An intervention to increase alcohol treatment engagement: a pilot trial

An assessment of beliefs about mental health care among community-based adults with severe, untreated alcohol use disorder

OBJECTIVE

Alcohol use disorder (AUD) is among the most prevalent substance use disorders in the USA. Despite availability of effective interventions, treatment initiation and engagement remain low. Existing interventions target motivation and practical barriers to accessing treatment among individuals established within treatment systems. In contrast, Cognitive Behavioral Therapy for Treatment-Seeking (CBT-TS) aims to elicit and modify treatment-seeking beliefs to increase treatment-seeking behaviors among treatment-naïve samples. We aim to understand which beliefs were endorsed by those who did/did not initiate treatment, including changes in number of drinking days.

METHOD

We examined treatment seeking beliefs elicited during CBT-TS among community-based adults with moderate-severe AUD with no treatment history. In this study, we discuss which beliefs were modifiable (i.e. those discussed during the intervention among individuals who subsequently attended treatment and may be associated with treatment-seeking behaviors).

RESULTS

Of the 194 participants who received the intervention, 16 categories of beliefs were endorsed. Of the 38 participants (19.6%) who attended treatment, the most frequently endorsed belief was 'Not wanting specific types of substance use treatment or supports' (50%), a belief that may inhibit treatment seeking. The idea 'Treatment is positive' (47%) was also frequently cited, a belief that may facilitate treatment seeking.

CONCLUSIONS

This study describes the beliefs that were more frequently endorsed among adults with moderate-severe, but untreated AUD who reported attending treatment following CBT-TS. Findings point to the potential of discussing and modifying treatment-seeking beliefs among treatment-naïve adults with severe AUD to increase treatment-seeking behaviors.

Deaf perceptions about treatment for alcohol use and mental health

INTRODUCTION

Recent research suggests that alcohol use disorder may be more prevalent in the Deaf community, a diverse sociolinguistic minority group. However, rates of treatment-seeking among Deaf individuals are even lower than in the general society. This study used the Theory of Planned Behavior to identify Deaf adults' beliefs about treatment that may prevent their treatment-seeking behaviors.

METHODS

This study conducted elicitation interviews with 16 Deaf adults. The study team recruited participants from across the U.S. and conducted interviews on Zoom. Participant ages ranged from 27 to 67 years (M = 40, SD =10.8). Seventy-five percent of the sample was male, 75 % were White, and 12.5 % were Hispanic/Latine. The study conducted interviews in American Sign Language, subsequently interpreted into English by a nationally certified interpreter, and transcribed for data analyses. The study analyzed transcripts using the Framework Method. The study team coded the interviews in groups and assessed for saturation (≤ 5 % new themes) of themes throughout the analysis. This study reached saturation in the third group (six total groups).

RESULTS

Identified themes followed the Theory of Planned Behavior constructs. The study identified nine Behavioral Beliefs with four advantages and five disadvantages of seeking treatment, four Normative Beliefs with one support and three oppositions to seeking treatment, and thirteen Control Beliefs with five facilitators and eight barriers to seeking treatment. Overall, the Deaf participants reported several unique beliefs based on their cultural and linguistic perspectives, including a concern about unqualified providers, experiencing stress in treatment with hearing providers, stigma within the Deaf community, less access to cultural information about alcohol and mental health, less encouragement of traditional treatment in marginalized communities, and additional barriers (e.g., communication, limited Deaf treatment options, discrimination, etc.).

CONCLUSIONS

A thorough understanding of individual beliefs about treatment is necessary to develop interventions that may increase treatment-seeking behaviors. Previous research has demonstrated that individual beliefs may be modified using Cognitive Behavioral Therapy techniques to increase treatment-seeking behaviors among hearing individuals. Similar interventions may be useful with Deaf individuals; however, they must consider the unique cultural and linguistic perspectives of the community.

Screening, brief intervention, and referral to treatment for tobacco consumption, alcohol misuse, and physical inactivity: an equity-informed rapid review

OBJECTIVE

This rapid review systematically synthesizes evidence of the effectiveness of the Screening, Brief Intervention, and Referral (SBIR/T) approach for tobacco use, alcohol misuse, and physical inactivity.

STUDY DESIGN

This was a rapid review.

