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Wolitzky-Taylor K. Integrated behavioral treatments for comorbid anxiety and substance use disorders: A model for understanding integrated treatment approaches and meta-analysis to evaluate their efficacy. Drug Alcohol Depend 2023; 253:110990. [PMID: 37866006 DOI: 10.1016/j.drugalcdep.2023.110990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Substance use disorders (SUD) and anxiety disorders are highly comorbid, and this comorbidity is associated with poor clinical outcomes. Emerging research in the last decade has shifted from addressing these problems separately to the development and evaluation of behavioral treatments that integrate care for anxiety disorders (or elevated symptoms of anxiety) and SUD. METHODS An extensive literature search revealed a sufficient number of studies (K=11) to conduct a meta-analysis comparing the efficacy of integrated SUD/anxiety disorder behavioral treatment to SUD treatment alone on substance use and anxiety symptom outcomes. Randomized clinical trials including those with SUD and either anxiety disorders or elevations in constructs implicated in the maintenance of anxiety disorder/SUD comorbidity were included. This study meta-analyzes the effects of these studies. RESULTS Integrated treatments outperformed SUD treatments alone on both substance use and anxiety outcomes, with small to moderate effects favoring integrated treatments. There was no significant heterogeneity across studies in the primary analyses, such that moderator analyses to identify variables that yielded differential patterns of effect sizes were not conducted. DISCUSSION Integrated treatments for SUD/anxiety disorders demonstrate an incremental but significant and clinically meaningful improvement over SUD treatment alone for SUD/anxiety disorder comorbidity. Implications for future research and clinical practice paradigm shifting are discussed.
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Drossel G, Brucar LR, Rawls E, Hendrickson TJ, Zilverstand A. Subtypes in addiction and their neurobehavioral profiles across three functional domains. Transl Psychiatry 2023; 13:127. [PMID: 37072391 PMCID: PMC10113211 DOI: 10.1038/s41398-023-02426-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 04/20/2023] Open
Abstract
Rates of return to use in addiction treatment remain high. We argue that the development of improved treatment options will require advanced understanding of individual heterogeneity in Substance Use Disorders (SUDs). We hypothesized that considerable individual differences exist in the three functional domains underlying addiction-approach-related behavior, executive function, and negative emotionality. We included N = 593 participants from the enhanced Nathan Kline Institute-Rockland Sample community sample (ages 18-59, 67% female) that included N = 420 Controls and N = 173 with past SUDs [54% female; N = 75 Alcohol Use Disorder (AUD) only, N = 30 Cannabis Use Disorder (CUD) only, and N = 68 Multiple SUDs]. To test our a priori hypothesis that distinct neuro-behavioral subtypes exist within individuals with past SUDs, we conducted a latent profile analysis with all available phenotypic data as input (74 subscales from 18 measures), and then characterized resting-state brain function for each discovered subtype. Three subtypes with distinct neurobehavioral profiles were recovered (p < 0.05, Cohen's D: 0.4-2.8): a "Reward type" with higher approach-related behavior (N = 69); a "Cognitive type" with lower executive function (N = 70); and a "Relief type" with high negative emotionality (N = 34). For those in the Reward type, substance use mapped onto resting-state connectivity in the Value/Reward, Ventral-Frontoparietal and Salience networks; for the Cognitive type in the Auditory, Parietal Association, Frontoparietal and Salience networks; and for the Relief type in the Parietal Association, Higher Visual and Salience networks (pFDR < 0.05). Subtypes were equally distributed amongst individuals with different primary SUDs (χ2 = 4.71, p = 0.32) and gender (χ2 = 3.44, p = 0.18). Results support functionally derived subtypes, demonstrating considerable individual heterogeneity in the multi-dimensional impairments in addiction. This confirms the need for mechanism-based subtyping to inform the development of personalized addiction medicine approaches.
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Affiliation(s)
- Gunner Drossel
- Graduate Program in Neuroscience, University of Minnesota, Minneapolis, MN, USA
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
| | - Leyla R Brucar
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
| | - Eric Rawls
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
| | - Timothy J Hendrickson
- University of Minnesota Informatics Institute, University of Minnesota, Minneapolis, MN, USA
- Masonic Institute for the Developing Brain, University of Minnesota, Minneapolis, MN, USA
| | - Anna Zilverstand
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA.
- Medical Discovery Team on Addiction, University of Minnesota, Minneapolis, MN, USA.
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Norton EO, Hailemeskel R, Bravo AJ, Pilatti A, Kaimner D, Conway CC, Mezquita L, Hogarth L. Childhood Traumatic Experiences and Negative Alcohol-Related Consequences in Adulthood: A Cross-Cultural Examination of Distress Tolerance and Drinking to Cope. Subst Use Misuse 2023; 58:804-811. [PMID: 36935590 PMCID: PMC10124750 DOI: 10.1080/10826084.2023.2188563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Background: Prior research has established that Adverse Childhood Experiences (ACEs) predict harmful alcohol use outcomes. However, underlying mechanisms that could explain these associations are less clear. The present study examined if ACEs are indirectly related to alcohol negative consequences through their associations with distress tolerance and drinking to cope. Method: A sample of 3,763 (71.9% female) college students who drink alcohol from seven countries (U.S., Argentina, Canada, Uruguay, Spain, South Africa, and England) completed online surveys. Path analysis was performed within the whole sample testing the serial unique associations between ACEs→distress tolerance→drinking to cope→negative alcohol-related consequences. Multi-group analysis was performed to determine if the proposed pathways were invariant across gender and countries. Results: Both distress tolerance and drinking to cope uniquely accounted for the relationship between ACEs and negative alcohol-related consequences. Additionally, a significant double-mediation effect was found illustrating that a higher endorsement of ACEs was associated with lower distress tolerance, which in turn was associated with higher drinking to cope, which in turn was associated with more negative alcohol-related consequences. These effects were invariant across countries and gender groups. Conclusions: These findings provide support for the relevance of distress tolerance and coping motives as potential factors in linking ACEs to problematic alcohol use across nations. Our data are consistent with the idea that intervening on distress tolerance and drinking motives could mitigate downstream alcohol-related consequences related to ACEs in college student populations around the world.
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Affiliation(s)
| | | | | | - Angelina Pilatti
- Universidad Nacional de Córdoba, Facultad de Psicología, Instituto de Investigaciones Psicológicas, IIPsi, CONICET. Córdoba, Argentina
| | - Debra Kaimner
- Department of Psychology, University of Cape Town, South Africa
| | | | - Laura Mezquita
- Department of Basic and Clinical Psychology and Psychobiology, Universitat Jaume I, Castelló de la Plana, Castellón, Spain
| | - Lee Hogarth
- School of Psychology, University of Exeter, United Kingdom
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Brief Negative Affect Focused Functional Imagery Training Abolishes Stress-Induced Alcohol Choice in Hazardous Student Drinkers. JOURNAL OF ADDICTION 2021; 2021:5801781. [PMID: 34580617 PMCID: PMC8464424 DOI: 10.1155/2021/5801781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 08/25/2021] [Accepted: 09/07/2021] [Indexed: 11/17/2022]
Abstract
Introduction Imagery-based stress management therapies are effective at reducing alcohol use. To explore the therapeutic mechanism, the current study tested whether brief functional imagery training linked to personal negative affect drinking triggers would attenuate sensitivity to noise stress-induced alcohol seeking behaviour in a laboratory model. Methods Participants were UK-based hazardous student drinkers (N = 61, 80.3% women, aged 18–25) who reported drinking to cope with negative affect. Participants in the active intervention group (n = 31) were briefly trained to respond to personal negative drinking triggers by retrieving an adaptive strategy to mitigate negative affect, whereas participants in the control group (n = 30) received risk information about binge drinking at university. The relative value of alcohol was then measured by preference to view alcohol versus food pictures in two-alternative choice trials, before (baseline) and during noise stress induction. Results There was a significant two-way interaction (p < .04) where the control group increased their alcohol picture choice from baseline to the noise stress test (p < .001), whereas the active intervention group did not (p=.33), and the control group chose alcohol more frequently than the active group in the stress test (p=.03), but not at baseline (p=.16). Conclusions These findings indicate that imagery-based mood management can protect against the increase in the relative value of alcohol motivated by acute stress in hazardous negative affect drinkers, suggesting this mechanism could underpin the therapeutic effect of mood management on drinking outcomes.
