Examining the effect of the Life Enhancement Treatment for Substance Use (LETS ACT) on residential substance abuse treatment retention
Research Highlights
► Tested a behavioral activation treatment developed for substance users (LETS ACT). ► Compared LETS ACT to supportive counseling in a substance abuse treatment setting. ► LETS ACT patients had significantly higher rates of residential treatment retention. ► LETS ACT was associated with greater increases in activation. ► Behavioral activation may be a means to improve substance abuse treatment outcomes.
Introduction
Depression is highly prevalent among substance users. Previous research has demonstrated over 50% of illicit drug users present to substance abuse treatment with clinically significant depressive symptoms and are in need of depression treatment (Johnson, Neal, Brems, & Fisher, 2006). Notably, the presence of depression among substance users has been associated with increased likelihood of dropping out of substance abuse treatment (McKay et al., 2002, Tate et al., 2004, Thase et al., 2001). Substance abuse treatment dropout is a significant clinical issue; treatment length is a consistent predictor of long-term psychosocial outcomes, including relapse, HIV risk, unemployment, homelessness, poverty (Hubbard et al., 2003, Simpson et al., 1997), and increased societal costs due to increased treatment utilization and re-admission (Mark, Coffey, Vandivort-Warren, Harwood, & King, 2005). Further, depression is also associated with relapse (Hasin et al., 2002, Rounsaville, Kosten, Weissman, et al., 1986), shorter abstinence durations following treatment (Greenfield et al., 1998), and increased inpatient recidivism (Alterman et al., 1993, Moos et al., 1994). Co-occurring depression has been demonstrated to be highest among low-income, minority substance users (Huang et al., 2006, Kessler et al., 2003), which is also a group at high risk for poor psychosocial outcomes. For instance, regarding substance abuse treatment dropout, African Americans have been identified as less likely to complete residential substance abuse treatment compared to Whites (Jacobson, Robinson, & Bluthenthal, 2007).
Despite the clinical need, few interventions have been developed for depressed, low-income substance users (Hasin et al., 2005, Moneyham et al., 2000), and there are often limited resources for evidence-based mental health approaches in substance abuse treatment settings. An approach is needed that is parsimonious, cost-effective, and fits with the substance abuse treatment model, for instance emphasizing a group approach and incorporating relapse prevention strategies (Grella et al., 2004, Timko et al., 2003).
Given mixed pharmacological findings in treating this comorbidity (Nunes, Sullivan, & Levin, 2004), there appears to be an important role for psychosocial treatment. Torrens, Fonseca, Mateu, and Farré (2005) conducted a systematic review on the efficacy of antidepressants among individuals with a range of substance use disorders (SUDs). Their review supports the use of antidepressants for comorbid depression and nicotine dependence; however, for other types of SUDs (i.e., alcohol and cocaine dependence), efficacy findings remain mixed. Other studies have highlighted the role of environmental context as a moderator of the effect of antidepressants on depression among substance users. This work has pinpointed the need to enhance pharmacological treatment with a "behavioral intervention targeting the accessibility of reinforcement" (Carpenter, Brooks, Vosburg, & Nunes, 2004).
Targeting reinforcement as a means to treat this comorbidity may hold particular promise. Emerging lines of evidence suggest that depression and substance use share similar environmental contexts lacking positive reinforcement (Van Etten, Higgins, Budney, & Badger, 1998). Human and animal studies have identified a clear link between substance use and the degree of alternative substance-free reinforcement in the environment (Carroll, 1996, Higgins et al., 2004). This is consistent with behavioral economic theory suggesting that substance use is a function of the availability of reinforcing alternatives (Green & Kagel, 1996).
A reinforcement-based approach that may be particularly useful in this context is behavioral activation. Behavioral activation approaches target depressive symptoms by increasing engagement in rewarding activities as a means to increase positive reinforcement (Jacobson et al., 1996, Lejuez et al., 2001, Lewinsohn, 1974). Numerous reviews and meta-analyses suggest the efficacy of this approach in treating depression (Cuijpers et al., 2007, Ekers et al., 2007, Mazzuchelli et al., 2009, Sturmey, 2009). Further, behavioral activation has been suggested to be especially well-suited for addressing co-existent Axis I psychological disorders, such as substance abuse (Sturmey, 2009).
