Depressive symptoms as a predictor of alcohol relapse after residential treatment programs for alcohol use disorder

Alcohol use disorder (AUD) and depressive disorders often co-occur. Findings on the effects of major depressive disorder (MDD) or depressive symptoms on posttreatment alcohol relapse are controversial. The study's aim is to examine the association of MDD and depressive symptoms with treatment outcomes after residential AUD programs. In a naturalistic-prospective, multisite study with 12 residential AUD treatment programs in the German-speaking part of Switzerland, 64 patients with AUD with MDD, 283 patients with AUD with clinically significant depressive symptoms at admission, and 81 patients with AUD with such problems at discharge were compared with patients with AUD only on alcohol use, depressive symptoms, and treatment service utilization. MDD was provisionally identified at admission and definitively defined at discharge. Whereas patients with MDD did not differ from patients with AUD only at 1-year follow-up, patients with AUD with clinically significant depressive symptoms had significantly shorter time-to-first-drink and a lower abstinence rate. These patients also had elevated AUD indices and treatment service utilization for psychiatric disorders. Our results suggest that clinically significant depressive symptoms are a substantial risk factor for relapse so that it may be important to treat them during and after residential AUD treatment programs.

Self-efficacy as a predictor of outcome after residential treatment programs for alcohol dependence: simply ask the patient one question!

Self-efficacy has been identified as one of the most consistent variables that predict the outcome of alcohol treatment. However, many previous studies in this field failed to control for other important predictors (e.g., dependences severity, psychiatric symptoms, and treatment goal). Our study's first goal was to evaluate the predictive value of self-efficacy when most other relevant variables were statistically controlled. The second goal was to compare the predictive values of self-efficacy assessed with the Situational Confidence Questionnaire (SCQ), and general self-efficacy assessed with a single question.

Association of alcohol craving and proximal outcomes of a residential treatment program for patients with alcohol use disorders

Background: Alcohol craving is an essential construct in research and treatment of alcohol use disorders (AUD). Craving is mostly investigated in association with concurrent variables or distal treatment outcomes at follow-up. Objectives: The aim of this study is to examine craving at admission and its relevance for essential proximal outcomes at discharge from AUD treatment such as positive alcohol expectancy, abstinent-related self-efficacy, and substance-related coping, as well as patients’ demographic and AUD characteristics. Methods: In total, 36 patients were recruited within an inpatient treatment AUD program. Results: An association between craving and positive alcohol expectancies at discharge was found in the regression model even when the respective expectancies, age, gender, and severity of alcohol dependence at admission were controlled for (F(2,29)1⁄432.71, p50.001). Craving explained 2.3% of the variance of change in positive alcohol expectancy. Conclusion: The results suggest a low predictive value of craving for positive alcohol expectancy. In addition, we found significant associations between the craving and the severity of AUD and alcohol consumption before admission. Future studies should include proximal outcomes related to treatment efficacy as well as distal outcomes.

The Impact of Family Stressors on the Social Development of Adolescents Admitted to a Residential Treatment Facility

The focus of this research was to determine the impact of family stressors on the social development of adolescents at admission to long-term mental health residential care. The study was conducted at the Waco Center for Youth, the only long-term residential care agency serving emotionally and behaviorally challenged adolescents and their families that functions under the authority of the Texas Department of State Health Services. Data was obtained from social assessment forms (N=457) in case records of clients. The prevalence of problem behaviors exhibited by the youth upon entry to the residential facility was examined and it was found that the youth entering the facility were experiencing severe impairment in their social development across several domains. Results indicated that youth with more family stressors exhibited significantly greater impairment in their social development (b = .19, p = .000) which suggests that the combination of multiple stressors within a family inhibits adolescent social development. The research supports a family systems approach to treatment that focuses on building family strengths and actively involving family in the intervention process.

Motivation as a predictor of drinking outcomes after residential treatment programs for alcohol dependence

OBJECTIVES: Patients' motivation to change their substance use is usually viewed as a crucial component of successful treatment. The objective of this study was to examine whether motivation contributes to drinking outcomes after residential treatment for alcohol dependence. METHODS: Our sample included 415 Swiss patients from 12 residential alcohol treatment programs. We statistically controlled for important predictors, such as sex, employment, alcohol consumption before admission, severity of alcohol dependence, severity of psychiatric symptoms at admission, and alcohol-related self-efficacy at discharge. Abstinence, alcohol consumption, and time to first drink were used as primary outcome measures and were assessed 1 year after discharge from treatment. RESULTS: Action-oriented motivation to change substance use had a modest impact on drinking outcomes. At the 1-year follow-up, only the Taking Steps subscale of the Stages of Change Readiness and Treatment Eagerness Scale and alcohol-related self-efficacy were found to be significant predictors of abstinence and the number of standard drinks. CONCLUSIONS: The impact of action-oriented motivation at admission to residential treatment is modest but still relevant, compared with other outcome predictors. It may be useful to focus treatment on improving action-oriented motivation to reduce substance use

