Psychotherapy Brown Bag

Behavioral treatment of depression for individuals with substance use disorders

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.

Rationale

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.

Results:

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.

Results:

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.

Overall Summary

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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If you would like to learn more about the topics discussed on PBB, we recommend that you consult our online store for scientifically-based psychological resources.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

Quitting smoking cessation treatment before treatment even begins: The role of psychological and physical distress tolerance

by Michael D. Anestis, M.S.

Anyone who has tried to quit smoking will attest to the fact that doing so is extremely difficult.  If this was not the case, companies that produce products aimed to help in the process would not be nearly as profitable as they are.  Despite the likely universal agreement that quitting smoking is difficult, however, there are clear differences between individuals on exactly how hard the process is.  For some people, quitting is cumbersome, but can be accomplished quickly without relapse.  For others, relapse occurs soon after recovery if recovery happens at all.  Because of these differences, a number of researchers have compiled data in studies attempting to determine what variables account for particular individuals' inability to persist in quit attempts, with the hope of then devising treatment techniques aimed at altering those variables and decreasing the difficulty of quitting.  Less attention has been paid to another subsection of the population that is of equal importance: those who quit treatment prior to their first session.  Quite obviously, pre-treatment attrition is unlikely to result in a positive outcome, so identifying who is most likely to quit treatment before it begins and initiating treatments capable of addressing their particular vulnerabilities would serve to increase the success rate of smoking cessation interventions.

A group of researchers - MacPherson, Stipleman, Duplinsky, Brown, and Lejuez (2008) - recently published a study that provided some insight into why certain individuals do not even make it to their initial treatment session after agreeing to take part in a smoking cessation program.  The authors of this particular study noted that prior research had already demonstrated links between a variety of variables and pre-treatment attrition, including motivation to quit, younger age, lower education, weight concerns, and a history of psychotropic medication use (Ahluwalia et al., 2002; Copeland, Marin, Geiselman, Rash, & Kendzor, 2006; Curtin, Brown, & Sales, 2000; Schnoll et al., 2004; Woods et al., 2002).  Less research, they noted, had been conducted examining the relationship between affective variables and pre-treatment attrition.  Affective variables, unlike some of the variables listed above (e.g., age, education level, and history of psychotropic medication use), are excellent targets for psychosocial interventions and, as such, identifying affective variables relevant to pre-treatment attrition would provide an avenue for potential points of treatment.

Along these lines, the authors noted that depression symptoms have been linked to poorer treatment outcomes in individuals attempting to quit smoking (Kassel & Hankin, 2006).  Surprisingly, however, depression symptoms have been shown to be unrelated to pre-treatment attrition (El-Khorazaty et al., 2007), meaning that this particular affective variable does not account for why some individuals do not even make it to their first session.  As such, the authors designed a study examining a different set of affective variables - psychological and physical distress tolerance - as possible explanations for pre-treatment drop-out.  Psychological distress tolerance, as defined in this particular study, is the degree to which an individual will continue with goal directed behavior in the presence of negative emotions.  Physical distress tolerance, on the other hand, involves persistence in goal directed behavior in the presence of physical discomfort.  Prior studies have linked low levels of distress tolerance to a variety of problematic outcomes, including increased severity of substance use (Quinn, Brandon, & Copeland, 1996), shorter time to relapse in individuals attempting to quit smoking or drugs (Brandon et al., 2003; Brown, Lejuez, Kahler, & Strong, 2002), in patient substance use treatment drop-out (Daughters et al., 2005), binge eating (Anestis, Selby, Fink, & Joiner, 2007), and non-suicidal self-injury (NSSI; Nock & Mendes, 2008).

In this study, the authors examined psychological and physical distress tolerance in a sample of 53 adult smokers signed up to participate in a randomized controlled trial of a behavioral activation treatment for smokers with depression.  Psychological distress tolerance was measured using two computer tasks, each of which ask participants to engage in increasingly difficult tasks.  Psychological distress tolerance is measured by how long participants persist on the task after being given the option to quit.  Physical distress tolerance was measured by two tasks that required the participants to experience moderate levels of physical discomfort.  In one task, participants were told to hold their breath and signal when they first felt discomfort.  They were told to then continue holding their breath until they were no longer able to tolerate the discomfort.  Physical distress tolerance was measured by the number of seconds between the first experience of discomfort and the point at which the participant quit the task.  The second physical distress tolerance task - a cold pressor - required participants to place their arm in a container full of freezing water.  Again, they indicated when they first felt discomfort, then persisted until they were unable to tolerate the sensation any longer, with physical distress tolerance measured by the number of seconds between the first feeling of discomfort and the time at which the participant quit the task.