METHODS

We searched primary studies between 2012 and 2022 in seven electronic databases. The search strategy used concepts related to alcohol-related disorders, intoxication, cigarette, nicotine, physical activity, exercise, sedentary, screening, therapy, and referral. We reviewed both title/abstract and full-text using a priori set inclusion and exclusion criteria to identify the eligible studies. We appraised study quality, extracted data, and summarized the characteristics of the included studies. We applied health equity lenses in the synthesis.

RESULTS

Of the 44 included studies, most focused on alcohol misuse. SBIR/T improved patients' attitudes toward alcohol behavior change, improved readiness and referral initiation for change, and effectively reduced alcohol consumption. Few studies pertained to smoking and physical inactivity. Most studies on smoking demonstrated effectiveness pertaining to patients' acceptance of referral recommendations, improved readiness and attempts to quitting smoking, and reduced or cessation of smoking. Findings were mixed about the effectiveness of SBIR/T in improving physical activity. Minimal studies exist on the impacts of SBIR/T for these three risk factors on healthcare resource use or costs. Studies considering diverse population characteristics in the design and effectiveness assessment of the SBIR/T intervention are lacking.

CONCLUSIONS

More research on the impacts of SBIR/T on tobacco use, alcohol misuse, and physical inactivity is required to inform the planning and delivery of SBIR/T for general and disadvantaged populations.

Brief, cognitive-behavioral intervention to promote treatment seeking in adults with severe alcohol use disorder: A randomized controlled trial

BACKGROUND AND AIMS

There is little RCT evidence that brief interventions improve treatment seeking in individuals with severe alcohol use disorder (AUD) or treatment seeking reduces alcohol use. The aim was to test the efficacy of a brief intervention to increase treatment seeking in treatment naïve adults with severe AUD and measure its effects on alcohol use.

DESIGN

Parallel group, non-pharmacologic RCT with intervention (n = 197) and active control (n = 203) conditions, with blinded assessors conducting follow-ups at 1, 3 and 6 months.

SETTING

Online recruitment in a 17-county region of upstate New York, USA.

PARTICIPANTS

Inclusion criteria consisted of ages ≥18 years, Alcohol Use Disorders Identification Test score ≥16, exceeds recommended limits for alcohol use and no history of AUD treatment. n = 400; 50% female; 79% white; mean age, 40.7; mean education, 14.6 years.

INTERVENTION AND COMPARATOR

One-session telephone-delivered interventions: Cognitive-Behavioral Therapy for Treatment Seeking (CBT-TS; intervention), review of a National Institute on Alcohol Abuse and Alcoholism pamphlet on AUD treatment (control).

MEASUREMENTS

Self-report of any AUD treatment use over 3 months (primary outcome) and two standard measures of alcohol use over 6 months (secondary outcomes).

FINDINGS

Intent-to-treat analyses were used. Assessment follow-up rates were ≥93%. Any alcohol-related treatment use over 3-month follow-up was obtained by 38 (19%) intervention participants and 36 (18%) control participants, a non-significant difference, χ2 [1] = 0.16, P = 0.689. Secondary analysis showed a significant interaction term between sex and intervention assignment (β = -1.197, P = 0.027). The interaction suggested CBT-TS was effective in men (22% vs 13%), although the evidence was somewhat weak (P = 0.071), and it was not effective in women (17% vs 24%).

CONCLUSIONS

A one-session cognitive-behavioral therapy intervention to increase treatment seeking in treatment naïve adults with severe alcohol use disorder did not increase treatment seeking.

Efficacy of CBT for Treatment Seeking (CBT-TS) in Untreated Veterans and Service Members at Risk for Suicidal Behavior

OBJECTIVE

Military members and Veterans at-risk for suicide are often unlikely to seek behavioral health treatment. The primary aim of this study was to test the efficacy of brief CBT for Treatment Seeking (CBT-TS) to improve behavioral health treatment utilization among U.S. military service members and Veterans at-risk for suicide.

METHODS

A total of 841 participants who served in the U.S. military since 9/11 and who reported suicidality but were not in behavioral health treatment were recruited to participate in this trial. Participants were randomly assigned to either brief CBT-TS delivered by phone or an assessment-only control condition. Follow-up assessments were conducted at baseline and months 1, 3, 6, and 12 to track treatment utilization and symptoms.

RESULTS

CBT-TS resulted in significantly greater behavioral health treatment initiation within 1 month compared to the control condition (B = .93, p < .001); and the higher treatment initiation persisted for 12 months post intervention.

