Community-based Outpatient Treatment Research Articles

Caregiver Engagement in Outpatient Treatment for Adolescents in Community Settings: Construct and Predictive Validity of Family Therapy Techniques.

Caregiver engagement and participation in community-based outpatient treatment services for adolescents is generally poor, which is problematic given the integral role of caregivers prescribed by evidence-based treatments across orientations. The current study explores the psychometric and predictive properties of a set of caregiver engagement techniques distilled from family therapy, used by community clinicians in routine care. It highlights relational engagement interventions and adds to growing work distilling core elements of family therapy. The study examined caregiver engagement techniques observed in 320 recorded sessions and outcome data from 152 cases treated by 45 therapists participating in one of three randomized trials investigating delivery of family therapy for adolescent behavior problems in community settings. Construct and predictive validity of caregiver engagement coding items were analyzed to understand the degree to which they cohered as a single factor and predicted outcomes in predictable ways. Results demonstrated item reliability and construct validity of a Caregiver Engagement Techniques factor. Greater use of these techniques was associated with decreased adolescent substance use. Unexpected results suggested greater use of techniques was associated with worsening internalizing symptoms and family cohesion per youth-report only. Post-hoc analyses revealed additional complexities in the association between engagement techniques and outcomes. Caregiver engagement practices tested in the current study represent a unified treatment factor that may contribute to positive therapeutic outcomes for adolescents in some clinical domains. Further research is needed to understand predictive effects.

Trends and correlated outcomes in population-level prescription opioid and transdermal fentanyl use in Israel

BackgroundIn the last twenty years, there was a documented increase in prescription opioid procurement in Israel. However, there is still little evidence of the association between opioid procurement rates, health service utilisation in secondary care, and enrollment rates to substance use disorder treatment programmes. In this study, we show trends in the reports of opioid-related hospitalisations, emergency department visits, enrollment to community-based outpatient treatment for Prescription Opioid Use Disorder and opioid-related mortality rates. Additionally, we examine potential correlations between these health service utilisation rates and prescription opioid procurement rates at the population level, with a focus on transdermal fentanyl.MethodsA longitudinal study at the population level. We used seven-year data on indicators of opioid-related morbidity, prescription opioid procurement data for 2015–2021, and six-year opioid-related mortality data for 2015–2020. We measure the correlation between procurement rates of prescription opioids in Oral Morphine Equivalent per capita, and aggregated rates obtained from hospital administrative data for hospitalisations, emergency department visits, and patient enrolment in specialised prescription opioid use disorder outpatient treatment in the community setting.ResultsBetween 2015 and 2021, procurement rates in primary care per capita for all prescription opioids increased by 85%, while rates of transdermal fentanyl procurement increased by 162%. We found a significant positive correlation at the population level, between annual opioid procurement rates, and rates per population of opioid-related visits to emergency departments (r = 0.96, p value < 0.01, [CI 0.74–0.99]), as well as a positive correlation with the rates per population of patient enrolment in specialised prescription opioid use disorder outpatient treatment (r = 0.93, p value = 0.02, [CI 0.58–0.99]). Opioid-related mortality peaked in 2019 at 0.31 deaths per 100,000 but decreased to 0.20 deaths per 100,000 in 2020.ConclusionData shows that all-opioid and transdermal fentanyl procurement has increased yearly between 2015 and 2021. This increase is positively correlated with a growing demand for community-based Prescription Opioid Use Disorder outpatient treatment. Efforts to reduce opioid-related morbidity may require effective approaches toward appropriate prescribing, monitoring, and further increasing access to prescription opioid outpatient treatment.

Cost-effectiveness implications of increasing the efficiency of the extended-release naltrexone induction process for the treatment of opioid use disorder: a secondary analysis.

