Stepped care treatment for eating disorders.

A stepped care approach would link different patient needs to therapeutic modalities that range from simple advice to intensive inpatient care. Brief methods, including self-help and psychoeducation, may be effective for a subset of patients with bulimia nervosa and binge eating disorder. Identifying this subset remains a challenge. It is unclear how patients who fail to respond to evidence-based, first-line treatments should be treated. Given the absence of data on effective treatment of anorexia nervosa (AN), discussion of a stepped care approach is speculative. Because AN typically demands expert and sustained treatment, the lower levels of stepped care models are inapplicable for these patients. A stepped care approach poses methodological challenges for clinical research and raises important clinical issues, such as when to switch from 1 level of treatment to another. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Minimal therapist-assisted cognitive–behavioral therapy interventions in stepped care for childhood anxiety.

New effective, efficient, and accessible service delivery methods for cognitive–behavioral therapies for pediatric anxiety disorders are needed. Many anxious children do not receive needed treatment because of barriers such as limited availability of trained practitioners, costs of treatment, and time. A cognitive–behavioral therapy (CBT) stepped care approach that “steps up” care as needed from less intensive therapies with minimal therapist assistance to therapist-directed treatment may address barriers and provide more accessibility to treatment. A stepped care approach does not necessarily mean that traditional weekly face-to-face therapy sessions will not be needed. However, different service delivery methods that begin with CBT minimal therapist-assisted interventions may be a first line of treatment because not all children may need the full treatment package. This article provides an overview of the current research on CBT minimal therapist-assisted interventions (i.e., modified CBT protocols, computer-based therapy, bibliotherapy, telephone-based therapy, group treatment, and pharmacology) and information on how these first-line treatments may be incorporated into a stepped care model. Minimal therapist-assisted interventions within a stepped care model are in the early stages of development, although there is evidence that these types of treatment may be a viable first step to treating pediatric anxiety disorders. More research on minimal therapist-assisted interventions within stepped care models is needed, and challenges associated with disseminating and implementing stepped care need to be addressed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Stepped care: Doing more with less?

Several issues concerning stepped care are discussed: the constraints of using Diagnostic and Statistical Manual of Mental Disorders diagnoses in randomized clinical trials (RCTs), the importance of basic and process research, the unintended negative effects of exaggerated claims of effectiveness and efficiency, the limits of RCTs in evaluating improvement and deterioration, the self-correcting nature of stepped care, the link between stepped care and empirically supported treatments, clinical judgment in clinical work, the concept of the least restrictive alternative, the costs of using low-intensity but ineffective psychosocial treatments, and the costs of both ineffective and effective psychotropic drug therapy. An analysis of stepped care can lead to an appreciation that the dialectic operating between science and practice affords an opportunity to synthesize the seemingly irreconcilable standards and needs of researchers and clinicians. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effectiveness of stepped care for chronic fatigue syndrome: A randomized noninferiority trial.

Objective: In this randomized noninferiority study, the effectiveness and efficiency of stepped care for chronic fatigue syndrome (CFS) was compared to care as usual. Stepped care was formed by guided self-instruction, followed by cognitive behavior therapy (CBT) if the patient desired it. Care as usual encompassed CBT after a waiting period. Method: A total of 171 CFS patients were randomly allocated to stepped care or care as usual. Patients in both conditions were assessed 3 times: at baseline, after guided self-instruction or the waiting period, and after CBT. The primary outcome variables were fatigue severity (Checklist Individual Strength) and disabilities (Sickness Impact Profile and Medical Outcomes Survey Short Form–36). Results: An intention to treat analysis showed that stepped care (N = 84) for CFS is noninferior to care as usual (N = 85). Both conditions were equivalent in reducing fatigue severity, reducing disabilities, and increasing physical functioning. The treatment results of both conditions were in accordance with those of previous randomized controlled trials testing the effectiveness of CBT for CFS. The total therapist time needed to treat a patient was significantly less in the stepped care condition. Conclusions: Stepped care is as effective as CBT and is more time efficient for the therapist. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interest in a stepped approach model (SAM): identification of recruitment strategies for university alcohol programs

This study evaluates interest in a stepped approach model (SAM) of service delivery and identifies variables to enhance recruitment to alcohol programs. Subjects were 2,443 college student drinkers (1,420 men and 1,023 women) at a large midwestern university (selected by stratified systematic sampling) who completed a questionnaire on drinking behavior and interest in five intervention steps. Results indicated that there was more interest in interventions that required less time, which supports predictions of SAM. Overall lack of interest peaked at 67% for men and 65% for women and did not change significantly across the last three steps of SAM, which included traditional interventions of group and individual counseling. The data suggest that the stepped approach is more viable than conventional approaches, recruitment is unquestionably an exigent research priority because of the overwhelming lack of interest in alcohol programs, and specific variables that were identified may be important for recruiting particular subgroups.     