CONCLUSIONS

This study employed a low-cost, easily implementable one-session intervention administered by phone. The study provides evidence that CBT-TS is efficacious in promoting behavioral health treatment initiation in an adult population at risk for suicidal behavior and showed enduring benefits for 6-12 months. CBT-TS provides a unique strategy for treatment engagement for at-risk adults unlikely to seek treatment.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05077514.

The impact of an annual mass media campaign on treatment seeking for alcohol use disorders in the Danish population: An interrupted time-series analysis

INTRODUCTION

A minority of individuals with alcohol use disorder (AUD) seek treatment. In Denmark, a mass media campaign, "RESPEKT", aiming to increase treatment seeking, has been broadcasted nationwide since 2015. The campaign is unique from an international perspective. Similar interventions have, up until now, not been scientifically evaluated.

AIM

To investigate whether there was an association between campaign periods and treatment seeking for AUD. A secondary aim was to investigate possible gender differences. The hypotheses were that treatment seeking would increase during the campaign periods, and that men would increase their treatment seeking more compared to women.

METHOD

Study design: Interrupted time-series analysis.

PARTICIPANTS

Adults aged 18 years and above in the Danish population seeking AUD treatment.

EXPOSURE

Campaign periods year 2015-2018.

OUTCOME

Changes in treatment seeking defined as treatment entry respectively filled prescription of AUD pharmacotherapy.

DATA

National Alcohol Treatment Register on treatment entries for specialist addiction care and National Prescription Registry for filled prescriptions on AUD pharmacotherapies 2013-2018.

ANALYSIS

Segmented negative binomial regression, including the full cohort and stratified by sex.

RESULTS

The results show no association between campaign periods and treatment seeking. Nor were there any gender differences in treatment seeking. The hypotheses were not confirmed.

CONCLUSION

The campaign periods showed no association with treatment seeking. Eventual future campaigns should possibly focus on earlier steps of the treatment seeking process, as problem recognition, to increase treatment seeking. There is a great need to develop other ways to narrow the treatment gap for AUD.

Alcohol-related consequences and the intention to seek care in treatment naïve women and men with severe alcohol use disorder

INTRODUCTION

Research on treatment utilization for alcohol use disorder (AUD) is based primarily on clinical samples and community samples of low AUD severity that may not need formal care. Using a community sample of adults with untreated but severe AUD symptoms, we tested the hypothesis that alcohol-related consequences, but not alcohol consumption levels, are associated with the intention to seek AUD treatment, examined associations of specific types of alcohol-related consequences with intention, and explored sex differences in these associations.

METHODS

The sample was recruited using social media ads for a randomized controlled trial to test a brief intervention to promote AUD treatment seeking. This report is based on analysis of baseline data collected prior to treatment intervention. Multiple linear regressions examined associations of measures of alcohol consumption, alcohol-related consequences broadly, and specific alcohol-related consequences with the intention to seek treatment. Moderating effects of sex on associations were explored.

RESULTS

Subjects (n = 349) averaged 41 years of age, 48% were female, 6% were Latinx, 80% were white, 15% were Black, and 92% met criteria for severe AUD. Alcohol consumption measures were not associated with intention to seek treatment whereas interpersonal- and intrapersonal- consequences were associated with intention. Sex served as a moderator, with intrapersonal consequences (e.g., sad mood) showing a stronger association with intention in women and social responsibility consequences (particularly financial) associated with intention in men.

CONCLUSION

Select alcohol-related consequences may be keys to understanding increased intention to seek AUD treatment including intrapersonal consequences in women and financial consequences in men.

Heterogeneity in Alcohol-Related Severity and Interests in Going to Treatment in Community Adults with Alcohol Use Disorder (AUD)

RATIONALE

Alcohol use disorder (AUD) is highly prevalent among adults in the US and is associated with substantial personal and societal costs. Yet only a small percentage of adults with AUD initiate treatment, including those with severe AUD symptoms who are most in need of treatment. In this paper we use latent profile analysis (LPA) to describe differences in symptoms of AUD severity and alcohol-related consequences among untreated adults with severe AUD symptoms who were recruited from the community. Identification of such differences will result in better understanding of this population and will improve methods of treatment outreach.

