CREMS Webinar Series: Welcome!

Transcription

1 CREMS Webinar Series: Welcome! Effective Drug Prevention for Aboriginal and Torres Strait Islander Youth: what do we know and what can we do better? Tuesday 13 th March, 4pm AEDT Presented by Dr Mieke Snijder Tackling Stigma in a 2018 environment Monday 19 th March, 12pm AEDT Presented by Mr Jack Nagle Register at Full details available at: Join our mailing list to receive updates about upcoming webinars.

2 What is CREMS? CREMS aims to significantly improve understanding prevention treatment of comorbid mental health disorders and substance use NHMRC Centre of Research Excellence in Mental Health and Substance Use (CREMS)

3 CREMS Team NHMRC Centre of Research Excellence in Mental Health and Substance Use (CREMS) Directed by Prof Maree Teesson

4 The link between anxiety and alcohol use: Implications for treatment and early intervention Dr Lexine Stapinski facebook.com/inroadsprogram1 twitter.com/inroads_program twitter.com/lex_stapinski

5 Outline 1. Link between anxiety & alcohol use: what s the evidence and why is it important? 2. Effective treatment approaches for anxiety and alcohol use problems 3. Can we intervene early on to prevent escalation of anxiety and alcohol use problems? 5

6 Background: Why talk about alcohol? Globally, alcohol use is among the biggest health challenges leading contributor to death and disability Embedded in Australian culture? Source: SMH Source: Julian Smith AAP Source: Daily Mail 6

7 Background: Why talk about alcohol? Recent data National Drug Strategy Household Survey 2016 Trend towards people drinking less frequently compared to 2013 (driven by young people and males), but 15.4% of Australians consumed alcohol at very high-risk levels 26% of Australians (18+) binge-drinking at least once a month 7

8 Is there a link between anxiety and alcohol use? Lifetime prevalence of alcohol use disorder in Australia 22.1% Anxiety is associated with higher risk of alcohol problems & dependence Anxiety disorders linked to 2-3 times the risk of having an alcohol use disorder In Australia, 1 in 3 people with a substance use disorder also has an anxiety disorder (Teesson et al, 2009) Smith, & Randall, (2012). Alcohol Research, 34(4),

9 Co-occurring anxiety and alcohol use disorders Models to explain anxiety and alcohol relationship: Anxiety Use Disorder Alcohol Use Disorder Self-medication, Stress dampening models (Khantzian, 1985; Sher & Levenson, 1982) Onset of anxiety disorders typically precede onset of AUDs Coping-motivated drinking has been identified as risk factor for alcohol-related harms and development of AUD (Stapinski et al 2016, Beseler et al. 2008; Kuntsche et al. 2005; Merrill et al 2014). 9

10 Co-occurring anxiety and alcohol use disorders Models to explain anxiety and alcohol relationship: Anxiety Use Disorder Alcohol Use Disorder Anxiety Use Disorder Alcohol Use Disorder Induce anxiety during withdrawal, prolonged use may disrupt stress-response system Some anxiety disorders (GAD) improve/remit after period of alcohol abstinence (Brown et al 1991) Due to order of onset, at most explains 25% of cases (Stewart & Conrod, 2008) 10

11 Co-occurring anxiety and alcohol use disorders Models to explain anxiety and alcohol relationship: Anxiety Use Disorder Alcohol Use Disorder Anxiety Use Disorder Alcohol Use Disorder Third variable Anxiety Use Disorder Alcohol Use Disorder 11

12 Co-occurring anxiety and alcohol use disorders Anxiety symptoms, Stress Selfmedication with alcohol Alcohol-related problems, Anxiety & stress More drinking Increasing reliance on alcohol to cope Vicious Cycle of Anxiety & Alcohol Use Stewart & Conrod, 2008; Kushner et al 2000, Hussong et al, 2011

13 Co-occurring anxiety and alcohol use disorders Why important clinically? People with anxiety and AUD tend to experience more debilitating and chronic symptoms Standard single disorder treatments work less well Delivering standard anxiety treatment without addressing alcohol issues may be ineffective, eg Behavioural experiments/exposure as part of anxiety treatment may lead to increased alcohol use to cope Use of alcohol as a safety behaviour may reduce the effectiveness of exposure treatment 13

14 Asking about alcohol use Useful assessment tools: Alcohol Use Disorders Identification Test, scores >8 indicate hazardous use, >15 probable dependence (AUDIT; Babor et al, 2001): Some clients may require supervised alcohol withdrawal management (GP, inpatient detox); Clinical Institute Withdrawal Assessment for Alcohol- Revised assists decision-making (Sullivan et al, 1989) Severity of Alcohol Dependence Questionnaire (SAD-Q) for community samples (Stockwell et al 1997) Cognitive functioning assessment may also be required Alcohol Expectancies Questionnaire (Kushner et al, 1994) 14