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Stapinski LA, Prior K, Newton NC, Biswas RK, Kelly E, Deady M, Lees B, Teesson M, Baillie AJ. Are we making Inroads? A randomized controlled trial of a psychologist-supported, web-based, cognitive behavioral therapy intervention to reduce anxiety and hazardous alcohol use among emerging adults. EClinicalMedicine 2021; 39:101048. [PMID: 34622183 PMCID: PMC8478683 DOI: 10.1016/j.eclinm.2021.101048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 07/09/2021] [Accepted: 07/13/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Anxiety and alcohol use disorders are common and disabling conditions that people typically endure for many years before accessing treatment. The link between anxiety and alcohol use is well-established, with these issues commonly emerging and/or escalating during emerging adulthood. This randomized controlled trial evaluated a psychologist-supported, web-based intervention, designed with and for emerging adults, that aims to promote adaptive coping strategies, and prevent anxiety and alcohol use from progressing to chronic, mutually-reinforcing disorders. METHODS Between December 2017 and September 2018, 123 emerging adults (aged 17-24) reporting anxiety symptoms and hazardous alcohol use were randomized to receive the Inroads or control (assessment plus alcohol information) intervention. The Inroads program combined five web-based cognitive behavioral therapy modules with weekly psychologist support via email/phone. Primary outcomes were alcohol consumption, severity of alcohol-related consequences, and general anxiety symptoms, assessed at baseline, 2 and 6-months post-baseline. Secondary outcomes included hazardous alcohol use and social anxiety. Trial Registration: Prospectively registered in the Australian New Zealand Clinical Trials Registry, ACTRN12617001609347. FINDINGS Alcohol consumption and associated consequences reduced in both groups, with the Inroads group reporting greater alcohol reductions by 6-month follow-up (mean difference -0.74, 95% CI: -1.47 to -0.01, d = 0.24). Relative to controls, hazardous alcohol use reduced among Inroads participants at both follow-ups (2-month mean difference -2.14, 95% CI: -4.06 to -0.22). Inroads participants also reported reduced symptoms of general (mean difference -3.06, 95% CI: -4.97 to -1.15, d = 0.88) and social anxiety (mean difference -3.21, 95% CI: -6.34 to -0.07, d = 0.32) at 2-month follow-up, with improvements in social anxiety sustained at 6-months. INTERPRETATION The Inroads program demonstrated beneficial effects on alcohol consumption, hazardous alcohol use, and anxiety symptoms. The web-based format is aligned with youth treatment preferences and can be delivered at scale to achieve wide dissemination and reduce the significant burden associated with these chronic, mutually reinforcing conditions. FUNDING Australian Rotary Health, Australian National Health and Medical Research Council.
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Affiliation(s)
- Lexine A. Stapinski
- The Matilda Centre for Research in Mental Health and Substance Use, Sydney Medical School, The University of Sydney, Camperdown, NSW 2006, Australia
- Corresponding author.
| | - Katrina Prior
- The Matilda Centre for Research in Mental Health and Substance Use, Sydney Medical School, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Nicola C. Newton
- The Matilda Centre for Research in Mental Health and Substance Use, Sydney Medical School, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Raaj Kishore Biswas
- The Matilda Centre for Research in Mental Health and Substance Use, Sydney Medical School, The University of Sydney, Camperdown, NSW 2006, Australia
- Transport and Road Safety (TARS) Research Centre, School of Aviation, University of New South Wales, Sydney 2052, Australia
| | - Erin Kelly
- The Matilda Centre for Research in Mental Health and Substance Use, Sydney Medical School, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Mark Deady
- Black Dog Institute, University of New South Wales, Sydney 2052, Australia
| | - Briana Lees
- The Matilda Centre for Research in Mental Health and Substance Use, Sydney Medical School, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Maree Teesson
- The Matilda Centre for Research in Mental Health and Substance Use, Sydney Medical School, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Andrew J. Baillie
- Sydney School of Health Sciences, University of Sydney, Sydney 2006, Australia
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Mehta K, Hoadley A, Ray LA, Kiluk BD, Carroll KM, Magill M. Cognitive-Behavioral Interventions Targeting Alcohol or Other Drug Use and Co-Occurring Mental Health Disorders: A Meta-Analysis. Alcohol Alcohol 2021; 56:535-544. [PMID: 33778869 PMCID: PMC8406071 DOI: 10.1093/alcalc/agab016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/19/2021] [Accepted: 02/20/2021] [Indexed: 01/10/2023] Open
Abstract
AIMS This meta-analysis reviewed 15 clinical trials (18 study sites/arms), examining the efficacy of an integrated cognitive-behavioral intervention (CBI) delivered to individuals with an alcohol or other drug use disorder and a co-occurring mental health disorder (AOD/MHD). Outcomes were alcohol or other drug use and mental health symptoms at post-treatment through follow-up. METHODS The inverse-variance weighted effect size was calculated for each study and pooled under random effects assumptions. RESULTS Integrated CBI showed a small effect size for AOD (g = 0.188, P = 0.061; I2 = 86%, τ2 = 0.126, k = 18) and MHD (g = 0.169, P = 0.024; I2 = 58%, τ2 = 0.052, k = 18) outcomes, although only MHD outcomes were statistically significant. Analysis by subgroup suggested that effect magnitude varied by type of contrast condition (integrated CBI + usual care vs. usual care only; integrated CBI vs. a single-disorder intervention), follow-up time point (post-treatment vs. 3-6 months) and primary AOD/MHD diagnosis, although these sub-groups often contained significant residual heterogeneity. In a series of mixed effects, meta-regression models, demographic factors were non-significant predictors of between-study heterogeneity. For AOD outcomes, greater effects were observed in higher quality studies, but study quality was not related to effect size variability for MHD outcomes. CONCLUSIONS The current meta-analysis shows a small and variable effect for integrated CBI with the most promising effect sizes observed for integrated CBI compared with a single disorder intervention (typically an AOD-only intervention) for follow-up outcomes, and for interventions targeting alcohol use and/or post-traumatic stress disorder. Given the clinical and methodological variability within the sample, results should be considered a preliminary, but important step forward in our understanding of treatment for co-occurring AOD/MHD.
