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1.  Process Predictors of the Outcome of Group Drug Counseling 
This study examined the relation of process variables to the outcome of group drug counseling, a commonly used community treatment, for cocaine dependence.
Videotaped group drug counseling sessions from 440 adult patients (23% female, 41% minority) were rated for member alliance, group cohesion, participation, self-disclosure, positive and non-positive feedback and advice, during the 6-month treatment of cocaine dependence. Average, session-level, and slopes of process scores were evaluated. Primary outcomes were monthly cocaine use (days using out of 30), next session cocaine use, and duration of sustained abstinence from cocaine. Secondary outcomes were endorsement of 12-step philosophy and beliefs about substance abuse.
More positive alliances (with counselor) were associated with reductions in days using cocaine per month and next-session cocaine use, and increases in endorsement of 12-step philosophy. Patient self-disclosure about the past and degree of participation in the group were generally not predictive of group drug counseling outcomes. More advice from counselor and other group members were consistently associated with poorer outcomes in all categories. Individual differences in changes in process variables over time (linear slopes) were generally not predictive of treatment outcomes.
Some group behaviors widely believed to be associated with outcome, such as self-disclosure and participation, were not generally predictive of outcomes of group drug counseling, but alliance with the group counselor was positively associated, and advice giving negatively associated, with the outcome of treatments for cocaine dependence.
PMCID: PMC3565014  PMID: 23106760
group drug counseling; cocaine dependence; predictors; process ratings
2.  How many treatment sessions and patients are needed to create a stable score of adherence and competence in the treatment of cocaine dependence? 
The study utilized a generalizability theory analysis of adherence and competence ratings to evaluate the number of sessions and patients needed to yield dependable scores at the patient and therapist levels. Independent judges’ ratings of supportive expressive therapy (n = 94), cognitive therapy (n = 103), and individual drug counseling (n = 98) were obtained on tapes of sessions from the NIDA Collaborative Cocaine Treatment Study. Generalizability coefficients revealed that, for all three treatments, ratings made on approximately five to 10 sessions per patient are needed to achieve sufficient dependability at the patient level. At the therapist level, four to 14 patients need to be evaluated (depending on the modality), to yield dependable scores. Many studies today use fewer numbers.
PMCID: PMC3411921  PMID: 22449079
statistical methodology; generalizability theory; adherence; competence
3.  Gender, Race, and Group Behavior in Group Drug Treatment 
Drug and alcohol dependence  2011;119(3):e39-e45.
Group drug counseling is the primary treatment modality used to treat drug dependence in community settings in the United States. Findings from the social psychology literature suggest that gender may influence how individuals participate in groups, and that race may moderate the effects of gender on group behavior. This study examined gender, race, and their interaction as predictors of alliance, participation, self-disclosure, and receipt of advice and feedback in drug counseling groups, and explored how gender and racial differences in drug counseling group behavior related to outcome of cocaine dependence treatment.
Ratings of group behavior were made from videotaped sessions of group drug counseling drawn from a randomized trial of treatment for cocaine-dependent individuals (n = 438). Analyses examined the effects of race (African American vs. non-Hispanic White), gender, and race by gender on group behavior. Additional analyses examined race, gender, and group behavior, and interactions among these variables in predicting monthly cocaine use.
Race and the race by gender interaction, but not gender alone, predicted many group behaviors. Non-Hispanic White women had the highest rates of self-disclosure and receipt of advice and non-positive feedback, followed by men of both races, with African American women having the lowest levels. These differences were unrelated to cross-sectional cocaine outcome.
Women, but not men, of different races acted differently in mixed-race, mixed-gender cocaine treatment groups, with African American women exhibiting less of several behaviors. Additional research on causes and consequences of these differences could inform interventions for drug-dependent women.
PMCID: PMC3178731  PMID: 21689897
cocaine dependence; group drug counseling; race; gender; group process
4.  Combined Medication and Cognitive Therapy for Generalized Anxiety Disorder 
Journal of anxiety disorders  2011;25(8):1087-1094.
The current study assessed efficacy of combined cognitive behavioral therapy (CBT) and venlafaxine XR compared to venlafaxine XR alone in the treatment of generalized anxiety disorder (GAD) within settings where medication is typically offered as the treatment for this disorder. Patients with DSM-IV–diagnosed GAD who were recently enrolled in a long-term venlafaxine XR study were randomly offered (n=77), or not offered (n=40), the option of adding 12 sessions of CBT. Of those offered CBT, 33% (n=26) accepted and attended at least one treatment session. There were no differences between the combined treatment group and the medication only group on primary or secondary efficacy measures in any of the sample comparisons. Many patients who present in medical/psychopharmacology settings seeking treatment for GAD decline the opportunity to receive adjunctive treatment. Of those that receive CBT, there appears to be no additional benefit of combined treatment compared to venlafaxine XR alone.
