Coping with stressful events: influence of parental alcoholism and race in a community sample of women

The study explores the role of race and differences in coping among 290 white women and black women with and without alcoholic parents, addressing two questions: (1) Does coping vary by parental alcoholism or race? and (2) How is coping in adulthood affected by childhood stressors and resources and by adulthood resources? Standardized self-administered questionnaires (Coping Responses Inventory and the Children of Alcoholics Screening Test) measuring approach and avoidant coping methods were used. Collateral information was obtained from siblings who completed questionnaires focused on parental drinking, parental psychiatric history, and key childhood events. Women with alcoholic parents and black women more often reported avoidant coping. Women with negative childhood family environments and a lack of adolescent social support more often reported avoidant coping responses. Self-esteem was associated with a higher score on active cognitive coping and a lower score on avoidant coping. Findings of greater use of avoidant coping by women with alcoholic parents contrast with other studies showing no differences in coping, or very small group differences. The fact that all women in this sample lived with two parents in childhood may be one explanation.

Adherence to pharmacotherapy in bipolar disorder patients with and without co-occurring substance use disorders

OBJECTIVE

To examine patterns of adherence to mood stabilizers and reasons for nonadherence in patients with bipolar disorder, with and without substance use disorder (SUD).

METHOD

From December 2003 to October 2004, 115 patients with DSM-IV-diagnosed bipolar disorder (58 with SUD and 57 without SUD) were administered a structured interview regarding their lifetime experience with mood stabilizers.

RESULTS

Lifetime adherence with mood stabilizers for the SUD group was 65.5%, versus 82.5% for the non-SUD group (p < .05). Lifetime lithium adherence for the SUD group was lower than for the non-SUD group (65.9% vs. 85.0%, p < .05). Substance-related reasons were more commonly cited by the SUD group than the non-SUD group. In contrast, pill- and dosage-related reasons were more frequently endorsed by the non-SUD group than the SUD group.

CONCLUSION

In bipolar disorder patients, those with co-occurring SUD were less adherent than those without SUD. The SUD group was also less adherent to lithium than the non-SUD group. The reasons for nonadherence differed by presence or absence of a SUD. Physicians should be alert to these differences in their clinical practices while prescribing medications.

Black women and white women: do perceptions of childhood family environment differ?

INTRODUCTION

Few studies have examined racial differences in perceptions of childhood. Little is known about how Blacks perceive their own families, particularly the family environment that they experienced in childhood.

METHODS

A community sample of 290 women (55% White, 45% Black) from two-parent families, heterogeneous in age and social class, was examined using a self-administered questionnaire, including the Family Environment Scale (FES), followed by a focused interview. Siblings were used as collateral informants.

RESULTS

The psychometric properties of the FES showed remarkably little variation by race: The internal scale reliability, correlations between scales, and factor structures were quite similar. Although both White and Black women reported good childhood family environments, Black women when compared with White women rated their families of origin as more cohesive, organized, and expressive, and lower in conflict. Sibling responses corroborated these findings.

DISCUSSION

This study addresses a gap in the research literature and provides important evidence of strengths in Black family relationships as reported by a community sample of women. The psychometric properties of the FES, found to be strong for families of both races, lends support to our findings and those of other researchers who have used this measure.

Differential transitions between cocaine use and abstinence for men and women

The longitudinal course of cocaine dependence is characterized by alternating periods of abstinence and relapse. Although gender has emerged as an important predictor of relapse, previous studies have examined mean differences in use by gender. Focusing strictly on differences in averages between men and women does not address potential gender differences in transitions between use and abstinence. Transition rates for men and women were compared using data from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Abstinence and nonabstinence for each of the 6 months of active treatment was determined by using a composite measure of use that incorporated information from weekly and monthly self-reports and urine toxicology screenings. Random effects were introduced to describe intersubject heterogeneity in transition rates. In this sample of 454 patients, rates of transition between abstinence and use were significantly different between men and women, with men showing twice the rate of transition between states despite similar average levels of use. These data may have important implications for both treatment planning and the types of outcomes considered in clinical practice and research.

