by Michael D. Anestis, M.S.
I had actually planned to write about a different topic today, but an interaction this morning led me to shift gears. A few hours ago, I attended a seminar led by Carl Lejuez of the University of Maryland, whose work on distress tolerance has been covered on PBB on prior occasions. Today, he gave a presentation on behavioral treatments of depression in individuals with substance use disorders. He discussed some impressive data in a very modest manner and left me thinking a lot about the material. Anyway, I thought it might make sense to share with you a brief overview of the rationale for his presentation and a couple of the studies he discussed.
Dr.Lejuez noted that, in large part, behavioral treatments have been overshadowed by the cognitive revolution. Therapeutic approaches like behavioral activation have come to be thought of as components of larger approaches rather than stand alone treatments. That being said, there has been a bit of a resurgence in behavioral treatments in recent years. Now, Dr.Lejuez was careful to point out that this resurgence might be moving a little too quick given the strength of the data and that nobody is saying that cognitive approaches are unhelpful or less valuable. The true point to take from the situation is that there is mounting evidence that strictly behavioral approaches might have some real value in their own right and that they might be readily applied in populations that might not respond as well to more complex forms of treatment.
The real focus of the presentation was on using behavioral treatments for clients with comorbid depression and substance use disorders. In discussing the topic in general, he set the stage for the value of these approaches by making what, to me, was a really interesting point. To paraphrase him, Dr.Lejeuz said we need to make the alternative choices suggested in therapy more like substance use. I realize that sounds a little wacky, but here's what he meant:
- Addictive substances offer immediate, guaranteed reinforcing properties (rewards). These properties could include any pleasure associated with intoxication (positive reinforcement) as well as an opportunity to escape from uncomfortable emotions, thoughts, or physical sensations (negative reinforcement). When determining whether or not to use, these rewards are very salient and heavily influence the individual's eventual decision.
- Similarly, depressive behaviors can have immediate, guaranteed reinforcing properties. For instance, choosing to stay in bed might allow for an escape from negative thoughts and emotions.
- When we make suggestions in therapy that offer potential long term benefits, but no immediate short term high likelihood reward, we are not asking for a fair trade with the client. The value of the maladaptive behaviors comes, in large part, from the fact that their rewards are immediate and guaranteed. Treatments need to be able to supply healthy options that provide that same reward scheme, otherwise the price of the healthy decision will seem too steep given the potential value of the harmful behavior.
So, the point in behavioral treatments - and this is a gross over simplification here, so please do not assume that this explains everything going on in the therapy room and between sessions - is to help the client plan rewarding behaviors in valued areas of their lives and to implement these behaviors in a planned and consistent manner. The idea here is that, with greater positive and healthy experiences, symptoms of depression and/or substance use will decline. All this being said, let's take a look at a couple of studies on which Dr.Lejeuz collaborated with a number of colleagues.
Daughters et al. (2008)
In 2008, Stacey Daughters and a number of her colleagues published a study in the Journal of Clinical Psychiatry on a behavioral treatment for substance abusing clients with elevated symptoms of depression. This is particularly noteworthy because it is fairly rare for a study on a purely behavioral treatment to be published in a psychiatry journal.
Daughters et al (2008) opened their article with a clear justification for investigating this issue in this population. For one thing, depression rates are highly elevated in illicit drug-dependent populations (e.g., Regier et al., 1990). Additionally, there is compelling evidence that depressed drug users are more likely than non-depressed drug users to prematurely drop out of treatment and to relapse (e.g., Brown et al., 1998; McKay et al., 2002). Thus far, treatments aimed at targeting depressive symptoms in individuals with substance use disorders have been primarily pharmacological in nature (Carpenter et al., 2004; McDowell, Nunes, & Seracini, 2005), so there is a clear need to investigate the relative merit of psychosocial interventions.
The first instinct for most scientifically-minded psychologists might be to investigate cognitive behavioral therapy (CBT) as a useful approach; however, as strong as the results are in general from this approach, there are reasons to wonder whether it might be less successful here. Specifically, Daughters and colleagues (2008) noted that the time demands of CBT - typically 12-20 sessions - would be difficult to meet in standard substance use treatment protocols in which clients are generally only in treatment for a limited number of days (Morgenstern et al., 2001). Additionally, they noted that the more complex components of cognitive techniques might be difficult to successfully implement in a sample of chronic drug users, as such samples tend to involve low educations levels and cognitive deficits (Aharonovich et al., 2006). Third, they noted that the counselors involved in many substance use treatment teams might lack the training to successfully implement cognitive protocols. I am admittedly a bit skeptical about this third point (click here to read our coverage of another study in which nurses with very little training successfully implemented a CBT protocol for inpatient clients with schizophrenia), but it is certainly a point worth investigating empirically.