PMCID: PMC3196054  PMID: 21840164
Generalized Anxiety Disorder; Cognitive-Behavioral Therapy; venlafaxine; combined treatment
5.  A generalizability theory analysis of group process ratings in the treatment of cocaine dependence 
Psychotherapy Research  2011;21(3):252-266.
Videotaped group drug counseling sessions were rated for alliance, self-disclosure, positive and negative feedback, group cohesion, and degree of participation of each group member. Interrater reliability was good to excellent for most measures. However, generalizability coefficients based on statistical models that included terms for patient, counselor, session, group, and rater revealed that some measures had inadequate dependability at the patient level if only two raters and two sessions were used to create patient-level scores. In contrast, good generalizability coefficients based on two raters and two sessions were obtained for alliance, non-positive learning statements received from counselor, participation variables, and self-disclosures about the past. The implications of the findings for the design of process-outcome studies are discussed.
PMCID: PMC3361025  PMID: 21409739
group psychotherapy; process research; alliance; substance abuse
6.  Developing Research and Recruitment While Fostering Stakeholder Engagement in a National Institutes of Mental Health–Funded Interventions and Practice Research Infrastructure Programs Grant for Depression 
In the context of a National Institutes of Mental Health-funded Interventions and Practice Research Infrastructure Programs (IP-RISP) grant for the treatment of depression, a partnership was developed between a community mental health organization and a team of researchers.
This paper describes the collaborative process, key challenges, and strategies employed to meet the goals of the first phase of the grant, which included development of a working and sustainable partnership and building capacity for recruitment and research.
This paper was developed through the use of qualitative interviews and discussion with a variety of IP-RISP partners.
Lessons Learned
Communication with multiple stakeholders through varied channels, feedback from stakeholders on research procedures, and employing a research liaison at the clinic have been key strategies in the first phase of the grant.
The strategies we employed allowed multiple stakeholders to contribute to the larger mission of the IP-RISP and helped to establish an ongoing research program within the mental health organization.
PMCID: PMC3355190  PMID: 21169707
Mental health; psychiatry and psychology; depression; research infrastructure; community health partnerships
7.  Changes in Psychotherapy Utilization Among Consumers of Services for Major Depressive Disorder in the Community Mental Health System 
The goal of this investigation was to explore changes in psychotherapy utilization for patients with major depressive disorder (MDD) treated in community mental health agencies across two cohorts. We used a Medicaid claims database including approximately 300,000 public sector clients. Although the use of psychotherapy alone showed a small decrease, there was a large increase in the use of combined medication and psychotherapy as a treatment for MDD. Race was a significant predictor of both treatment type received and length of treatment. African American consumers were more likely to receive psychotherapy alone than combined treatment and attended significantly fewer psychotherapy sessions.
PMCID: PMC3350098  PMID: 21298475
Depression; Psychotherapy; Racial disparities; Community mental health system
8.  Interpersonal Accuracy of Interventions and the Outcome of Cognitive and Interpersonal Therapies for Depression 
The purpose of the current investigation was to examine the interpersonal accuracy of interventions in cognitive and interpersonal therapy as a predictor of the outcome of treatment for patients with major depressive disorder.
The interpersonal accuracy of interventions was rated using transcripts of treatment sessions for 72 patients who were being treated with cognitive or interpersonal therapy for major depressive disorder through the NIMH Treatment of Depression Collaborative Research Program. Interpersonal accuracy of interventions was assessed by first identifying core conflictual relationship themes for each patient and then having judges rate therapist intervention statements for the extent to which each statement addressed each component of the patient-specific interpersonal theme.
Using early in treatment sessions, statistically significant interactions of interpersonal accuracy of interventions and treatment group in relation to outcome were evident. These findings included significant accuracy by treatment group interactions in the prediction of subsequent change of depressive symptoms and social adjustment from Week 4 to Week 16, with higher levels of interpersonal accuracy associated with relatively poorer outcomes for patients receiving cognitive therapy but relatively better outcomes for patients in interpersonal therapy.
The process of interpersonal and cognitive therapies may differ in important ways. Accurately addressing interpersonal themes may be particularly important to the process of interpersonal therapy, but not cognitive therapy.
PMCID: PMC3135378  PMID: 20515217
interpersonal therapy; cognitive therapy; depression; therapeutic process; outcome
9.  A Pilot Study of Community-Friendly Manual Guided Drug Counseling 
To facilitate effectiveness testing and dissemination of treatments to community based setting, therapist training manuals that are more “community friendly” are needed. The aim of the current project was to create revised versions of individual drug counseling (IDC) and group drug counseling (GDC) treatment manuals for cocaine dependence and to conduct a preliminary study of their effectiveness. After changing the format and context of existing drug counseling manuals to have greater ease of use in the community, draft manuals were given to 23 community-based counselors for their feedback. Final versions were then used in a pilot randomized clinical trial involving 41 cocaine dependent patients who received 3 months of either IDC + GDC or GDC alone treatment. Counselors implemented the new treatment manuals with acceptable levels of adherence and competence. Outcome results indicated that substantial change in drug use was evident, but the amount of abstinence obtained was limited.
