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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.addbeh.2009.03.009 Byline: Mark P. McGovern (a), Chantal Lambert-Harris (a), Stephanie Acquilano (a), Haiyi Xie (a), Arthur I. Alterman (b), Roger D. Weiss (c) Keywords: Co-occurring disorders; PTSD; CBT; Addiction treatment Abstract: Co-occurring posttraumatic stress disorder (PTSD) is prevalent in addiction treatment programs and a risk factor for negative outcomes. Although interventions have been developed to address substance use and PTSD, treatment options are needed that are effective, well tolerated by patients, and potentially integrated with existing program services. This paper describes a cognitive behavioral therapy (CBT) for PTSD that was adapted from a treatment for persons with severe mental illnesses and PTSD in community mental health settings. The new adaptation is for patients in community addiction treatment with co-occurring PTSD and substance use disorders. In this study, 5 community therapists delivered the CBT for PTSD. Outcome data are available on 11 patients who were assessed at baseline, post-CBT treatment, and at a 3-month follow-up post-treatment. Primary outcomes were substance use, PTSD severity, and retention, of which all were favorable for patients receiving the CBT for PTSD. Author Affiliation: (a) Dartmouth Medical School, United States (b) University of Pennsylvania, United States (c) McLean Hospital, Harvard Medical School, United States

Abstract: Count data with skewness and many zeros are common in substance abuse and addiction research. Zero-adjusting models, especially zero-inflated models, have become increasingly popular in analyzing this type of data. This paper reviews and compares five mixed-effects Poisson family models commonly used to analyze count data with a high proportion of zeros by analyzing a longitudinal outcome: number of smoking quit attempts from the New Hampshire Dual Disorders Study. The findings of our study indicated that count data with many zeros do not necessarily require zero-inflated or other zero-adjusting models. For rare event counts or count data with small means, a simpler model such as the negative binomial model may provide a better fit. [Copyright &y& Elsevier]

Abstract: Depression with psychotic features afflicts a substantial number of people and has been characterized by significantly greater impairment, higher levels of dysfunctional beliefs, and poorer response to psychopharmacologic and psychosocial interventions than nonpsychotic depression. Those with psychotic depression also experience a host of co-occurring disorders, including posttraumatic stress disorder (PTSD), which is not surprising given the established relationships between trauma exposure and increased rates of psychosis and between PTSD and major depression. To date, there has been very limited research on the psychosocial treatment of psychotic depression; and even less is known about those who also suffer from PTSD. The purpose of this study was to better understand the rates and clinical correlates of psychotic depression in those with PTSD. Clinical and symptom characteristics of 20 individuals with psychotic depression and 46 with nonpsychotic depression, all with PTSD, were compared before receiving cognitive-behavioral therapy for PTSD treatment or treatment as usual. Patients with psychotic depression exhibited significantly higher levels of depression and anxiety, a weaker perceived therapeutic alliance with their case managers, more exposure to traumatic events, and more negative beliefs related to their traumatic experiences, as well as increased levels of maladaptive cognitions about themselves and the world, compared with participants without psychosis. Implications for cognitive-behavioral therapy treatment aimed at dysfunctional thinking for this population are discussed. [Copyright &y& Elsevier]

Abstract: This study examined the frequency, stability, predictors, and long-term outcomes of 6-month remissions of alcohol use disorders among 116 adults with co-occurring severe mental illnesses followed up prospectively for 10 years. Remission was defined as 6 months without meeting syndromal criteria for alcohol abuse or dependence. Most participants (86%) experienced at least one 6-month remission, and these remissions were relatively durable. One third did not relapse during follow-up, and two thirds relapsed on average 3 years after remission. Six-month remissions were preceded by increased participation in substance abuse treatments, reductions in alcohol and drug use, decreases in psychiatric symptoms, increases in competitive employment, and increases in life satisfaction. Following remissions, participants improved in multiple domains of adjustment: reductions of psychiatric symptoms, decreases in alcohol and drug use, increases in work and social contacts with nonabusers, decreases in hospitalizations and incarcerations, increases in independent living, and increases in life satisfaction. Participants with alcohol dependence rather than alcohol abuse were less likely to attain 6-month remissions and more likely to relapse after attaining remissions. [ABSTRACT FROM AUTHOR]

