Psychological interventions for alcohol misuse among people with co-occurring depression or anxiety disorders: A systematic review

Abstract OBJECTIVE: Depression, anxiety and alcohol misuse frequently co-occur. While there is an extensive literature reporting on the efficacy of psychological treatments that target depression, anxiety or alcohol misuse separately, less research has examined treatments that address these disorders when they co-occur. We conducted a systematic review to determine whether psychological interventions that target alcohol misuse among people with co-occurring depressive or anxiety disorders are effective. DATA SOURCES: We systematically searched the PubMed and PsychINFO databases from inception to March 2010. Individual searches in alcohol, depression and anxiety were conducted, and were limited to 'human' published 'randomized controlled trials' or 'sequential allocation' articles written in English. STUDY SELECTION: We identified randomized controlled trials that compared manual guided psychological interventions for alcohol misuse among individuals with depressive or anxiety disorders. Of 1540 articles identified, eight met inclusion criteria for the review. DATA EXTRACTION: From each study, we recorded alcohol and mental health outcomes, and other relevant clinical factors including age, gender ratio, follow-up length and drop-out rates. Quality of studies was also assessed. DATA SYNTHESIS: Motivational interviewing and cognitive-behavioral interventions were associated with significant reductions in alcohol consumption and depressive and/or anxiety symptoms. Although brief interventions were associated with significant improvements in both mental health and alcohol use variables, longer interventions produced even better outcomes. CONCLUSIONS: There is accumulating evidence for the effectiveness of motivational interviewing and cognitive behavior therapy for people with co-occurring alcohol and depressive or anxiety disorders.

Attachment Security and Alexithymia in a Heavy Drinking Population

Attachment difficulties have been proposed as a key risk factor for the development of alexithymia, a multifaceted personality trait characterised by difficulties identifying and describing feelings, a lack of imagination and an externally oriented thinking style. The present study investigated the relationship between attachment and alexithymia in an alcohol dependent population. Participants were 210 outpatients in a Cognitive Behavioural Treatment Program assessed on the Toronto Alexithymia Scale (TAS-20) and the Revised Adult Attachment Scale (RAAS). Significant relationships between anxious attachment and alexithymia factors were confirmed. Furthermore, alexithymic alcoholics reported significantly higher levels of anxious attachment and significantly lower levels of closeness (secure attachment) compared to non-alexithymic alcoholics. These findings highlight the importance of assessing and targeting anxious attachment among alexithymic alcoholics in order to improve alcohol treatment outcomes. Keywords: Attachment, alexithymia, alcohol dependence.

Commentary on Spence et al. : "Problem solving programme implemented by teachers may prevent depression in the short term, but longer term benefits are unclear"

This is a methodologically exemplary trial of a population based (universal) approach to preventing depression in young people. The programme used teachers in a classroom setting to deliver cognitive behavioural problem solving skills to a cohort of students. We have little knowledge about “best practice” to prevent depression in adolescence. Classroom-based universal approaches appear to offer advantages in recruitment rates and lack of stigmatisation over approaches that target specific groups of at risk students. Earlier research on a universal school-based approach to preventing depression in adolescents showed promise, but employed mental health professionals to teach cognitive behavioural coping skills in small groups.1 Using such an approach routinely would be economically unsustainable. Spence’s trial, with teachers as facilitators, therefore represents a “real world” intervention that could be routinely disseminated.

Workforce indicators of health literacy

The concept of health literacy has evolved over the last forty years from an individual, literacy driven focus in clinical settings to one associated with a contemporary approach to health promotion. The World Health Organization has defined health literacy as ‘the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health’ (World Health Organization, 1998, p. 10). The conceptual evolution of health literacy has seen a shift beyond a functional orientation to also recognise cognitive, behavioural and environmental influences. This more comprehensive view of health literacy acknowledges factors like efficacy, motivation, self-efficacy, autonomy, social support and empowerment. A health literate workforce could present benefits for the employee and employer...

What's in your tool box?

This is a professional practice paper for Psychology practitioners to reflect on their skills and therapeutic practices. A Master- practitioner model or Artizan - apprentice analogy is used to understand the development of a practicing psychologist from his/her "salad days" (when we are green [Shakespeare- Anthony and Cleopatra]) to our Autumn years in the profession.

A systematic review of psychological interventions for excessive alcohol consumption among people with psychotic disorders

Objective: Excessive alcohol consumption is common among people with psychotic disorders. While there is an extensive literature on the efficacy of psychological treatments for excessive drinking, few studies have examined interventions addressing this issue among people with psychotic disorders. Method: Systematic searches in PubMed and PsycINFO were conducted to identify randomized controlled trials comparing manual guided psychological interventions for excessive alcohol consumption among individuals with psychotic disorders. Of the 429 articles identified, 7 met inclusion criteria. Data were extracted from each study regarding study sample characteristics, design, results, clinical significance of alcohol consumption results, and methodological limitations. Results: Assessment interviews, brief motivational interventions and lengthier cognitive behavior therapy have been associated with reductions in alcohol consumption among people with psychosis. While brief interventions (i.e., 1-2 sessions) were generally as effective as longer duration psychological interventions (i.e., 10 session) for reducing alcohol consumption, longer interventions provided additional benefits for depression, functioning and other alcohol outcomes. Conclusion: Excessive alcohol consumption among people with psychotic disorders is responsive to psychological interventions. It is imperative that such approaches are integrated within standard care for people with psychosis.

