Jefferson D. Parker

Anxiety sensitivity, controllability, and experiential avoidance and their relation to drug of choice and addiction severity in a residential sample of substance-abusing veterans.

The aim of the present study was to evaluate anxiety-related psychological risk factors (e.g., anxiety sensitivity, perceived uncontrollability, emotional avoidance) and their relation to drug of choice and addiction severity in an inpatient residential substance abuse population. Fully detoxified veterans (N=94) meeting criteria for Axis I substance abuse disorders were enrolled in a 28-day residential substance abuse treatment program and completed the following measures at intake and discharge: Anxiety Sensitivity Index, Body Sensations Questionnaire (BSQ), Acceptance and Action Questionnaire (AAQ), Beck Depression Inventory (BDI; intake only), and the Anxiety Control Questionnaire (ACQ). Consistent with the expectation, veterans who reported more distress over bodily sensations (anxiety sensitivity, BSQ) and depressive symptoms (BDI) were more likely to avoid experiencing negative affect (AAQ) and perceived themselves as lacking in control (ACQ). Further, extent of avoidance, and to a lesser extent, controllability, discriminated between participants as a function of primary and comorbid diagnostic status, whereas anxiety sensitivity did not. No relation was found between anxiety sensitivity and drug of choice, and relations between assessed psychological factors and domains of addiction severity were mixed. Findings suggest that heightened bodily sensitivity, emotional avoidance, and perceived uncontrollability are common sequelae of patients seeking residential substance abuse treatment, but they do not contribute uniquely to drug of choice and measures of addiction severity. Theoretical and treatment implications are discussed with particular emphasis on approaches that may increase coping with untoward bodily cues, decrease avoidance of negative affect, and improve patients sense of personal control over their responses and the environment.

A psychometric evaluation of the BDI-II in treatment-seeking substance abusers

The Beck Depression Inventory-II (BDI-II) was administered to 416 consecutive male admissions to a 28-day residential chemical dependence treatment program as part of a routine intake procedure. Psychometric analyses revealed that the BDI-II scores were internally consistent in this treatment-seeking population based on coefficient alpha. The mean BDI-II score for patients in this study was higher than that noted for other clinical samples in previous studies. The use of the BDI-II for clinical decision making with chemically dependent individuals is discussed in light of this elevated distribution of scores. Confirmatory factor-analytic examinations of the instrument revealed that a three-factor model, with cognitive, affective, and somatic symptoms loading as separate factors, provided the most adequate account of the data. In total, the study supported the use of the BDI-II for the assessment of depression in chemically dependent male patients entering a residential treatment program at a VAMC facility, provided population-specific normative data is utilized for making clinical decisions.

Psychometric Evaluation of the National Opinion Research Center DSM-IV Screen for Gambling Problems (NODS)

The present study examined the reliability, validity, and clinical utility of a brief self-report measure of gambling behavior, the National Opinion Research Center DSM-IV Screen for Gambling Problems (NODS). Participants were 157 consecutively enrolled male military veterans taking part in substance use disorder treatment. The NODS displayed good internal consistency. Concurrent and discriminant validity were demonstrated by comparing scores on the NODS to scores on the South Oaks Gambling Screen and to a measure of medical problems, respectively. Overall, the NODS appears to be a reliable, valid, and clinically useful measure of gambling problems among patients in substance use disorder treatment programs.

Administrative, clinical, and ethical issues surrounding the use of waiting lists in the delivery of mental health services

The waiting list is commonly used in the delivery of mental health services. Despite their prevalence, their design and management are generally not standardized; rather, they take place on an ad hoc basis as a response to undesirable circumstances. The formulation and management of a waiting list initially appear to be simple, straightforward, and benign. However, on close examination, waiting lists are complicated, and implementation involves pervasive costs and benefits. This article delineates the costs and benefits involved in the use of waiting lists. It outlines administrative, clinical, and ethical issues intrinsic in the use of waiting lists and provides recommendations aimed at assisting in their design and management. While recommendations encompassing the range of possible unique situations are impractical, guidelines for consideration of important variables are provided.

Personality Assessment Inventory substance-use scales: Convergent and discriminant relations with the Addiction Severity Index in a residential chemical dependence treatment setting.

This study examined the convergent and discriminant validity of the Alcohol Problems (ALC) and Drug Problems (DRG) scales of the Personality Assessment Inventory (PAI; Morey, 1991). Participants were 103 male veterans (mean age = 41.7 years) in a Veterans Affairs residential treatment for chemical dependence. The PAI was compared to the Addiction Severity Index (ASI; McLellan et al., 1992), a semi structured interview. The sampling strategy that was used resulted in a diverse sample (66% African American, 33% Caucasian; 59% with primary alcohol diagnosis, 38% with primary drug diagnosis, 56% with comorbid alcohol and drug diagnoses) and adequately variable ALC and DRG scores. Results supported the convergent validity of both the ALC and DRG scales in relation to both the ASI and substance-use diagnosis. The ALC scale also demonstrated excellent discriminant validity, whereas the discriminant validity of the DRG scale was less impressive. Despite this, the DRG scale performed better in the current diverse sample than observed in an earlier study (Alterman et al., 1995). Recommendations for the use of the PAI in chemical dependence treatment settings are discussed.