Abstract: As the model for treating co-occurring disorders in addiction treatment settings becomes articulated, service systems need data on prevalence, current practice, and barriers to the implementation of evidence-based practices. A self-report survey was administered to 453 addiction treatment providers (43 agency directors, 110 clinical supervisors, and 300 clinicians) from a single state system of care. Data on prevalence estimates, treatment practices, and barriers to implementing services for co-occurring disorders were obtained. The three groups estimated that several co-occurring disorders were extremely common: mood disorders (40%–42%), anxiety disorders (24%–27%), posttraumatic stress disorder (24%–27%), severe mental illnesses (16%–21%), antisocial personality disorder (18%–20%), and borderline personality disorder (17%–18%). Practice patterns for patients with these co-occurring disorders differed widely, from referral to mental health programs to provision of integrated treatment. Common barriers to providing services to persons with co-occurring disorders were lack of psychiatric personnel and resources. Comprehensive surveys of an addiction treatment service system can rapidly and economically produce estimates of prevalence, current practices, and barriers to evidence-based practices. This objective information is critical for systems intending to enhance services to persons with co-occurring disorders. [Copyright &y& Elsevier]

Little is known about the long-term outcomes of patients in the public mental health system who are disabled by co-occurring bipolar and substance use disorders. This article reports on the 3-year course of 51 patients with co-occurring bipolar and substance use disorders in the New Hampshire Dual Diagnosis Study. Participants received integrated dual disorders treatments in the state mental health system and were independently assessed with standardized measures at baseline and every 6 months for 3 years. Though psychiatric symptoms improved only modestly, participants improved steadily in terms of remission from substance abuse (61% in full remission at 3 years); they also achieved greater independent living (average 239 days in third year), competitive employment (49% in third year), regular social contacts with nonsubstance abusers (46% at 3 years), and quality of life (56% satisfied with life at 3 years). Different domains of outcome were only weakly related to each other. Long-term, disabled patients with co-occurring bipolar and substance use disorders have potential for remission from substance abuse and substantial improvements in functioning and quality of life. [Copyright &y& Elsevier]

Conventional thermosetting materials lack of reprocessability, acid-degradability, and fire-safety, which limit the further popularization and application of materials. In this study, a hexasubstituted cyclotriphosphazene (HVP) was synthesized from abundant renewable vanillin, and then combined with two bio-based amines (castor oil polyamine and furan-derived diamine) to establish polyimine networks through a condensation reaction between amino groups and aldehyde groups. Five bio-based polyimine thermoset networks (FA-0, FA-25, FA-50, FA-75, and FA-100) were prepared with an ammonia-formaldehyde ratio of 1:1, and varying the ratio of the two bio-based amines allowed for regulating the final mechanical properties (from tough plastic-like to hard plastic-like) and flame resistance of the materials. Among the five experimental samples, FA-100 exhibited the best physical properties stress and Tg of 28.47 MPa and 63.8 °C, respectively. FA-100 networks also showed the best flame retardant properties (LOI, 28.8 vol/%). Furthermore, due to the dynamic imine bonds in the polymer network, the material could be recycled under hot pressing conditions (120 °C and 15 MPa). Meanwhile, the monomer HVP could be recovered under mild acidic circumstances. These thermosetting polyimine networks provide a new avenue for the development of multifunctional bio-based polymer materials for practical applications. [Display omitted] • Five bio-based polyimine networks were successfully prepared. • The ratio of two bio-based amines affects the properties of polymers. • Phosphoronitrile units make the polymer exhibit flame retardant properties. • The dynamic imine bond gives the material multiple recovery properties. [ABSTRACT FROM AUTHOR]

Abstract: Alcohol use disorder is common in patients with schizophrenia and is associated with poor clinical outcomes. Preliminary reports from our group and others suggest that the atypical antipsychotic clozapine may decrease alcohol use in these patients. We have previously shown that clozapine suppresses alcohol consumption for 9 days in Syrian golden hamsters. Here, we assessed the effects of clozapine on alcohol consumption in hamsters over a 27-day period, using a continuous access, 2-bottle (15% alcohol vs. water) protocol. Clozapine (4, 8, or 12 mg/kg/day, injected subcutaneously [s.c.]) dose-dependently suppressed alcohol drinking, while increasing food and water intake. There was no tolerance within individual groups to the effect of clozapine on alcohol drinking over time. In a separate experiment, the effects of clozapine on sucrose and water drinking and food intake over a 9-day period were assessed. Clozapine (4, 8, or 12 mg/kg/day s.c.) failed to suppress sucrose (0.09 M), food, or water consumption at any time-point tested. In a related study, assessment of blood alcohol levels in hamsters indicated that blood alcohol levels were maintained within a narrow and moderate range (7–13 mg/dL), levels noted by others to produce physiologic effects in rodents. The ability of clozapine to suppress alcohol drinking in the hamster over an extended period of time without suppressing sucrose, water, or food consumption is consistent with preliminary reports indicating that clozapine limits frequent alcohol use, even producing abstinence in many patients with schizophrenia. [Copyright &y& Elsevier]