A randomized trial of integrated group therapy versus group drug counseling for patients with bipolar disorder and substance dependence

OBJECTIVE

Although bipolar disorder and substance use disorder frequently co-occur, there is little information on the effectiveness of behavioral treatment for this population. Integrated group therapy, which addresses the two disorders simultaneously, was compared with group drug counseling, which focuses on substance use. The authors hypothesized that patients receiving integrated group therapy would have fewer days of substance use and fewer weeks ill with bipolar disorder.

METHOD

A randomized controlled trial compared 20 weeks of integrated group therapy or group drug counseling with 3 months of posttreatment follow-up. Sixty-two patients with bipolar disorder and current substance dependence, treated with mood stabilizers for >or=2 weeks, were randomly assigned to integrated group therapy (N=31) or group drug counseling (N=31). The primary outcome measure was the number of days of substance use. The primary mood outcome was the number of weeks ill with a mood episode.

RESULTS

Intention-to-treat analysis revealed significantly fewer days of substance use for integrated group therapy patients during treatment and follow-up. Groups were similar in the number of weeks ill with bipolar disorder during treatment and follow-up, although integrated group therapy patients had more depressive and manic symptoms.

CONCLUSIONS

Integrated group therapy, a new treatment developed specifically for patients with bipolar disorder and substance dependence, appears to be a promising approach to reduce substance use in this population.

The Relationship of Self-Esteem and Self-Efficacy to Treatment Outcomes of Alcohol-Dependent Men and Women

This study investigates whether self-esteem is associated with clinical and demographic characteristics, self-efficacy expectancies, and post-treatment drinking outcomes. Forty-one (40.6%) women and 60 (59.4%) men were recruited during inpatient alcohol dependence treatment. At baseline, lower self-esteem was significantly associated with current depression and other psychiatric disorders. Self-esteem was not related to gender, relapse, other one-year drinking outcomes, or self-efficacy. Age and psychiatric disorders were strong predictors of self-esteem at follow-up. This study suggests that different perceptions of the self have unique roles in recovery from alcohol use disorders.

Childhood sexual abuse among Black women and White women from two-parent families

Differences in childhood sexual abuse (CSA) between Black women and White women are explored in a community sample of 290 women raised in two-parent families.A self-administered questionnaire and a face-to-face interview assessed CSA characteristics, aftermath, and prevalence as well as family structure and other childhood variables. Siblings served as collateral informants for the occurrence of CSA. Overall, comparisons of the nature, severity, and aftermath of CSA showed similarities by race; some differences, for example, in age of onset, are potentially relevant for the planning of prevention programs. Logistic regression models examined effects of childhood variables on CSA prevalence. Initial analyses showed a higher CSA prevalence among Black women (34.1% [45] of Black women vs. 22.8% [36] of White women) that was attenuated when family structure (e.g., living with two biological parents throughout childhood or not) and social class were considered. Of interest, differences in family structure remained important even among these two-parent families. Understanding the dynamics of abuse by race and family structure will facilitate the design of more targeted CSA prevention programs.

Racial differences in social support: kin versus friends

Social support was examined among 290 Black and White women recruited from the community. We hypothesized that (1) social support, adjusted for social class, would not vary by race and (2) social support would be related to well-being. Standardized measures were administered, examining support provided by friends versus kin separately. Multivariate models showed that Black women reported similar numbers of kin and fewer friends than Whites, while satisfaction with support did not vary by race. Measures of social support were generally associated with well-being. These findings question earlier reports that Black women have stronger kin support than White women, suggesting that clinicians should not assume that Blacks can rely on kin for social support.

