Treatment of adolescents with a cannabis use disorder: Main findings of a randomized controlled trial comparing multidimensional family therapy and cognitive behavioral therapy in The Netherlands
Introduction
Although there are no recent data on the prevalence of cannabis use disorders among Dutch adolescents, the European School survey Project on Alcohol and other Drugs (ESPAD; Hibell et al., 2009) classified one out of ten Dutch past year adolescent cannabis users as having a high risk of developing cannabis-related problems. Of the adolescents who developed problematic cannabis use, an increasing number sought professional addiction care. From 2004 to 2008, the annual treatment demand of adolescents (≤18 years old) and young adults (19–24 years old) for primary cannabis use problems in The Netherlands increased from 2161 to 3060, with the largest increase occurring in the subgroup of adolescents. In addition, of all adolescents seeking help for substance-related problems in 2008, the majority (64%) sought help for primary cannabis use problems (Landelijk Alcohol en Drugs Informatie Systeem, 2010).
Various types of treatment are offered to individuals with a cannabis use disorder in The Netherlands, and these treatments – which include counselling, cognitive approaches, relapse prevention, and residential treatment – nearly all incorporate important elements of motivational enhancement therapy and cognitive behavioral therapy (CBT). Based on its effectiveness in adults with addictive behaviors (e.g., Miller and Wilbourne, 2002), outpatient CBT is considered the standard, first-choice treatment for adult patients, but empirical support for its effectiveness in adolescent cannabis abusers is still limited (e.g., Dennis et al., 2004a, Kaminer and Burleson, 1999, Kaminer et al., 2002, Waldron et al., 2001, Waldron and Turner, 2008). Hence, to meet the treatment needs of the rapidly growing number of adolescents who seek help for cannabis use problems, new or supplementary types of treatment are needed. In the United States, several controlled studies in young cannabis abusers have shown promising results of a new family-based intervention named multidimensional family therapy (MDFT). In these studies, MDFT showed clinically relevant and significant benefits in terms of reduced cannabis and other substance use and less psycho-social and behavioral problems, compared to family education and adolescent group therapy (Liddle, 2001) and peer group treatment (Liddle et al., 2004, Liddle et al., 2009). However, MDFT's effectiveness was similar to that of combined motivational enhancement/CBT and the adolescent community reinforcement approach in the cannabis youth treatment (CYT) study (Dennis et al., 2004a), while in another controlled comparison, MDFT was superior to CBT on some variables (e.g., psychological involvement with substances) but not on others (i.e., frequency of cannabis use) (Liddle, 2002, Liddle et al., 2008a). Given that almost all these results were obtained by one research group, independent replication studies are needed. In addition, it is unclear whether the positive outcomes of MDFT observed in the United States can be generalized to The Netherlands. Notably, the Dutch socio-cultural viewpoint on cannabis use differs from that in the United States, The Netherlands showing a more permissive attitude towards the use of soft drugs, which is expressed by, for instance, the possibility for adults to purchase cannabis in so-called ‘coffee shops’.
The aim of the present study was to evaluate and compare the effectiveness of MDFT and CBT in The Netherlands in adolescents with a cannabis use disorder, in terms of cannabis use and use of other substances, delinquency, and treatment retention. The study is both a ‘stand-alone’ study in The Netherlands – the results of which are presented here – and part of a larger European research project in which MDFT's effectiveness is compared with that of treatment as usual in Belgium, France, Germany, Switzerland and The Netherlands (Rigter et al., 2010).
Section snippets
Design
One hundred and nine patients between 13 and 18 years old with a cannabis use disorder participated in a parallel-group randomized controlled trial (registration ISRCTN00179361) at two study sites. Following initial screening and baseline assessment, eligible patients were randomly allocated (ratio 1:1) by our research group to outpatient CBT (control group; n = 54) or MDFT (experimental group; n = 55) by using a computer-generated randomization list. Randomization was concealed and was conducted
Results
One hundred and sixty six patients were assessed for eligibility and 57 patients were excluded prior to randomization (Fig. 1), mostly because either the adolescent, the parent(s) or both refused to participate in the study or study treatments (n = 28). Of the 109 randomized patients in the intent-to-treat sample, one participant in MDFT and seven participants in CBT never started treatment, and many more patients completed treatment in MDFT than in CBT, both within the planned 22 weeks treatment
Discussion
This study represents the first randomized controlled comparison between the efficacy of MDFT and that of CBT outside the United States. The study incorporated a range of features aimed at maximizing the validity of the findings, including the use of DSM diagnosis to define the target population, the use of manual-guided, supervised interventions, MDFT-training by the original developers of the intervention, the use of pre-specified outcome measures, derived from standardized and broadly
Conclusion
The current study indicates that MDFT and CBT are equally effective in reducing cannabis use and delinquent behavior in adolescents with a cannabis use disorder in The Netherlands. Despite some limitations, we are confident that the results are robust and valid for the majority of treatment-seeking adolescents with problematic cannabis use in The Netherlands. Given that this study also found indications of a differential treatment effect in high problem severity subgroups, further research
Role of funding source
This study was commissioned and financed by The Netherlands Ministry of Health, Welfare and Sports. The Ministry had no further role in study design, nor in the collection, analysis and interpretation of the data or in the writing of the report.
Contributors
All authors were responsible for analysis and interpretation of the data, and contributed to and approved the final manuscript. Vincent Hendriks and Peter Blanken were also responsible for concept and design of this study.
Conflict of interest
No conflict declared.
Ethical approval
The study was approved by the medical-ethical committee for research in mental health care settings of The Netherlands (METiGG; registration nr. 5238). All participants provided written informed consent.
Acknowledgements
The authors wish to thank Henk Rigter for initiating the INCANT project and for his work as main developer of the international multi-site study design. Nathalia Brusse, Manja van der Toorn and Renske Rigter are acknowledged for their great efforts in collecting the study data, and all therapists, the supervisor-therapists Peter van Hoorn and Kees Mos and the adolescents, parents and their families for their participation in the study. Henk Rigter, Kees Mos, Sylvia Cool and the reviewers of
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