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Affiliation(s)
- Kahini Mehta
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI 02912, USA
| | - Ariel Hoadley
- College of Public Health, Temple University, Philadelphia, PA 19122, USA
| | - Lara A Ray
- Department of Clinical Psychology, University of California at Los Angeles, Los Angeles, CA 90095, USA
| | - Brian D Kiluk
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06520, USA
| | - Kathleen M Carroll
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06520, USA
| | - Molly Magill
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI 02912, USA
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Efficacy of the Unified Protocol for the treatment of comorbid alcohol use and anxiety disorders: Study protocol and methods. Contemp Clin Trials 2021; 108:106512. [PMID: 34284152 DOI: 10.1016/j.cct.2021.106512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 11/20/2022]
Abstract
Alcohol Use Disorder (AUD) and anxiety disorders (ANX) are each highly prevalent and frequently co-occur, resulting in a complex clinical presentation. The existing literature to date has not yet identified how to best treat comorbid AUD/ANX, partially due to limitations in understanding what factors and mechanisms are implicated in their co-occurrence. This manuscript describes the rationale and methods for an ongoing randomized-controlled trial designed to evaluate the efficacy of a cognitive behavioral intervention, the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP), compared to Take Control (TC), a psychosocial and motivational treatment serving as a control condition in this study, for comorbid AUD/ANX. Sixty individuals with comorbid AUD/ANX will be randomized to UP or TC, and complete assessments at pre- and post-treatment, as well as one- and six-month follow-up points. We hypothesize that the UP, compared to TC, will result in significantly greater reductions in drinking-related outcomes, as well as anxiety and depressive-related outcomes. Additionally, the current study is designed to evaluate exploratory aims to contribute to our theoretical understanding of why AUD and ANX frequently co-occur. Specifically, we will examine the relationship between changes in AUD and ANX symptoms in relation to changes in emotional disorder mechanisms, such as emotion regulation. Because the UP is a transdiagnostic treatment that specifically targets underlying components of emotional disorders generally, it may be well suited to effectively target comorbid AUD/ANX.
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Berenz EC, Edalatian Zakeri S, Demos AP, Paltell KC, Bing-Canar H, Kevorkian S, Ranney R. Negative affect and alcohol craving in trauma-exposed young adult drinkers. Alcohol Clin Exp Res 2021; 45:1479-1493. [PMID: 34241905 DOI: 10.1111/acer.14641] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 05/05/2021] [Accepted: 05/12/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Clinical research indicates that successful posttraumatic stress disorder (PTSD) treatment does not lead to improvements in alcohol use outcomes in comorbid PTSD and alcohol use disorder (AUD). Emerging theory suggests that treating PTSD may not disrupt an association between negative affect and alcohol craving, which underlies negative reinforcement drinking. The goal of the current study was to determine the respective influences of PTSD symptoms, coping motives, and negative affect on trauma and alcohol cue reactivity to inform theoretical models of co-occurring PTSD and AUD. METHODS The sample consisted of 189 young adults (50.3% women; 49.2% current PTSD; 84.0% current AUD) who endorsed interpersonal trauma (e.g., sexual/physical assault) and current weekly alcohol use. Participants completed a trauma and alcohol cue reactivity assessment, in which subjective (e.g., craving, affect) and physiological (i.e., salivation) measures were recorded in response to 4 narrative (i.e., personalized trauma or standard neutral) and in vivo beverage (i.e., personalized alcohol or water) cue combinations. RESULTS Forward-fitted linear mixed-effects (LME) models confirmed that trauma cue-elicited craving was elevated among those high but not low in PTSD symptoms, consistent with prior research and theory. Trauma cue-elicited craving was fully explained by increases in negative affect, with no evidence of a direct effect of trauma cue on craving. PTSD symptoms moderated an association between trauma cue and negative affect (but not negative affect and craving), and coping motives for alcohol moderated an association between negative affect and craving (but not trauma cue and negative affect). CONCLUSIONS This study provides novel laboratory evidence for the respective contributions of negative affect, PTSD symptoms, and coping motives on alcohol craving in trauma-exposed drinkers. It offers a methodological framework in which to evaluate novel strategies that aim to disrupt negative reinforcement drinking in individuals with co-occurring PTSD and AUD.
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Affiliation(s)
- Erin C Berenz
- Department of Psychology, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Alexander P Demos
- Department of Psychology, University of Illinois at Chicago, Chicago, IL, USA
| | - Katherine C Paltell
- Department of Psychology, University of Illinois at Chicago, Chicago, IL, USA
| | - Hanaan Bing-Canar
- Department of Psychology, University of Illinois at Chicago, Chicago, IL, USA
| | - Salpi Kevorkian
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Rachel Ranney
- Department of Psychology, University of Illinois at Chicago, Chicago, IL, USA
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Stapinski LA, Sannibale C, Subotic M, Rapee RM, Teesson M, Haber PS, Baillie AJ. Randomised controlled trial of integrated cognitive behavioural treatment and motivational enhancement for comorbid social anxiety and alcohol use disorders. Aust N Z J Psychiatry 2021; 55:207-220. [PMID: 32900220 DOI: 10.1177/0004867420952539] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Alcohol use disorder and social anxiety disorder are interconnected disorders that commonly co-occur. We report the first trial to assess whether integrated treatment for social anxiety and alcohol use disorder comorbidity improves outcomes relative to standard alcohol-focussed treatment. METHOD Participants were recruited to a randomised controlled trial, and randomly allocated to one of two treatments, Integrated (n = 61) or Control (alcohol-focussed; n = 56). Assessment and treatment session were conducted at two sites in Sydney, Australia. Inclusion criteria were as follows: (1) clinical diagnosis of social anxiety disorder and (2) Diagnosis or sub-clinical symptoms of alcohol use disorder. Diagnoses were determined according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.). All participants (n = 117) received 10 sessions of cognitive behavioural treatment and motivational enhancement. The Integrated treatment simultaneously targeted social anxiety disorder, alcohol use disorder and the connections between these disorders. The Control treatment focussed on alcohol use disorder only. Outcomes were assessed at 6-month follow-up, with interim assessments at post-treatment and 3 months. Primary outcomes were social anxiety disorder severity (composite Social Phobia Scale and Social Interaction Anxiety Scale), alcohol use disorder severity (standard drinks per day and Severity of Alcohol Dependence Questionnaire) and quality of life (Short-Form Health survey) was assessed to capture the combined impairment of social anxiety and alcohol use disorder comorbidity. RESULTS At 6-month follow-up, both conditions showed significant reductions in social anxiety and alcohol use disorder symptoms, and improved quality of life. There was no evidence of between-condition differences for alcohol outcomes, with mean consumption reduced by 5.0 (0.8) and 5.8 (1.0) drinks per day following Alcohol and Integrated treatments, respectively. Integrated treatment achieved greater improvements in social anxiety symptoms (mean difference = -14.9, 95% confidence interval = [-28.1, -1.6], d = 0.60) and quality of life (mean difference = 7.6, 95% confidence interval = [1.2, 14.0], d = 0.80) relative to alcohol-focused treatment. CONCLUSION These results suggest that integrated social anxiety and alcohol use disorder treatment enhances quality of life and social anxiety disorder symptom improvement, but not alcohol outcomes, compared to treatment focussed on alcohol use disorder alone.