Anxiety disorders among patients with co-occurring bipolar and substance use disorders

Bipolar and substance use disorders are known to co-occur frequently, but limited attention has been paid to anxiety disorders that may accompany this dual diagnosis. Therefore, we examined the prevalence and nature of anxiety disorders among treatment-seeking patients diagnosed with current bipolar and substance use disorders, and investigated the association between anxiety disorders and substance use. Among 90 participants diagnosed with bipolar disorder I (n = 75, 78%) or II (n = 15, 22%), 43 (48%) had a lifetime anxiety disorder, with post-traumatic stress disorder (PTSD) occurring most frequently (n = 21, 23%). We found that those with PTSD, but not with the other anxiety disorders assessed, began using drugs at an earlier age and had more lifetime substance use disorders, particularly cocaine and amphetamine use disorders, than those without PTSD. Further examination revealed that (1) most participants with PTSD were women, (2) sexual abuse was the most frequently reported index trauma, and (3) the mean age of the earliest index trauma occurred before the mean age of initiation of drug use. Our findings point to the importance of further investigating the ramifications of a trauma history among those who are dually diagnosed with bipolar and substance use disorders.

Predicting long-term outcomes for women sexually abused in childhood: contribution of abuse severity versus family environment

OBJECTIVE

Child sexual abuse (CSA) has been associated with adverse adult psychosocial outcomes, although some reports describe minimal long-term effects. The search for explanations for the heterogeneous outcomes in women with CSA has led to an examination of a range of CSA-related factors, from the severity of individual CSA incidents to the childhood family environment. This study compares three factors for predicting adult outcomes: a multidimensional CSA Severity Scale, the presence or absence of CSA, and family environment.

METHODS

The effect of CSA on adult outcomes was examined among 290 community-dwelling women raised in intact families. Standardized measures and a focused interview were used to collect data, with siblings as collateral informants.

RESULTS

Comparison of a multidimensional CSA Severity Scale to a dichotomous measure of the presence or absence of CSA showed that the Severity Scale did not have greater predictive value for adult outcomes than the dichotomous measure, nor was it as parsimonious. Childhood family environment scales added significantly to the predictive ability of the dichotomous measure.

CONCLUSION

The specific characteristics of a CSA experience may be less important than the occurrence of CSA and the family environment of women for predicting long-term outcomes.

The effect of 12-step self-help group attendance and participation on drug use outcomes among cocaine-dependent patients

OBJECTIVE

Although cocaine-dependent patients are frequently referred to 12-step self-help groups, little research has examined the benefits of 12-step group attendance in this population. Moreover, the distinction between attending meetings and actively participating in 12-step activities has not typically been examined.

METHOD

In the National Institute on Drug Abuse Collaborative Cocaine Treatment Study, 487 cocaine-dependent outpatients were recruited at five sites for a randomized controlled trial of 24-week behavioral treatments. Study data were examined to see whether self-help attendance or active participation were related to subsequent drug use.

RESULTS

Twelve-step group attendance did not predict subsequent drug use. However, active 12-step participation in a given month predicted less cocaine use in the next month. Moreover, patients who increased their 12-step participation during the first 3 months of treatment had significantly less cocaine use and lower ASI Drug Use Composite scores in the subsequent 3 months. Finally, Individual Drug Counseling, based on a 12-step model, and increasing levels of 12-step participation each offered discrete benefits.

CONCLUSIONS

Results suggest that active 12-step participation by cocaine-dependent patients is more important than meeting attendance, and that a combination of Individual Drug Counseling and active 12-step participation is effective for these patients.

Mediating Factors for the Long-term Effects of Parental Alcoholism in Women: The Contribution of Other Childhood Stresses and Resources

The primary aim of this study was to identify the stresses and resources in childhood that mediate the relationship between parental alcoholism and adult outcomes in women. Adult outcomes included alcohol problems and measures of psychosocial adjustment. Standardized measures and a face-to-face interview were used to collect data on 290 community-dwelling women, with siblings as collateral informants. Mediation analysis showed that the effect of parental alcoholism on several adult outcomes was indirect, mediated by the other stresses and resources examined. Contextual models such as those presented here are helpful in understanding the long-term effects of childhood environment on women.

