Cor A.J. de Jong

E-therapy for mental health problems: a systematic review.

The widespread availability of the Internet offers opportunities for improving access to therapy for people with mental health problems. There is a seemingly infinite supply of Internet-based interventions available on the World Wide Web. The aim of the present study is to systematically assess the methodological quality of randomized controlled trials (RCTs) concerning e-therapy for mental health problems. Two reviewers independently assessed the methodological quality of the RCTs, based on a list of criteria for the methodological quality assessment as recommended by the Cochrane Back Review Group. The search yielded 14 papers that reported RCTs concerning e-therapy for mental-health problems. The methodological quality of studies included in this review was generally low. It is concluded that e-therapy may turn out to be an appropriate therapeutic entity, but the evidence needs to be more convincing. Recommendations are made concerning the method of reporting RCTs and the need to add some content items to an e-therapy study.

Psychiatric Comorbidity Reduces Quality of Life in Chronic Methadone Maintained Patients

Despite the efficacy of methadone maintenance treatment (MMT), opioid dependence still involves severe impairment of functioning and low quality of life. This study examines the influence of the psychiatric comorbidity of MMT patients on their quality of life. A total of 193 middle-aged patients in long-term MMT were assessed for current and lifetime Axis I psychiatric disorders, substance use disorders, and personality disorders using the MINI, the CIDI-SAM, and the SIDP-IV. Quality of life (Qol) was assessed using the EQ-5D. Psychiatric comorbidity was documented in 78% of the patients. Mood disorders (60%) and anxiety disorders (46%) were the most common diagnoses. Additional substance use disorders were diagnosed in 70% of the MMT patients. While a probable personality disorder was documented for 65% of the patients, 66 of these patients actually showed an antisocial personality disorder. Qol was severely diminished to a level comparable to that for patients with chronic psychiatric and/or somatic disorders. Multivariate analyses showed the occurrence of comorbid psychiatric disorders to explain about 32% of the variance in Qol. The quality of life for MMT patients is generally low. The present results showed a high rate of psychiatric comorbidity for this patient group with mood disorders, additional substance use disorders, and personality disorders occurring in particular. Such comorbid psychopathology substantially affects quality of life. The negative influence of comorbid psychopathology on quality of life is an important reason to provide additional mental health services for MMT patients.

Effectiveness of a web-based intervention for problem drinkers and reasons for dropout: randomized controlled trial.

Background Online self-help interventions for problem drinkers show promising results, but the effectiveness of online therapy with active involvement of a therapist via the Internet only has not been examined. Objective The objective of our study was to evaluate an e-therapy program with active therapeutic involvement for problem drinkers, with the hypotheses that e-therapy would (1) reduce weekly alcohol consumption, and (2) improve health status. Reasons for dropout were also systematically investigated. Method In an open randomized controlled trial, Dutch-speaking problem drinkers in the general population were randomly assigned (in blocks of 8, according to a computer-generated random list) to the 3-month e-therapy program (n = 78) or the waiting list control group (n = 78). The e-therapy program consisted of a structured 2-part online treatment program in which the participant and the therapist communicated asynchronously, via the Internet only. Participants in the waiting list control group received “no-reply” email messages once every 2 weeks. The primary outcome measures were (1) the difference in the score on weekly alcohol consumption, and (2) the proportion of participants drinking under the problem drinking limit. Intention-to-treat analyses were performed using multiple imputations to deal with loss to follow-up. A dropout questionnaire was sent to anyone who did not complete the 3-month assessment. Reasons for dropout were independently assessed by the first and third author. Results Of the 156 individuals who were randomly assigned, 102 (65%) completed assessment at 3 months. In the intention-to-treat analyses, the e-therapy group (n = 78) showed a significantly greater decrease in alcohol consumption than those in the control group (n = 78) at 3 months. The e-therapy group decreased their mean weekly alcohol consumption by 28.8 units compared with 3.1 units in the control group, a difference in means of 25.6 units on a weekly basis (95% confidence interval 15.69-35.80, P < .001). The between-group effect size (pooled SD) was large (d = 1.21). The results also showed that 68% (53/78) of the e-therapy group was drinking less than 15 (females) or 22 (males) units a week, compared with 15% (12/78) in the control group (OR 12.0, number needed to treat 1.9, P < .001). Dropout analysis showed that the main reasons for dropouts (n = 54) were personal reasons unrelated to the e-therapy program, discomfort with the treatment protocol, and satisfaction with the positive results achieved. Conclusions E-therapy for problem drinking is an effective intervention that can be delivered to a large population who otherwise do not seek help for their drinking problem. Insight into reasons for dropout can help improve e-therapy programs to decrease the number of dropouts. Additional research is needed to directly compare the effectiveness of the e-therapy program with a face-to-face treatment program. Trial registration ISRCTN39104853; http://controlled-trials.com/ISRCTN39104853/ISRCTN39104853 (Archived by WebCite at http://www.webcitation.org/5uX1R5xfW)