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Affiliation(s)
- Lexine A Stapinski
- Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, NSW, Australia.,The Matilda Centre of Research in Mental Health and Substance Use, The University of Sydney, Camperdown, NSW, Australia
| | - Claudia Sannibale
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Mirjana Subotic
- Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, NSW, Australia
| | - Ronald M Rapee
- Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, NSW, Australia
| | - Maree Teesson
- The Matilda Centre of Research in Mental Health and Substance Use, The University of Sydney, Camperdown, NSW, Australia.,National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Paul S Haber
- Discipline of Addiction Medicine, The University of Sydney, Camperdown, NSW, Australia
| | - Andrew J Baillie
- Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, NSW, Australia
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Abstract
OBJECTIVES Relapse rates in subjects with an alcohol use disorder who have undergone alcohol detoxification are high, and risk factors vary according to the studied population and the context in which withdrawal occurred. Subjects being treated in psychiatric settings require increased monitoring at the moment of detoxification and during follow-up. It is thus important to identify specific risk factors for relapse in such patients. The objective of this study was to determine factors associated with maintenance of abstinence 2 months after alcohol withdrawal (M2) and to characterize factors associated with later relapses 6 months after withdrawal (M6) among those who were abstainers at M2. METHODS We conducted an ancillary study of a specific psychiatric cohort of subjects with an alcohol use disorder who were followed after withdrawal, by analyzing clinical and biological data collected at M2 and M6. RESULTS The specific factors predictive of future relapse were age, intensity of craving, number of standard glasses consumed, psychiatric comorbidity (depression), and employment and family/marital status. Substance use (other than the use of tobacco) decreased the likelihood of abstinence at M2, whereas a depressive state at the time of alcohol withdrawal increased the likelihood of abstinence at M2. Consumption of other substances and a greater intensity of craving at the time of alcohol withdrawal decreased the likelihood of abstinence at M6. CONCLUSIONS The results of this study highlight the importance of identifying craving, multiple substance use, and psychiatric comorbidities (depression) during comprehensive interviews in follow-up after alcohol withdrawal. In caring for patients after alcohol detoxification, priority should be given to factors that have been shown to enhance the beneficial effects of abstinence, such as mood enhancement.
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Kummerfeld E, Rix A, Anker JJ, Kushner MG. Assessing the collective utility of multiple analyses on clinical alcohol use disorder data. J Am Med Inform Assoc 2019; 26:1046-1055. [PMID: 30990526 DOI: 10.1093/jamia/ocz034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/14/2019] [Accepted: 03/14/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The objective of this study was to assess the potential of combining graph learning methods with latent variable estimation methods for mining clinically useful information from observational clinical data sets. MATERIALS AND METHODS The data set contained self-reported measures of psychopathology symptoms from a clinical sample receiving treatment for alcohol use disorder. We used the traditional graph learning methods: Graphical Least Absolute Shrinkage and Selection Operator, and Friedman's hill climbing algorithm; traditional latent variable estimation method factor analysis; recently developed graph learning method Greedy Fast Causal Inference; and recently developed latent variable estimation method Find One Factor Clusters. Methods were assessed qualitatively by the content of their findings. RESULTS Recently developed graphical methods identified potential latent variables (ie, not represented in the model) influencing particular scores. Recently developed latent effect estimation methods identified plausible cross-score loadings that were not found with factor analysis. A graphical analysis of individual items identified a mistake in wording on 1 questionnaire and provided further evidence that certain scores are not reflective of indirectly measured common causes. DISCUSSION AND CONCLUSION Our findings suggest that a combination of Greedy Fast Causal Inference and Find One Factor Clusters can enhance the evidence-based information yield from psychopathological constructs and questionnaires. Traditional methods provided some of the same information but missed other important findings. These conclusions point the way toward more informative interrogations of existing and future data sets than are commonly employed at present.
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Affiliation(s)
- Erich Kummerfeld
- University of Minnesota - Institute for Health Informatics, Minneapolis, Minnesota, USA
| | - Alexander Rix
- University of Minnesota - Institute for Health Informatics, Minneapolis, Minnesota, USA
| | - Justin J Anker
- University of Minnesota - Department of Psychiatry, Minneapolis, Minnesota, USA
| | - Matt G Kushner
- University of Minnesota - Department of Psychiatry, Minneapolis, Minnesota, USA
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12
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Stapinski LA, Prior K, Newton NC, Deady M, Kelly E, Lees B, Teesson M, Baillie AJ. Protocol for the Inroads Study: A Randomized Controlled Trial of an Internet-Delivered, Cognitive Behavioral Therapy-Based Early Intervention to Reduce Anxiety and Hazardous Alcohol Use Among Young People. JMIR Res Protoc 2019; 8:e12370. [PMID: 30977742 PMCID: PMC6484258 DOI: 10.2196/12370] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/09/2019] [Accepted: 01/09/2019] [Indexed: 11/13/2022] Open
Abstract
Background The transition to adulthood is a unique developmental period characterized by numerous personal and social role changes and increased opportunities for alcohol consumption. Using alcohol to cope with anxiety symptoms is commonly reported, and young people with anxiety are at a greater risk of hazardous alcohol use and progression to alcohol use disorder. Anxiety and alcohol use tend to fuel each other in an exacerbating feed-forward cycle, leading to difficult-to-treat chronic problems. The peak in onset of anxiety and alcohol disorders suggests this developmental window represents a promising opportunity for early intervention before these problems become entrenched. Objective This study aims to evaluate the efficacy of the Inroads program, a therapist-supported, internet-delivered early intervention for young adults that targets alcohol use, anxiety symptoms, and the interconnections between these problems. Methods A randomized controlled trial will be conducted nationally among young Australians (aged 17-24 years) who experience anxiety symptoms and drink alcohol at hazardous or harmful levels. Participants will be individually randomized on a 1:1 basis to receive the Inroads intervention or assessment plus alcohol guidelines. Participants randomized to the Inroads intervention will receive access to 5 Web-based cognitive behavioral therapy (CBT) modules and weekly therapist support via email and/or phone. The primary outcome assessment will be 8 weeks post baseline, with follow-up assessment 6 months post baseline to determine the sustainability of the intervention effects. Primary outcomes will be the total number of standard drinks consumed in the past month (assessed by the Timeline Follow-Back procedure), severity of alcohol-related harms (assessed by the Brief Young Adult Alcohol Consequences Questionnaire), and anxiety symptoms across multiple disorders (assessed by the Generalized Anxiety Disorder-7). Secondary outcomes will include alcohol outcome expectancies; functional impairment and quality of life; and symptoms of social anxiety, anxious arousal, and depression. Results will be analyzed by intention-to-treat using multilevel mixed effects analysis for repeated measures. Results The study is funded from 2017 to 2020 by Australian Rotary Health. Recruitment is expected to be complete by late-2018, with the 6-month follow-ups to be completed by mid-2019. Results are expected to be published in 2020. Conclusions The study will be the first to evaluate the benefits of a youth-focused early intervention that simultaneously targets anxiety and hazardous alcohol use. By explicitly addressing the interconnections between anxiety and alcohol use and enhancing CBT coping skills, the Inroads program has the potential to interrupt the trajectory toward co-occurring anxiety and alcohol use disorders. The Web-based format of the program combined with minimal therapist support means that if effective, the program could be widely disseminated to reach young people who are not currently able or willing to access face-to-face treatment. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12617001609347; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372748&isReview=true (Archived by WebCite at http://www.webcitation.org/77Au19jmf) International Registered Report Identifier (IRRID) DERR1-10.2196/12370