In a US randomized-effectiveness trial comparing extended-release naltrexone (XR-NTX) with buprenorphine-naloxone (BUP-NX) for the prevention of opioid relapse among participants recruited during inpatient detoxification (CTN-0051), the requirement to complete opioid detoxification prior to initiating XR-NTX resulted in lower rates of initiation of XR-NTX (72% XR-NTX versus 94% BUP-NX). This was a retrospective secondary analysis of CTN-0051 trial data, including follow-up data over 24-36weeks. Eight community-based, inpatient-detoxification and follow-up outpatient treatment facilities in the United States. A total of 283 participants randomized to receive XR-NTX. Efficiency was estimated using a multivariable generalized structural equation model to explore simultaneous determinants of XR-NTX induction and induction duration (detoxification+residential days). Cost-effectiveness was estimated from the health-care sector perspective and included expected costs and quality-adjusted life-years (QALYs). Treatment site was the only modifiable factor that simultaneously increased the likelihood of XR-NTX induction and decreased induction duration. Incorporating the higher predicted probability of XR-NTX induction, and fewer predicted days of detoxification and subsequent residential treatment into the cost-effectiveness framework, reduced the incremental average 24-week total cost of XR-NTX treatment from $5317 more than that of BUP-NX (P=0.01) to a non-statistically-significant difference of $1016 (P=0.63). QALYs gained remained similar across arms. Adopting an efficient model of extended-release naltrexone initiation could result in extended-release naltrexone and buprenorphine-naloxone being of comparable economic value from the health-care sector perspective over 24-36weeks for patients seeking treatment for opioid use disorder at an inpatient detoxification facility.

Group versus individual treatment for substance use disorders: a study protocol for the COMDAT trial

BackgroundAlcohol and other drug use disorders contribute substantially to the global burden of illness. The majority of people with substance use disorders do not receive any treatment for their problems, and developing treatments that are attractive and effective to patients should be a priority. However, whether treatment is best delivered in a group format or an individual format has only been studied to a very limited degree. The COMDAT (Combined Drug and Alcohol Treatment) trial evaluates the feasibility, acceptability, and cost effectiveness of MOVE group (MOVE-G) treatment versus MOVE individual (MOVE-I) treatment in four community-based outpatient treatment centres in Denmark.MethodsA two-arm non-inferiority trial comparing MOVE-I (Pedersen et al., Drug Alcohol Depend 218:108363, 2020) with MOVE-G a combined group treatment for both alcohol use disorder and drug use disorder. The primary objective is to examine whether MOVE-G is non-inferior to MOVE-I in relation to abstinence from drug and/or alcohol, number of sessions received, and completion of treatment as planned. All participants will receive treatment based on cognitive behavioral therapy and motivational interviewing, vouchers for attendance and text reminders, as well as medication as needed (MOVE). Participants (n = 300) will be recruited over a one-year period at four public treatment centers in four Danish municipalities. A short screening will determine eligibility and randomization status. Hereafter, participants will be randomized to the two treatment arms. A thorough baseline assessment will be conducted approximately 1 week after randomization. Follow-up assessments will be conducted at 9 months post-randomization. In addition, patients’ use of drugs and alcohol, and patients’ wellbeing will be measured in all sessions. The main outcome measures are drug and alcohol intake at 9 months follow-up, number of sessions attended, and dropout from treatment.DiscussionThe present study will examine the potential and efficacy of combined groups (patients with alcohol and drug disorders in the same group) versus individually based treatment both based on the treatment method MOVE (Pedersen et al., Drug Alcohol Depend 218:108363, 2020).Trial registrationISRCTN88025085, registration date 30/06/2020.

Long-term efficacy of contingency management treatment based on objective indicators of abstinence from illicit substance use up to 1 year following treatment: A meta-analysis.

Contingency management (CM) is often criticized for limited long-term impact. This meta-analysis focused on objective indices of drug use (i.e., urine toxicology) to examine the effects of CM on illicit substance use up to 1 year following treatment. Analyses included randomized trials (k = 23) of CM for stimulant, opioid, or polysubstance use disorders that reported outcomes up to 1 year after the incentive delivery had ended. Using random effects models, odds ratios (OR) were calculated for the likelihood of abstinence. Metaregressions and subgroup analyses explored how parameters of CM treatment, namely escalation, frequency, immediacy, and magnitude of reinforcers, moderated outcomes. The overall likelihood of abstinence at the long-term follow-up among participants who received CM versus a comparison treatment (nearly half of which were community-based comprehensive therapies or protocol-based specific therapies) was OR = 1.22, 95% confidence interval [1.01, 1.44], with low to moderate heterogeneity (I² = 36.68). Among 18 moderators, longer length of active treatment was found to significantly improve long-term abstinence. CM showed long-term benefit in reducing objective indices of drug use, above and beyond other active, evidence-based treatments (e.g., cognitive-behavioral therapy, 12-step facilitation) and community-based intensive outpatient treatment. These data suggest that policymakers and insurers should support and cover costs for CM, which is the focus of hundreds of studies demonstrating its short-term efficacy and, now, additional data supporting its long-term efficacy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