METHOD

The LPAs were conducted on the baseline data of 403 (50% male, 77% White, M age = 40.74 with severe AUD recruited from the community and enrolled in a trial of an intervention designed to encourage treatment initiation. Participants reported no prior AUD treatment history. The LPAs were based on indicators of AUD severity, alcohol-related negative consequences, and self-reported intention to initiate AUD treatment.

RESULTS

The LPAs revealed 4 profiles. Profile membership was predicted by baseline participant sex and whether they were living with a partner and was associated with baseline past 30-days alcohol consumption.

CONCLUSIONS

The findings characterize and describe the variability among adults in the community with untreated severe AUD on variables that tend to motivate such individuals to seek treatment, which could significantly advance treatment outreach efforts.

Alcohol Use During COVID-19 in Adults with Severe Untreated AUD

Evidence demonstrating increased alcohol use during COVID-19 comes from low- to moderate-alcohol use samples and has yet to use adults with severe but untreated AUD. Using a community sample of adults with severe AUD, this exploratory, cross-sectional study examined associations of COVID-19 alcohol use. Participants were recruited for a phase-II RCT. Only baseline measures, completed prior to randomization, were analyzed in the present study. Key variables were alcohol consumption, COVID-19-related worries and experiences, and qualitative responses of 1) alcohol use and 2) positive changes during COVID-19. 176 pariticpants recruited since COVID-19 were on average 41.4 years old, 49.1% female, and 79% White. Participants drank alcohol nearly 23 of the past 30 days, consumed 7 standard drinks per drinking day, and nearly 90% reported increased alcohol use. More heavy episodic drinking was reported in the first six-months of COVID-19 and more COVID-related concerns in the most recent six-months. Participants reported drinking increased due to "more time on their hands", but the pandemic also "strengthened relationships". Results affirm an increase in alcohol use during COVID-19 in adults with severe, untreated AUD. Findings underscore the need to understand how alcohol use and pandemic-related circumstances may influence one another for adults with severe AUD.

Problem recognition and treatment beliefs relate to mental health utilization among veteran primary care patients

Mental health concerns are prevalent among primary care patients, but many do not utilize services for these conditions. This study aims to conduct a comprehensive assessment of barriers and facilitators to mental health care utilization among veteran primary care patients with common mental health concerns. We hypothesized that beliefs and knowledge about mental illness and mental health care would be more strongly associated with recent mental health care utilization than stigma, help-seeking behaviors, or logistical barriers. Veterans (n = 116) enrolled in primary care with current symptoms of depression (58%), posttraumatic stress disorder (37%), and/or hazardous alcohol use (50%) who either recently used mental health services (47%) or had no recent mental health treatment utilization (53%) completed a telephone-based screening, medical records review, and mail survey of 10 measures of barriers and facilitators to mental health treatment utilization. Recognition of problems as a cause for concern, odds ratio = 5.95, 95% confidence interval [2.36, 15.01], and beliefs about psychotherapy, odds ratio = 2.53, 95% confidence interval [1.39, 4.60], emerged as stronger correlates of recent mental health care utilization than stigma, self-efficacy, and external barriers to treatment. Results suggest the use of specific theories, measures, and interventions that focus on patient recognition of problems and beliefs about treatment over those that focus on other treatment barriers and facilitators. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Strategies to improve treatment utilization for substance use disorders: A systematic review of intervention studies

BACKGROUND

Many people who need specialty treatment for substance use disorders (SUDs) do not receive it. Clinical interventions could increase treatment utilization but are not routinely used. This systematic review aimed to describe clinical interventions that may increase SUD specialty treatment utilization (i.e., treatment initiation, attendance, meaningful engagement) and to determine which intervention(s) most consistently increase treatment utilization.

METHODS

We conducted a systematic review of clinical intervention studies (published in English between 2000 and 2017) reporting outcomes relevant to specialty SUD treatment utilization. Outcomes were treatment initiation, attendance, and meaningful engagement. Risk of bias was assessed using Cochrane guidelines and randomized controlled trials (RCTs) with bias scores < 3 were included in a synthesis of results. Proportions of positive to negative utilization outcomes were calculated for each low-bias RCT; studies with 50% positive outcomes or more were considered "majority-positive". Studies were categorized by theory-based approach.