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Affiliation(s)
- Lexine A Stapinski
- Centre of Research Excellence in Mental Health and Substance Use, National Drug & Alcohol Research Centre, University of New South Wales, Sydney, Australia.,The Matilda Centre, University of Sydney, Sydney, Australia
| | - Katrina Prior
- Centre of Research Excellence in Mental Health and Substance Use, National Drug & Alcohol Research Centre, University of New South Wales, Sydney, Australia.,The Matilda Centre, University of Sydney, Sydney, Australia
| | - Nicola C Newton
- Centre of Research Excellence in Mental Health and Substance Use, National Drug & Alcohol Research Centre, University of New South Wales, Sydney, Australia.,The Matilda Centre, University of Sydney, Sydney, Australia
| | - Mark Deady
- Black Dog Institute, University of New South Wales, Sydney, Australia
| | - Erin Kelly
- Centre of Research Excellence in Mental Health and Substance Use, National Drug & Alcohol Research Centre, University of New South Wales, Sydney, Australia.,The Matilda Centre, University of Sydney, Sydney, Australia
| | - Briana Lees
- Centre of Research Excellence in Mental Health and Substance Use, National Drug & Alcohol Research Centre, University of New South Wales, Sydney, Australia.,The Matilda Centre, University of Sydney, Sydney, Australia
| | - Maree Teesson
- Centre of Research Excellence in Mental Health and Substance Use, National Drug & Alcohol Research Centre, University of New South Wales, Sydney, Australia.,The Matilda Centre, University of Sydney, Sydney, Australia
| | - Andrew J Baillie
- The Matilda Centre, University of Sydney, Sydney, Australia.,Faculty of Health Sciences, University of Sydney, Sydney, Australia
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13
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Lo Coco G, Melchiori F, Oieni V, Infurna MR, Strauss B, Schwartze D, Rosendahl J, Gullo S. Group treatment for substance use disorder in adults: A systematic review and meta-analysis of randomized-controlled trials. J Subst Abuse Treat 2019; 99:104-116. [PMID: 30797382 DOI: 10.1016/j.jsat.2019.01.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS From residential programs to outpatient services, group therapy permeates the clinical field of substance misuse. While several group interventions for substance use disorders (SUDs) have demonstrated effectiveness, the existing evidence on group therapy has not been systematically reviewed. The current meta-analysis aims to provide estimates of the efficacy of group therapy for SUDs in adults using rigorous methods. METHODS We included studies comparing group psychotherapy to no treatment control groups, individual psychotherapy, medication, self-help groups, and other active treatments applying no specific psychotherapeutic techniques for patients with substance use disorder. The primary outcome was abstinence, and the secondary outcomes were frequency of substance use and symptoms of substance use disorder, anxiety, depression, general psychopathology, and attrition. A comprehensive search was conducted in Medline, Web of Science, CENTRAL, and PsycINFO, complemented by a manual search. Random-effects meta-analyses were run separately for different types of control groups. RESULTS Thirty-three studies were included. Significant small effects of group therapy were found on abstinence compared to no treatment, individual therapy, and other treatments. Effects on substance use frequency and SUD symptoms were not significant, but significant moderately sized effects emerged for mental state when group therapy was compared to no treatment. There were no differences in abstinence rates between group therapy and control groups. These results were robust in sensitivity analyses and there was no indication of publication bias. CONCLUSIONS The current findings represent the best available summary analysis of group therapy for SUDs in adults, however cautious interpretation is warranted given the limitations of the available data.
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Affiliation(s)
- Gianluca Lo Coco
- University of Palermo, Department of Psychology, Educational Sciences and Human Movement, Palermo, Italy.
| | | | | | | | - Bernhard Strauss
- University Hospital Jena, Friedrich Schiller University Jena, Institute of Psychosocial Medicine and Psychotherapy, Jena, Germany
| | - Dominique Schwartze
- University Hospital Jena, Friedrich Schiller University Jena, Institute of Psychosocial Medicine and Psychotherapy, Jena, Germany
| | - Jenny Rosendahl
- University Hospital Jena, Friedrich Schiller University Jena, Institute of Psychosocial Medicine and Psychotherapy, Jena, Germany
| | - Salvatore Gullo
- University of Palermo, Department of Psychology, Educational Sciences and Human Movement, Palermo, Italy
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14
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Anker JJ, Kummerfeld E, Rix A, Burwell SJ, Kushner MG. Causal Network Modeling of the Determinants of Drinking Behavior in Comorbid Alcohol Use and Anxiety Disorder. Alcohol Clin Exp Res 2018; 43:91-97. [PMID: 30371947 DOI: 10.1111/acer.13914] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 10/12/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Anxiety and depression disorders (internalizing psychopathology) occur in approximately 50% of patients with alcohol use disorder (AUD) and mark a 2-fold increase in the rate of relapse in the months following treatment. In a previous study using network modeling, we found that perceived stress and drinking to cope (DTC) with negative affect were central to maintaining network associations between internalizing psychopathology INTP and drinking in comorbid individuals. Here, we extend this approach to a causal framework. METHODS Measures of INTP, drinking urges/behavior, abstinence self-efficacy, and DTC were obtained from 362 adult AUD treatment patients who had a co-occurring anxiety disorder. Data were analyzed using a machine-learning algorithm ("Greedy Fast Causal Inference"[ GFCI]) that infers paths of causal influence while identifying potential influences associated with unmeasured ("latent") variables. RESULTS DTC with negative affect served as a central hub for 2 distinct causal paths leading to drinking behavior, (i) a direct syndromic pathway originating with social anxiety and (ii) an indirect stress pathway originating with perceived stress. CONCLUSIONS Findings expand the field's knowledge of the paths of influence that lead from internalizing disorder to drinking in AUD as shown by the first application in psychopathology of a powerful network analysis algorithm (GFCI) to model these causal relationships.
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Affiliation(s)
- Justin J Anker
- Department of Psychiatry , University of Minnesota, Minneapolis, Minnesota
| | - Erich Kummerfeld
- Institute for Health Informatics , University of Minnesota, Minneapolis, Minnesota
| | - Alexander Rix
- Institute for Health Informatics , University of Minnesota, Minneapolis, Minnesota
| | - Scott J Burwell
- Department of Psychiatry , University of Minnesota, Minneapolis, Minnesota
| | - Matt G Kushner
- Department of Psychiatry , University of Minnesota, Minneapolis, Minnesota
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15
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[Evidence-based psychotherapy of addictive disorders]. DER NERVENARZT 2018; 89:283-289. [PMID: 29368015 DOI: 10.1007/s00115-018-0483-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Addictive disorders form the group of the most common mental disorders. A wide range of psychotherapeutic treatment interventions exists; however, the proportion of patients receiving evidence-based interventions or psychotherapeutic treatment in outpatient care is very low. OBJECTIVE The aim of the present review was a systematic reassessment of the empirical evidence for the efficacy of the different forms of psychotherapeutic treatment, identification of new effective interventions and derivation of recommendations for treatment practitioners. MATERIAL AND METHODS A comprehensive literature search in a multistage method in the relevant national and international data banks was conducted. Subsequent analysis of topical guidelines, systematic reviews and original studies about addictions and therapy was performed. RESULTS A total of 3 topical national guidelines, 2 reviews and 16 original studies could be identified. In particular, cognitive behavioral therapy, behavioral interventions and motivational interventions could be identified as evidence-based interventions for the treatment of addictive disorders. Hypnotherapy can be recommended alternatively for patients dependent on tobacco. Also interesting for practitioners could be new treatment methods, such as neurocognitive training and mindfulness-based interventions. CONCLUSION At present, although of high quality, results from existing studies are sometimes inconsistent or are numerically insufficient with respect to special treatment options. Future studies are warranted with respect to different substance use disorders and further patient groups.
