The two studies presented here compared an important aspect of the relapse process in adolescents and adults by examining the relationships between depression, substance use coping self-efficacy and initial abstinence duration after drug and alcohol treatment. Results indicated a role for self-efficacy and depression in both adolescent and adult relapse. Among adolescents, contrary to hypotheses, the relationship between depression symptoms and initial abstinence duration could be explained by coping self-efficacy (i.e., there was full mediation). Among adults, however, also contrary to hypotheses, coping self-efficacy did not mediate the relationship between depression and initial abstinence duration. The best fitting-model showed that higher levels of depression were significantly associated only with lower self-efficacy, which in turn predicted shorter time to substance use.
The findings for adolescents, although inconsistent with our hypothesis, were consistent with the premise of the Youth Relapse Model that affective distress makes teens vulnerable to more rapid relapse in part by influencing substance use-related cognitions (Brown & Ramo, 2006
). However, these findings contrast with recent evidence that self-efficacy assessed during treatment is not related to relapse (Burleson & Kaminer, 2005
). In the present study, we measured self-efficacy prospectively and closely preceding relapse (within one month), and these assessments took place both during and following treatment. Previous studies, including Burleson and Kaminer's (2005)
study, and work in our own lab (Ramo, Anderson, Tate, & Brown, 2005
), which have not demonstrated a relationship between self-efficacy and relapse, have only examined self-efficacy assessed while teens are in treatment, which is more distal from the first use episode. Our hypothesis that self-efficacy would not mediate the relationship between depression symptoms and initial abstinence duration was based on these previous findings. This highlights the potential temporal instability of the self-efficacy concept, and the benefit of measuring cognitive variables such as self-efficacy frequently throughout longitudinal studies.
Another difference between this study and earlier work is that abstinence duration was examined in a sample consisting entirely of teens who relapsed. In contrast, our hypothesis was derived from studies that investigated prediction of outcome status in abstinent and relapsed participants. For example, Burleson and Kaminer's (2005)
study examined the relationship between self-efficacy and substance use outcomes among teens who had both positive and negative urine toxicology screens at 3 months and 9 months after a treatment episode. Our findings support the Youth Relapse Model's premise that self-efficacy plays an important role in the relapse process in that lower self-efficacy predicts more rapid relapse among youth who resume substance use following treatment. The present study does not address whether self-efficacy is a protective factor against using in high risk situations, or whether it will influence outcomes among those experiencing depressive symptoms. As such, it will be important to replicate the present analysis with teens who have and have not relapsed after treatment in order to test the full prediction of the Cognitive Behavioral Model of relapse.
In the best-fitting model for adults, depression was associated with lower self-efficacy, and self-efficacy was associated with length of time to relapse. These findings mirror others who have found that self-efficacy distinguishes those who are drinking from those who are not drinking after treatment for alcohol use disorders in the Project MATCH study (Carbonari & DiClemente, 2000
; Project MATCH Research Group, 1998
). They also extend the self-efficacy research by demonstrating a relationship between self-efficacy and time to relapse specifically among those who return to use. This sheds further light on the important role of self-efficacy in the relapse process and the significance of assessing it throughout treatment in order to prevent relapse.
Contrary to our prediction, the best fitting adult model indicated no significant association between depression symptoms and length of time to relapse. This is consistent with early findings in the study of depression and alcoholism comorbidity demonstrating that alcohol dependent adults have high rates of depression comorbidity while in treatment that tend to abate during the course of treatment (Brown & Schuckit, 1988
). Other studies have found that symptoms of depression are associated with heavier relapse in drug using adults. For example Levin et al. (2008)
found that among cocaine dependent patients who exhibited positive urine toxicology screens at a baseline assessment of psychiatric symptoms, comorbid depression and ADHD symptoms were associated with poorer substance use outcomes than those with cocaine dependence alone. The present study attempted to account for changes in depression symptoms during treatment by assessing depressive symptoms prospectively and proximally to relapse, a methodological approach infrequently employed in previous studies. In our study, however, many of the participants were diagnosed with substance dependence and another independent psychiatric condition marked by affective distress. These high rates of psychiatric disorders may have resulted in insufficient variability in depression symptoms experienced by our sample to explain variations in relapse time after treatment. This issue may have been exacerbated by including only individuals who relapsed in the present analysis, thereby reducing the range of variables of interest.