A systematic review of the effectiveness of naltrexone in the maintenance treatment of opioid and alcohol dependence

This systematic review summarises evidence of the effectiveness of naltrexone (NTX) and the added value of psychosocial treatment in the maintenance treatment of opioid and alcohol dependence. Studies were selected through a literature search conducted in March 2004. Seven opioid and seventeen alcohol studies were identified. When possible, meta-(regression) analyses were performed. There is lack of evidence about the effectiveness of NTX in the maintenance treatment of opioid dependence. There is evidence for the effectiveness and applicability of NTX in the management of alcohol dependence. The opioid studies combined NTX with a variety of psychosocial interventions, which plagued the evaluation of their value. Concomitant psychosocial interventions used in the alcohol studies were mainly cognitive behavioural, which seems to be more effective than NTX combined with supportive therapy. Available data do not allow firm conclusions regarding the added effect of psychosocial interventions. However, the data suggest that a combination of naltrexone with cognitive behavioural relapse prevention therapy is beneficial in alcohol dependent patients.

Attrition in Web-Based Treatment for Problem Drinkers

Background Web-based interventions for problem drinking are effective but characterized by high rates of attrition. There is a need to better understand attrition rates in order to improve the completion rates and the success of Web-based treatment programs. Objective The objectives of our study were to (1) examine attrition prevalence and pretreatment predictors of attrition in a sample of open-access users of a Web-based program for problem drinkers, and (2) to further explore attrition data from our randomized controlled trial (RCT) of the Web-based program. Methods Attrition data from two groups of Dutch-speaking problem drinkers were collected: (1) open-access participants enrolled in the program in 2009 (n = 885), and (2) RCT participants (n = 156). Participants were classified as noncompleters if they did not complete all 12 treatment sessions (9 assignments and 3 assessments). In both samples we assessed prevalence of attrition and pretreatment predictors of treatment completion. Logistic regression analysis was used to explore predictors of treatment completion. In the RCT sample, we additionally measured reasons for noncompletion and participants’ suggestions to enhance treatment adherence. The qualitative data were analyzed using thematic analysis. Results The open-access and RCT group differed significantly in the percentage of treatment completers (273/780, 35.0% vs 65/144, 45%, χ2 1 = 5.4, P = .02). Logistic regression analysis revealed a significant contribution of treatment readiness, gender, education level, age, baseline alcohol consumption, and readiness to change to predict treatment completion. The key reasons for noncompletion were personal reasons, dissatisfaction with the intervention, and satisfaction with their own improvement. The main suggestions for boosting strategies involved email notification and more flexibility in the intervention. Conclusions The challenge of Web-based alcohol treatment programs no longer seems to be their effectiveness but keeping participants involved until the end of the treatment program. Further research should investigate whether the suggested strategies to improve adherence decrease attrition rates in Web-based interventions. If we can succeed in improving attrition rates, the success of Web-based alcohol interventions will also improve and, as a consequence, their public health impact will increase. Trial International Standard Randomized Controlled Trial Number (ISRCTN): 39104853; http://www.controlled-trials.com/ISRCTN39104853 (Archived by WebCite at http://www.webcitation.org/63IKDul1T)

Substance use disorders in individuals with mild to borderline intellectual disability: Current status and future directions

Knowledge regarding substance use (SU) and substance use disorder (SUD) in individuals with mild to borderline intellectual disabilities (ID) has increased over the last decade, but is still limited. Data on prevalence and risk factors are fragmented, and instruments for screening and assessment and effective treatment interventions are scarce. Also, scientific developments in other fields are insufficiently incorporated in the care for individuals with ID and SUD. In this selective and critical review, we provide an overview of the current status of SU(D) in ID and explore insights on the conceptualisation of SUD from other fields such as addiction medicine and general psychiatry. SU(D) turns out to be a chronic, multifaceted brain disease that is intertwined with other physical, psychiatric and social problems. These insights have implications for practices, policies and future research with regard to the prevalence, screening, assessment and treatment of SUD. We will therefore conclude with recommendations for future research and policy and practice, which may provide a step forward in the care for individuals with ID and SUD.