PMCID: PMC2744318  PMID: 19038525
Cocaine dependence; drug counseling; randomized trial
10.  Additional Treatment Services in a Cocaine Treatment Study: Level of Services Obtained and Impact on Outcome 
The objective of this study was to examine the level of additional treatment services obtained by patients enrolled in the NIDA Cocaine Collaborative Study, a multi-center efficacy trial of four treatments for cocaine dependence, and to determine whether these services impact treatment outcome. Cocaine-dependent patients (N = 487) were recruited at five sites and randomly assigned to six months of one of four psychosocial treatments. Assessments were made at baseline, monthly during treatment, and at follow-ups at 9, 12, 15, and 18 months post-randomization. On average, patients received little or no additional treatment services during active treatment (first 6 months), but the rate of obtaining most services increased during the follow-up phase (month 7 to 18). In general, the treatment groups did not differ in the rates of obtaining non-protocol services. For all treatment groups, patients with greater psychiatric severity received more medical and psychiatric services during active treatment and follow-up. Use of treatment services was unrelated to drug use outcomes during active treatment. However, during the follow-up period, increased use of psychiatric medication, 12-step attendance, and 12-step participation was related to less drug use. The results suggest that during uncontrolled follow-up phases, additional non-protocol services may potentially confound the interpretation of treatment group comparisons in drug use outcomes.
PMCID: PMC2794690  PMID: 18463998
substance abuse; treatment services; treatment outcome; cocaine dependence
11.  Supportive-Expressive Psychodynamic Therapy for Cocaine Dependence: A Closer Look 
Using data from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study, this article focuses on the outcomes of patients who received supportive-expressive (SE) psychodynamically-oriented psychotherapy (plus group drug counseling; GDC). Short-term SE for cocaine dependent individuals, while not the most efficacious treatment examined in the study (individual drug counseling [IDC] plus GDC was), produced large improvements in cocaine use. In addition, there was evidence that SE was superior to IDC on change in family/social problems at the 12 month follow-up assessment, particularly for those patients with relatively more severe difficulties in this domain at baseline. For patients who achieved abstinence early in treatment, SE produced comparable drug use outcomes to IDC, with mean drug use scores numerically lower for SE at all of the follow-up assessments (9, 12, 15, and 18 months). SE patients who achieved initial abstinence decreased cocaine use from a mean 10.1 days per month at baseline to a mean of 1.3 days at 12 months.
PMCID: PMC2786223  PMID: 19960117
12.  Development and Initial Validation of a Multi-Domain Self-Report Measure of Work Functioning 
The need for a self-report measure of work functioning that is flexible to involvement in work across three domains (employment, school, and home) led to the development of the Work History Inventory (WHI). The WHI was administered to 185 patients who participated in psychotherapy studies and to 110 community control respondents who were not in treatment. The WHI Total score and subscales (Performance and Interpersonal) demonstrated adequate to good reliability. WHI scores correlated moderately with symptom measures and strongly with another work functioning measure. Changes across treatment indicated that the WHI Total and Performance scores increased significantly across psychotherapy. The WHI appears to be a reliable and valid instrument for measuring treatment related changes in work functioning.
PMCID: PMC2782633  PMID: 18852620
work functioning; work performance; interpersonal; psychotherapy; self-report measure
13.  Dopamine Transporter Levels in Cocaine Dependent Subjects 
Drug and alcohol dependence  2008;98(1-2):70-76.
Cocaine use is a significant problem in the US and it is well established that cocaine binds to the dopamine transporter (DAT) in the brain. This study was designed to determine if the DAT levels measured by 99mTc TRODAT SPECT brain scans are altered in cocaine dependent subjects and to explore clinical correlates of such alterations. SPECT brain scans were acquired on 21 cocaine dependent subjects and 21 healthy matched controls. There were significantly higher DAT levels in cocaine dependent subjects compared to controls for the anterior putamen (p = 0.003; Cohen’s d effect size = 0.98), posterior putamen (p < 0.001; effect size = 1.32), and caudate (p = 0.003; effect size = 0.97). DAT levels in these regions were 10%, 17%, and 8% higher in the cocaine dependent subjects compared to controls. DAT levels were unrelated to craving, severity of cocaine use, or duration of cocaine use, but DAT levels in the caudate and anterior putamen were significantly (p < 0.05) negatively correlated with days since last use of cocaine.
PMCID: PMC2564619  PMID: 18565692
Dopamine transporter; Cocaine dependence; SPECT

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