We also Know INTEGRATED GROUP COGNITIVE BEHAVIORAL THERAPY FOR PATIENTS WITH CONCURRENT DEPRESSIVE AND SUBSTANCE USE DISORDERS

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1 INTEGRATED GROUP COGNITIVE BEHAVIORAL THERAPY FOR PATIENTS WITH CONCURRENT DEPRESSIVE AND SUBSTANCE USE DISORDERS May 13, 2010 Kasia Galperyn, Ph.D., R. Psych. Kelly Rose, B.A. David Crockford, MD, FRCPC Saneeta Saunders, M.A. Addiction Centre, Foothills Medical Centre, Calgary Co-morbidity: Depressive and Substance Use Disorders Present in 25-50% of addiction treatment seeking patients Associated with: severity of substance use (Lubman et al., 2007) compliance with addiction treatments (Drake et al., 1996) addiction treatment outcomes (Project MATCH, 1997) risk of relapse in general (Hodgins et al., 1999) rates of suicide (attempted and completed) (Cornelius et al., 1995; Dalton et al., 2003) employment status and psychosocial functioning (McLellan et al., 1994) We also Know CBT for depressive and substance use disorders Efficacy established individually but not concurrently CBT for substance use: Relapse prevention techniques (e.g. Marlatt, 1985; Project MATCH research group, 1997) Functional analysis of using/drinking behavior and skills training Original CBT for depression (Beck et al., 1993) Behavior activation, restructuring of thoughts and beliefs, Socratic questioning 1

2 Why Treat both Disorders Concurrently? Situations involving negative mood states are most frequent precipitant of relapse (Marlatt, 1985) Prolonged alcohol abuse and dependence is linked to increased mood disregulation and can lead to an increased risk of MDD (Fergusson et al., 2009) For substance abusers with severe mental illness: brief R.P. interventions have limited impact and extended CBT has better outcomes (Kavanagh & Mueser, 2007) In summary: Depressive symptomatology is associated with higher vulnerability and risks among substance abusers Unified treatment approach: a preferred model focusing on the relationship between the two disorders Our Integrated Group CBT Model Self Depressive Core Beliefs Future Others Addictive Beliefs Anticipatory Facilitating Feelings Thoughts Behaviours Integrated Group CBT Components Behavioral activation: NOT just increase pleasant activities Experiments to decrease avoidant pattern of coping or to challenge avoidant thinking and beliefs Emotional awareness: Developing metacognition or observer stance Interventions for negative thinking Self Depressive Core Beliefs Future Others Addictive Beliefs Anticipatory Facilitating Feelings Thoughts Behaviours 2

3 Components continued Interventions for dysfunctional beliefs depressive beliefs about self, future and others addictive beliefs about anticipating the use or facilitating the use Depressive Core Beliefs Addictive Beliefs Self Future Others Anticipatory Facilitating (All components integrated in a fluid manner with a focus on Socratic Questioning) Thoughts Feelings Behaviours Socratic Questioning Beliefs are revealed through guided discovery Facilitates Development of control beliefs Collaboration Experimentation Consideration of different options Patients initiation to take the lead Leads to changes in beliefs underlying and maintaining addictive and depressive thinking and behaviors Criteria and Demographics 10 weekly sessions, closed group Criteria: DSM-IV diagnosis of depressive disorder (SCID) DSM-IV diagnosis of SUD BDI of 14 or greater Abstinence not necessary Psychosis and current mania excluded Demographics Adult population Mixed gender 11 patients in total 3