Substance use and perceived symptom improvement among patients with bipolar disorder and substance dependence

BACKGROUND

Bipolar disorder (BPD) is the Axis I disorder with the highest risk for coexisting substance use disorder. One explanation for this phenomenon is the 'self-medication hypothesis', which states that some patients experience improvement in psychiatric symptoms as a result of substance use. We thus investigated reasons for substance use and perceived substance-induced improvement in BPD symptoms among patients with current BPD and substance dependence.

METHODS

A total of 45 patients received six monthly assessments; 21 also received integrated group therapy (IGT), focusing simultaneously on BPD and substance dependence, while 24 did not receive IGT. Patients reported at intake their current reasons for initiating substance use (including BPD symptoms) and the effects of substance use on those symptoms.

RESULTS

Nearly all patients initiated substance use because of at least one BPD symptom, especially depression (77.8%) and racing thoughts (57.8%); most (66.7%) reported improvement in at least one BPD symptom as a result of substance use. Among patients reporting substance-induced improvement in BPD symptoms, those receiving IGT reported fewer days of drug use over the 6-month study period than those not receiving IGT; this difference was not significant among patients without substance-induced improvement in BPD symptoms.

LIMITATIONS

The study is limited by its small sample size and by the potential inaccuracy of self-reports regarding the effects of substance use on mood.

CONCLUSIONS

Substance dependent patients who report that substance use improves their BPD symptoms may benefit from treatment that focuses simultaneously on both disorders.

The relationship between cocaine craving, psychosocial treatment, and subsequent cocaine use

OBJECTIVE

Regular measurement of craving during treatment for cocaine dependence can monitor patients' clinical status and potentially assess their risk for drug use in the near future. Effective treatment can reduce the correlation between craving and subsequent drug use by helping patients abstain despite high craving. This study examined the relationship between cocaine craving, psychosocial treatment, and cocaine use in the ensuing week.

METHOD

In the National Institute on Drug Abuse Collaborative Cocaine Treatment Study, which compared four psychosocial treatments for cocaine dependence, a three-item craving questionnaire was administered weekly to 449 patients to see whether it predicted cocaine use in the ensuing week. Cocaine use was assessed with self-reports and urine screening.

RESULTS

With control for the previous week's cocaine use, a higher composite score on the craving questionnaire was associated with greater likelihood of cocaine use in the subsequent week; each 1-point increase on the composite score of the craving questionnaire increased the likelihood of cocaine use in the ensuing week by 10%. However, among patients who received individual plus group drug counseling, the treatment condition with the best overall cocaine use outcome, increased craving scores were not associated with greater likelihood of cocaine use in the subsequent week.

CONCLUSIONS

A three-item cocaine craving questionnaire predicted the relative likelihood of cocaine use during the subsequent week. Moreover, the relationship between craving and subsequent cocaine use varied by treatment condition, suggesting that the most effective treatment in the study might have weakened the link between craving and subsequent use.

Retention in psychosocial treatment of cocaine dependence: predictors and impact on outcome

This report describes retention in treatment in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study (CCTS), a multi-site trial of four psychosocial treatments for 487 cocaine dependent patients. Younger, African-American, and unemployed patients were retained in treatment for fewer days than their counterparts. African-American patients who lived with a partner were retained in treatment for less time than if they lived alone. Higher psychiatric severity kept men in treatment longer but put women at risk for dropping out sooner. Patients who completed the full treatment used drugs less often than patients who dropped out, but outcome did not differ at each month. Patients in the drug counseling condition stayed in treatment for fewer days than patients in psychotherapy, but they were more likely to be abstinent after dropout. Patients with higher psychiatric severity were more at risk for continuing to use drugs after dropout.