Association Between Drinking Goal and Alcohol Use One Year After Residential Treatment: A Multicenter Study

This study examined whether patients’ drinking goals at admission to and discharge from 12 residential alcohol use disorder treatment programs were associated with alcohol-related outcomes at 1-year follow-up. Detoxified patients (N D 289) completed assessments at admission, after treatment, and at 1-year follow-up. Drinking goals of abstinence, conditional abstinence (in principle abstinence but potential occurrence of lapses or drinking, when urges are strong), and controlled drinking changed during treatment and predicted the 1-year follow-up outcomes (abstinence, number of standard drinks, and number of days to the first alcohol use). Goals at discharge had a better predictive value. The goal of abstinence at discharge had better outcomes than conditional abstinence; the poorest had controlled drinking.

Resistance to Temptation: The Interaction of External and Internal Control on Alcohol Use During Residential Treatment for Alcohol Use Disorder

Background: There is evidence that drinking during residential treatment is related to various factors, such as patients’ general control beliefs and self-efficacy, as well as to external control of alcohol use by program’s staff and situations where there is temptation to drink. As alcohol use during treatment has been shown to be associated with the resumption of alcohol use after discharge from residential treatment, we aimed to investigate how these variables are related to alcohol use during abstinenceoriented residential treatment programs for alcohol use disorders (AUD). Methods: In total, 509 patients who entered 1 of 2 residential abstinence-oriented treatment programs for AUD were included in the study. After detoxification, patients completed a standardized diagnostic procedure including interviews and questionnaires. Drinking was assessed by patients’ selfreport of at least 1 standard drink or by positive breathalyzer testing. The 2 residential programs were categorized as high or low control according to the average number of tests per patient. Results: Regression analysis revealed a significant interaction effect between internal and external control suggesting that patients with high internal locus of control and high frequency of control by staff demonstrated the least alcohol use during treatment (16.7%) while patients with low internal locus of control in programs with low external control were more likely to use alcohol during Treatment (45.9%). No effects were found for self-efficacy and temptation. Conclusions: As alcohol use during treatment is most likely associated with poor treatment outcomes, external control may improve treatment outcomes and particularly support patients with low internal locus of control, who show the highest risk for alcohol use during treatment. High external control may complement high internal control to improve alcohol use prevention while in treatment. Key Words: Alcohol Dependence, Alcohol Use, Locus of Control, Alcohol Testing.

Self-injury in a residential treatment population of children and adolescents

Objectives. The aim of this study was to describe the relationship between child-abuse and self-injury among children and adolescents living in a residential treatment center in a large urban area. ^ Methods. A retrospective study was conducted through a chart review of the residents who were placed at the center from 2003-2006. A total of 35 cases (with at least one documented incident of self-injury during placement at the residential treatment center) were age/gender matched with 35 controls (without at least one documented incident of self-injury during placement at the residential treatment center). ^ Results. In this study, the case subjects were far more likely to be victims of sexual abuse than were the controls (74.3% vs. 25.7%, respectively). Self-harm was found to be 9.5 times as frequent in the group that was exposed to sexual abuse in the source population (OR = 9.500 with a 95% CI = 2.292, 84.111). The difference was statistically significant (McNemar's test, x2 = 12.190 with 1 df. The two-tailed P value equals 0.0005). ^ Conclusion. These findings suggest that school-age and early-adolescent children who have a history of sexual abuse may engage in a variety of self-harming behaviors. Clinicians should consider a history of sexual abuse when working with self-harming children. ^

Residential treatment for the disturbed child: basic principles in planning and design of programs and facilities.

Includes index.

