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1.  Social Network Moderators of Naltrexone and Behavioral Treatment Effects on Heavy Drinking in the COMBINE Study 
Oral naltrexone is an efficacious medication for treatment of alcohol dependence, but small effect sizes and variability in outcomes suggest the presence of person-level moderators of naltrexone response. Identification of contextual or psychosocial moderators may assist in guiding clinical recommendations. Given the established importance of social networks in drinking outcomes, as well as the potential effects of naltrexone in reducing cue reactivity which may be especially important among those with more heavy drinkers and more alcohol cues in their networks, we examined pretreatment social network variables as potential moderators of naltrexone treatment effects in the COMBINE study.
The sample included all COMBINE study participants in medication conditions with full data on the Important People Inventory (IPI) and covariates at intake (N = 1,197). The intake IPI assessed whether participants had any frequent drinkers in their network and the average frequency of contact with these drinkers. The effects of treatment condition, pretreatment network variables, and their interactions on percent heavy drinking days were tested in hierarchical linear models, controlling for demographics and baseline clinical covariates.
In treatment conditions involving medical management and combined behavioral intervention (CBI), the effects of active naltrexone on heavy drinking were significantly greater for individuals with frequent drinkers in their network (z = −2.66, p < 0.01) and greater frequency of contact with those drinkers (z = −3.19, p < 0.01). These network variables did not moderate the effects of active naltrexone without CBI.
When delivered in conjunction with behavioral interventions, naltrexone can be more potent for alcohol-dependent adults who have greater contact with frequent drinkers prior to treatment, which may indicate patterns of environmental exposure to alcohol. Contextual, social risk factors are a potential avenue to guide personalized treatment of alcohol dependence.
PMCID: PMC4418469  PMID: 25623409
Alcohol Dependence; Naltrexone; Pharmacotherapy; Social Network; Moderators
2.  12-step Affiliation and Attendance following Treatment for Comorbid Substance Dependence and Depression: A Latent Growth Curve Mediation Model 
Among substance-dependent individuals comorbid major depressive disorder (MDD) is associated with greater severity and poorer treatment outcomes, but little research has examined mediators of post-treatment substance use outcomes within this population. Using latent growth curve models we tested relationships between individual rates of change in 12-step involvement and substance use, utilizing post-treatment follow-up data from a trial of group Twelve-Step Facilitation (TSF) and Integrated Cognitive-Behavioral Therapy (ICBT) for veterans with substance dependence and MDD. While TSF patients were higher on 12-step affiliation and meeting attendance at end-of-treatment as compared to ICBT, they also experienced significantly greater reductions in these variables during the year following treatment, ending at similar levels as ICBT. Veterans in TSF also had significantly greater increases in drinking frequency during follow-up, and this group difference was mediated by their greater reductions in 12-step affiliation and meeting attendance. Patients with comorbid depression appear to have difficulty sustaining high levels of 12-step involvement after the conclusion of formal 12-step interventions, which predicts poorer drinking outcomes over time. Modifications to TSF and other formal 12-step protocols or continued therapeutic contact may be necessary to sustain 12-step involvement and reduced drinking for patients with substance dependence and MDD.
PMCID: PMC3558836  PMID: 23327503
12-step involvement; comorbidity; mediation
3.  Predictors of Suicide-Related Hospitalization among U.S. Veterans Receiving Treatment for Comorbid Depression and Substance Dependence. Who is the Riskiest of the Risky? 
Suicide & life-threatening behavior  2011;41(5):10.1111/j.1943-278X.2011.00051.x.
This study examined whether widely accepted suicide risk factors are useful in predicting suicide-related hospitalization, beyond history of a suicide attempt, in high-risk treatment-seeking veterans with depression and substance dependence. Negative mood regulation expectancies were the only significant predictor of hospitalization during six-months of outpatient treatment. History of a suicide attempt was the only significant predictor of hospitalization during the one-year follow-up period. Results suggest that within high-risk populations, standard suicide risk factors may not identify individuals who will engage in suicidal behaviors resulting in hospitalization. Assessing negative mood regulation expectations may assist in identifying those most at risk.
PMCID: PMC3821394  PMID: 21815915
4.  Mediational Relations between 12-step Attendance, Depression, and Substance Use in Patients with Comorbid Substance Dependence and Major Depression 
Addiction (Abingdon, England)  2012;107(11):1974-1983.
Among patients with substance dependence and comorbid major depressive disorder (MDD) receiving treatment in a controlled trial, we examined if group differences in depression were mediated by 12-step involvement, and if the effects of 12-Step involvement on future alcohol and drug use were mediated by reductions in depression.
Controlled trial of Twelve-Step Facilitation (TSF) and Integrated Cognitive Behavioral Therapy (ICBT), delivered in outpatient groups for 6 months with adjunct pharmacotherapy.