Readiness to change as a mediator of the effect of a brief motivational intervention on posttreatment alcohol-related consequences of injured emergency department hazardous drinkers.

Brief motivational interventions (BMIs) are usually effective for reducing alcohol use and consequences in primary care settings. We examined readiness to change drinking as a mediator of the effects of BMI on alcohol-related consequences. Participants were randomized into three conditions: (a) standard care plus assessment (SC), (b) SC plus BMI (BI), and (c) BI plus a booster session (BIB). At 12-month follow-up BIB patients had significantly reduced alcohol consequences more than had SC patients. Patients receiving BI or BIB maintained higher readiness scores 3 months after treatment than did patients receiving SC. However, readiness mediated treatment effects only for those highly motivated to change prior to the intervention but not for those with low pre-intervention motivation. BI and BIB for these patients decreased alcohol consequences in part because they enhanced and maintained readiness for those highly motivated prior to the intervention, but not for those with low motivation. Results are opposite of what would be expected from MI theory. An alternative explanation is offered as to why this finding occurred with this opportunistically recruited Emergency Department patient population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment settings for persons with alcoholism: Evidence for matching clients to inpatient versus outpatient care.

This study compared inpatient, intensive outpatient, and standard outpatient treatment settings for persons with alcoholism and tested a priori hypotheses about the interaction of setting with client alcohol involvement and social network support for drinking. Participants (N?=?192) were assigned randomly in cohorts to 1 of the 3 settings. The settings did not differ in posttreatment primary drinking outcomes, although inpatients had significantly fewer jail and residential treatment days combined than outpatients. Clients high in alcohol involvement benefited more from inpatient than outpatient care; the opposite was true at low alcohol involvement levels. Network drinking support did not moderate setting effects. Clients low in cognitive functioning also appeared to benefit more from inpatient than outpatient care. Improved outcomes might be achieved by matching degree of alcohol involvement and cognitive functioning to level of care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relation of depression diagnoses to 2-year outcomes in cocaine-dependent patients in a randomized continuing care study.

This study examined the relation between depression diagnoses and outcomes in 132 cocaine-dependent patients who were randomized to relapse prevention (RP) or standard 12-step focused group continuing rare and followed for 2 years. Depressed patients attended more treatment sessions and had more cocaine-free urines during treatment than participants without depression, but they drank alcohol more frequently before treatment and during the 18-month posttreatment follow-up. Cocaine outcomes in depressed patients deteriorated to a greater degree after treatment than did cocaine outcomes in patients without depression, particularly in patients in RP who had a current depressive disorder at baseline. The best alcohol outcomes were obtained in nondepressed patients who received RIP. The results suggest that extended continuing care treatment may be warranted for cocaine-dependent patients with co-occurring depressive disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Addressing comorbid depressive symptomatology in alcohol treatment.

Clinicians often encounter patients who have comorbid alcoholism and depression. The presence of both disorders makes treatment especially challenging. Among individuals seeking treatment for alcohol dependence, depression and depressive symptoms are associated with poorer treatment outcomes, and depressed mood may play an important role in relapse to drinking. Results of a recent study suggest that adding cognitive-behavioral treatment of depression to alcohol treatment can be an effective means of reducing depressive symptoms and improving drinking outcomes in alcoholics with elevated levels of depressive symptoms. This approach may be particularly useful for clinicians seeking a nonmedical intervention to reduce depression during alcohol treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Rural american indians' perspectives of obstacles in the mental health treatment process in three treatment sectors.