1110 Characteristics Of Untreated Sleep Disturbance During Intensive Outpatient Treatment For Substance Use Disorders: Preliminary Results From A Longitudinal Study

Abstract Introduction Previous studies have shown that sleep problems are commonly reported during treatment for substance use disorders (SUDs) and sleep complaints have been linked to subsequent relapse. However, most of these findings were in well-controlled clinical trials and may not generalize to the public. Little is known about the natural progression of sleep complaints during treatment in community clinics, the most common treatment approach for SUDs. The aim of this study is to longitudinally assess prevalence of clinically significant sleep disturbance at baseline and post-treatment in a community-based intensive outpatient (IOP) SUD treatment program using a multi-method approach with well-validated measures of sleep. Methods Adults beginning IOP SUD treatment completed the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Nightmare Disorder index (NDI), and one week of actigraphy and sleep diaries. Measures were repeated following treatment (approximately 5 weeks later). Results Preliminary analyses on 21 adults who have been enrolled thus far revealed 85.6% of participants experienced sleep disturbance (PSQI &amp;gt; 5) at baseline. 28.5% of participants reached cutoff for moderate-to-severe insomnia symptoms (ISI &amp;gt; 15) and 42.9% reported nightmares more than once per week. Sleep parameters taken from actigraphy and sleep diaries revealed mean sleep efficiency was 77.5% (TST M = 6.2 hours; TIB M = 7.9 hours). These variables did not improve from baseline to post-treatment. Further, most measures indicated a worsening of sleep, though this did not reach significance (all ps &amp;gt; .05). Conclusion This preliminary data show a high prevalence of self-reported sleep complaints and objectively measured poor sleep efficiency that do not improve over the course of treatment. Data collection is ongoing and expected to at least double. More robust analyses, including differences between SUD type (e.g., cannabis vs. opioid) and relationship to relapse at post-treatment, will then be completed. Support K12DA031794

Sexual orientation and substance use treatment outcomes across five clinical trials of contingency management.

Lesbian, gay, and bisexual (LGB) individuals have elevated rates of substance use disorders and present to treatment with more severe substance use problems. Despite this health disparity, recent reviews highlight the paucity of studies reporting sexual orientation in substance use research (e.g., Flentje, Bacca, & Cochran, 2015). Using data from 5 clinical trials of contingency management (CM), the current study investigated the impact of sexual orientation on 3 substance use outcomes: treatment retention, longest duration of abstinence, and percent negative samples submitted. Participants (N = 912; mean age = 36.6 years; 51.1% female; 45% African American, 42.2% Caucasian) were randomized to standard care in community-based intensive outpatient treatment (IOP) or the same plus CM. Patients identifying as LGB made up 10.6% of the sample. A significant proportion identified as bisexual (8.2% of the total sample). Regardless of sexual orientation, participants receiving CM achieved better treatment outcomes than those receiving IOP alone. There were no statistically significant differences between LGB and heterosexual participants in their response to IOP in general, and CM specifically, across all 3 treatment outcomes (ps > .05). However, equivalence testing revealed that outcomes were not statistically equivalent for LGB and heterosexual participants, with the exception of percentage of negative samples, which was equivalent within the CM group only. Differences in treatment response to CM and standard community-based IOP do not reach the level of statistical significance; however, in most cases, we cannot conclude that treatment response is equivalent for LGB and heterosexual individuals. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Psychological and Autonomic Correlates of Emotion Dysregulation among Women in Substance Use Disorder Treatment