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16
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Hogarth L, Hardy L. Depressive statements prime goal-directed alcohol-seeking in individuals who report drinking to cope with negative affect. Psychopharmacology (Berl) 2018; 235:269-279. [PMID: 29082424 PMCID: PMC5748391 DOI: 10.1007/s00213-017-4765-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 10/13/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND Most variants of negative reinforcement theory predict that acute depressed mood can promote alcohol-seeking behaviour, but the precise mechanisms underpinning this effect remain contested. One possibility is that mood-induced alcohol-seeking is due to the formation of a stimulus-response (S-R) association, enabling depressed mood to elicit alcohol-seeking automatically. A second possibility is that depressed mood undergoes incentive learning, enabling it to enhance the expected value of alcohol and thus promote goal-directed alcohol-seeking. OBJECTIVES These two explanations were distinguished using a human outcome-revaluation procedure. METHODS One hundred and twenty-eight alcohol drinkers completed questionnaires of alcohol use disorder, drinking to cope with negative affect and depression symptoms. Participants then learned that two responses earned alcohol and food points respectively (baseline) in two alternative forced choice trials. At test, participants rated the valence of randomly sampled negative and positive mood statements and, after each statement, chose between the alcohol- and food-seeking responses in extinction. RESULTS The percentage of alcohol- versus food-seeking responses was increased significantly in trials containing negative statements compared to baseline and positive statement trials, in individuals who reported drinking to cope with negative affect (p = .004), but there was no such interaction with indices of alcohol use disorder (p = .87) or depression symptoms (p = .58). CONCLUSIONS Individuals who drink to cope with negative affect are more sensitive to the motivational impact of acute depressed mood statements priming goal-directed alcohol-seeking. Negative copers' vulnerability to alcohol dependence may be better explained by excessive affective incentive learning than by S-R habit formation.
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Affiliation(s)
- Lee Hogarth
- School of Psychology, University of Exeter, Washington Singer Building, Perry Road, Exeter, EX4 4QG, UK.
| | - Lorna Hardy
- School of Psychology, University of Exeter, Washington Singer Building, Perry Road, Exeter, EX4 4QG, UK
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17
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Hogarth L, Mathew AR, Hitsman B. Current major depression is associated with greater sensitivity to the motivational effect of both negative mood induction and abstinence on tobacco-seeking behavior. Drug Alcohol Depend 2017; 176:1-6. [PMID: 28460322 PMCID: PMC5499379 DOI: 10.1016/j.drugalcdep.2017.02.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 01/30/2017] [Accepted: 02/01/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although depression and smoking commonly co-occur, the mechanisms underpinning this association are poorly understood. One hypothesis is that depression promotes tobacco dependence, persistence and relapse by increasing sensitivity to acute negative mood and abstinence induced tobacco-seeking behavior. METHODS Twenty nine daily smokers of >10 cigarettes per day, nine with major depression and 20 without, completed two laboratory sessions one week apart, smoking as normal prior to session 1 (sated session), and 6h abstinent prior to session 2 (abstinent session). In both sessions, tobacco-seeking was measured at baseline by preference to view smoking versus food images. Negative mood was then induced by negative ruminative statements and sad music, before tobacco-seeking was measured again at test. RESULTS In the sated session, negative mood induction produced a greater increase in tobacco choice from baseline to test in depressed (p<0.001, ηp2=0.782) compared to non-depressed smokers (p=0.045, ηp2=0.216, interaction: p=0.046, ηp2=0.150). Abstinence also produced a greater increase in baseline tobacco choice between the sated and abstinent sessions in depressed (p=0.002, ηp2=0.771) compared to non-depressed smokers (p=0.22, ηp2=0.089, interaction: p=0.023, ηp2=0.189). These mood and abstinence induced increases in tobacco choice were positively associated with depression symptoms across the sample as a whole (ps≤0.04, ηp2≥0.159), and correlated with each other (r=0.67, p<0.001). CONCLUSIONS Current major depression or depression symptoms may promote tobacco dependence, persistence and relapse by increasing sensitivity to both acute negative mood and abstinence induced tobacco-seeking behavior. Treatments should seek to break the association between adverse states and smoking to cope.
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Affiliation(s)
- Lee Hogarth
- School of Psychology, University of Exeter, Washington Singer Building, Perry Road, Exeter EX4 4QG, UK
| | - Amanda R. Mathew
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brian Hitsman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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18
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Associations between early internalizing symptoms and speed of transition through stages of alcohol involvement. Dev Psychopathol 2017; 29:1455-1467. [PMID: 28397620 DOI: 10.1017/s0954579417000384] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Alcohol use disorders and internalizing disorders are highly comorbid, but how this comorbidity unfolds over development is not well understood. The present study investigated effects of internalizing symptoms in late childhood on speed of transition between three alcohol involvement milestones: first drink, first binge, and onset of first alcohol dependence symptom. Greater early internalizing symptoms were expected to predict a later age of first drink, a slower transition from first drink to first binge, and a faster transition from first binge to first dependence symptom. The effects of age and moderating effects of gender were also examined. Data were from a longitudinal study of children of alcoholics and matched controls (N = 454) followed from late childhood to midlife. Generally, stage-specific hypotheses were not supported; rather, greater internalizing symptoms predicted an earlier age of first drink and a faster transition through the full interval from first drink to first dependence symptom. Regarding gender moderation, internalizing significantly predicted a faster transition between each milestone as well as through the full interval among women but not men. These results suggest that early internalizing problems confer risk for a rapid transition through all stages of alcohol involvement, and this risk may be limited to women.
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19
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Anker JJ, Forbes MK, Almquist ZW, Menk JS, Thuras P, Unruh AS, Kushner MG. A network approach to modeling comorbid internalizing and alcohol use disorders. JOURNAL OF ABNORMAL PSYCHOLOGY 2017; 126:325-339. [PMID: 28182444 PMCID: PMC5388354 DOI: 10.1037/abn0000257] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Internalizing disorders co-occur with alcohol use disorder (AUD) at a rate that exceeds chance and compromise conventional AUD treatment. The "vicious cycle" model of comorbidity specifies drinking to cope (DTC) as a link between these disorders that, when not directly addressed, undermines the effectiveness of conventional treatments. Interventions based on this model have proven successful but there is no direct evidence for how and to what extent DTC contributes to the maintenance of comorbidity. In the present study, we used network analysis to depict associations between syndrome-specific groupings of internalizing symptoms, alcohol craving, and drinking behavior, as well as DTC and other extradiagnostic variables specified in the vicious cycle model (e.g., perceived stress and coping self-efficacy). Network analyses of 362 individuals with comorbid anxiety and AUD assessed at the beginning of residential AUD treatment indicated that while internalizing conditions and drinking elements had only weak direct associations, they were strongly connected with DTC and perceived stress. Consistent with this, centrality indices showed that DTC ranked as the most central/important element in the network in terms of its "connectedness" to all other network elements. A series of model simulations-in which individual elements were statistically controlled for-demonstrated that DTC accounted for all the relationships between the drinking-related elements and internalizing elements in the network; no other variable had this effect. Taken together, our findings suggest that DTC may serve as a "keystone" process in maintaining comorbidity between internalizing disorders and AUD. (PsycINFO Database Record
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Affiliation(s)
| | | | | | - Jeremiah S Menk
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute
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20
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Karpyak VM, Biernacka JM, Geske JR, Abulseoud OA, Brunner MD, Chauhan M, Hall‐Flavin DK, Lewis KA, Loukianova LL, Melnyk GJ, Onsrud DA, Proctor BD, Schneekloth TD, Skime MK, Wittkopp JE, Frye MA, Mrazek DA. Gender-specific effects of comorbid depression and anxiety on the propensity to drink in negative emotional states. Addiction 2016; 111:1366-75. [PMID: 27009547 PMCID: PMC4940218 DOI: 10.1111/add.13386] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 10/23/2015] [Accepted: 03/07/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Depression and anxiety are often comorbid with alcoholism and contribute to craving and relapse. We aimed to estimate the prevalence of life-time diagnoses of major depressive disorder (MDD), substance-induced depression (SID), anxiety disorder (AnxD) and substance-induced anxiety (SIA), the effects of these comorbidities on the propensity to drink in negative emotional states (negative craving), and test whether these effects differ by sex. DESIGN Secondary analyses of baseline data collected in a single-arm study of pharmacogenetic predictors of acamprosate response. SETTING Academic medical center and affiliated community-based treatment programs in the American upper mid-west. PARTICIPANTS A total of 287 males and 156 females aged 18-80 years, meeting DSM-IV criteria for alcohol dependence. MEASUREMENTS The primary outcome measure was 'propensity to drink in negative emotional situations' (determined by the Inventory of Drug Taking Situations) and the key predictors/covariates were sex and psychiatric comorbidities, including MDD, SID, AnxD and SIA (determined by Psychiatric Research Interview of Substance and Mood Disorders). FINDINGS The prevalence of the MDD, SID and AnxD was higher in females compared with males (33.1 versus 18.4%, 44.8 versus 26.4% and 42.2 versus 27.4%, respectively; P < 0.01, each), while SIA was rare (3.3%) and did not differ by sex. Increased propensity to drink in negative emotional situations was associated with comorbid MDD (β = 6.6, P = 0.013) and AnxD (β = 4.8, P = 0.042) as well as a SID × sex interaction effect (P = 0.003), indicating that the association of SID with propensity to drink in negative emotional situations differs by sex and is stronger in males (β = 7.9, P = 0.009) compared with females (β = -6.6, P = 0.091). CONCLUSIONS There appears to be a higher prevalence of comorbid depression and anxiety disorders as well as propensity to drink in negative emotional situations in female compared with male alcoholics. Substance-induced depression appears to have a sex-specific effect on the increased risk for drinking in negative emotional situations in males.