Gender differences in behavioral and psychosocial correlates of substance abuse among adolescents in residential treatment

This dissertation reports the results of a study that examined differences between genders in a sample of adolescents from a residential substance abuse treatment facility. The sample included 72 males and 65 females, ages 12 through 17. The data were archival, having been originally collected for a study of elopement from treatment. The current study included 23 variables. The variables were from multiple dimensions, including socioeconomic, legal, school, family, substance abuse, psychological, social support, and treatment histories. Collectively, they provided information about problem behaviors and psychosocial problems that are correlates of adolescent substance abuse. The study hypothesized that these problem behaviors and psychosocial problems exist in different patterns and combinations between genders.^ Further, it expected that these patterns and combinations would constitute profiles important for treatment. K-means cluster analysis identified differential profiles between genders in all three areas: problem behaviors, psychosocial problems, and treatment profiles. In the dimension of problem behaviors, the predominantly female group was characterized as suicidal and destructive, while the predominantly male group was identified as aggressive and low achieving. In the dimension of psychosocial problems, the predominantly female group was characterized as abused depressives, while the male group was identified as asocial, low problem severity. A third group, neither predominantly female or male, was characterized as social, high problem severity. When these dimensions were combined to form treatment profiles, the predominantly female group was characterized as abused, self-harmful, and social, and the male group was identified as aggressive, destructive, low achieving, and asocial. Finally, logistic regression and discriminant analysis were used to determine whether a history of sexual and physical abuse impacted problem behavior differentially between genders. Sexual abuse had a substantially greater influence in producing self-mutilating and suicidal behavior among females than among males. Additionally, a model including sexual abuse, physical abuse, low family support, and low support from friends showed a moderate capacity to predict unusual harmful behavior (fire-starting and cruelty to animals) among males. Implications for social work practice, social work research, and systems science are discussed. ^

The Relation between Substance Use and Medication Adherence among HIV Positive Substance Users in Residential Treatment

Poor medication adherence is problematic among HIV positive, low-income African-American substance users. Substance use has been shown to be associated with poor medication adherence, though we do not know the mechanism that underlies this relationship. Lack of positive environmental rewards and the propensity to discount delayed rewards may be possible mechanisms to explain this relationship. Using baseline data from a randomized controlled trial, we examined the relationships between substance use and medication adherence, testing both environmental rewards and delay discounting as independent mediators. There was a main effect of substance use on adherence, such that high frequency of substance use predicted poor adherence. There was also a main effect of environmental rewards on adherence, such that a lack of environmental reinforcement predicted poor adherence. This study shed light on the processes that contribute to low adherence, namely substance use and lack of environmental contingencies, and suggests important targets for intervention.

DIFFERENCES IN PSYCHOPATHOLOGY AMONG SUBSTANCE USERS IN RESIDENTIAL TREATMENT RELATED TO HIV STATUS

HIV-positive individuals engage in substance use at higher rates than the general population and are more likely to also suffer from concurrent psychiatric disorders and substance use disorders. Despite this, little is known about the unique clinical concerns of HIV-positive individuals entering substance use treatment. This study examined the clinical characteristics of clients (N=1712) entering residential substance use treatment as a function of self-reported HIV status (8.65% HIV-positive). Results showed higher levels of concurrent substance use and psychiatric disorders for HIV-positive individuals, who were also significantly more likely to meet criteria for bipolar disorder and borderline personality disorder. Past diagnoses of depression, posttraumatic stress disorder, and social phobia were also significantly more common. Study findings indicate a need to provide more intensive care for HIV-positive individuals, including resources targeted at concurrent psychiatric problems, to ensure positive treatment outcomes following residential substance use treatment discharge.

Involuntary treatment of alcohol-dependent patients: a study of 17 consecutive cases of civil commitment.

AIM: To investigate the baseline and follow-up characteristics of a group of alcohol-dependent patients being treated under civil commitment. METHODS: This study involved a cross-sectional comparative analysis of baseline characteristics and a follow-up survey of a group of committed alcoholic patients. The study was undertaken in the Alcohol Unit of a 1,000-bed general and university hospital. The study included 17 consecutive cases of civil commitment (representing 15 patients, of whom 2 were committed twice) and a comparative group of 34 randomly selected age- and sex-matched patients. Baseline characteristics of the cases (at the time of commitment) and of patients from the comparative group were collected from medical records, including sociodemographic data, medical condition, patterns of drinking and number and dates of previous treatments for alcohol-related problems. A structured follow-up interview of the cases provided information on their medical condition, social status, patterns of alcohol use, type and duration of residential treatment as well as their perceptions of commitment. RESULTS: During a 4-year period, our Unit referred 23 cases of alcohol-dependent patients (out of 367) to the Guardianship Authority, requesting civil commitment. On 17 occasions, patients were committed to residential treatment, including 2 patients who underwent commitment on two separate occasions, thus representing a total of 15 different patients. In comparison with age- and sex-matched patients seen at the Unit, the cases were characterized by multiple medical, social and psychological alcohol-related impairments. At the time of follow-up, 14 out of 15 patients were alive, among whom 10 agreed to be interviewed. Eight of these reported complete abstinence, whereas 9 considered their alcohol problem as less severe than before. The average duration of commitment was 29 weeks. The majority of patients retrospectively considered the measure as having been justified and useful. The patients' satisfaction with the decision to commit was higher among women than among men. Health-related quality of life at the time of follow-up, as assessed by the MOS 36-Item Short Form Health Survey questionnaire, was good on average and better than that usually reported by other cohorts of alcoholics undergoing treatment. CONCLUSIONS: The usefulness of residential civil commitment of certain severely impaired alcohol-dependent patients is underscored. This study suggests that civil commitment not only may save the lives of endangered patients but could also be a health-promoting measure that may sometimes allow for recovery from dependence. Unexpectedly, this measure was retrospectively well accepted by many patients, who considered the commitment decision as having been justified and useful.