Background: Emotion regulation is increasingly recognized as important for the prevention and treatment of substance use disorder (SUD). However, there is an identified lack of physiological indexes of emotion dysregulation in SUD treatment studies, critically needed to better understand the link between emotion regulation capacity (measured physiologically) and self-report health outcomes among individuals in SUD treatment. Objective: To examine the association between respiratory sinus arrhythmia (RSA) and self-report health outcomes among women in SUD treatment. Methods: This is a cross-sectional study based on baseline data from 217 women enrolled in a randomized control trial to study a mind-body intervention as an adjunct to SUD treatment. All participants were enrolled in community-based outpatient treatment. Participants were administered questionnaires to examine sample characteristics, mental health symptoms, and interoceptive awareness and mindfulness skills. RSA data was gathered as an index of emotion dysregulation. Descriptive statistics, bivariate correlations, and regression were used in the analyses. Results: Findings highlight the extensive trauma histories, low SES, and the high symptoms of distress in this sample. RSA was only significantly correlated with interoceptive awareness after controlling for age and BMI. Measures of symptomatic distress and mindfulness were not correlated with RSA. Conclusions/Importance: Results provide the first evidence of RSA as an index of interoceptive awareness in this population. The inclusion of biomarkers such as RSA in SUD clinical studies may help identify individuals that are in need of targeted treatments that include interoceptive awareness training focused on improving emotion regulation.

A Preliminary Study of Activation, Stress, and Self-Management of Parents of Children with Autism Spectrum Disorder

Children with autism spectrum disorder (ASD) and developmental disabilities are high users of services, yet very little is known about how parents of these children interact with the health care system. Further, compared to parents of children with other developmental disabilities, parents of children with ASD experience more stress and dissatisfaction with services. Current efforts for improving services point to a need for understanding caregivers’ perceptions of their own health-care related beliefs and actions. Activation is a construct that measures the belief, knowledge, action, and persistence of managing one’s health care needs. The objective of this preliminary study was to evaluate the activation of parents of children with ASD using an adapted parent activation measure (PAM) for children with developmental disabilities called the PAM-DD. Data were collected from parents who received treatment as usual from a community-based outpatient treatment planning service for children with ASD. PAM-DD scores were compared with parent ratings of stress, self-management, and service satisfaction. Results indicated that increased activation correlated positively with parent report of satisfaction and ability to self-manage child issues such as eating, sleeping, and behavior and correlated negatively with parenting stress. The study of activation shows promise as a feature of quality of care for parents of children with developmental disabilities.

Reflections on a Service User Perspective in Supporting Persons with Dual Diagnosis: the Case of Villa Voortman

Inclusive citizenship is an important concept in today’s mental health care. Still, persons with co-occurring substance use problems and psychiatric problems seem to fall through the cracks of existing (community) treatment services. At the same time, they are the persons least asked for their opinions as service users. This commentary sheds light on Villa Voortman, an innovative community-based outpatient treatment service for persons with dual diagnosis in Ghent (Belgium) that gives a central position to user perspectives in its daily practice.

Does Age Moderate the Effect of Spirituality/Religiousness in Accounting for Alcoholics Anonymous Benefit?

ABSTRACTGains in spiritual/religious (S/R) practices among Alcoholics Anonymous (AA) members are associated with reductions in drinking. This study had the following aims: (1) examine spirituality/religiousness as a mediator of the relationship between AA attendance and reductions in drinking behavior to replicate past research findings and to (2) examine age cohort as a moderator of the mediational analyses given that empirical evidence (e.g., generational differences in spirituality) suggests that age may influence the acquisition of gains in spirituality/religiousness during AA as well as the expression of these gains on drinking behavior. Measures were administered to 253 participants recruited from community-based AA and outpatient treatment programs at baseline, 3, 6, 9, and 12 months, and 210 (83%) participants provided complete data to test study aims. Gains in S/R practices mediated the relationship between AA attendance and increased abstinence but not drinking intensity. Simple slopes analyses indicated a positive association between AA attendance and gains in S/R practices among younger AA affiliates but not older AA affiliates in the moderated-mediational analyses. However, age was not found to moderate the global mediational effect. The results from the current study inform efforts to increase positive change in AA affiliates’ drinking behavior by highlighting specific aspects of S/R practices that should be targeted based on the age of an AA affiliate.