Addiction research is challenged to disseminate evidence-based practices into routine clinical settings. The successful adoption of innovation must consider issues of fit, such as the characteristics, readiness, and attitudes of clinicians in the community. We constructed a survey to assess clinical practices and readiness to adopt certain evidence-based practices in addiction treatment programs. The instrument was administered to directors (n = 21) and clinicians (n = 89) from 24 public addiction treatment programs in New Hampshire (USA). Clinicians are more motivated to adopt some evidence-based practices (twelve-step facilitation, cognitive behavioral therapy, motivational interviewing, relapse prevention therapy) than others (contingency management, behavioral couples therapy, pharmacotherapies). Translational strategies for treatment development and research dissemination are discussed. [Copyright &y& Elsevier]

Medicaid recipients with serious mental illness die 25–30 years earlier than people in the general population due to health conditions that are modifiable through lifestyle changes. Cardiovascular diseases from excess weight, smoking, and sedentary lifestyle contribute substantially to this life expectancy disparity. The current study evaluated the impact of incentives on participation in weight management programming (for overweight and obese adults) and smoking cessation treatment (for regular smokers). Participants were Medicaid recipients with disabling mental illness receiving services at any one of 10 community mental health centers across New Hampshire. Using an equipoise stratified randomized design, n = 1348 were enrolled and assigned to one of four weight management programs (Healthy Choices Healthy Changes: HCHC) and n = 661 were enrolled and assigned to one of three smoking cessation interventions (Breathe Well Live Well: BWLW). Following assignment to an intervention, participants were randomized to receive financial incentives (to attend weight management programs, or to achieve abstinence from smoking) or not. Data were collected at baseline and every 3 months for 12 months. New Hampshire's HCHC and BWLW programs were designed to address serious and preventable health disparities by providing incentivized health promotion programs to overweight/obese and/or tobacco-smoking Medicaid beneficiaries with mental illness. This study was an unprecedented opportunity to evaluate an innovative statewide implementation of incentivized health promotion targeting the most at-risk and costly beneficiaries. If proven effective, this program has the potential to serve as a national model for widespread implementation. [ABSTRACT FROM AUTHOR]

Veterans from conflicts such as the wars in Iraq and Afghanistan commonly return with behavioral health problems, including posttraumatic stress disorder (PTSD) and hazardous or harmful substance use. Unfortunately, many veterans experience significant barriers to receiving evidence-based treatment, including poor treatment motivation, concerns about stigma, and lack of access to appropriate care. To address this need, the current study developed and evaluated a web-based self-management intervention based on cognitive behavioral therapy (CBT), targeting PTSD symptoms and hazardous substance use in a group of symptomatic combat veterans enrolled in VA primary care. Veterans with PTSD/subthreshold PTSD and hazardous substance use were randomized to primary care treatment as usual (TAU; n = 81) or to TAU plus a web-based CBT intervention called Thinking Forward (n = 81). Thinking Forward consisted of 24 sections (approximately 20 minutes each), accessible over 12 weeks. Participants completed baseline and 4-, 8-, 12-, 16-, and 24-week follow-up assessments. Three primary outcomes of PTSD, alcohol and other drug use, and quality of life were examined. Significant treatment effects were found for heavy drinking, but not for PTSD or quality of life. The effect of the intervention on heavy drinking was mediated by intervening increases in coping, social support, self-efficacy, and hope for the future. These results demonstrate the promise of a web-based, self-management intervention for difficult-to-engage OEF/OIF veterans with behavioral health and substance use concerns. [ABSTRACT FROM AUTHOR]

