recovery.
Concurrently addressing psychiatric symptoms and
relapse susceptibility may optimize outcomes in this
population.
True or False: People who stay abstinent
from methamphetamine during treatment
show reductions in depression symptoms.
Integrated Interventions (CBT and MI)
Integrated Interventions

Gold standard approach for the treatment of COD;
demonstrated efficacy in:



Reducing hospitalizations in substance users with comorbid
affective disorders or schizophrenia (e.g., Granholm et al., 2003)
Reducing psychiatric symptoms and substance abuse among
those with co-occurring SUD and PTSD (Back et al., 2010)
Improving depressive symptoms and reducing substance use
among adults with SUD and major depression (Brown et al.,
2006)
Changes in Depression in Twelve-Step
Facilitation versus Integrated CBT
TSF
ICBT
PreTx
Source: Brown et al. (2006)
Treatment
Posttreatment
Changes in Substance Use in Twelve-Step
Facilitation versus Integrated CBT
P e rce n t D a ys A b stin e n t
100
TSF
ICBT
90
80
70
TRT
60
12 st
ICBT
50
0PreTx
1Treatment 2
3Posttreatment
4
WAVE
Source: Brown et al. (2006)
5
Continuing Care Approaches

Continuing care is critical, particularly within the first 6 months
after treatment, given the relapsing nature of addictive disorders

Randomized continuing care trials for substance users to date
have mostly excluded those with concomitant psychopathology

12-step self-help programs are the most prevalent aftercare
approaches, and outcomes appear to be comparable to CBT
and MET (Ouimette et al., 1997, Brown et al., 2002) for those
with SUD-only.

But what about those with comorbidity?
Study Overview

Pilot clinical trial of integrated CBT and Motivational Therapy (CBT-MT) for
Substance Dependent adults with Major Depressive Disorder (N=68)

CBT-MT addresses both depression and substance dependence with CBT
and incorporates motivational exercises in each session targeting engagement
and retention in continuing care for both conditions.

CBT-MT is expected to facilitate retention in treatment and to improve
depression and substance use outcomes, relative to treatment as usual, a dual
recovery anonymous self-help group (DRA).

Study Design: Participants receiving treatment in a day hospital program at UCLA
were randomly assigned at discharge to either:
 Integrated CBT and Motivational Therapy (CBT-MT)
 Treatment As Usual (Dual Recovery Anonymous) (DRA)
Inclusion Criteria

Participants qualified for the study if they:

Were at least 18 years old

Had a diagnosis of current substance dependence
(alcohol, cannabis, stimulant, or opioid)
Had a diagnosis of lifetime Major Depressive Disorder
(independent of substance use)
Had current depressive symptoms >13 on the BDI


Potential participants were excluded for psychosis and bipolar
disorder, or suicidality warranting hospitalization.
Study Design

Group CBT-MT, a weekly, 12-week group intervention draws from group CBT
and MI manualized treatments:



Participants were assessed for depression and substance use at baseline, weekly
during treatment, and 12 and 24 weeks post-treatment. Measures included:





Integrated CBT for depression and SUDs (Brown et al., 2006)
Group Motivational Interviewing (Santa Ana, 2005)
BDI
HAM-D
Addiction Severity Index
Psychiatric Research Interview for Substance and Mental Disorders (PRISM) (Hasin et al.,
2006)
We hypothesized that CBT-MT would produce superior treatment retention,
depression and substance use outcomes.
Demographics
Overall
N
CBT
%
68
Age
N
DRA
%
35
N
%
33
35
--
36
--
34
--
Male
33
49
17
49
16
48
Female
35
51
18
51
17
52
Caucasian
52
76
28
80
24
73
Married
12
18
5
14
7
21
Never Married
38
56
20
57
18
55
30.55
--
30.5
--
30.6
--
Gender
Ethnicity
Marital Status
Baseline BDI scores
The sample comprised mostly cannabis (40%) and alcohol (25%) users, followed by
prescription drug (19%) and stimulant users.
Percent Attending Sessions Each Week, By Group
.
Percentage of Participants With Improvement
in Depression, By Attendance to >10 Sessions
In the overall sample, a significantly greater % of those who attended more than
10 sessions experienced improvements in depressive symptoms, (100%) chisquare=4.8, p=0.02, relative to those who attended 10 sessions or fewer (67%).
Percentage of Participants Attending >10
Sessions, by Group
Compared to those who received DRA, the proportion of those in CBT-MT who
completed most or all of the sessions was significantly greater, chi square=4.48,
p=.03.
Percentage of Participants With Improvement in
Depressive Symptom Severity Over Baseline
A significantly greater proportion of those in the CBT-MT condition (67%)
showed a reduction from baseline to their last available assessment in total BDI
scores, as compared to controls (37%); chi-square=5.9, p=0.01).
Percentage of Participants Who Used Drug of
Choice in the Past 30 Days
Conclusions

In our pilot study of CBT-MT as a continuing care
approach for depressed substance users, preliminary
results suggest that :