RESULTS

Twenty-three RCTs had low risk of bias and were synthesized. Among intervention types with two or more studies, cognitive-behavioral (100% majority-positive) and coordinated care (67% majority-positive) interventions were most likely to increase treatment initiation, while 12-step promotion interventions were most likely to increase treatment attendance (50% majority-positive). One study (12-step promotion) measured meaningful engagement, with majority-positive outcomes.

CONCLUSIONS

A systematic review and narrative synthesis of clinical interventions promoting specialty SUD treatment utilization provided preliminary evidence that cognitive-behavioral and coordinated care interventions may increase treatment initiation, while 12-step promotion interventions may promote treatment attendance. More quality studies and greater consistency in treatment utilization measurement are needed.

Profiles of Risk for Suicidal Behavior in Past and Current United States Military Personnel: Latent Profile Analysis of Current Risk Factors

Person-centered approaches are underutilized to identify people with shared risk profiles. In this study, an at-risk sample of 773 past/current military personnel (Mage = 31.3 years, SD = 6.8) with current ideation (90.6%) and/or a prior suicide attempt (43.9%) were assessed using latent profile analysis. Variables included prior suicide attempts, suicidal ideation, alcohol/drug use, insomnia, depression, belongingness, burdensomeness, and post-traumatic stress disorder symptoms. Three classes emerged: Low Symptoms (N = 502), Elevated Suicidality (N = 176), and Elevated Substance Use (N = 95). At 1-month follow-up, the Elevated Suicidality and Elevated Substance Use classes had the highest odds of suicidal behavior. The finding concerning the Elevated Substance Use class suggests it may represent a distinct short-term risk group in military personnel.

Defining the things we can change to improve access to mental health care

Access and utilization of mental health care are critical components of ensuring public health. In this conceptual article, we define modifiable factors affecting mental health care utilization with the goal of providing a pragmatic framework for providers and clinics to increase access to mental health care. Five shared constructs emerged from a review of prominent health behavior theories: (a) mental illness beliefs, knowledge, and recognition; (b) mental health treatment beliefs and knowledge; (c) stigma including perceived norms, public stigma, and self-stigma; (d) help-seeking behaviors including knowledge, motivation, self-efficacy, and skills; and (e) external barriers and facilitators such as cues, logistics, and social support. We explore how these constructs influence mental health care utilization including interpretation and perception of mental health symptoms, acceptability and awareness of treatment options, and skills and ability to find, schedule, and attend mental health care. Finally, we make recommendations on how this broader framework can be used by primary care clinician innovators to implement interventions to reduce disparities and improve access to mental health care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Randomized clinical trial of exercise for nontreatment seeking adults with alcohol use disorder

The vast majority of individuals with alcohol use disorder (AUD) do not seek professional help despite its significant consequences upon the individual and society. Current interventions for nontreatment seeking individuals with AUD (e.g., screening, brief intervention, and referral to treatment [SBIRT]) have limited efficacy and alternative nonstigmatizing approaches are needed. This randomized clinical trial examined the utility of exercise as an intervention for sedentary nontreatment seeking adults with AUD. Participants (N = 66) were randomized to receive (a) a 4-month YMCA gym membership only (MO) or (b) a 4-month YMCA gym membership plus a 16-week integrated motivational intervention for exercise consisting of motivational interviewing and contingency management (MI + CM). Participants in both study conditions significantly increased their exercise behavior compared to baseline, and the MI + CM participants exercised significantly more often and an overall larger volume of exercise than the MO participants (ds > 2.0). Significant reductions in drinking and alcohol-related consequences were noted over time but did not differ significantly by study condition and were not related to changes in exercise. Future interventions using exercise as an intervention for AUD may want to frame this type of intervention as "wellness," directly link the 2 behaviors, and compare this intervention to SBIRT. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Exploring Psychiatric Inpatients' Beliefs About the Role of Post-discharge Follow-up Care in Suicide Prevention

Introduction:

Patients are at increased risk for death by suicide following a psychiatric hospitalization. There has been limited study of the association between patient engagement in follow-up care after psychiatric hospitalization and suicide risk. Understanding why psychiatric inpatients choose to engage in post-discharge care is important in developing effective suicide prevention strategies.

Materials and Methods:

The theory of planned behavior (TPB) has been widely used to understand many health behaviors including healthcare utilization. Using the TPB, we developed an interview guide that assessed psychiatric inpatients’ attitudes and beliefs about the role of post-discharge care in addressing suicide risk. We also inquired about perception of future risk for suicide after discharge. We conducted semi-structured interviews prior to discharge and administered the Columbia-Suicide Severity Rating Scale (C-SSRS). We assessed healthcare utilization at 1 and 3 mo after discharge. We coded and grouped the transcribed data according to the three domains of the TPB model: attitudes, subjective norms, and perceived behavioral control.