Alcohol dependence and anxiety increase error-related brain activity

AIMS Detection of errors is crucial for efficient goal-directed behaviour. The ability to monitor behaviour is found to be diminished in patients with substance dependence, as reflected in decreased error-related brain activity, i.e. error-related negativity (ERN). The ERN is also decreased in other psychiatric disorders with impaired response inhibition, such as attention-deficit hyperactivity disorder and borderline personality disorder, but increased in anxiety disorders. The objective of the current study was to assess error monitoring in alcohol-dependent patients in relation to psychiatric comorbidity. We expected decreased error monitoring in alcohol-dependent patients with impulse control disorders and increased error monitoring in anxious alcohol-dependent patients. DESIGN In a case-control design alcohol-dependent patients were compared with healthy controls. SETTING AND PARTICIPANTS A consecutive series of 29 male alcohol-dependent patients, between 18 and 55 years of age, applying for in-patient detoxification were recruited at Novadic Kentron Center for Addiction Treatment. Fifteen age-matched healthy controls were recruited through advertisements in regional newspapers. MEASUREMENTS Event-related potentials were recorded while performing a speeded choice-reaction task, from which ERN amplitudes were calculated. Axis-I and -II psychiatric comorbidity were assessed using the MINI International Neuropsychiatric Interview and the Structured Interview for DSM-IV Personality disorders. All participants completed the Temperament and Character Inventory and Profile of Mood States. FINDINGS ERN amplitudes were increased for alcohol-dependent patients compared to healthy controls, particularly in patients with comorbid anxiety disorders. CONCLUSIONS Increased error monitoring in alcohol-dependent patients, particularly those with comorbid anxiety disorders, is in contrast with previous studies that suggested decreased error monitoring to be a general feature in substance use disorders. Psychiatric disorders co-occurring with alcohol dependence, such as anxiety disorders, may indicate subpopulations of alcohol-dependent patients, with distinct neurobiological and genetic characteristics, possibly requiring different treatment strategies.

Interrater Reliability of the Structured Interview for DSM-IV Personality in an Opioid-Dependent Patient Sample

We examined the interrater reliability of the Structured Interview for DSM-IV Personality (SIDP-IV) in an opioid-dependent patient sample at the criterion as well as at the diagnostic level for both categorical and dimensional data. At the criterion level (Cohen’s kappa ranging from 0.76 to 0.93 and intraclass correlation coefficient ranging from 0.67 to 0.97) as well as at the diagnostic level (Cohen’s kappa ranging from 0.66 to 1.00 and intraclass correlation coefficient ranging from 0.88 to 0.99), the reliability was excellent. The results suggest the SIDP-IV to be an adequate instrument for the assessment of personality disorders in opioid-dependent patients.

High Abstinence Rates in Heroin Addicts by a New Comprehensive Treatment Approach

In this multi-center, naturalistic study, the effectiveness of naltrexone maintenance combined with the Community Reinforcement Approach (CRA) was investigated in detoxified, opioid-dependent patients (N=272). Patients were recruited from methadone maintenance programs. With intention-to-treat analysis, 10 months of treatment yielded abstinence rates of 28% and 32% at 10 and 16 months after detoxification. The cumulative abstinence rate at 16 months was 24%. Quality of life, craving, general psychopathology, use of other psychoactive substances, and addiction severity of the abstinent group significantly improved when compared to the relapsed group. This abstinence-oriented approach appears to be a feasible goal, and remains an important option next to long-term methadone maintenance in the management of opioid dependence.

Motivation for treatment in substance-dependent patients. Psychometric evaluation of the TCU motivation for treatment scales.

The objective of this paper is to analyze the psychometric properties of the TCU Motivation for Treatment (MfT) scale in alcohol- and drug-dependent patients in an inpatient treatment facility in the Netherlands, to see whether it is useful in European populations as well. In the study, 279 consecutive patients were enrolled: 132 drug and 147 alcohol dependents. Exploratory and confirmatory factor analysis revealed 4 subscales: recognition of general problems (4 items), recognition of specific problems (5), desire for help (5) and treatment readiness (8). The results of the analyses showed that the MfT scale is a valid instrument for measuring treatment motivation, both in drug- and in alcohol-dependent patients. We demonstrated evidence for consistency of the scale through cultural barriers, in different populations and in different treatment settings.