Predictors of self-help group attendance in cocaine dependent patients

OBJECTIVE

While referral to self-help groups for patients dependent on drugs other than alcohol has become widespread in the substance abuse treatment field, little is known about the characteristics of people who attend these groups. This study examines particular sociodemographic and clinical characteristics as possible predictors of attendance at self-help groups in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study.

METHOD

A multicenter study randomly assigned 487 patients (76.8% men) to one of four psychosocial treatments for cocaine dependence. Patients were treated for 24 weeks. Among other measures, the Weekly Self-Help Questionnaire was administered each week and completed, at least once, by 411 subjects.

RESULTS

Approximately two thirds of the patients attended one or more self-help meetings during the 24-week period. Patients initially more likely to attend self-help groups frequently were those who were unemployed, had no religious preference, had more severe baseline drug use and reported treatment for prior substance-related problems. Patients with more severe baseline drug use and those who previously received treatment for substance-related problems were more likely to maintain frequent attendance throughout the study period. Only severity of baseline drug use predicted more frequent attendance during Month 6, although there was a trend in Month 6 favoring more frequent attendance by women. These findings remained significant when treatment condition was added to the models.

CONCLUSIONS

Although these findings are consistent with past research on alcohol dependent individuals, they challenge popular clinical notions about the types of people who attend self-help groups. These findings demonstrate that self-help groups can appeal to a wide variety of cocaine dependent patients.

The use of collateral reports for patients with bipolar and substance use disorders

This study investigated the value of collateral informant reports of substance use for patients with current bipolar disorder and substance dependence. We collected collateral informant reports on 132 occasions for 32 patients and found a high level of agreement between collateral reports and self-report/urine screen data (75.0%). In only 3 instances did collateral informants report substance use for patients who denied use and had negative urine screens. Frequency of contact between informants and patients was associated significantly with the level of agreement. These findings suggest that obtaining collateral informant data when studying this population may be of limited value.

Self-help group attendance and participation among cocaine dependent patients

The authors examined frequency and patterns of self-help group attendance and active participation over a 6-month period among 411 patients receiving treatment in the NIDA Collaborative Cocaine Treatment Study. Nearly two-thirds of patients attended at least one self-help group, and nearly all of these actively participated. Alcoholics Anonymous and Narcotics Anonymous meetings were attended most frequently. Statistical analyses included chi square, one-way analyses of variance, and cluster techniques. While patterns of attendance were relatively consistent over time, findings suggest that a treatment emphasizing the importance of self-help groups is likely to encourage more self-help group attendance and participation over time.

Group therapy for patients with bipolar disorder and substance dependence: results of a pilot study

BACKGROUND

The authors' goal was to pilot test a newly developed manual-based group psychotherapy, called Integrated Group Therapy (IGT), for patients with bipolar disorder and substance dependence.

METHOD

In this open trial, patients with DSM-IV bipolar disorder and substance dependence (N = 45) were recruited in sequential blocks to receive either group therapy (N = 21) or 6 monthly assessments, but no experimental treatment (N = 24).

RESULTS

When compared with patients who did not receive group therapy, patients who received IGT had significantly better outcomes on the Addiction Severity Index drug composite score (p < .03), percentage of months abstinent (p < .01), and likelihood of achieving 2 (p < .002) or 3 (p < .004) consecutive abstinent months.

CONCLUSION

IGT is a promising treatment for patients with bipolar disorder and substance dependence, who have traditionally had poor outcomes. It is unclear, however, how much of the improvement among the group therapy patients is attributable to the specific content of the treatment. A study comparing this treatment with another active psychotherapy treatment is warranted.

Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study

BACKGROUND

This was a multicenter investigation examining the efficacy of 4 psychosocial treatments for cocaine-dependent patients.