4 Measures Beck Depression Inventory-II (BDI-II) Beck Anxiety Inventory (BAI) The Alcohol Use Disorders Identification Test: Self-Report Version (AUDIT) Drug Abuse Screening Test (DAST) Dysfunctional Attitudes Scale (DAS) Mood Related Pleasant Events Schedule (MRPES) Protocol developed from: Cognitive Therapy of Substance Abuse (Beck, A.T., Wright, F.D., Newman, C.F, & Liese, B.S., 1993) Overcoming Depression: A Cognitive- Behavior Protocol for the Treatment of Depression (Emery, G.E., 2000) Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors (Marlatt, A., & Donavan, D., 2005) Results: Pre and Post Comparisons Paired Sample T-Tests (n=11) Questionnaire _ X s.d t Sig. AUDIT Pre: 20.8 Post: 13.3 BDI Pre: 32.6 Post:

5 Results: Post and 3 month Comparisons Paired Sample T-Tests (n=7) Questionnaire MRPES Social _ X s.d t Sig. Pre: 0.80 Post: Results: Post and 6 Month Comparisons Paired Sample T-Tests (n=6) Questionnaire MRPES Social _ X s.d t Sig. Pre: 0.87 Post: Results: Post and 1 Year Comparisons Paired Sample T-Tests (n=4) Questionnaire AUDIT Pre: 16.0 Post: 5.50 _ X s.d t Sig

6 Final Comments Preliminary results support the efficacy of an integrated CBT approach The gains seem to be maintained long term Results from group satisfaction questionnaires Study Halls useful for helping with homework Thank you! Questions? You can the first author for more discussion: References Beck, A.T., Wright, F.D., Newman, C.F., & Liese, B.S. (1993). Cognitive therapy of substance abuse. New York: The Guilford Press. Cornelius, J.R., Salloum, I.M., Mezzich, J., Cornelius, M.D., Fabrega, H., Ehler, J.G., Ulrich, R.F., Thase, M.E., & Mann, J.J. (1995). Disproportionate suicidality in patients with comorbid major depression and alcoholism. American Journal of psychiatry, 152, Drake, R.E., Mueser, K.T., Clark, R.E., & Wallach, M.A. (1996). The course, treatment, and outcome of substance use disorder in patients with severe mental illness. American Journal of Orthopsychiatry,66,

7 References Dalton, E. J., Cate-Carter, T.D., Mundo, E., Parikh, S.V., Kennedy, J.L., (2003). Suicide risk in bipolar patients: the role of co-morbid substance use disorders. Bipolar Disorders, 5, Emery, G. (2000). Overcoming depression: A cognitivebehavior protocol for the treatment of depression. California: New Harbinger Publications. Fergusson, D.M., Boden, J.M., & Horwood, J. (2009). Tests of causual links between alcohol abuse or dependence and major depression. Archives of General Psychiatry, 66, References Hodgins, D.C., el-guebaly, N., Armstrong, S., & Dufour, M. (1999). Implications of depression on outcome from alcohol dependence: A three-year prospective follow-up. Alcoholism: Clinical and Experimental Research, 23, Kavanagh, D. J. & Mueser, K. T. (2007). Current evidence on integrated treatment for serious mental disorder and substance misuse. Journal of the Norwegian Psychological Association, 44, Lubman, D.I., Allen, N.B., Rogers, N., Cementon, E., Bonomo, Y. (2007). The impact of co-occuring mood and anxiety disorders among substance abusing youth. Journal of Affective Disorders, 103, References Marlatt, G.A. (1985). Cognitive factors in the relapse process. In G.A. Marlatt & J.R. Gordon (Eds), Relapse prevention: Maintenance strategies in the treatment of addictive behaviors (1 st ed., pp ). New York: Guilford Press. Marlatt, G.A., & Donovan, D.M. (Eds.). (2008). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. (2 nd ed.). New York: Guilford Press. McLellan, A.T., Alterman, A.I., Metzger, D.S., Grissom, G.R., Woody, G.E., Luborsky, L., et al. (1994). Similarity of outcome predictors across opiate, cocaine, and alcohol treatments: Role of treatment services. Journal of Consulting and Clinical Psychology, 62,

8 References Project MATCH Research Group. (1997). Matching alcoholism treatments to clients heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol, 58, Thank you for your participation For information about telelearning sessions: (403) or (780)