This study sought to identify obstacles associated with alcohol, drug, and mental (ADM) health care utilization in three treatment sectors for residents on three reservations in the United States. Participants (N = 224) disclosed that they had sought treatment for ADM problems in the past year and identified obstacles they faced during this process. Four obstacles were identified: (a) self-reliance, (b) privacy issues, (c) quality of care, and (d) communication/trust. A vast majority (71%) of participants reported at least one of these obstacles during treatment, and 61% faced two or more obstacles. There were no differences in the type or number of obstacles by treatment sector. Privacy and communication/trust obstacles were more likely to occur in emotional treatment compared to alcohol/drug treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluation of Preaeration with V-Notch Weir and Cascade Structures in Clarifiers

Hydraulic structures, such as stepped cascades and weirs, involve air entrainment (aeration) and oxygen transfer. Therefore, they can increase dissolved oxygen levels. Weir aeration occurs in rivers, fish hatcheries, and wastewater treatment plants. A stepped cascade aerator is another type of aeration structure. A stepped cascade consists of a series of steps or drops, built into the face of the chute. Often, the hydraulic head is naturally available and incurs no operating cost. For the preaeration process, weir and stepped cascade structures can be previously designed for clarifiers where weirs can be used as an aid to aeration process of treatment plants. Therefore, this paper aims to review the design considerations of circular clarifiers with combined weir and stepped cascade structures as a new approach and alternative preaeration system without energy requirement before aeration tank units. The detailed example for preaeration in circular clarifiers with combined weir and stepped cascade structures is presented. Thus, the circular clarifiers with weir and stepped cascade structures as effluent and preaeration strucures can be effectively redesigned with given new design considerations.     

Compulsory treatment: Some practical methods of treating the mandated client.

Discusses alternative treatment strategies targeted at the compulsory and often unmotivated client (e.g., the child abuser, the alcohol or substance abuser). Six guidelines (e.g., focused motivation, multimodal approach) useful in treating compulsory patients are suggested. Alternative treatment methods are discussed, including pretreatment structuring, application of the borderline-conditions approaches, and the use of peer support groups. (39 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Children's mental health: The gap between what we know and what we do.

There is widespread agreement that over 11% of our nation's children need mental health treatment, but the majority of these children receive inadequate or inappropriate treatment. This gap between what we know should be provided and what is provided is the result of a poorly structured health care financing system and a poorly coordinated treatment system. The treatment system fails to recognize that children's mental health problems are interactions between intraindividual difficulties and environmental conditions. A wealth of models of prevention and treatment have been developed, and a substantial scientific basis for children's mental health interventions now exists, but there is a shortage of community based services and a lack of coordination across services. Public policy toward children with mental health problems must encourage application of knowledge about effective treatment systems and encourage care in the least restrictive and most cost-effective settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Empirically supported treatments for panic disorder: Costs, benefits, and stepped care.

Treatment outcome findings suggest that cognitive-behavioral therapy (CBT) and pharmacotherapy offer similar short-term treatment gains for panic disorder and that CBT may afford more optimal maintenance of treatment gains without the need for ongoing treatment. However, efficacy is not the only consideration for patients, and because of limited health care resources, evaluation of the cost-benefit ratio of these treatments is important. In this article, the authors review estimates of the relative efficacy, acceptability, tolerability, and costs of these treatments; empirically examine the costs and outcome of cognitive-behavioral and pharmacologic interventions as they are delivered in an outpatient clinic specializing in these treatments; and comment on how these data inform a stepped care model of treatment. Analysis of the "services" data indicated that CBT was at least equal to pharmacotherapy in terms of pretreatment severity and acute treatment outcome and that CBT is an especially cost-effective treatment option. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The impact of continuing care adherence on environmental risks, substance use, and substance-related problems following adolescent residential treatment.

The effectiveness of adolescent treatment to reduce substance use has been demonstrated by a number of different literature reviews, yet longer term outcome studies have suggested that continued alcohol and other drug use is common. Participation in continuing care services and reductions in environmental risk factors (e.g., peer substance use or alcohol or drug use in the home) have both been found to be associated with improved posttreatment substance use. The authors conducted Path analysis to examine the experimental direct effect of the Assertive Continuing Care Protocol (S. H. Godley, M. D. Godley, & M. L. Dennis, 2001) on general continuing care adherence following residential treatment and the protocol's indirect effect (via general continuing care adherence) on social and environmental risk factors, as well as subsequent substance use and substance-related problems. Supporting previous findings, the final model indicates that greater adherence to continuing care is associated with reductions in environmental risk, which in turn is associated with reduced adolescent substance use and substance-related problems 9 months after discharge from residential treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contributions from behavioral theories of choice to an analysis of alcohol abuse.

