The co-occurrence of substance use disorders (SUDs) and other mental health disorders is highly prevalent, with depressive disorders being the most common comorbidity (US Substance Abuse and Mental Health Services Administration, 1999
). The need for interventions specifically tailored to these comorbid disorders has been advocated, but few clinical trials have been conducted. We developed two psychotherapy interventions for individuals with comorbid SUDs and depression (Brown et al., 2006
). The addiction portions of our interventions were based on the treatments utilized in the Project MATCH study: the Twelve Step Facilitation (Nowinksi, Baker, & Carroll, 1994
) and the Cognitive-Behavioral Coping Skills (Kadden et al., 1994
) interventions. Along with the addiction-focused Project MATCH Cognitive-Behavioral Coping Skills manual, we incorporated depression treatment from the Munoz and Miranda (1996)
manual into our new Integrated Cognitive Behavioral Therapy (ICBT; Brown et al., 2006
). An issue that has been raised in efficacy studies concerns the delivery method of the treatments: most research interventions are provided in an individual format, which maximizes the internal validity but limits the generalizability to standard treatment delivery scenarios (Persons & Siberschatz, 1999
). Group formats are not only more typical in addiction settings but are hypothesized to be more effective due to their social facilitation effects (Kadden et al., 1994
; San, 1999
Consequently, in addition to other changes we modified the Project MATCH interventions from individual to group formats. However, one difficulty associated with group formats is utilizing a single entry point for all participants, resulting in a longer waiting period for patients (in our case, once every 12 weeks). An alternative is to allow for more frequent entry points, which has the disadvantage of participants starting at different points in the interventions. Following the model put forth by Munoz and Miranda (1996)
, we rejected the 12-week waiting period as too long, and therefore adapted our interventions to a three-module format, each module lasting four weeks and covering distinct topics. Participants entered treatment at the beginning of any of the three modules. Our preliminary findings document similar reductions for both the ICBT and TSF interventions in substance use and depression symptoms during the 24 week active treatment phase (Brown et al., 2006
). However, although these adjustments permitted group delivery of our interventions with acceptable waiting periods, they raised the question of whether treatment response might differ based on which module was received first.
The design of the current clinical trial allowed us to examine whether initial focus when entering treatment (i.e., the beginning module for each participant) affected treatment retention and outcome. ICBT was parsed out into three discrete modules: a Thoughts module, an Activities module, and an Interpersonal module. Every session, regardless of module, focused on both substance use and depression. We were, therefore, able to examine if starting with a particular component of ICBT was more effective in ultimately reducing substance use or depression, or retaining participants in treatment. Previously, others have shown that depressed individuals had similar outcomes utilizing the Munoz and Miranda (1996)
manual with a modular format regardless of which module was presented first (McQuaid, Callaghan, Laumakis, Pedrelli, & Guarino, 1998
The effect of the initial treatment focus and the importance of timing of change have been discussed widely in the psychotherapy treatment literature, especially for depression treatments. For example, Ilardi and Craighead (1994)
observed that in seven of the eight major efficacy studies of cognitive behavior therapy (CBT) for depression, 60-70% of the total change in depression occurred within the first three weeks of the treatment and surmised that these changes were too early to be related to the “cognitive” component of CBT. Additionally, research has examined specific components of CBT (e.g., behavioral activation, automatic thoughts, etc.), comparing the effectiveness of one component over another (Jacobson et al., 1996
; Zeiss, Lewinsohn, & Munoz, 1979
). However, to date, there are no conclusive guidelines available as to the order of presentation of CBT interventions. Therefore, understanding the impact of initial treatment focus on outcomes has important clinical and research ramifications.
We based our comparison intervention on Twelve Step interventions, as these are one of the most widely used components of addiction treatment programs. The Twelve Step Facilitation Therapy Manual used in Project MATCH (Nowinksi et al., 1994
) begins with Steps 1, 2, and 3, followed by encouragement of involvement in Twelve Step activities (attending, participating, and volunteering at meetings, readings, getting a sponsor, using telephone support). In Project MATCH, these sessions are followed by elective topics that include core topics in Twelve Step (helpful slogans and memory devices) and Steps 4 and 5. Individual delivery of Project MATCH interventions provided for presentation of these sessions in the accepted sequence for all participants, consistent with the Twelve Step premise of orderly progression through the Steps. In our Twelve Step Facilitation (TSF) modification which allowed for group delivery, one module focused on Steps 1, 2 and 3 (Steps 1-3 Module), a second module focused on core topics discussed in many AA/NA meetings and Twelve Step literature (e.g., helpful slogans and memory devices; Core AA/NA Topics Module), and the third module focused on Steps 4 and 5 (Steps 4-5 Module). The group format with entry points at the beginning of each module meant that some individuals began at a traditional Twelve Step point (i.e., Steps 1-3 Module) while others started with the Steps 4-5 Module or Core AA/NA Topics Module. It is possible that individuals who are presented Twelve Step principles in the prescribed order benefit more than individuals who receive these principles out of the accepted order. We found no research examining this unquestioned premise. However, many individuals with alcohol and substance use disorders have previously been exposed to Twelve Step programs and could benefit even when topics are presented out of the prescribed order.
The current study examined the effect of initial treatment focus (i.e., entry module) on substance use and depression outcomes in this comorbid sample. Furthermore, due to high attrition rates in alcohol and drug treatment programs (e.g., Dobkin, DeCivita, Paraherakis, & Gill, 2002
; McKay et al., 1998
), we also examined whether initial treatment focus affected retention in treatment.