So, in this study, the authors randomly assigned 44 inpatient clients with substance use disorders and elevated depression symptoms to receive either treatment as usual (TAU) or TAU plus a brief behavioral treatment called Life Enhancement Treatment for Substance Use (LETS Act!). TAU consisted of daily Alcoholics Anonymous/Narcotics Anonymous meetings and daily treatment groups, which covered topics such as relapse prevention, functional analysis, stress management, and spirituality. LETS Act! was based upon an empirically supported behavioral protocol known as Behavioral Activation for Depression (BAT-D). This component of treatment involved six small group sessions (3-5 patients per group) over a 2-week period. The first three sessions were one hour in length and the final three were approximately 30 minutes. The language and concepts in the protocol were simplified and adjusted to more specifically reference substance use.
Individuals in the TAU group did not improve on depression symptoms as measured by the Hamilton Rating Scale for Depression (HAM-D), anxiety symptoms as measured by the Beck Anxiety Inventory (BAI) or enjoyment and reward value in activities from pretreatment to post-treatment (click here to view our "Assessment Tools" page and to learn more about these measures). They did, however, improve during this time period on depression symptoms as measured by the Beck Depression Inventory (BDI-II). The improvement in BDI-II scores did not continue between post-treatment and 2-week follow-up and 22.5% of the participants in this group dropped out of treatment for non-medical reasons.
Individuals in the LETS Act! group significantly improved from pretreatment to post-treatment on depression symptoms (HAM-D and BDI-II), anxiety symptoms, and enjoyment and reward value in activities. Additionally, significant improvements were seen in depression symptoms (BDI-II) from post-treatment to follow-up. Only 4.5% of individuals in the LETS Act! group dropped out of treatment for non-medical reasons and the average level of client satisfaction with treatment was higher than in the TAU group.
So, it appears that individuals in the TAU group had a rather poor treatment response whereas the LETS Act! protocol resulted in fairly strong responses. Given that this study was conducted in an inpatient facility with an underrepresented population, this is very useful information. That being said, the study was not without limitations, in that depression symptoms were measured purely by self-report rather than diagnostic interviews, the sample size was rather small, and the follow-up period was only two-weeks post-treatment. Given all of these strengths and weaknesses, the message that Dr.Lejuez kept mentioning in his presentation today seems more than reasonable: these results should not be seen as proving anything or completely shift the way we think about treating this particular population, but they do provide a strong foundation upon which to build future research on this topic. In other words, there is reason to believe that LETS Act! is a promising treatment for individuals with comorbid depression and substance use disorders, but we need to compile more evidence to feel more secure in saying this.
MacPherson et al., 2010
In the most recent issue of the Journal of Consulting and Clinical Psychology, Laura MacPherson and colleagues (2010) published a similar study. In this one, the authors examined the utility of behavioral activation for smoking (BATS) relative to standard treatment for individuals with nicotine additions. The background justifying this study is rather similar to that of the Daughters et al (2008) work, so rather than repeat that information, let me simply tell you what they did and what they found.
68 adult smokers were randomly assigned to receive either BATS plus standard treatment (ST) smoking cessation strategies or ST alone. In both groups, ST included nicotine replacement therapy. In both conditions, quit date was assigned as the fourth session and follow-up assessments were taking at 1, 4, 16, and 26 weeks post quit date.
Higher baseline depression scores were associated with lower odds of abstinence and females were less likely than males to remain abstinent from smoking. That being said, there was a linear trend in both groups indicating that overall smoking rates decreased during the course of treatment. Across each follow-up assessment, individuals in the BATS plus ST group demonstrated greater smoking abstinence and greater relief from depression symptoms.
Here again, there are a number of strengths and weaknesses to the study. In his presentation this morning, Dr.Lejuez again cautioned against becoming overly enthusiastic in response to this study or inferring that behavioral success negates the importance of cognitive techniques. At the same time, he noted that these results are promising and highlight the importance of implementing very specific behavioral changes in individuals whose symptoms match those of the folks in this study.
Essentially, what Dr.Lejuez talked about this morning and what these two studies demonstrate is that there is evidence to support the notion that purely behavioral treatments can have a strong impact on both depression and substance use symptoms in individuals who struggle with both of those difficulties. This does not discredit other approaches and the evidence presented in these two studies is preliminary in nature, but despite the limitations, these studies provide us with some meaningful results to consider and a powerful theoretical framework through which to consider them.
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