People with serious mental illness (SMI) and intellectual disabilities and/or developmental disabilities (ID/DD) living in group homes (GHs) and residential staff are at higher risk for COVID-19 infection, hospitalization, and death compared with the general population. We describe a hybrid type 1 effectiveness-implementation cluster randomized trial to assess evidence-based infection prevention practices to prevent COVID-19 for residents with SMI or ID/DD and the staff in GHs. The trial will use a cluster randomized design in 400 state-funded GHs in Massachusetts for adults with SMI or ID/DD to compare effectiveness and implementation of "Tailored Best Practices" (TBP) consisting of evidence-based COVID-19 infection prevention practices adapted for residents with SMI and ID/DD and GH staff; to "General Best Practices" (GBP), consisting of required standard of care reflecting state and federal standard general guidelines for COVID-19 prevention in GHs. External (i.e., community-based research staff) and internal (i.e., GH staff leadership) personnel will facilitate implementation of TBP. The primary effectiveness outcome is incident SARS-CoV-2 infection and secondary effectiveness outcomes include COVID-19-related hospitalizations and mortality in GHs. The primary implementation outcomes are fidelity to TBP and rates of COVID-19 vaccination. Secondary implementation outcomes are adoption, adaptation, reach, and maintenance. Outcomes will be assessed at baseline, 3-, 6-, 9-, 12-, and 15-months post-randomization. This study will advance knowledge on comparative effectiveness and implementation of two different strategies to prevent COVID-19-related infection, morbidity, and mortality and promote fidelity and adoption of these interventions in high-risk GHs for residents with SMI or ID/DD and staff. Clinical Trial Registration Number: NCT04726371. [ABSTRACT FROM AUTHOR]

Background: Young people who engage in substance use are at risk for becoming infected with HIV and diseases with similar transmission dynamics. Effective disease prevention programs delivered by prevention specialists exist but are rarely provided in systems of care due to staffing/resource constraints and operational barriers-and are thus of limited reach. Web-based prevention interventions could possibly offer an effective alternative to prevention specialist-delivered interventions and may enable widespread, cost-effective access to evidence-based prevention programming. Previous research has shown the HIV/disease prevention program within the Web-based therapeutic education system (TES) to be an effective adjunct to a prevention specialist-delivered intervention. The present study was the first randomized, clinical trial to evaluate the comparative effectiveness of this Web-based intervention as a standalone intervention relative to a traditional, prevention specialist-delivered intervention.Methods: Adolescents entering outpatient treatment for substance use participated in this multi-site trial. Participants were randomly assigned to either a traditional intervention delivered by a prevention specialist (n=72) or the Web-delivered TES intervention (n=69). Intervention effectiveness was assessed by evaluating changes in participants' knowledge about HIV, hepatitis, and sexually transmitted infections, intentions to engage in safer sex, sex-related risk behavior, self-efficacy to use condoms, and condom use skills.Findings: Participants in the TES intervention achieved significant and comparable increases in HIV/disease-related knowledge, condom use self-efficacy, and condom use skills and comparable decreases in HIV risk behavior relative to participants who received the intervention delivered by a prevention specialist. Participants rated TES as easier to understand.Conclusion: This study indicates that TES is as effective as HIV/disease prevention delivered by a prevention specialist. Because technology-based interventions such as TES have high fidelity, are inexpensive and scalable, and can be implemented in a wide variety of settings, they have the potential to greatly increase access to effective prevention programming. [ABSTRACT FROM AUTHOR]

Background Technology-based interventions (TBIs) for substance use disorders have been increasing steadily. The mechanisms by which TBIs produce change in substance use outcomes have not been reviewed. This article is the first review of the conceptual and empirical underpinnings of the mechanisms associated with TBIs for substance use disorders. Methods We review the literature on potential mechanisms associated with TBIs targeting tobacco, alcohol, and poly-substance use. We did not identify TBIs targeting other drug classes and that assessed mechanisms. Results Research suggests that TBIs impact outcomes via similar potential mechanisms as in non-TBIs (e.g., in-person treatment), with the exception of substance use outcomes being associated with changes in the quality of coping skills. The most frequent potential mechanisms detected were self-efficacy for tobacco abstinence and perceived peer drinking for alcohol abstinence. Conclusions Research on mechanisms associated with TBIs is still in a nascent stage. We provide several recommendations for future work, including broadening the range of mechanisms assessed and increasing the frequency of assessment to detect temporal relations between mechanisms and outcomes. We also discuss unique challenges and opportunities afforded by technology that can advance theory, method, and clinical practice. [ABSTRACT FROM AUTHOR]