The authors noted that prior research has indicated that women are more likely to smoke in an effort to reduce negative emotions (al'Absi, 2006) whereas men are more likely to smoke due to the physiological effects of nicotine (Perkins, 2001) and, as such, they anticipated that psychological distress tolerance would be a significant predictor of pre-treatment attrition for women whereas physical distress tolerance would be a significant predictor for men.  Indeed, the results were consistent with their hypotheses.  Women who dropped out of treatment prior to their first session were less able to persist in one of the psychological distress tolerance tasks than were both men and women in the treatment engagement group (individuals who took part in at least one treatment session).   On the other hand, men who dropped out of treatment prior to their first session were less able to persist in either of the physical distress tolerance tasks than were men in the treatment engagement group.

Ultimately, these findings tell us several things.  First, psychological distress tolerance appears to be a particularly important variable in determining which women are likely to drop out of smoking cessation treatment prior to attending their first treatment session.  Second, physical distress tolerance appears to be a particularly important variable in determining which men are likely to drop out of smoking cessation treatment prior to attending their first treatment session.  With respect to psychological distress tolerance, these findings have important treatment implications.  Dialectical behavior therapy (DBT; Linehan, 1993) includes a component that is specifically designed to increase psychological distress tolerance skills.  As such, it might be beneficial to include DBT distress tolerance skills in the initial stages of smoking cessation treatments - perhaps even during the initial assessment appointment - in an effort to decrease pre-treatment attrition.  Similarly, the findings relevant to physical distress tolerance also have important treatment implications.  Men with low physical distress tolerance might benefit from interoceptive exposure exercises.  As Joye noted earlier this week in an article on interoceptive exposure, this particular treatment approach reduces anxiety regarding specific physical sensations and, when paired with aspects of cognitive therapy, can also help individuals to change the way they interpret and respond to those same physical sensations.

As is the case with any study, there were some important limitations to note when drawing conclusions regarding the data.  First, the sample size was fairly small, which can limit the ability of researchers to statistically detect important between and within group effects.  Additionally, the exclusion criteria were quite extensive.  Individuals who were outside the age range (18-65 years of age), did not exhibit sufficient depressive symptoms, did not endorse motivation to quit smoking, met criteria for a DSM-IV disorder (other than depression), met criteria for any substance use or dependence (other than nicotine) in the past six months, were currently using psychotropic medication or psychotherapy, were unable to use the nicotine patch for physical reasons, or did not smoke enough cigarettes (at least 10 per day) or smoke long enough (at least one year) were excluded from the study.  Obviously, this means that the sample was not necessarily representative of the population in general and, as such, it is unclear to what degree these findings apply to individuals who differ on those variables.  The criteria were strict for a reason - to rule out these variables as better explanations for pre-treatment attrition - but future studies will need to change the exclusion criteria in order to increase the generalizability of the findings.

Ultimately, the take-home points from this particular study are quite clear.  First, it appears that men and women may differ on their reasons for quitting smoking cessation treatment prior to the onset of treatment.  Second, distress tolerance, whether distress refers to psychological or physical discomfort, appears to play a pivotal role in the vulnerability to pre-treatment attrition.  Finally, because distress tolerance is a variable that can be directly addressed through empirically supported treatments, there is reason to believe that clinicians can help to increase the likelihood that vulnerable individuals will remain in treatment.

If you would like to learn more about distress tolerance, dialectical behavior therapy, or smoking cessation, we recommend the following products, all of which can be found through our online store:

• Cognitive-Behavioral Treatment of Borderline Personality Disorder

• Skills Training Manual for Treating Borderline Personality Disorder

• Dialectical Behavior Therapy for Binge Eating and Bulimia

• Cognitive-Behavioral Therapy for Smoking

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.