Evaluation of a treatment program for individuals with an intellectual disability who have high risk behaviours

In the past two decades numerous programs have emerged to treat individuals with developmental disabilities who have sexual offending behaviours. There has, however been very few studies that systematically examine the effectiveness of long term treatment with this population. The present research examines the therapeutic outcomes of a multi-modal behaviour approach with six individuals with intellectual disabilities previously charged with sexual assault. The participants also exhibited severe behavioural challenges that included verbal aggression, physical aggression, destruction and self-injury. These six participants (5 males, 1 female) were admitted to a Long Term Residential Treatment Program (LTRTP), due to the severity of their behaviours and due to their lack of treatment success in other programs. Individualized treatment plans focused on the reduction of maladaptive behaviours and the enhancing of skills such as positive coping strategies, socio-sexual knowledge, life skills, recreation and leisure skills. The treatment program also included psychiatric, psychological, medical, behavioural and educational interventions. The participants remained in the Long Term Residential Treatment Program (LTRTP) program from 181 to 932 days (average of 1.5 years). Pre and post treatment evaluations were conducted using the following tools: frequency of target behaviours, Psychopathology Inventory for Mentally Retarded Adults (PIMRA), Emotional Problems Scale (EPS), Socio-Sexual Knowledge and Attitudes Assessment Tool (SSKAAT-R) and Quality of Life Questionnaire (QOL-Q). Recidivism rates and the need for re-hospitalization were also noted for each participant. By offering high levels of individualized interventions, all six participants showed a 37 % rate of reduction in maladaptive behaviours with zero to low rates of inappropriate sexualbehaviour, there were no psychiatric hospitalizations, and there was no recidivism for 5 of 6 participants. In addition, medication was reduced. Mental health scores on the PIMRA were reduced across all participants by 25 % and scores on the Quality of Life Questionnaire increased for all participants by an average of 72 %. These findings add to and build upon the existing literature on long term treatment benefits for individuals with a intellectual disability who sexually offend. By utilizing an individualized and multimodal treatment approach to reduce severe behavioural challenges, not only can the maladaptive behaviours be reduced, but adaptive behaviours can be increased, mental health concerns can be managed, and overall quality of life can be improved.

Substance use disorder treatment programs in Switzerland and the USA: Program characteristics and 1-year outcomes

AIM: This study compared matched samples of substance use disorder (SUD) patients in Swiss and United States (US) residential treatment programs and examined the relationship of program characteristics to patients' substance use and psychosocial functioning at a 1-year follow-up. DESIGN AND SETTING: The study used a prospective, naturalistic design and a sample of 10 public programs in the German-speaking part of Switzerland and 15 US public treatment programs. PARTICIPANTS: A total of 358 male patients in Swiss programs were matched on age, marital status and education with 358 male patients in US programs. A total of 160 Swiss and 329 US patient care staff members also participated. MEASUREMENT: Patients completed comparable inventories at admission, discharge and 1-year follow-up to assess their substance use and psychological functioning and receipt of continuing care. Staff members reported on program characteristics and their beliefs about substance use. FINDINGS: Compared to Swiss patients, US patients had more severe substance use and psychological problems at intake and although they did not differ on abstinence and remission at follow-up, had somewhat poorer outcomes in other areas of functioning. Swiss programs were longer and included more individual treatment sessions; US programs included more group sessions and were more oriented toward a disease model of treatment. Overall, length of program, treatment intensity and 12-step orientation were associated with better 1-year outcomes for patients in both Swiss and US programs. CONCLUSIONS: The sample of Swiss and US programs studied here differed in patient and treatment characteristics; however, in general, there were comparable associations between program characteristics and patients' 1-year outcomes. These findings suggest that associations between treatment processes and patients' outcomes may generalize from one cultural context to another.