Outpatient dual diagnosis clinic in Veteran’s Affairs Healthcare Center.
Veterans (N = 209) diagnosed with alcohol, stimulant, or marijuana dependence and substance-independent MDD.
Twelve-step attendance and affiliation, depression severity, percent days drinking, and percent days using drugs assessed at baseline and Months 3, 6, and 9.
In multilevel analyses greater 12-step meeting attendance predicted lower depression and mediated the superior depression outcomes of the TSF group, explaining 24.3% of the group difference in depression. Independent of treatment group, lower depression severity predicted lower future alcohol use and mediated the effects of 12-step meetings, explaining 15.7% of their effects on future drinking. Controlled, lagged models indicated these effects were not confounded by current substance use, suggesting that depression had unique associations with 12-step meeting attendance and future drinking.
For patients with substance dependence and MDD, attendance at 12-step meetings is associated with mental health benefits that extend beyond substance use, and reduced depression could be a key mechanism whereby 12-step meetings reduce future drinking in this population.
PMCID: PMC3466338  PMID: 22578037
5.  Comorbid Depression and Substance Use Disorder: Longitudinal Associations Between Symptoms in a Controlled Trial 
The current study examined the longitudinal association between substance use and depressive symptoms, in veterans receiving outpatient treatment for comorbid substance use disorder and major depression. Veterans (N =237, mean age = 48.2 years, 90% male, 70% Caucasian) received either six months of group Integrated Cognitive-Behavioral Therapy or Twelve-Step Facilitation. Hamilton Depression Rating Scale scores and Percent Days Using any substance were assessed every 3 months up to one year post-treatment. Greater substance use predicted time-varying elevations in depression above individual patterns of change in depression. Moreover, change in depressive symptoms was associated with change in both the likelihood of any substance use and the frequency of use during the treatment and follow-up periods. Changes in these symptoms appear to be linked, such that individuals with greater reductions in substance use have greater reductions in depressive symptoms (and vice versa).
PMCID: PMC3382030  PMID: 22406052
Comorbidity; latent growth curve; parallel process; depressive symptoms; substance use
6.  Pre-Adolescent Alcohol Expectancies: Critical Shifts and Associated Maturational Processes 
Children's alcohol expectancies shift in late childhood/early adolescence in ways thought to lead to increased risk for adolescent alcohol use. The precise nature of this shift and the maturational processes that may influence it remain to be clarified. To these ends, we compared expectancy endorsement by grade across four expectancy domains: positive, negative, arousal and sedation, in a cross-sectional sample of 3rd-6th grade children attending afterschool programs (n = 299). Structural equation modeling (SEM) then was used to describe the relationships between expectancies and differences in: (a) cognitive ability and concept formation, (b) risk-taking personality traits, and (c) social exposure or values regarding alcohol-related information. Results showed those children in higher grades endorsed significantly more positive, negative and sedating expectancies for alcohol than their younger peers. Concept formation partially and fully mediated the relationships between grade and both positive and sedating expectancies, respectively, but not the relationship between grade and negative expectancies. Sensation seeking did not increase across grades in this sample, and the relationship between sensation seeking and positive expectancies was fully mediated by reported alcohol exposure and values. This study provides a basis for future exploration of developmental influences on alcohol expectancies, an understanding of which may be helpful in the design of prevention efforts targeting high risk youth prior to adolescence.
PMCID: PMC3777425  PMID: 21942260
children; adolescent; sensation seeking; neurocognitive development; alcohol risk factors
7.  Mediating Influences of Negative Affect and Risk Perception on the Relationship Between Sensation Seeking and Adolescent Cigarette Smoking 
Nicotine & Tobacco Research  2011;13(6):457-465.
A substantial number of adolescents are current and regular cigarette smokers, and there is a need to better understand factors that contribute to smoking behavior during these years. Sensation seeking (SS) is one factor that has consistently been associated with smoking, but less is known about mechanisms that may explain this relationship.
The present study tested the hypothesis that high school students high in SS would report heavier cigarette smoking and that this relationship would be mediated by negative affect and by perceptions about the risks of smoking. Students (n = 1,688) participated in an annual survey of substance use and related attitudes and characteristics.
As expected, higher SS was associated with greater levels of past 30-day (odds ratio [OR] = 1.46, p = .004) and lifetime (OR = 1.37, p = .004) smoking, particularly for males. Multiple mediation models indicated that effect of SS on both 30-day (combined indirect effect z = 5.38, p < .001) and lifetime (z = 6.14, p < .001) smoking was mediated by both negative affect and risk perception.
These findings suggest a need for increasing the sensation value of anti-tobacco messages to increase their efficacy for high SS youth. High SS youth may also benefit from prevention efforts designed to teach healthy ways of coping with negative affect.
PMCID: PMC3103719  PMID: 21436297
8.  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
9.  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

Results 1-9 (9)