Results:

Sixteen individuals consented to enrollment. More than half (N = 10) believed that they were at no or low future suicide risk after discharge. Participants who felt that their future risk for suicide was low or none were significantly older (mean 59.3 yr, SD: 8.3) and reported significantly less severe suicidal ideation in the past month (mean CSSR-S 2.5, SD 2.1) compared to those participants who believed that their future risk was high (mean age 47.5, SD: 8.6; mean CSSR-S 4.7, SD 0.5, p < 0.05). However, all participants had a lifetime history of severe suicidal ideation (mean CSSR-S > 4.7). Many participants felt that peers facilitated treatment engagement. However, participants expressed a tendency to avoid treatment if they experienced unwanted side effects, encountered stigma, or experienced poor-therapeutic alliance. Five participants experienced poor continuity of care after discharge. Of these participants, four reported at the time of discharge no or low perceived future risk of suicide and three were readmitted within 90 d after discharge.

Conclusions:

Individuals may not appreciate that they are at heightened risk for suicide after hospitalization and this may negatively impact treatment engagement.

Predictors of Mental Health Care Utilization in Veterans With Post-Traumatic Stress Disorder Symptoms and Hazardous Drinking

OBJECTIVES

Describe outpatient mental health service use in a sample of recent combat Veterans with post-traumatic stress disorder (PTSD) symptoms and hazardous alcohol use and investigate predictors of mental health care utilization.

METHODS

In this prospective study, 126 Veterans with full or subthreshold PTSD and hazardous alcohol use completed a baseline assessment and reported mental health service use through a 12-month follow-up period. Logistic regressions were used to identify factors predicting mental health care utilization.

RESULTS

Veterans who were employed were 63% less likely to use outpatient mental health care in the 12 months following baseline. Additionally, for each 1-point increase in negative mental health care beliefs, participants were 70% less likely to use outpatient mental health care. For each 1-point worsening in social support and leisure functioning, participants were 2.2 times more likely to use outpatient mental health care.

CONCLUSIONS

The current study indicates that negative mental health beliefs are barriers to mental health care while unemployment and poor social support/leisure functioning are predictors of mental health care utilization for recent combat Veterans with PTSD symptoms and hazardous alcohol use. Patient and system level interventions for these factors are discussed to guide efforts to improve mental health care among this high-need population.

Web-Delivered CBT Reduces Heavy Drinking in OEF-OIF Veterans in Primary Care With Symptomatic Substance Use and PTSD

Veterans from conflicts such as the wars in Iraq and Afghanistan commonly return with behavioral health problems, including posttraumatic stress disorder (PTSD) and hazardous or harmful substance use. Unfortunately, many veterans experience significant barriers to receiving evidence-based treatment, including poor treatment motivation, concerns about stigma, and lack of access to appropriate care. To address this need, the current study developed and evaluated a web-based self-management intervention based on cognitive behavioral therapy (CBT), targeting PTSD symptoms and hazardous substance use in a group of symptomatic combat veterans enrolled in VA primary care. Veterans with PTSD/subthreshold PTSD and hazardous substance use were randomized to primary care treatment as usual (TAU; n = 81) or to TAU plus a web-based CBT intervention called Thinking Forward (n = 81). Thinking Forward consisted of 24 sections (approximately 20 minutes each), accessible over 12 weeks. Participants completed baseline and 4-, 8-, 12-, 16-, and 24-week follow-up assessments. Three primary outcomes of PTSD, alcohol and other drug use, and quality of life were examined. Significant treatment effects were found for heavy drinking, but not for PTSD or quality of life. The effect of the intervention on heavy drinking was mediated by intervening increases in coping, social support, self-efficacy, and hope for the future. These results demonstrate the promise of a web-based, self-management intervention for difficult-to-engage OEF/OIF veterans with behavioral health and substance use concerns.