Time-varying associations between confidence and motivation to abstain from marijuana during treatment among adolescents

IntroductionAn important goal of addictions treatment is to develop a positive association between high levels of confidence and motivation to abstain from substance use. This study modeled the time-varying association between confidence and motivation to abstain from marijuana use among youth in treatment, and the time-varying effect of pre-treatment covariates (marijuana abstinence goal and perceived peer marijuana use) on motivation to abstain. Method150 adolescents (75% male, 83% White) in community-based intensive outpatient treatment in Pennsylvania completed a pre-treatment assessment of abstinence goal, perceived peer marijuana use, and motivation and confidence to abstain from marijuana. Ratings of motivation and confidence to abstain also were collected after each session. A time-varying effect model (TVEM) was used to characterize changes in the association between confidence and motivation to abstain (lagged), and included covariates representing pre-treatment abstinence goal and perceived peer marijuana use. ResultsConfidence and motivation to abstain from marijuana generally increased during treatment. The association between confidence and motivation strengthened across sessions 1–4, and was maintained through later sessions. Pre-treatment abstinence goal had an early time-limited effect (through session 6) on motivation to abstain. Pre-treatment perception of peer marijuana use had a significant effect on motivation to abstain only at session 2. ConclusionsEarly treatment sessions represent a critical period during which the association between confidence and motivation to abstain generally increased. The time-limited effects of pre-treatment characteristics suggest the importance of early sessions in addressing abstinence goal and peer substance use that may impact motivation to abstain from marijuana.

Decision-making capacity for research participation among addicted people: a cross-sectional study.

BackgroundInformed consent is a key element of ethical clinical research. Addicted population may be at risk for impaired consent capacity. However, very little research has focused on their comprehension of consent forms. The aim of this study is to assess the capacity of addicted individuals to provide consent to research.Methods53 subjects with DSM-5 diagnoses of a Substance Use Disorder (SUD) and 50 non psychiatric comparison subjects (NPCs) participated in the survey from December 2014 to March 2015. This cross-sectional study was carried out at a community-based Outpatient Treatment Center and at an urban-located Health Centre in Spain. A binary judgment of capacity/incapacity was made guided by the MacArthur Competence Assessment Tool for Clinical Research (MacCAT–CR) and a clinical interview. Demographics and clinical characteristics were assessed by cases notes and the Mini-Mental State Examination, the Global Assessment Functional Scale and the Clinical Global Impression Scale.ResultsNPCs performed the best on the MacCAT–CR, and patients with SUD had the worst performance, particularly on the Understanding and Appreciation subscales. 32.7 % SUD people lacked research-related decisional capacity. There were no statistically significant differences between the groups in terms of capacity to consent to research.ConclusionsThe findings of our study provide evidence that a large proportion of individuals with SUD had decisional capacity for consent to research. It is therefore inappropriate to draw conclusions about capacity to make research decisions on the basis of a SUD diagnosis. In the absence of advanced cognitive impairment, acute withdrawal or intoxication, we should assume that addicted persons possess decision-making capacity. Thus, the view that people with SUD would ipso facto lose decision-making power for research consent is flawed and stigmatizing.

Regional brain activation supporting cognitive control in the context of reward is associated with treated adolescents’ marijuana problem severity at follow-up: A preliminary study

This preliminary study examined the extent to which regional brain activation during a reward cue antisaccade (AS) task was associated with 6-month treatment outcome in adolescent substance users. Antisaccade performance provides a sensitive measure of executive function and cognitive control, and generally improves with reward cues. We hypothesized that when preparing to execute an AS, greater activation in regions associated with cognitive and oculomotor control supporting AS, particularly during reward cue trials, would be associated with lower substance use severity at 6-month follow-up. Adolescents (n=14, ages 14–18) recruited from community-based outpatient treatment completed an fMRI reward cue AS task (reward and neutral conditions), and provided follow-up data. Results indicated that AS errors decreased in reward, compared to neutral, trials. AS behavioral performance, however, was not associated with treatment outcome. As hypothesized, activation in regions of interest (ROIs) associated with cognitive (e.g., ventrolateral prefrontal cortex) and oculomotor control (e.g., supplementary eye field) during reward trials were inversely correlated with marijuana problem severity at 6-months. ROI activation during neutral trials was not associated with outcomes. Results support the role of motivational (reward cue) factors to enhance cognitive control processes, and suggest a potential brain-based correlate of youth treatment outcome.