The factor structure of the COPE Questionnaire in a sample of clinically depressed and anxious adults

The Coping Orientation to Problems Experienced is a multidimensional scale designed to assess how people respond to stress. The COPE has been validated in a variety of populations displaying variations in factor structure. However, in terms of mental health populations, it has only been validated in alcohol-dependent samples. This paper investigated the factor structure of the COPE in a sample of adults diagnosed with depression and anxiety. Two hundred and seventy-one patients attending cognitive behaviour therapy for anxiety and depression completed the COPE. Confirmatory factor analysis found a poor fit for both lower order and higher order factors based upon the Lyne and Roger (2000) study. Exploratory factor analyses identified six primary subscales (Active Planning, Social Support, Denial, Acceptance, Disengagement, Restraint) which explained approximately 60% of the variance in coping. These 6 subscales may assist researchers and clinicians to validly measure coping in anxious and depressed adults.

Understanding body image disturbance in the promotion of mental health : a discourse analytic study

Health care interventions in the area of body image disturbance and eating disorders largely involve individual treatment approaches, while prevention and health promotion are relatively underexplored. A review of health promotion activities in the area of body image in Australia revealed three programmes, the most extensive and longest standing having been established in 1992. The aims of this programme are to reduce body image dissatisfaction and inappropriate eating behaviour, especially among women. Because health promotion is concerned with the social aspects of health, it was hypothesized by the authors that a social understanding of body image and eating disorders might be advanced in a health promotion setting and reflected in the approach to practice. In order to examine approaches to body image in health promotion, 10 health professionals responsible for the design and management of this programme participated in a series of semi-structured interviews between 1997 and 2000. Three discursive themes were evident in health workers' explanations of body image problems: (1) cognitive-behavioural themes; (2) gender themes; and (3) socio-cultural themes. While body image problems were constructed as psychological problems that are particularly experienced by women, their origins were largely conceived to be socio-cultural. The implications of these constructions are critically discussed in terms of the approach to health promotion used in this programme.

Randomized controlled trial of MICBT for co-existing alcohol misuse and depression : outcomes to 36-months

Integrated psychological treatment addressing co-existing alcohol misuse and depression has not been compared with single-focused treatment. This trial evaluates changes over 36 months following randomization of 284 outpatients to one of four motivational interviewing and cognitive-behavior therapy (MICBT) based interventions: (1) brief integrated intervention (BI); or BI plus 9 further sessions with (2) an integrated-, (3) alcohol-, or (4) depression-focus. Outcome measures included changes in alcohol consumption, depression (BDI-II: Beck Depression Inventory) and functioning (GAF: Global Assessment of Functioning), with average improvements from baseline of 21.8 drinks per week, 12.6 BDI-II units and 8.2 GAF units. Longer interventions tended to be more effective in reducing depression and improving functioning in the long-term, and in improving alcohol consumption in the short-term. Integrated treatment was at least as good as single-focused MICBT. Alcohol-focused treatment was as effective as depression-focused treatment at reducing depression and more effective in reducing alcohol misuse. The best approach seems to be an initial focus on both conditions followed by additional integrated- or alcohol-focused sessions.

A group psychological intervention to enhance the coping and acculturation of international students

There is a shortage of psychological interventions to aid the acculturation of international students. To address this issue, the present study developed and trialled a brief group psychological intervention, the STAR program: Strengths, Transitions, Adjustments, and Resilience. This program was developed using suggestions from international students and university professional and academic staff that had significant dealings and designated roles to guide support international students. It comprises of four weekly two-hour sessions, and is experiential and cognitive-behavioural in nature. The STAR program aims to enhance coping, which is predicted to subsequently improve psychological adaptation (an acculturation outcome). Sixteen international students participated in the pilot trial of the STAR program. The participants completed measures on coping self-efficacy, social self-efficacy, psychological adaptation, and psychological distress pre-intervention, post-intervention, and one-month follow-up. Results showed that participants’ psychological adaptation and coping self-efficacy significantly increased from pre to post, with the treatment gain maintained at the one-month follow-up for psychological adaptation. Increases in social self-efficacy were evident, but these did not reach significance, possibly due to a lack of power. The STAR program did not have an impact on psychological distress; however, participants were only minimally distressed at the commencement of the program. The qualitative feedback gathered from the participants, provided suggestions for further refinement, as well as information about the clinical utility of the STAR program.