Abstract: Emerging evidence suggests that the atypical antipsychotic clozapine decreases alcohol consumption in patients with schizophrenia, while typical antipsychotics, all of which are potent dopamine (DA) D2 receptor antagonists, do not. We have proposed that clozapine, through its weak DA D2 receptor blocking action, coupled with its ability to potentiate noradrenergic and serotonergic activity, may ameliorate a dysfunction in the mesocorticolimbic DA reward circuitry that underlies alcohol use disorder in patients with schizophrenia. In prior studies, we have demonstrated that clozapine also decreases alcohol drinking in the Syrian golden hamster, but haloperidol does not. The purposes of the current study were: (1) to further assess the effect of clozapine (2 or 4 mg/kg/day, s.c.) on alcohol consumption in hamsters, using a continuous access, 2-bottle choice paradigm; and (2) to examine whether clozapine’s effect on alcohol drinking is affected by increasing its DA D2 blockade through adjunctive use of the potent DA D2 receptor antagonist raclopride (2, 4, or 6 mg/kg/day, s.c.). The major findings were: (1) clozapine suppressed both initiation and maintenance of alcohol drinking in hamsters; and (2) these effects of clozapine were lessened when raclopride was given adjunctively with clozapine. These data suggest that clozapine may limit alcohol drinking in the golden hamster (and possibly in patients with schizophrenia) in part because of its weak blockade of the DA D2 receptor. [Copyright &y& Elsevier]

Background: Most studies of active travel to school (ATS) have been conducted in urban or suburban areas and focused on young children. Little is known about ATS among rural adolescents. Purpose: To describe adolescent ATS in two predominantly rural states and determine if school neighborhood built environment characteristics (BECs) predict ATS after adjusting for school and individual characteristics. Methods: Sixteen BECs were assessed through census data and onsite observations of 45 school neighborhoods in 2007. ATS and individual characteristics were assessed through telephone surveys with 1552 adolescents and their parents between 2007 and 2008. Active travelers were defined as those who walked/cycled to/from school ≥1 day/week. Hierarchic linear modeling was used for analysis, conducted in 2009. Results: Slightly less than half (n=735) of the sample lived within 3 miles of school, of whom 388 (52.8%) were active travelers. ATS frequency varied by season, ranging from a mean of 1.7 (SD=2.0) days/week in the winter to 3.7 (SD=1.6) in the spring. Adolescents who attended schools in highly dense residential neighborhoods with sidewalks were most likely to be active travelers. ATS frequency was greater in school neighborhoods with high residential and intersection densities, on-street parking, food outlets, and taller and continuous buildings with small setbacks. Conclusions: The BECs that support safe travel may be necessary to allow for ATS, whereas ATS frequency among adolescents may be influenced by a wider variety of design characteristics. Additional strategies to promote ATS and physical activity are needed in rural areas because of long commuting distances for many students. [Copyright &y& Elsevier]

Health anxiety is a chronic mental health condition that exerts substantial personal and economic burdens on patients, providers, and the larger healthcare system. Patients with health anxiety experience persistent worry and dread over the possibility that they are presently ill with an undetected or poorly defined physical illness or may soon become ill despite an absence of evidence and physician reassurance of wellness. A complication of health anxiety is that the sufferer frequently denies the presence of excessive anxiety, typically attributing their distress to an inability of the medical team to correctly identify the feared illness. As a result, these patients are challenging to engage in evidence-based psychosocial interventions. The present study protocol describes a psychosocial intervention based on cognitive-behavioral therapy that is adapted for delivery by Medical Assistants in the primary care setting. The rationale for this approach is that delivery by Medical Assistants has the potential to overcome barriers to engagement that prevent effective care. Moreover, deploying a task-shifted intervention relieves strain on the care team by sharing the responsibility for helping the patient manage health anxiety. The aim of this study is to demonstrate the effectiveness of this intervention and approach on health anxiety, while simultaneously collecting data on the barriers and facilitators of implementation, consistent with a hybrid type 1 study design. We will compare patient-level outcomes for participants randomized to the study intervention versus routine referral to mental health services and characterize the potential for implementation using qualitative data drawn from patient and clinical stakeholders. • Health anxiety is a common and chronic mental health condition. • Patients with health anxiety frequently refuse psychosocial intervention. • Psychosocial intervention led by Medical Assistants may improve engagement. • We will evaluate the effectiveness and implementation of this approach. [ABSTRACT FROM AUTHOR]