A Web-Based Self-Management Program for Recent Combat Veterans With PTSD and Substance Misuse: Program Development and Veteran Feedback

Combat veterans from the wars in Iraq and Afghanistan commonly experience posttraumatic stress disorder (PTSD) and substance use problems. In addition, these veterans often report significant barriers to receiving evidence-based mental health and substance use care, such as individual beliefs that treatment will be unhelpful, inconvenient, or that they should be able to handle their problems on their own. To increase access to treatment for this underserved population, a Web-based patient self-management program that teaches cognitive-behavioral therapy (CBT) skills to manage PTSD symptoms and substance misuse was developed. This paper describes and provides results from an iterative, multistage process for developing the Web-based program and seeks to inform clinicians in the field about the preferences of veterans for using a Web-based CBT program. Systematic feedback was gathered from (a) three expert clinicians in the field, (b) focus groups of combat veterans (n = 18), and (c) individual feedback sessions with combat veterans (n = 34). Clinician feedback led to the incorporation of motivational strategies to increase participant engagement and an optional module that guides written trauma exposure work. Focus group feedback guided the research team to frame the program in a strength-based approach and allows for maximum flexibility, adaptability, interactivity, and privacy for veterans. In individual feedback sessions, veterans generally found the program likable, easy to use, and relevant to their experiences; critiques of the program led to revised content meant to increase clarity and participant interest. Our findings provide specific guidance for clinicians who are interested in developing or providing technology-based treatment, including the need to gather feedback from an intervention's target audience when adapting a psychotherapeutic intervention and that the treatment must be highly interactive and private to engage clients.

Predicting substance abuse treatment completion using a new scale based on the theory of planned behavior

We examined whether a 9-item scale based on the theory of planned behavior (TPB) predicted substance abuse treatment completion. Data were collected at a public, outpatient program among clients initiating treatment (N=200). Baseline surveys included measures of treatment-related attitudes, norms, perceived control, and intention; discharge status was collected from program records. As expected, TPB attitude and control components independently predicted intention (model R-squared=.56), and intention was positively associated with treatment completion even including clinical and demographic covariates (model R-squared=.24). TPB components were generally associated with the alternative readiness scales as expected, and the TPB remained predictive at higher levels of coercion. Meanwhile, none of the standard measures of readiness (e.g., the URICA and TREAT) or treatment coercion were positively associated with treatment participation. Results suggest promise for application of the TPB to treatment completion and support use of the intention component as a screener, though some refinements are suggested.

Preferences for Gender-Targeted Health Information

No prior research has examined men’s opinions or preferences regarding receiving health education materials related to sexual violence. The objective of the current study was to investigate whether male veteran patients who have experienced military sexual trauma (MST) prefer gender-targeted versus gender-neutral printed health information and whether receipt of this information increased utilization of outpatient mental health services in the following 6-month period. In-person 45-minute interviews were conducted with 20 male veterans receiving health care services at a large Veterans Health Administration facility to evaluate opinions on a gender-targeted and a gender-neutral brochure about MST. An additional 153 veterans received psychoeducational materials through the mail and participated in the completion of a survey as part of a psychoeducational intervention. Our results demonstrate that male veterans prefer gender-targeted information about sexual trauma compared to gender-neutral information. Whereas veterans in the study had clear preferences for gender-targeted materials, receipt of information about MST (whether gender-targeted or gender-neutral) did not increase utilization of mental health care in the 6 months following receipt of these materials. These results demonstrated that materials about sexual trauma are acceptable to men and should be gender-targeted. Further research is needed to examine strategies to increase access to mental health care among male Veterans who have experienced MST.

Personality disorders and treatment drop out in the homeless

The homeless drop out of treatment relatively frequently. Also, prevalence rates of personality disorders are much higher in the homeless group than in the general population. We hypothesize that when both variables coexist - homelessness and personality disorders - the possibility of treatment drop out grows. The aim of this study was to analyze the hypotheses, that is, to study how the existence of personality disorders affects the evolution of and permanence in treatment. One sample of homeless people in a therapeutic community (N = 89) was studied. The structured clinical interview for the diagnostic and statistical manual of mental disorders (DSM-IV-TR) was administered and participants were asked to complete the Millon Clinical Multiaxial Inventory-II (MCMI-II). Cluster B personality disorders (antisocial, borderline, and narcissistic) avoided permanence in the treatment process while cluster C disorders, as dependent, favored adhesion to the treatment and improved the prognosis. Knowledge of these personality characteristics should be used to advocate for better services to support homeless people and prevent their dropping out before completing treatment.