15 Unrealistically positive expectations? vs

16 Unrealistically positive expectations? vs

17 Asking about alcohol use Motivational style: Non-confrontational, motivational approach is most effective Explore ambivalence reasons for use, and reasons to change Motivation is likely to fluctuate over course of treatment, will need to be revisited I shouldn t drink so much But I like drinking

18 Outline 1. Link between anxiety & alcohol use: what s the evidence and why is it important? 2. Effective treatment approaches for anxiety and alcohol use problems 3. Can we intervene early on to prevent escalation of anxiety and alcohol use problems? 18

19 Accessing Treatment Co-morbidity Roundabout Anxiety Clinic Drug & Alcohol Clinic Should we treat these problems together? When people have both anxiety and alcohol use problems standard treatment doesn t work as well People typically see the problems as inter-related

20 Treating co-occurring anxiety & alcohol use disorders Anxiety Clinic Drug & Alcohol Clinic Should we treat these problems together? Previous attempts to treat anxiety and alcohol use together have involved parallel or sequential unintegrated treatments (Randall et al., 2001; Schade et al., 2005) Parallel dual-focussed treatment - worse alcohol outcomes (Randall et al., 2001) Due to the interconnections between these disorders, an integrated treatment approach may be required that provides explicit assistance in addressing these links

21 Should we treat anxiety & alcohol use together? Baillie et al, 2013, BMC Psychiatry 21

22 Integrated Treatment for Social Anxiety & Alcohol Use Based on evidencebased approaches: Rapee & Heimberg Social Anxiety Monti et al Alcohol Use Kadden et al

23 Integrated Treatment for Social Anxiety & Alcohol Use Motivational Interviewing Build coping skills + social support Develop Alternative Reinforcers Social Anxiety Alcohol Use Cognitive Therapy Behavioral Experiments (exposure) Attention re-training Relapse Prevention Interrelationship between social anxiety & alcohol use

24 Integrated Treatment for Social Anxiety & Alcohol Use Stapinski et al, 2015, Cognitive and Behavioural Practice

25 Integrated Treatment for Social Anxiety & Alcohol Use Motivational Interviewing Social Anxiety Enhance motivation and empower to make changes Collaborative understanding of the problem and goal setting Alcohol Use Interrelationship between social anxiety & alcohol use

26 Integrated Treatment for Social Anxiety & Alcohol Use Build coping skills + social support Social Anxiety Alcohol Use Coping skills to manage triggers for drinking and/or anxiety Enhancing social support networks Interrelationship between social anxiety & alcohol use

27 Integrated Treatment for Social Anxiety & Alcohol Use Social Anxiety Develop Alternative Reinforcers Alcohol Use Building up interests & activities that do not revolve around drinking Interrelationship between social anxiety & alcohol use

28 Integrated Treatment for Social Anxiety & Alcohol Use Social Anxiety Cognitive Therapy Alcohol Use Identify & target: High expectation of negative social consequences Drinking thinking Interrelationship between social anxiety & alcohol use

29 Integrated Treatment for Social Anxiety & Alcohol Use Gradually reduce avoidance of social situations & build anxiety management skills Social Anxiety Alcohol Use Behavioral Experiments (exposure) Interrelationship between social anxiety & alcohol use

30 Integrated Treatment for Social Anxiety & Alcohol Use Social Anxiety Reduce hypervigilance for negative feedback Disengage & refocus from sticky thoughts Alcohol Use Attention Training Interrelationship between social anxiety & alcohol use

31 Integrated Treatment for Social Anxiety & Alcohol Use Social Anxiety Alcohol Use Continuing change and planning for set-backs Relapse Prevention Interrelationship between social anxiety & alcohol use

32 Treatment Evaluation: Can we improve outcomes? Participants (n = 117) with social anxiety + alcohol use disorder Random Allocation* 49.6% female Primary problem: - 53% alcohol use - 47% social anxiety Treatment for alcohol use only (10 sessions) (n = 56) Integrated Treatment for alcohol use & social anxiety (10 sessions) (n = 61)

33 Integrated Treatment for Social Anxiety & Alcohol Use Motivational Interviewing Build coping skills + social support Develop Alternative Reinforcers Social Anxiety Alcohol Use Cognitive Therapy Behavioral Experiments (exposure) Attention re-training Relapse Prevention Interrelationship between social anxiety & alcohol use

