Björn Philips

Methylphenidate for attention deficit hyperactivity disorder and drug relapse in criminal offenders with substance dependence: a 24‐week randomized placebo‐controlled trial

Aim To test the efficacy and safety of osmotic release oral system (OROS) methylphenidate (MPH) in doses up to 180 mg/day to treat attention deficit hyperactivity disorder (ADHD) and prevent any drug relapse in individuals with a co-diagnosis of ADHD and amphetamine dependence. Design Randomized placebo-controlled 24-week double-blind trial with parallel groups design. Setting Participants were recruited from medium security prisons in Sweden. The medication started within 2 weeks before release from prison and continued in out-patient care with twice-weekly visits, including once-weekly cognitive behavioural therapy. Participants Fifty-four men with a mean age of 42 years, currently incarcerated, meeting DSM-IV criteria for ADHD and amphetamine dependence. Measurements Change in self-reported ADHD symptoms, relapse to any drug use (amphetamine and other drugs) measured by urine toxicology, retention to treatment, craving and time to relapse. Findings The MPH-treated group reduced their ADHD symptoms during the trial (P = 0.011) and had a significantly higher proportion of drug-negative urines compared with the placebo group (P = 0.047), including more amphetamine-negative urines (P = 0.019) and better retention to treatment (P = 0.032). Conclusions Methylphenidate treatment reduces attention deficit hyperactivity disorder symptoms and the risk for relapse to substance use in criminal offenders with attention deficit hyperactivity disorder and substance dependence.

Long-term outcome and post-treatment effects of psychoanalytic psychotherapy with young adults

OBJECTIVES The short- and long-term effects of open-ended, long-term psychoanalytic psychotherapy for young adults were investigated. Possible changes during the year and a half follow-up, as well as predictors of change, were explored. DESIGN Patients aged 18-25 years who accepted the offered psychoanalytic individual or group psychotherapy were included. Patients filled out questionnaires and were interviewed at intake, termination, and follow-up. Alliance data were collected after the second session of psychotherapy proper. METHODS The primary outcome measures were the Symptom Checklist-90 and the Inventory of Interpersonal Problems. The Helping Alliance Questionnaire-II was used to measure alliance. Mixed model ANOVAs were used to analyse changeover time and prediction of change in relation to gender, treatment format, treatment duration, and in individual psychotherapy, therapist- and patient-rated alliance. RESULTS All outcome measures changed significantly from intake to follow-up. None changed significantly during the follow-up period, but there was a tendency towards recurring symptoms and an improvement in one of the object relational measures during the follow-up. The latter was the only outcome measure that did not change significantly during treatment. Lower therapist-rated alliance was predictive of greater change in psychiatric symptoms for patients with high levels of symptoms at intake. CONCLUSIONS The long-term effectiveness of psychoanalytic psychotherapy for young adults was supported. Low therapist-rated alliance implies that the therapists have identified problematic interactions, which might have mobilized their effort to solve the problems. Further research on cases reporting no gain or even deterioration is needed.

An Epidemiological Study of ADHD, Substance Use, and Comorbid Problems in Incarcerated Women in Sweden

Objective: The aim of this study was to examine the prevalence of ADHD and psychiatric comorbidity, including substance use in incarcerated women. Method: This was a cross-sectional study, consisting of two parts: (a) screening using the ADHD Self-Rating Scale (ASRS) and (b) diagnostic assessment using a structured interview. Results: A sample of 96 incarcerated women was screened and 56 underwent the diagnostic assessment. Twenty-nine percent of the women met the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnostic criteria for adult ADHD in the diagnostic assessment. Forty-four of the women had misuse of alcohol, and 83% had misuse of narcotics the year prior to the incarceration. The ASRS showed sensitivity of 1.0 and specificity of 0.66. Conclusion: The prevalence rate of ADHD in incarcerated women was high and comparable to that in male offenders. Illicit stimulant use and antisocial personality disorder were significantly more common in women with ADHD. ASRS is useful as a screener in this population.

The Swedish version of the Outcome Questionnaire (OQ-45): Reliability and factor structure in a substance abuse sample

This study described the psychometric properties of the Swedish version of the Outcome Questionnaire (OQ-45.2) in a substance abuse sample (N=227). The test properties were satisfactory except for somewhat low internal consistency in the social role subscale. The results were similar to those obtained in other countries but systematic international comparisons are still lacking.

Mentalization-based therapy adherence and competence stimulates in-session mentalization in psychotherapy for borderline personality disorder with co-morbid substance dependence

Abstract Objective: To test whether adherence to mentalization-based treatment (MBT) principles predict better patient in-session mentalizing. Methods: Two sessions for each of 15 patients with borderline personality disorder and comorbid substance abuse disorder were rated for MBT adherence and competence. Individual patient statements were rated for Reflective Functioning (RF), therapist statements were rated as demanding RF or not. Data were analysed using multilevel modelling. Results: MBT adherence and competence predicted higher session RF (β = .58–.75), even while controlling for pre-treatment RF. In addition, therapist interventions directed toward exploring mental states predicted higher RF of subsequent patient responses (β = .11–.12). Conclusions: MBT adherence and competence were significantly related to patient in-session mentalizing, supporting the validity of MBT principles. Results point to the importance of supervision for therapists to become adherent to MBT principles. The small number of patients and sessions limits generalizability of results.

Comparing apples and oranges: how do patient characteristics and treatment goals vary between different forms of psychotherapy?