This approach effectively facilitates treatment retention.
Treatment retention is associated with reductions in
depressive symptoms.
Preliminary drug use outcomes do not differ between
groups.
Areas we are currently evaluating include: mechanisms
of therapeutic change, effects of the intervention on
time to relapse, and evaluation of the impact of baseline
cognitive functioning on treatment response.
References
Brown, S.A., Glasner, S.V., Tate, S.R., McQuaid, J.R., Chalekian, J., & Granholm, E.
(2006). Integrated cognitive behavioral therapy versus twelve-step facilitation for
substance dependent adults with depressive disorders. Journal of Psychoactive Drugs., 38(4): 449-460.
Brown, T.G., Seraganian, P., Tremblay, J., & Annis, H. (2002). Process and outcome changes with
relapse prevention versus 12-step aftercare programs for substance abusers. Addiction, 97:
677-689.
Hasin, D., Samet, S., Nunes, E., Meydan, J., Matseoane, K., & Waxman, R. (2006). Diagnosis of
comorbid disorders in substance users: Psychiatric Research Interview for Substance and
Mental Disorders (PRISM-IV). American Journal of Psychiatry., 163(4), 689-696.
Ouimette, P.D., Finney, J.W., & Moos, R.H. (1997). Twelve-step and cognitive-behavioral treatment for
substance abuse: a comparison of treatment effectiveness. Journal of Consulting and Clinical
Psychology, 65: 230-240.
Santa Ana, E. (2005). Group Motivational Interviewing Treatment Manual
(GMI) for Individuals with Psychiatric and Comorbid Substance Use Problems (pp. 1-25): Yale University
School of Medicine and VA CT Healthcare System.
Stein, M.D., Herman, D.S., Solomon, D.A., Anthony, J.L., et al. (2004). Adherence to treatment of depression
in active injection drug users: the Minerva study. Journal of Substance Abuse Treatment, 26(2): 87-93.
True or False: Outcomes of integrated
treatments for continuing care are no better
than those of standard, 12-step self-help
based continuing care for those with cooccurring disorders.
Mindfulness Based Relapse Prevention
Study Overview

Pilot RCT of Mindfulness Based Relapse Prevention (MBRP) for
Stimulant Users (N=62)

Mindfulness involves cultivating awareness of one’s moment-tomoment experience in a non-judgmental way.

Mindfulness is expected to improve affect regulation as well as stress
reactivity, thereby reducing relapse susceptibility

Study Design: All participants receive contingency management for 12
weeks and are concurrently randomly assigned to either
 Mindfulness Based Relapse Prevention (MBRP) or
 Health Education
Beck Depression Inventory
20
15
Mindf
Control
10
5
0
0
1
2
3
4
5*
6
7
8*
9* 10 11 12 16*
Those in the MBRP condition showed a greater reduction in depressive symptoms
through 1 month post-treatment , relative to controls (p<0.03; Effect Size=0.58).
Beck Anxiety Inventory
20
15
Mindf
Control
10
5
0
0
1
2
3
4
5
6
7
8
9
10 11 12 16*
Those in the MBRP condition showed a greater reduction in anxiety symptoms
through 1 month post-treatment, relative to controls (p<0.02; Effect Size=0.72).
Addiction Severity Index: Psychiatric Composite
0.4
0.3
Mindf
Control
0.2
0.1
0
0
12
16*
Those in the MBRP condition showed a greater reduction in overall psychiatric
severity through 1 month post-treatment as compared to controls (p<0.02; Effect
Size=0.61).
Short Inventory of Problems
25
20
15
Mindf
Control
10
5
0
0
12
16
Those in the MBRP condition showed a greater reduction from baseline to 1
month post-treatment in problems related to stimulant dependence, as compared
to controls (p<0.10; Effect Size=0.06).
Stimulant Use Outcomes
Number of stimulant-free UA
% UA that were stimulant-free
25
20
15
Mindf
Control
10
5
0
CM Lead-In
Intv phase
Those in the MBRP condition showed comparable reductions in stimulant use
during both the 4-week Contingency Management Lead-In and the subsequent 8week Mindfulness Intervention Phase, compared to controls.
Stress Reactivity Before and After
Treatment With Mindfulness or Health
Education Control
Pre-Treatment
Post-Treatment
After treatment ended (right panel), cortisol levels during the hour following
exposure to a laboratory stressor were elevated in a substantially larger proportion
of control group participants, relative to MBRP participants, for whom poststressor cortisol levels returned to baseline or lower.
Difficulty in Emotional Regulation Scale
100
90
80
Mindf
Control
70
60
50
0
12*
16*
Five Factor Mindfulness Scale
150
140
130
Mindf
Control
120
110
100
5
6
7
8*
9
10
11
12
Summary

In our pilot study of mindfulness based relapse
prevention for stimulant users, preliminary
results suggest that :
This approach effectively reduces negative affect,
stress reactivity, psychiatric impairment, and may
reduce stimulant dependence severity.
 Changes in putative psychological mechanisms
underlying the effectiveness of mindfulness (e.g.,
emotion regulation, adoption of a mindful approach
to living) are observed in this population.

True or False: Mindfulness interventions
were originally developed as a means of
reducing stress.
Conclusions



Clinical course and outcomes of substance users
with COD are poorer across multiple domains
compared to those with SUD alone.
Integrated interventions effectively improve
outcomes, both as a primary treatment strategy, and
for continuing care for those with affective
disorders and SUDs.
Mindfulness based interventions are a promising
new target for COD, with efficacy in reducing stress
reactivity, negative affect, and overall psychiatric
severity among substance users.
Thank you!
Suzette Glasner-Edwards, Ph.D.
sglasner@ucla.edu
310-267-5206