34 Comparison Group: Treatment for Alcohol Use Only Motivational Interviewing Build coping skills + social support Develop Alternative Reinforcers Alcohol Use Cognitive Therapy Problem-solving Relapse Prevention

35 Measures Social Anxiety & Alcohol Use disorder determined by diagnostic interview Primary outcomes Social anxiety symptons (Social Phobia and Social Interaction Anxiety Scale) Number of drinks consumed (Timeline Follow-back) Severity of Alcohol Dependence (SAD-Q) Overall functioning & quality of life (SF-12)

36 Treatment Evaluation: Can we improve outcomes? Participants (n = 117) with social anxiety + alcohol use disorder Random Allocation* 49.6% female Primary problem: - 53% alcohol use - 47% social anxiety 79% completed treatment Treatment for alcohol use only (10 sessions) (n = 56) Optional pharmacotherapy (naltrexone ) Integrated Treatment for alcohol use & social anxiety (10 sessions) (n = 61) 77% completed treatment Post treatment Assessment (n = 44) Post treatment Assessment (n = 49) 3 month follow-up (n = 43) 3 month follow-up (n = 49) 6 month follow-up (n = 41) 6 month follow-up (n = 43)

37 Results: Social Anxiety Symptoms 120 Mean Social Anxiety symptom severity score Alcohol only treatment Integrated treatment 0 Baseline Post 3mth follow-up6mth follow-up Combined treatment resulted in greater improvement in social anxiety symptoms (F4,66)=7.527, p< Baillie, A., Stapinski, L. A., Sannibale, C., Teesson, M., Rapee, R. M. & Haber, P. (2013). ACER.

38 Results: Alcohol Consumption Mean standard drinks (30 days) Alcohol only treatment Integrated treatment 0 Baseline Post 3mth follow-up6mth follow-up Both groups showed significant reduction in alcohol consumption, no difference between groups F(3,107)= 1.250, p = 0.295

39 Results: Severity of Alcohol dependence 25 Mean Severity of dependence score Alcohol only 0 Baseline Post 3mth follow-up6mth follow-up Both groups showed significant reduction in alcohol disorder severity, no difference between groups F(4,88)= 1.281, sig =ns

40 Results: Overall functioning & Quality of Life 60 Mean SF 12 Quality of LIfe score Alcohol only treatment Integrated treatment 10 Baseline Post 3mth follow-up6mth follow-up Combined treatment resulted in greater improvement in overall functioning & quality of life (F3,2)=5.277, p<0.0001

41 Conclusions: Should we treat anxiety and alcohol use together? With the same number of treatment sessions, integrated treatment led to: Better social anxiety outcomes Equivalent reductions in alcohol consumption Better overall functioning/quality of life, lower depression People see their anxiety and alcohol as interrelated integrated treatment addresses this inter-connection Better fit with the person s experience?

42 Outline 1. Link between anxiety & alcohol use: what s the evidence and why is it important? 2. Effective treatment approaches for anxiety and alcohol use problems 3. Can we intervene early on to prevent escalation of anxiety and alcohol use problems? 42

43 Can we intervene earlier? Average delay to seek treatment for AUD is 18 years (Chapman et al 2015) Can we intervene earlier, before problems entrenched? 43

44 Can we intervene earlier? There is variation in young people s reasons for drinking alcohol Motives for drinking fall in 4 key domains: drinking for enhancement, social, conformity or coping (Cooper et al. 1994) Coping-motivated drinking may place young people at greater risk of alcoholrelated harms and development of disorder (Stapinski et al 2006, Beseler et al. 2008; Kuntsche et al. 2005; Merrill et al 2014). 44

45 Transition to Adulthood: Key Risk Period Increasing Autonomy, Drinking Contexts Increasing Responsibility/ Challenges New Job/Study Transition to adulthood New living situation New relationships & friendships Harms associated with alcohol peak in early adulthood In 12 months, almost 1 in 3 young adults consume alcohol at very high risk levels Impact of Anxiety and Coping Styles (ie Drinking to cope) may become even more pronounced across this transition to adulthood 45

46 Development Study over transition to adulthood Developmental approach: examine opportunities for intervention over the transition to adulthood UK birth cohort study: Avon Longitudinal Study of Parents and Children (ALSPAC), AKA Children of the Nineties Latent Transition Analysis to address theoretically driven Research Questions: Anxiety Disorders Coping-motivated Drinking? risky drinking and associated harms Our study focussed on assessments at age 18 and 21 (n = 2,147; 56% female) 46