Finally, previous work has demonstrated that negative affect is the most common precursor to relapse in adults (Marlatt & Gordon, 1980
). It is likely that depressive symptoms alone do not account for all of the variance associated with negative affect (Marlatt & Gordon, 1980
; Shiffman, et al., 2007
). Future studies should include other aspects of negative affect such as anger, frustration, or interpersonal conflict measured prospectively and proximal to relapse in models of the relationship between negative affect and adult relapse before it is concluded that the relationships do not exist. It should be noted that the sample studies here was made up of primarily male veterans who participated in two studies through the Veteran's Affiars substance abuse treatment programs, and thus may not generalize to a female and the non-veteran population of adults in substance abuse treatment. Given recent findings regarding gender differences in relationships between depression symptoms and type of relapse episode (Zywiak, et al., 2006
), the model tested in this study should be replicated with more female participants.
These findings have some important implications for cognitive and behavioral models of addiction relapse. The findings for adolescents suggest that depression symptoms are an important aspect of the relapse process because they may modify cognitions that are predictive of relapse. Thus, the Youth Relapse Model's emphasis on comorbid psychopathology as particularly important in understanding relapse for teens appears to be useful at least as it relates to symptoms of depression. While Relapse Prevention interventions do emphasize the importance of affective states, including sadness as a precursor to relapse and thus treat these states as “high risk” (Witkiewitz & Marlatt, 2004
), adolescents with comorbid psychopathology still tend to relapse most often in social situations with experiencing positive emotions or in a “complex” set of internal and external precipitants, making it hard to determine how strong a factor depression may be in the immediate precursors of relapse (Ramo & Brown, 2008
). In contrast, at least some portion of adults relapse when experiencing a negative emotional state coupled with urges and temptations to use, making depression a more obvious immediate, direct precursor to relapse and more imminently “high risk” (Ramo & Brown, 2008
). The findings here suggest that while depressive symptoms may not play as great a role in precipitating adolescent relapse, depression plays an important role nonetheless.
These studies have a number of strengths. First, the studies from which the samples were drawn for the present analyses provided the opportunity to examine similar factors associated with relapse in teens and adults, permitting more direct comparisons of developmental differences in the process of relapse. In addition, by using similar instruments and procedures, and measuring depression and self-efficacy prospectively and close in time to each individual's relapse, the design of these studies supported relapse as a dynamic process (Witkiewitz & Marlatt, 2004
). This type of design is an important step toward continuing to elucidate the cognitive and behavioral factors associated with relapse to addictive behaviors across the lifespan.
These studies also had some limitations. First, data for both studies were almost exclusively gathered using self-report measures, although there were multiple reports in the teen and adults studies and urine toxicology screens provided back-up information for substance use reports. In addition, the studies used measures of depression symptoms and self-efficacy as close in time to first use as they were available; however in many cases these two constructs were measured in the same time period. Thus, these studies are limited in the conclusions they can make related to mediation, because there was not temporal independence in measuring depression symptoms and substance-related coping self-efficacy. In addition, self-efficacy was assessed with respect to the primary substance of abuse for each participant (i.e., drug of choice), yet initial relapse episode was defined based on any substance use. Thus it is unclear to what extent self-efficacy generalizes across substances of abuse, and this should be addressed in future research testing cognitive behavioral models of relapse in teens and adults.
Given the positive impact of abstinence on longer term psychosocial functioning in treated SUD youth and adults, interventions focused on providing alternative avenues for managing negative affect (e.g., Integrated Cognitive Behavioral Therapy for substance abuse and depression) and increasing self-efficacy (e.g., relapse prevention targeted to youth; Ramo, et al., 2007
) could improve general functioning in both age groups. However, it appears from this research that targeting negative affect in teens may be particularly important. Further, our findings suggest that outpatient clinicians should evaluate self-efficacy often and be attentive to changes in adolescents, as they may portend relapse. This study provided an important step to understand how the dynamic process of relapse is developmentally unique. Future investigations should incorporate other factors known to play a part in addiction relapse (e.g., neurobiological factors, environmental factors) for both teens and adults in order to fully understand the extent of developmental differences in the relapse process.