Relation Between Cognitive Testing Performance and Pattern of Substance Use in Males at Treatment Entry

This study examined the frequency and pattern of cognitive impairment in individuals entering substance use disorder treatment and additionally examined the relation between pattern of cognitive impairment and type of substance(s) used: alcohol (n = 116), cocaine (n = 49), alcohol/cocaine (n = 76), and alcohol/multiple substance (n = 54). The Cognistat, a screening measure of cognitive functioning, and the Addiction Severity Index were given to male veterans at the time of entering 3- to 4-week residential/day drug treatment. The most prominent areas of impairment were memory (37% of the total sample) and similarities or abstract concept formation (21% of the total sample). Moderate or greater severity of impairment was noted on at least one Cognistat scale in 35% of the participants. Results indicated no significant differences in the patterns of cognitive domain impairment between groups based on type(s) of substances used at the time of entering treatment. Multiple substance use was significantly related to greater levels of psychiatric problems as identified by the Alcohol Severity Index. Given the rate of impairment in memory and verbal abstract reasoning noted, it is suggested that cognitive screening be a standard consideration in residential substance use disorder treatment to assist in treatment selection and delivery that is optimized to provide maximal benefit to patients.

Using vouchers to increase continuing care participation in veterans: does magnitude matter?

The present study examined the comparative effects of adding contingency management (CM) schedules to an existing substance abuse continuing care program, with the goal of increasing attendance. We retrospectively examined the attendance of 135 veterans enrolled in one of three CM programs and a quasi-control condition of 55 veterans. Results indicated that participants enrolled in the two higher magnitude CM voucher programs increased both continuing care attendance and length of participation. Findings support the use of CM to increase continuing care attendance among veterans with substance use disorders, and suggest that voucher magnitude and bonuses both had a positive impact.

Inappropriate psychiatric admission of elderly patients with unrecognized delirium.

Objectives: To explore factors that might contribute to misattribution of mental status changes to psychiatric illness when an elderly patient actually has a delirium (mental status changes due to a medical condition). Methods: Records of 900 elderly patients referred to a Veterans Affairs psychiatric inpatient unit and 413 to an inpatient psychiatric team at a public hospital from 2001 to 2007 were reviewed. Cases referred because of symptoms secondary to an unrecognized delirium underwent further analysis of preadmission assessments. Comparisons were made to elderly patients with delirium appropriately admitted to medical units. Results: Thirty (2.3%) of the patients referred to psychiatric units were found to have a physical disorder requiring medical intervention within twelve hours. Compared to 30 delirious patients admitted to medical units, those inappropriately referred to psychiatric units had significantly lower rates of adequate medical histories, physical examinations, cognitive assessments, and laboratory/radiological studies. Among patients with delirium referred to psychiatric units, 66.7% had a history of mental illness, versus 26.7% of comparable admissions to medical units (&khgr;2 (7) = 60.00, P < 0.001). Conclusions: Our findings suggest that elderly patients with delirium admitted to psychiatric units are less likely to undergo complete diagnostic assessments than delirious elderly patients admitted to medical units. Symptoms of delirium appear more likely to be incorrectly attributed to psychiatric illness in patients with a history of mental illness than in patients without such a history. Possible explanations for these findings and suggestions for addressing these issues are offered.

Smoking Cessation in Recovery: Comparing 2 Different Cognitive Behavioral Treatments

ObjectivesThe purpose of this pilot demonstration study was to evaluate the feasibility and effectiveness of adding a contingency management (CM) component to the standard cognitive-behavioral smoking cessation treatment offered to veterans in a residential substance-abuse treatment program. Specifically, we assessed the impact of CM on (1) engagement in smoking cessation treatment, (2) retention in smoking cessation treatment, and (3) abstinence from smoking. MethodsParticipants were 65 male veterans in inpatient treatment for a primary substance use disorder who expressed interest in quitting smoking. Participants were enrolled in either the standard or CM smoking cessation treatment program. All participants were offered 4 sessions of cognitive-behavioral group counseling; participants in the CM program also had the opportunity to earn cash vouchers for session attendance and abstinence from smoking. ResultsThe CM treatment program showed superior treatment engagement and retention rates. Survival analysis showed that 58% of participants receiving the CM treatment were smoke-free on quit day, versus only 17% of participants in standard care. In addition, the end of treatment continuous abstinence rate was significantly higher in the CM condition compared with standard care (21% vs. 0%). ConclusionsThese preliminary results suggest that contingency management approaches may be useful for maximizing participation in smoking cessation treatment and improving treatment outcomes among recovering substance users.

A brief telephone intervention targeting treatment engagement from a substance abuse program wait list

This study compares three brief participant-initiated telephone interventions aimed at enhancing treatment engagement of individuals on a substance abuse treatment wait list. Policies requiring that wait list members call at least every other week in order to remain eligible for treatment remained in place for the standard and enhanced conditions but not for the voluntary condition. The standard condition was a minimal intervention, providing information on the program. The enhanced condition focused on client motivation for treatment and recovery. If individuals in the voluntary condition called, they were provided information about current wait list number and approximate remaining wait time. The rate of treatment engagement was the same among treatment conditions. The best predictor of engagement was the number of calls placed to the program while waiting. Treatment condition was a positive predictor of call frequency; presence of a comorbid psychiatric diagnosis was a negative predictor. The article also discusses future directions.