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Affiliation(s)
| | - Joanna M. Biernacka
- Department of Psychiatry and PsychologyMayo ClinicRochesterMNUSA,Department of Health Sciences ResearchMayo ClinicRochesterMNUSA
| | | | - Osama A. Abulseoud
- Department of Psychiatry and PsychologyMayo ClinicRochesterMNUSA,Chemistry and Drug Metabolism, IRPNational Institute on Drug Abuse, National Institutes of HealthBaltimoreMDUSA
| | | | - Mohit Chauhan
- Addiction Recovery ServicesMayo Clinic Health SystemAustinMNUSA,Piedmont Medical CenterRock HillSCUSA
| | | | - Kriste A. Lewis
- Department of Psychiatry and PsychologyMayo ClinicRochesterMNUSA,Regions HospitalSt PaulMNUSA
| | | | - George J. Melnyk
- Department of PsychiatryMayo Clinic Health System—Franciscan HealthcareLa CrosseWIUSA
| | - David A. Onsrud
- Department of Family MedicineMayo Clinic Health System—Franciscan HealthcareLa CrosseWIUSA
| | - Brian D. Proctor
- Department of PsychiatryMayo Clinic Health System—Franciscan HealthcareLa CrosseWIUSA
| | | | | | | | - Mark A. Frye
- Department of Psychiatry and PsychologyMayo ClinicRochesterMNUSA
| | - David A. Mrazek
- Department of Psychiatry and PsychologyMayo ClinicRochesterMNUSA
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21
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Anker J, Kushner M, Thuras P, Menk J, Unruh A. Drinking to cope with negative emotions moderates alcohol use disorder treatment response in patients with co-occurring anxiety disorder. Drug Alcohol Depend 2016; 159:93-100. [PMID: 26718394 PMCID: PMC4782758 DOI: 10.1016/j.drugalcdep.2015.11.031] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 11/16/2015] [Accepted: 11/26/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Epidemiological studies and theory implicate drinking to cope (DTC) with anxiety as a potent moderator of the association between anxiety disorder (AnxD) and problematic alcohol use. However, the relevance of DTC to the treatment of alcohol use disorder (AUD) in those with a co-occurring AnxD has not been well studied. To address this, we examined whether DTC moderates the impact of two therapies: (1) a cognitive behavioral therapy (CBT) designed to reduce DTC and anxiety symptoms; (2) a progressive muscle relaxation training (PMRT) program designed to reduce anxiety symptoms only. METHODS Patients undergoing a standard AUD residential treatment with a co-occurring AnxD (N=218) were randomly assigned to also receive either the CBT or PMRT. DTC in the 30 days prior to treatment was measured using the Unpleasant Emotions subscale of the Inventory of Drinking Situations. RESULTS Confirming the predicted moderator model, the results indicated a significant interaction between treatment group and level of pre-treatment DTC behavior. Probing this interaction revealed that for those reporting more pre-treatment DTC behavior, 4-month alcohol outcomes were superior in the CBT group relative to the PMRT group. For those reporting less pre-treatment DTC behavior, however, 4-month alcohol outcomes were similar and relatively good in both treatment groups. CONCLUSIONS These findings establish a meaningful clinical distinction among those with co-occurring AUD-AnxD based on the degree to which the symptoms of the two disorders are functionally linked through DTC. Those whose co-occurring AUD-AnxD is more versus less strongly linked via DTC are especially likely to benefit from standard AUD treatment that is augmented by a brief CBT designed to disrupt this functional link.
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Affiliation(s)
| | - M.G. Kushner
- Corresponding author at: University of Minnesota, Department of Psychiatry, 282-2A West, 2450 Riverside Ave., Minneapolis, MN 55454, United States. (M.G. Kushner)
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Menary KR, Corbin WR, Leeman RF, Fucito LM, Toll BA, DeMartini K, O'Malley SS. Interactive and Indirect Effects of Anxiety and Negative Urgency on Alcohol-Related Problems. Alcohol Clin Exp Res 2015; 39:1267-74. [PMID: 26031346 DOI: 10.1111/acer.12762] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 04/23/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Although drinking for tension reduction has long been posited as a risk factor for alcohol-related problems, studies investigating anxiety in relation to risk for alcohol problems have returned inconsistent results, leading researchers to search for potential moderators. Negative urgency (the tendency to become behaviorally dysregulated when experiencing negative affect) is a potential moderator of theoretical interest because it may increase risk for alcohol problems among those high in negative affect. This study tested a cross-sectional mediated moderation hypothesis whereby an interactive effect of anxiety and negative urgency on alcohol problems is mediated through coping-related drinking motives. METHODS The study utilized baseline data from a hazardously drinking sample of young adults (N = 193) evaluated for participation in a randomized controlled trial of naltrexone and motivational interviewing for drinking reduction. RESULTS The direct effect of anxiety on physiological dependence symptoms was moderated by negative urgency such that the positive association between anxiety and physiological dependence symptoms became stronger as negative urgency increased. Indirect effects of anxiety and negative urgency on alcohol problems (operating through coping motives) were also observed. CONCLUSIONS Although results of the current cross-sectional study require replication using longitudinal data, the findings suggest that the simultaneous presence of anxiety and negative urgency may be an important indicator of risk for alcohol use disorders via both direct interactive effects and indirect additive effects operating through coping motives. These findings have potentially important implications for prevention/intervention efforts for individuals who become disinhibited in the context of negative emotional states.