Recommendations for Inpatient Psychiatric Treatment for Suicidal Adolescents

There is a great need for research that would provide empirical support for interventions and approaches to acute care that reduce the morbidity and mortality of suicide-related thoughts and behaviors in adolescents (Corcoran et al., 2011). The treatment adolescents currently receive on inpatient psychiatric units is sub-par, and this is not due to the experience and skills of clinicians, but rather, the larger system of psychiatric care in the United States. When parents agree to psychiatric hospitalization for their adolescents, they typically believe their adolescents will receive treatment at these units. However, rather than receive the active treatment they need on these units, they are essentially held there until they are “stable enough” to receive community-based residential treatment or outpatient treatment. This is an extremely ineffective way to treat adolescents with active suiciderelated thoughts and behaviors. Why not take advantage of the time when they are in crisis to deliver evidence-based treatments in brief formats but intensive doses? Currently, there are no evidence-based psychiatric inpatient treatments that have been found to reduce the frequency of suicide-related behaviors or suicide attempts subsequent to discharge (Knesper, 2010). Therefore, there is a critical need for the development and testing of brief, but intensive, treatments that can be delivered in acute psychiatric care settings (Knesper, 2010).

Does mandating offenders to treatment improve completion rates?

While it is known that community-based outpatient treatment for substance abusing offenders is effective, treatment completion rates are low and much of the prior research has been conducted with offenders in residential treatment or therapeutic communities. The aim of the present study was to assess whether offenders who are mandated to community-based outpatient treatment have better completion rates compared to those who enter treatment voluntarily. The 160 research participants were a heterogeneous group of substance abusers who were under various levels of criminal justice supervision (CJS) in the community. The participants were enrolled in an intensive outpatient program and were recruited into the study between July 2007 and October 2010. All offenders received weekly therapy sessions using a cognitive problem solving framework and 45% completed the 6month treatment program. Interestingly, those who were mandated demonstrated less motivation at treatment entry, yet were more likely to complete treatment compared to those who were not court-ordered to treatment. While controlling for covariates known to be related to treatment completion, the logistic regression analyses demonstrated that court-ordered offenders were over 10 times more likely to complete treatment compared to those who entered treatment voluntarily (OR=10.9, CI=2.0–59.1, p=.006). These findings demonstrate that stipulated treatment for offenders may be an effective way to increase treatment compliance.

Pre-treatment change in a randomized trial with pregnant substance-abusing women in community-based outpatient treatment

Participants in clinical trials of interventions for substance use frequently show substantial pre-treatment reductions in use. However, pre-treatment change has not been studied among pregnant women, a group with unique motivational characteristics. It is also not clear whether pre-treatment reduction in substance use can be clearly linked to research activities such as pre-treatment assessment, or if it is the result of more general factors such as the decision to seek treatment. Using an interrupted longitudinal design, we evaluated pre-treatment change among 148 pregnant women, all of whom had completed a clinical trial comparing motivational enhancement therapy to treatment as usual. When baseline period was compared to the period after randomization and before treatment, the change in substance use was substantial (dropping from an average of substance use on 30.5% of days during baseline to 16.7% of days during the pre-treatment phase; p<.001), and was greater in magnitude than change following initiation of study-related treatment. Further, this reduction was significant after controlling for a longitudinal time effect and did not apply to tobacco use. These findings suggest that change following pre-treatment research activities is independent of the decision to seek treatment and is present even among pregnant women, many of whom have already reduced their substance use. These findings also suggest the possible need for re-evaluation of the nature and causes of behavior change, as well as trial design, in clinical trials for substance abuse.