Can we text you? A qualitative exploration of young unemployed job-seekers’ attitudes to receiving resilience-building SMS messages

A significant minority of young job-seekers remain unemployed for many months, and are at risk of developing depression. Both empirical studies and theoretical models suggest that cognitive, behavioural and social isolation factors interact to increase this risk. Thus, interventions that reduce or prevent depression in young unemployed job-seekers by boosting their resilience are required. Mobile phones may be an effective medium to deliver resilience-boosting support to young unemployed people by using SMS messages to interrupt the feedback loop of depression and social isolation. Three focus groups were conducted to explore young unemployed job-seekers’ attitudes to receiving and requesting regular SMS messages that would help them to feel supported and motivated while job-seeking. Participants reacted favourably to this proposal, and thought that it would be useful to continue to receive and request SMS messages for a few months after commencing employment as well.

Development and evaluation of the Ontrack Diabetes Program : an automated, web-based type 2 diabetes self-management and dysphoria intervention

This research was conducted in the area of Clinical and Health Psychology. The study involved the development and evaluation of a novel, web-based program aimed to improve Type 2 diabetes self-management and mood. The program was developed as an original technological intervention aimed to improve access to support for rural and remote communities, and is currently being trialled across Australia with a larger sample size. The researcher aims to continue research into the field of clinical psychology, and in particular is interested in working on further interventions to support those with comorbid physical and mental health conditions.

Development of the OnTrack Diabetes program

Background: Type 2 diabetes affects an estimated 347 million people worldwide and often leads to serious complications including blindness, kidney disease, and limb amputation. Comorbid dysphoria is common and is an independent risk factor for poor glycaemic control. Professional support for diabetes self-management and dysphoria has limited availability and involves high costs, especially after regular hours, and in rural and remote areas. Web-based cognitive behavior therapy offers highly accessible, acceptable, and cost-effective support for people with diabetes. This paper describes the development of OnTrack Diabetes, a self-guided, Web-based program to promote improved physical and emotional self-management in people with Type 2 diabetes. Objective: The objective of the study is to describe the development of the OnTrack Diabetes program, which is a self-guided, Web-based program aimed to promote euthymia and improved disease self-management in people with Type 2 diabetes. Methods: Semistructured interviews with 12 general practitioners and 13 patients with Type 2 diabetes identified enablers of and barriers to effective diabetes self-management, requirements for additional support, and potential program elements. Existing resources and research data informed the development of content, and consultants from relevant disciplines provided feedback on draft segments and reviewed the program before release. Using a self-guided delivery format contained costs, in addition to adapting program features and modules from an existing OnTrack program. Results: A separate paper describes the protocol for a randomized controlled trial to provide this required evaluation. Conclusions: Development of the OnTrack Diabetes program demonstrates strategies that help ensure that a program is acceptable to users. The next stages involve testing users’ experiences and examining the program’s effectiveness and cost-effectiveness in randomized controlled trials.

Predictors of clinical improvement in children with recurrent abdominal pain

Forty-three children with recurrent abdominal pain who had received treatment from a paediatric gastroenterology clinic were reassessed 6 and 12 months after initial presentation. Measures of children's pain included a pain diary (PD) which measured pain intensity, a parent observation record (POR) which assessed pain behaviour and a structured interview to assess the degree to which pain interferes with the child's activities. Pretreatment measures of the child's history of pain, coping strategies in dealing with pain, and their mother's caregiving strategies were examined as predictors of two indices of clinical improvement: the extent of change in pain on the child's pain diary from pre-test to 6 months follow-up, and the degree of interference to the child's activities. All children had shown significant improvement in the level of pain at follow up, with 74.4% being pain free at 12 month follow-up on the PD and 83.7% being pain free on the POR. The amount of change they showed varied, with some showing residual impairment even though they were significantly improved. Regression analyses showed that children with greatest reductions on the child's pain diary at the 6 month follow-up were those with a stress-related mode of onset, whose mothers used more adaptive caregiving strategies, and who received cognitive behavioural family intervention. There was also a non significant trend for younger children to fare better. These data suggest the importance of early diagnosis and routinely assessing parental caregiving behaviour and beliefs about the origins of pain in planning treatment for children with RAP.

Therapeutic change in interaction

A process of change within a single case of cognitive-constructivist therapy is analyzed by means of conversation analysis (CA). The focus is on a process of change in the sequences of interaction, which consist of the therapist’s conclusion and the patient’s response to it. In the conclusions, the therapist investigates and challenges the patient’s tendency to transform her feelings of disappointment and anger into self-blame. Over the course of the therapy, the patient’s responses to these conclusions are recast: from the patient first rejecting the conclusion, to then being ambivalent, and finally to agreeing with the therapist. On the basis of this case study, we suggest that an analysis that focuses on sequences of talk that are interactionally similar offers a sensitive method to investigate the manifestation of therapeutic change. It is suggested that this line of research can complement assimilation analysis and other methods of analyzing changes in a client’s talk.