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Affiliation(s)
- Kyle R Menary
- Department of Psychology, Arizona State University, Tempe, Arizona
| | - William R Corbin
- Department of Psychology, Arizona State University, Tempe, Arizona
| | | | | | - Benjamin A Toll
- Yale School of Medicine, New Haven, Connecticut.,Yale Cancer Center, New Haven, Connecticut.,Smilow Cancer Hospital at Yale-New Haven, New Haven, Connecticut
| | | | - Stephanie S O'Malley
- Yale School of Medicine, New Haven, Connecticut.,Yale Cancer Center, New Haven, Connecticut
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Abstract
Anxiety disorders commonly co-occur with substance use disorders both in the general population and in treatment-seeking samples. This co-occurrence is associated with greater symptom severity, higher levels of disability, and poorer course of illness relative to either disorder alone. Little research has been conducted, however, on the treatment of these co-occurring disorders. This gap may not only leave anxiety untreated or undertreated but also increase the risk for relapse and poor substance use outcomes. The aim of this article is to review the current state of the literature on treating co-occurring anxiety and substance use disorders. In addition to presenting a brief overview of the epidemiology of this co-occurrence, the article discusses the challenges in assessing anxiety in the context of a substance use disorder, the evidence for various treatment approaches, and recent advances and future directions in this understudied area. Also highlighted is the need for future research to identify optimal behavioral and pharmacologic treatments for co-occurring anxiety and substance use disorders.
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24
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Ruglass LM, Lopez-Castro T, Cheref S, Papini S, Hien DA. At the crossroads: the intersection of substance use disorders, anxiety disorders, and posttraumatic stress disorder. Curr Psychiatry Rep 2014; 16:505. [PMID: 25224608 DOI: 10.1007/s11920-014-0505-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The co-occurrence of substance use disorders with anxiety disorders and/or posttraumatic stress disorder has been widely documented and when compared to each disorder alone, consistently linked to increased risk for a host of negative outcomes including greater impairment, poorer treatment response, and higher rates of symptom relapse. This article focuses on recent advances in the understanding and effective treatment of this common and highly complex comorbidity. Prevalence and epidemiological data are introduced, followed by a review of contemporary models of etiology and associative pathways. Conceptualizations of effective treatment approaches are discussed alongside evidence from the past decade of clinical research trials. Highlighted are ongoing questions regarding the benefit of sequential, parallel, and integrated approaches and the necessity of further investigation into the mechanisms underlying treatment efficacy. Lastly, recent contributions from neuroscience research are offered as a promising bridge for the development and testing of novel, interdisciplinary treatment approaches.
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Affiliation(s)
- Lesia M Ruglass
- Department of Psychology, The City College of New York, 160 Convent Avenue, NAC Building, Rm 7/120, New York, NY, 10031, USA,
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Lechner WV, Shadur JM, Banducci AN, Grant DM, Morse M, Lejuez CW. The mediating role of depression in the relationship between anxiety sensitivity and alcohol dependence. Addict Behav 2014; 39:1243-8. [PMID: 24813550 DOI: 10.1016/j.addbeh.2014.04.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/06/2014] [Accepted: 04/02/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Many studies have reported that Anxiety Sensitivity (AS) is positively associated with alcohol use or other alcohol-related variables. More recent mediator and moderator models have shown promise in elucidating mechanisms within this relationship; the literature to date suggests that the relationship between AS and alcohol is likely mediated by problematic coping motives. However, few studies have considered the effects of depression within the AS-alcohol use relationship, despite a strong body of evidence linking AS to subsequent depression and depression to subsequent alcohol use problems, independently. Therefore, the current study assessed depression as a potential mediator of this relationship. METHOD Participants were 418 sequential admissions to a substance abuse treatment facility. A mediation analysis using bootstrapping was utilized in order to estimate indirect effects of AS on alcohol dependence through depression. RESULTS Results reveal an indirect effect suggesting that the effects of anxiety sensitivity on alcohol dependence are mediated by symptoms of depression. More specifically, the effects of AS total score and AS somatic sensations on alcohol dependence were mediated by symptoms of depression. Lastly, a dual mediator model demonstrated that both depression and problematic coping uniquely mediate the relationship between AS and alcohol dependence. CONCLUSIONS While preliminary in nature, the current study provides evidence supporting the hypothesis that depression is an important factor to consider when examining the relationship between AS and alcohol dependence.
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Affiliation(s)
- William V Lechner
- Oklahoma State University, 118 North Murray Hall, Stillwater, OK 74075, United States; Center for Addictions, Personality, and Emotion Research, University of Maryland, College Park, MD 20742, United States.
| | - Julia M Shadur
- Center for Addictions, Personality, and Emotion Research, University of Maryland, College Park, MD 20742, United States
| | - Anne N Banducci
- Center for Addictions, Personality, and Emotion Research, University of Maryland, College Park, MD 20742, United States
| | - DeMond M Grant
- Oklahoma State University, 118 North Murray Hall, Stillwater, OK 74075, United States
| | - Melanie Morse
- Center for Addictions, Personality, and Emotion Research, University of Maryland, College Park, MD 20742, United States
| | - C W Lejuez
- Center for Addictions, Personality, and Emotion Research, University of Maryland, College Park, MD 20742, United States
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Marsh HW, Morin AJ, Parker PD, Kaur G. Exploratory Structural Equation Modeling: An Integration of the Best Features of Exploratory and Confirmatory Factor Analysis. Annu Rev Clin Psychol 2014; 10:85-110. [DOI: 10.1146/annurev-clinpsy-032813-153700] [Citation(s) in RCA: 799] [Impact Index Per Article: 79.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Herbert W. Marsh
- Department of Education, University of Western Sydney, Penrith NSW 2751, Australia;
- Department of Education, University of Oxford, Oxford, United Kingdom OX2 6PY
- King Saud University, School of Education, Riyadh, Saudi Arabia 11451
| | - Alexandre J.S. Morin
- Department of Education, University of Western Sydney, Penrith NSW 2751, Australia;
| | - Philip D. Parker
- Department of Education, University of Western Sydney, Penrith NSW 2751, Australia;
| | - Gurvinder Kaur
- Department of Education, University of Western Sydney, Penrith NSW 2751, Australia;
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Kushner MG, Krueger RF, Wall MM, Maurer EW, Menk JS, Menary KR. Modeling and treating internalizing psychopathology in a clinical trial: a latent variable structural equation modeling approach. Psychol Med 2013; 43:1611-23. [PMID: 23298776 PMCID: PMC3759231 DOI: 10.1017/s0033291712002772] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clinical trials are typically designed to test the effect of a specific treatment on a single diagnostic entity. However, because common internalizing disorders are highly correlated ('co-morbid'), we sought to establish a practical and parsimonious method to characterize and quantify changes in a broad spectrum of internalizing psychopathology targeted for treatment in a clinical trial contrasting two transdiagnostic psychosocial interventions. METHOD Alcohol dependence treatment patients who had any of several common internalizing disorders were randomized to a six-session cognitive-behavioral therapy (CBT) experimental treatment condition or a progressive muscle relaxation training (PMRT) comparison treatment condition. Internalizing psychopathology was characterized at baseline and 4 months following treatment in terms of the latent structure of six distinct internalizing symptom domain surveys. RESULTS Exploratory structural equation modeling (ESEM) identified a two-factor solution at both baseline and the 4-month follow-up: Distress (measures of depression, trait anxiety and worry) and Fear (measures of panic anxiety, social anxiety and agoraphobia). Although confirmatory factor analysis (CFA) demonstrated measurement invariance between the time-points, structural models showed that the latent means of Fear and Distress decreased substantially from baseline to follow-up for both groups, with a small but statistically significant advantage for the CBT group in terms of Distress (but not Fear) reduction. CONCLUSIONS The approach demonstrated in this study provides a practical solution to modeling co-morbidity in a clinical trial and is consistent with converging evidence pointing to the dimensional structure of internalizing psychopathology.
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Affiliation(s)
- M G Kushner
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, USA.
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