The Life Enhancement Treatment for Substance Use (LETS ACT; Daughters et al., 2008) is a group behavioral activation-based approach adapted from the empirically validated Brief Behavioral Activation Treatment for Depression (BAT-D; Lejuez et al., 2001). LETS ACT targets the link between mood, substance use, and behavior and focuses on identifying goal-driven, substance-free forms of positive reinforcement. LETS ACT was developed to complement residential substance abuse treatment; early sessions address goal-setting while in treatment, and final sessions focus on post-treatment planning. The protocol also has the potential to be adapted for other settings (Hopko, Bell, Armento, Hunt, & Lejuez, 2005). In a previous study (Daughters et al., 2008), LETS ACT was compared to treatment as usual (TAU) at a large, urban residential substance abuse treatment center among 44 patients with mild depressive symptoms. Patients in LETS ACT had six treatment sessions and two maintenance sessions while in residential substance abuse treatment. Compared to TAU, patients in LETS ACT reported significantly higher rates of environmental reward (following the last treatment session) and significantly lower rates of depression (following the maintenance sessions). Substance abuse treatment retention was also assessed; although not a statistically significant difference, fewer individuals in LETS ACT (4.5%) dropped out of the substance abuse treatment center compared to TAU (22.7%).
Based on these promising results, there is a pressing need to further explore the efficacy and effectiveness of LETS ACT in treating depression as well as improving substance abuse treatment retention. The first step is to compare LETS ACT to a contact–time matched control condition, such as supportive counseling (SC), as opposed to TAU used in Daughters et al. (2008). A second step to increase generalizability is to streamline the original protocol to accommodate the large portion of patients with inpatient stays of less than 4 weeks (Mark and Coffey, 2003, Mark et al., 2005). Lastly, research also is needed to understand which aspects of behavioral activation LETS ACT targets. Environmental reward, one aspect of the construct of behavioral activation (Manos, Kanter, & Busch, 2010), was assessed in Daughters et al. (2008); however, this also must be distinguished from overall levels of activation (Manos et al., 2010).
In line with these objectives, the current study is a randomized clinical trial comparing LETS ACT to a contact–time matched control condition (SC) among individuals who presented to substance abuse treatment with elevated depressive symptoms. Based upon findings from Daughters et al. (2008), we hypothesized that compared to SC individuals in LETS ACT would evidence the following post-treatment: significantly lower rates of substance abuse treatment dropout and depression severity, and significantly higher rates of overall activation and environmental reward.
Section snippets
Treatment setting
The study was conducted at a 136-bed residential substance abuse treatment facility in Washington, DC. Patients are required to have completed full detoxification and have a negative urine drug screen upon admission to the treatment facility. Once admitted, patients receive treatment for the use of a wide range of substances, including crack/cocaine, alcohol, heroin, PCP/hallucinogens, and marijuana. Length of treatment is determined by the funding agency providing financial support for the
Treatment retention
Treatment retention was examined categorically (dropout status in the 30-day study period). Baseline predictors of substance abuse treatment retention were examined, including all demographic and clinical variables depicted in Table 1, Table 2. No baseline variables were related to the categorical measurement of dropout. A chi square analysis was conducted comparing the two treatment groups on rates of dropout. 3.4% of the LETS ACT group (n = 1) and 24.1% of the SC group (n = 7) dropped out of the
Summary
The current study was the first randomized clinical trial comparing a brief LETS ACT protocol to a contact–time matched control condition to evaluate effects on substance abuse treatment retention, depression severity, and two measures of behavioral activation: overall activation and environmental reward. Findings indicated significant group differences in rates of substance abuse treatment retention, such that individuals in LETS ACT were significantly less likely to have dropped out of
Role of Funding Sources
This work was supported in part by the National Institute of Drug Abuse grants F31 DA026679 (PI: Magidson), R01 DA026424 (PI: Daughters), and K02 DA023200 (PI: Blanco). No funding source had any direct role in the study design; in the collection, analysis, or interpretation of the data; in the writing of the report; or in the decision to submit the report for publication. The corresponding authors had full access to all the data in the study and had final responsibility for the decision to
Contributors
J. Magidson, S. Daughters, and C. Lejuez designed the study. J. Magidson wrote and implemented the protocol with the guidance of S. Daughters and C. Lejuez. S. Gorka was a study therapist on the project and conducted literature reviews to aid in manuscript preparation. L. MacPherson aided with statistical analysis. D. Hopko and C. Blanco consulted on study design and manuscript preparation. All authors contributed to and have approved the final manuscript.
Conflict of Interest
All authors report no conflicts of interest.
Acknowledgments
We would like to thank Ms. Claudette Brooks, Ms. Adele Peeters, Ms. Raven Luckett, Mr. Wayne Garner, and Ms. Michelle Williams at the Salvation Army Harbor Light Substance Abuse Treatment Facility for their help with patient recruitment. The LETS ACT treatment manual can be accessed by contacting the corresponding authors.
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