47 Latent Transition Analysis Age 18 Age 21 AUDIT AUDIT 1 2 AUDIT 7 AUDIT AUDIT 1 2 AUDIT 7 Alcohol Use Typology Alcohol Use Typology Age 18 Age 21 Latent Transition Analysis Latent Class Analysis To To explore explore underlying underlying subgroups subgroups or or typologies typologies, and based transition on AUDIT between items these subgroups from age 18 to age 21

48 Results: Alcohol Use Typology at age % 80% 60% 40% 20% 0% Lower risk 100% 80% 60% 40% 20% 0% Bingeing Item probabilities in each alcohol use typology 82% 18% 1.8 x greater risk Anxiety disorder Age 18 Age 18

49 Results: Alcohol Use Typology at age 18 & 21 Item probabilities in each alcohol class Lower risk Bingeing High-risk use 100% 100% 100% 80% 80% 80% 60% 60% 60% 40% 40% 40% 20% 20% 20% 0% 0% 0% 82% 57% 18% 35% 8% Age 18 Age 21 Age 18 Age 21 Age 21

50 Results: Effect of Drinking to Cope on Transitions Age 18 Alcohol Status Drinking to Cope Age 21 Alcohol Status Low Risk Binge 2 x greater risk OR=1.4* OR=2.0* 1.4 x greater risk Low Risk Binge High Risk *effect for 1 standard deviation increase in DTC scores 50

51 So what can we do about it? Young people with anxiety disorders at age 18 were 1.8 x more likely to bingedrink at age 18 Opportunity for early intervention Previous work with adults shows promise for approaches that target anxiety and alcohol together Drinking to cope at age 18 was linked to: Greater risk of transitioning from low-risk use at 18 to high-risk use at age 21 Needs adaptation for the unique challenges for young people 51

52 Transition to adulthood opportunity for early intervention? Intervene early to enhance anxiety coping skills, & address coping-motivated drinking Address unique challenges, risk factors & drinking contexts relevant to young adults Use a delivery format that is suited to young peoples preferences/need: + therapist support Internet delivered, interactive Preferred by young people youth-focused design & vignettes Reduced stigma Convenience / flexibility Low cost Boydell et al

53 Inroads: A youth focussed early intervention -Drawing from previous work with adults integrating anxiety and alcohol tmt -Adapted for young adults Online program + weekly therapistsupport: /Text/phone Motivation Trouble-shooting Customise 53

54 Inroads: A youth focussed early intervention Video 1: Realistic Thinking Video 3: Taking Control Video 2: Facing Fears to overcome anxiety 54

55 Now recruiting: Participants for free trial of Inroads Now recruiting: Aged between 17 and 24, living in Australia Experiencing anxiety symptoms & drinking alcohol above recommended guidelines Questions about trial: Figure 1. Illustration of study design Online Screening Baseline assessment (n=118) Ineligible/ Referral Inroads Program (n=59; 8 weeks) Active Control (n=59, 8 weeks) 1-month post-intervention 6-month follow-up assessment Please help to spread the word! Primary Outcomes: Alcohol-related harms, including binge drinking Anxiety symptoms 55

56 Can we intervene earlier? Earlier onset of drinking greater risk Preventure program aimed at Year 8 Develop anxiety-coping skills, preventative Webinar available on demand at: Webinar: Personalitytargeted interventions for prevention: the Preventure program 56

57 Webinar Summary: In a nutshell Ask about alcohol use Motivate to change Mutual Understanding of the inter-relationship Enhance Coping strategies for anxiety, alcohol and the interconnection between them 57

58 Thank you Co-authors: Andrew Baillie, Ron Rapee, Claudia Sannibale, Paul Haber, Maree Teesson Jon Heron, Nicola Newton, Matthew Hickman, Alexis Edwards, Gemma Hammerton, Liam Mahedy, & Kenneth Kendler. Inroads development team: Erin Kelly, Katrina Prior, Briana Lees, Rachel Visontay, & Mark Deady Funding: NHMRC, Wellcome Trust UK, Society for Mental Health Research, Australian Rotary Health, Australian Department of Health Please me with any questions or feedback: More information: facebook.com/inroadsprogram1 twitter.com/inroads_program twitter.com/lex_stapinski 58

59 Thanks for being part of the CREMS Webinar Series! Video recording and handouts of this and our past webinars are available at: comorbidity.edu.au/training/we binars Join our mailing list to receive webinar updates Join us again: Effective Drug Prevention for Aboriginal and Torres Strait Islander Youth: what do we know and what can we do better? Tuesday 13 th March, 4pm AEDT Presented by Dr Mieke Snijder Tackling Stigma in a 2018 environment Monday 19 th March, 12pm AEDT Presented by Mr Jack Nagle Register at Example past webinars: We d love to hear you feedback! Please complete our survey at the end of the session The Difference is Research