Behavioral theories of choice are applied to an analysis of the conditions under which alcohol consumption emerges as a highly preferred activity from among a set of available activities. The approach highlights two classes of variables as important determinants of alcohol preference: (a) direct constraints on access to alcohol and (b) availability of other reinforcers and constraints on access to them. A selective review of studies of human and animal alcohol and drug self-administration indicates that preference for alcohol and drug consumption (a) varies inversely with direct constraints on consumption and (b) varies inversely with the availability of alternative reinforcers and directly with constraints on access to them. Environmental conditions under which alcohol consumption emerges as a highly preferred activity may thus involve minimal constraints on access to alcohol and sparse alternative reinforcers and/or heightened constraints on access to them. The latter variables may be more important in determining alcohol consumption in natural environments. A research application to alcoholic relapse is described, and general implications for clinical research in natural environments are explored. Limitations of the approach and its complementary relation to other approaches to studying alcohol abuse are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingency management is efficacious for cocaine abusers with prior treatment attempts.

Efforts are underway to detect subgroups who may be more or less responsive to contingency management (CM) substance abuse treatments. This study examined the impact of prior treatment attempts on primary and posttreatment outcomes in a combined sample of cocaine abusers randomized to standard care substance abuse outpatient treatment (SC) or SC plus CM. Participants (N = 393) were categorized according to self-reported prior treatment attempts (0-1, ≥2). Participants with multiple prior treatment attempts were older, had more severe alcohol and cocaine use disorders, and had greater employment-related problems. Participants with 0?1 prior treatment attempts had comparable treatment retention, regardless of treatment condition; however, among participants with multiple prior treatment attempts, retention was greater for CM than SC. A similar, but nonsignificant (p = .08) pattern was evident for longest duration of abstinence (LDA). LDA was a significant predictor of negative (for cocaine, alcohol, and opiates) specimen results at Month 9. The results provide support for CM as an advantageous option for individuals with multiple prior treatment attempts, as well as for substance abuse treatment patients in general. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Alcoholic liver disease. Treatment strategies for the potentially reversible stages

Even modest alcohol ingestion can increase the risk of steatosis, and long-term, excessive consumption can lead to alcoholic hepatitis and eventually cirrhosis. Most patients with clinically significant alcoholic liver disease have histologic findings typical of all three conditions. The only clearly beneficial treatment is abstinence from alcohol. Abstinence in combination with proper nutrition and general supportive care is state of the art. Steatosis is reversible upon withdrawal of alcohol, but alcoholic hepatitis can persist even with abstinence and may progress to cirrhosis. Corticosteroid therapy may reduce short-term mortality rates in patients with moderate or severe alcoholic hepatitis who have hepatic encephalopathy but no evidence of infection or gastrointestinal bleeding. Treatment with colchicine may decrease the risk of cirrhosis; however, once cirrhosis has developed, the liver damage is irreversible. The prognosis is improved with abstinence, but complications (e.g., ascites, gastrointestinal bleeding) often occur. Liver transplantation may be considered in patients with severe complications.     

A controlled trial of psychodynamic psychotherapy for co-occurring borderline personality disorder and alcohol use disorder.

A randomized controlled trial was conducted to determine whether a manual-based psychodynamic treatment, labeled dynamic deconstructive psychotherapy (DDP), would be feasible and effective for individuals with co-occurring borderline personality disorder (BPD) and alcohol use disorder. Thirty participants were assessed every 3 months during a year of treatment with either DDP or treatment as usual (TAU) in the community. DDP participants showed statistically significant improvement in parasuicide behavior, alcohol misuse, institutional care, depression, dissociation, and core symptoms of BPD, and treatment retention was 67% to 73%. Although TAU participants received higher average treatment intensity, they showed only limited change during the same period. The results support the feasibility, tolerability, and efficacy of DDP for the co-occurring subgroup and highlight the need for further research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relationship between clinical judgment, self-report, and breath-analysis measures of intoxication in alcoholics.

Three studies comparing 704 alcoholics' self-reports, observers' ratings, and breath-test determinations of alcohol intoxication found that (a) alcoholics' self-reports of their recent drinking were valid when they had not been drinking; (b) when they had been drinking, their self-reports were frequently invalid and underreported; (c) incidence of discrepant self-reports was not a function of level of intoxication; and (d) trained observers could identify only 50–67% of the Ss who were intoxicated but gave invalid self-reports. Breath analysis for blood alcohol concentration should be a mandatory component of alcohol treatment programs and alcohol treatment outcome evaluations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)