METHODS

Four hundred eighty-seven patients were randomly assigned to 1 of 4 manual-guided treatments: individual drug counseling plus group drug counseling (GDC), cognitive therapy plus GDC, supportive-expressive therapy plus GDC, or GDC alone. Treatment was intensive, including 36 possible individual sessions and 24 group sessions for 6 months. Patients were assessed monthly during active treatment and at 9 and 12 months after baseline. Primary outcome measures were the Addiction Severity Index-Drug Use Composite score and the number of days of cocaine use in the past month.

RESULTS

Compared with the 2 psychotherapies and with GDC alone, individual drug counseling plus GDC showed the greatest improvement on the Addiction Severity Index-Drug Use Composite score. Individual group counseling plus GDC was also superior to the 2 psychotherapies on the number of days of cocaine use in the past month. Hypotheses regarding the superiority of psychotherapy to GDC for patients with greater psychiatric severity and the superiority of cognitive therapy plus GDC compared with supportive-expressive therapy plus GDC for patients with antisocial personality traits or external coping style were not confirmed.

CONCLUSION

Compared with professional psychotherapy, a manual-guided combination of intensive individual drug counseling and GDC has promise for the treatment of cocaine dependence.

Medication compliance among patients with bipolar disorder and substance use disorder

BACKGROUND

This study examined patterns of medication compliance and reasons for noncompliance among patients with bipolar disorder and substance use disorder.

METHOD

Forty-four patients with current bipolar disorder and substance use disorder were administered a structured interview regarding lifetime compliance with prescribed psychotropic medications.

RESULTS

Patients who were prescribed both lithium and valproate were significantly (p = .03) more likely to report full compliance with valproate than with lithium. Side effects were the most common reason for lithium noncompliance, but were not cited as a reason for valproate noncompliance. Also, a common pattern of noncompliance among patients prescribed benzodiazepines, neuroleptics, and tricyclic antidepressants was the use of more medication than prescribed.

CONCLUSION

Valproate may have greater acceptability than lithium among patients with bipolar disorder and substance use disorder. Clinicians should also be aware that these patients may take higher doses of medication than prescribed.

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Rationale and methods

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study is a large, multisite psychotherapy clinical trial for outpatients who meet the DSM-IV criteria for cocaine dependence. For 480 randomized patients, the outcomes of 4 treatments are compared for an 18-month period. All treatments include group drug counseling. One treatment also adds cognitive therapy, one adds supportive-expressive psychodynamic therapy, and one adds individual drug counseling; one consists of group drug counseling alone. In addition, 2 specific interaction hypotheses, one involving psychiatric severity and the other involving degree of antisocial personality characteristics, are being tested. This article describes the main aims of the project, the background and rationale for the study design, the rationale for the choice of treatments and patient population, and a brief description of the research plan.

Early prediction of initiation of abstinence from cocaine. Use of a craving questionnaire

The authors administered a five-item craving questionnaire daily to 86 outpatients to determine whether initial craving scores predicted the likelihood of initiation of abstinence within a 30-day period. Patients with higher mean craving scores during the first 3 days of the study were less likely to initiate abstinence. However the relationship between craving and abstinence initiation was not linear. Rather, patients in the top quartile of craving scores were significantly less likely to abstain than were patients in the lower three quartiles. The findings suggest that this rapid, easily administered craving questionnaire may have short-term predictive validity.

Gender differences in cocaine dependent patients: a 6 month follow-up study

This 6-month follow-up study compared 64 men and 37 women hospitalized for cocaine dependence. Drug histories, sociodemographic characteristics, psychiatric diagnoses, and Addiction Severity Index (ASI) scores were compared during hospitalization; cocaine use and ASI scores were compared at 6 months. During hospitalization, women had significantly more severe family and social problems; men had more antisocial personality disorder. At follow-up, significantly more women had remained abstinent: family/social problem severity no longer differed. This replicates previous research showing better treatment outcome for cocaine dependent women. This may be related to specific characteristics of women who enter mixed-gender cocaine treatment programs.