OBJECTIVES The aim is to investigate whether different modalities and orientations of psychotherapy diverge with regard to patient characteristics and treatment goals, in a naturalistic setting for patients with substance use disorders. DESIGN All psychotherapies (N=262) during a year were surveyed at the Centre for Dependency Disorders, Stockholm County Council. Data were collected from the psychotherapists (N=38). METHODS A therapist questionnaire was used, covering the topics of interest. Data regarding problems and goals were categorized using a qualitative clustering method. Differences between therapy formats were analysed using statistical methods. RESULTS The prevalence of psychological problems among the patients was high (88%). Patients in cognitive behaviour therapy (CBT) and family therapy (FT) had less severe psychological problems than patients in the other psychotherapy formats. With regard to treatment goals, FT focused on improved family relations, group therapies on relational improvements, psychodynamic therapies on insight and improved functioning, while CBT focused on behaviour change and improved motivation for change. CONCLUSIONS These findings suggest a shortcoming of the aim of the EST movement to consider reduction of target symptom as the only relevant treatment goal and to compare the efficacy of different treatments in this regard.

Client and therapist agreement about the client's problems—Associations with treatment alliance and outcome

Abstract Objective: A shared understanding of the patients symptoms and problems is seen by most theories as a crucial aspect of the collaboration in therapy, presumably influencing alliance and outcome. The empirical ground for this argument is not solid, however. Several studies have found weak associations between a common view of the patients problems and outcome. The purpose of the present study was to analyze whether agreement in the understanding of the patients depression and anxiety problems was important for alliance and outcome. Method: The study used data from a practice-based study using the CORE system with 846 patients who received psychological treatment in primary care. Results: The analyses indicated that although patients who were assessed by their therapists as having depression and anxiety problems scored higher on these subscales than other patients, about half of the patients reported such problems when the therapists did not, and vice versa. Agreement was not associated with better alliance or outcome. Conclusions: Productive collaboration in psychotherapy may be based on other factors than agreement about symptoms.

Outcome of psychological treatment of patients with substance use disorders in routine care

Abstract Background: More knowledge is needed about outcome of treatments in routine care for patients with substance use disorders (SUDs). These patients often suffer from psychological distress in addition to SUDs. Objectives: To evaluate the effects of community-based psychological treatment on SUD patients’ psychosocial problems, as well as on their substance use. Design: All patients who were referred or self-referred for psychological treatment to a social worker or a psychotherapist at three outpatient treatment centers for SUD patients were asked to participate in the study. Methods: Ratings at treatment start and end were obtained on Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM, n = 100), Alcohol Use Disorders Identification Test - Consumption (AUDIT-C, n = 49), and Drug Use Disorders Identification Test - Consumption (DUDIT-C, n = 27). Results: CORE-OM mean scores were significantly improved. In total 14% of the patients were recovered, 10% improved, and 5% deteriorated. Both AUDIT-C and DUDIT-C mean scores were significantly improved for patients with alcohol use and patients using illicit drugs, respectively. Conclusions: Routine psychological treatment had positive effects on psychological distress as well as on reduction of substance use. A substantial number of patients remained however unchanged, particularly regarding psychological distress. More studies with larger patient groups are needed to develop treatment for SUD patients in routine care.

Mentalization-Based Treatment for Concurrent Borderline Personality Disorder and Substance Use Disorder: A Randomized Controlled Feasibility Study

Aims: There is a scarcity of clinical trials on psychological treatments for concurrent borderline personality disorder (BPD) and substance use disorder (SUD). Mentalization-based treatment (MBT) have shown efficacy in several trials on BPD. The aim of the present study was to examine the feasibility and effectiveness of MBT for concurrent BPD and SUD. Methods: Patients (n = 46) with concurrent BPD and SUD were randomized either to MBT in combination with SUD treatment (n = 24) or to SUD treatment alone (n = 22). Outcome was measured after 18 months using objective data, as well as interview and self-report measures. Results: There was no significant difference between the groups on any outcome variable. No suicide attempts occurred in the MBT group in contrast to 4 suicide attempts that occurred in the control group – a difference that did not reach statistical significance (p = 0.06). A majority of the therapists did not show sufficient MBT adherence and quality. Conclusion: MBT for patients with concurrent BPD and SD does not appear to be harmful; on the other hand, it is possibly helpful in reducing the risk involved in suicide attempts.

Early Therapeutic Process Related to Dropout in Mentalization-Based Treatment With Dual Diagnosis Patients.

Negative therapeutic reaction was first described by Freud, and theories about this phenomenon have focused on various patient factors, for example, unconscious guilt, narcissistic pride, and overwhelming feelings of shame, as well as devaluation of the therapist as a defense against envy. Different strategies to counteract negative therapeutic reactions in patients with severe personality disorder have been proposed. Bateman and Fonagy suggested that some psychoanalytic techniques are iatrogenic for patients with borderline personality disorder and, thus, the therapeutic method must be modified. One manifestation of negative therapeutic reaction is that patients discontinue therapy prematurely. The aim of this study was to explore the differences in the early therapeutic process between therapy dropouts and therapy completers in mentalization-based treatment (MBT) for patients with concurrent borderline personality disorder (BPD) and substance use disorder (SUD). The first 2 videotaped therapy sessions from 6 MBT therapies were selected—3 therapies that were completed and 3 therapies that were prematurely discontinued by the patient. The therapy process was analyzed using the Psychotherapy Process Q set (PQS). Lists of the most frequent and least frequent PQS items among therapy completers versus dropouts are presented. In comparing the sessions from therapy completers and dropouts, significant differences in frequencies were detected for 13 PQS items. These items included therapist and patient activities, as well as features of the therapeutic interaction. Continuation in therapy seems to be related to therapists’ general skills and adherence to MBT, as well as patients bringing up significant material and not being distant.