Combining cognitive behavioral therapy and contingency management to enhance their effects in treating cannabis dependence: less can be more, more or less

To evaluate reciprocal enhancement (combining treatments to offset their relative weaknesses) as a strategy to improve cannabis treatment outcomes. Contingency management (CM) with reinforcement for homework completion and session attendance was used as a strategy to enhance cognitive-behavioral therapy (CBT) via greater exposure to skills training; CBT was used as a strategy to enhance durability of CM with rewards for abstinence. Community-based out-patient treatment program in New Haven, Connecticut, USA. Twelve-week randomized clinical trial of four treatment conditions: CM for abstinence alone or combined with CBT, CBT alone or combined with CM with rewards for CBT session attendance and homework completion. A total of 127 treatment-seeking young adults (84.3% male, 81.1% minority, 93.7% referred by criminal justice system, average age 25.7 years). Weekly urine specimens testing positive for cannabis, days of cannabis use via the time-line follow-back method. Within treatment, reinforcing homework and attendance did not significantly improve CBT outcomes, and the addition of CBT worsened outcomes when added to CM for abstinence (75.5 versus 57.1% cannabis-free urine specimens, F = 2.25, P = 0.02). The CM for abstinence condition had the lowest percentage of cannabis-negative urine specimens and the highest mean number of consecutive cannabis-free urine specimens (3.3, F = 2.33, P = 0.02). Attrition was higher in the CBT alone condition, but random effect regression analyses indicated this condition was associated with the greatest rate of change overall. Cannabis use during the 1-year follow-up increased most rapidly for the two enhanced groups. Combining contingency management and cognitive-behavioural therapy does not appear to improve success rates of treatment for cannabis dependence in clients involved with the criminal justice system.

A pilot study on community-based outpatient treatment for patients with chronic psychotic disorders in Somalia: Change in symptoms, functioning and co-morbid khat use

BackgroundIn Low and Middle Income Countries, mental health services are often poorly developed due to the lack of resources and trained personnel. In order to overcome these challenges, new ways of care have been suggested such as a focus on community-based services. In Somalia, the consumption of the natural stimulant khat is highly prevalent, aggravating mental illness. At the same time, mental health care is largely unavailable to the vast majority of the population. In a pilot project, we tested possibilities for effective measures in community-based out-patient mental health care.MethodsThirty-five male patients with chronic psychotic disorders and their carers were involved in a 10-months follow-up study. All of them abused khat. Seventeen outpatients experiencing acute psychotic episodes were recruited from the community and received an intensive six week home-based treatment package. Additionally eighteen patients with chronic psychotic disorders in remission were recruited either following hospital discharge or from the community. In a second phase of the study, both groups received community-based relapse prevention that differed in the degree of the family’s responsibility for the treatment. The treatment package was comprised of psycho-education, low-dose neuroleptic treatment, monthly home visits and counseling. The Brief Psychiatric Rating Scale (BPRS) was applied three times. Additionally, we assessed functioning, khat use and other outcomes.ResultsOf the 35 patients enrolled in the study, 33 participated in the 10-month follow-up. Outpatients improved significantly in the first six weeks of treatment and did not differ from remitted patients at the start of the second treatment phase. In the preventive treatment phase, we find heterogeneous outcomes that diverge between symptom and functioning domains. With the exception of depressive symptoms, symptoms in all patients tended to worsen. The outpatient group had higher BPRS positive and negative symptom scores compared to the remitted group. Levels of functioning in 20 out of 33 patients significantly improved, with small differences between groups. Most patients experienced improvements in basic functioning, such as communication, self-care etc. Khat use could only be reduced in the group of outpatients.ConclusionsCommunity-based out-patient mental health treatment for chronic psychotic disorders has demonstrated positive effects in Somalia and is both feasible and practical, despite facing formidable challenges, e.g. controlling khat intake.

Utilization of community-based outpatient addiction treatment programmes in Kenya

This paper examines a number of outpatient addictions treatment programmes developed in various regions of Kenya. The uptake of outpatient services at four sites between 2007 and 2010 has been examined. A field-based follow-up survey was administered to determine abstinence rates among clients who participated in treatment. Factors involved in recovery outcomes are discussed. Utilization of outpatient addictions treatment and retention in services increased over the three-year period, and field-based follow up with clients showed 42% abstinence rates. Key Words: Outpatient treatment, Alcohol, Drug, Addiction recovery, HIV, Kenya