Predicting length of stay in long-term treatment for chemically dependent females

Maternal cognitive functioning and psychopathology predict quality of parent-child relationship in the context of substance use disorder: A 15-month longitudinal study

This longitudinal study aimed to investigate the role of maternal cognitive functioning and psychopathology in parent-child relationship quality during residential treatment for mothers with Substance Use Disorder (SUD), in order to identify factors that may enhance or limit intervention effects.We assessed cognitive functioning (Esame Neuropsicologico Breve-2 [ENB-2]) and psychopathology (Symptom Checklist-90 Revised [SCL-90-R]) in 60 mothers diagnosed with SUD (Mage = 30.13 yrs; SD = 6.79) at treatment admission. Parent-child relationship quality was measured during free-play interactions using the Emotional Availability Scales every three months from admission (Child Mage = 17.17m; SD = 23.60) to the 15th month of the residential treatment.A main effect of maternal psychopathology and an interaction effect of time and cognitive functioning were found. More maternal psychopathology predicted lower mother-child relationship quality. Mothers with higher cognitive functioning presented a better treatment trajectory, with an increase in mother-child relationship quality, whereas mothers with lower cognitive functioning showed a decrease in relationship quality after initial improvement.These findings suggest that maternal psychopathology and cognitive functioning may influence the treatment of parent-child relationships in the context of SUD, although causality is not yet established. Implications for assessment and intervention are discussed.

Analyzing health insurance claims on different timescales to predict days in hospital

Health insurers maintain large databases containing information on medical services utilized by claimants, often spanning several healthcare services and providers. Proper use of these databases could facilitate better clinical and administrative decisions. In these data sets, there exists many unequally spaced events, such as hospital visits. However, data mining of temporal data and point processes is still a developing research area and extracting useful information from such data series is a challenging task. In this paper, we developed a time series data mining approach to predict the number of days in hospital in the coming year for individuals from a general insured population based on their insurance claim data. In the proposed method, the data were windowed at four different timescales (bi-monthly, quarterly, half-yearly and yearly) to construct regularly spaced time series features extracted from such events, resulting in four associated prediction models. A comparison of these models indicates models using a half-yearly windowing scheme delivers the best performance on all three populations (the whole population, a senior sub-population and a non-senior sub-population). The superiority of the half-yearly model was found to be particularly pronounced in the senior sub-population. A bagged decision tree approach was able to predict 'no hospitalization' versus 'at least one day in hospital' with a Matthews correlation coefficient (MCC) of 0.426. This was significantly better than the corresponding yearly model, which achieved 0.375 for this group of customers. Further reducing the length of the analysis windows to three or two months did not produce further improvements.

The relative effectiveness of women-only and mixed-gender treatment for substance-abusing women

Following research indicating that the treatment needs of women are different from those of men, researchers and clinicians have argued that drug treatment programs for women should be designed to take their needs into account. Such programs tend to admit only women and incorporate philosophies and activities that are based on a social, peer-based model that is responsive to women's needs. To assess the relative effectiveness of women-only (WO) outpatient programs compared with mixed-gender (MG) outpatient programs, 291 study volunteers were recruited (152 WO, 139 MG), and a 1-year follow-up was completed with 259 women (135 WO, 124 MG). Using bivariate, logistic regression, and generalized estimating equation analysis, the following four outcomes were examined: drug and alcohol use, criminal activity, arrests, and employment. In both groups, women showed improvement in the four outcome measures. Comparison of the groups on outcomes yielded mixed results; women who participated in the WO treatment reported significantly less substance use and criminal activity than women in the MG treatment, but there were no differences in arrest or employment status at follow-up compared with those in the MG treatment.

Meta-analysis of depression and substance use and impairment among cocaine users

BACKGROUND

The study evaluated, among cocaine users, the hypothesized positive association of depression and concurrent cocaine use and impairment, alcohol use and impairment, and general drug use and impairment. The hypothesis that gender would moderate these associations, with women showing a stronger correlation between depression and measures of substance use and impairment, was also tested. Also examined was the association of depression with future cocaine use and impairment and substance use treatment participation.

METHODS

Empirical reports on adult cocaine users published in English in peer-reviewed journals since 1986 that contained data on depression and substance use outcome(s) were obtained using a systematic search. Studies that placed restrictions on range of depression scores to select the sample, experiments that administered cocaine to subjects, and trials of antidepressant medications were excluded. The search yielded 60 studies for the analysis including 53 reports that collected data from clinical venues and seven that were community-based.

RESULTS

As hypothesized, the analyses showed that depression is associated with concurrent cocaine-, alcohol-, and general drug use and impairment. Effect sizes were small. Hypothesized moderating effects of gender were not supported. Depression was not associated, at a statistically significant level, with treatment participation or future cocaine use and impairment.

CONCLUSIONS

Depression is consistently but modestly associated with measures of cocaine-, alcohol-, and general drug use and impairment among cocaine users. Associations of depression with treatment participation and with future cocaine use and impairment are not immediately evident, although limitations of data warrant cautious interpretation.

Mood disorders affect drug treatment success of drug-dependent pregnant women

This study examined the impact of co-occurring Axis I disorders on drug treatment outcomes of drug-dependent pregnant women. Participants (N = 106) were women who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for opioid dependence and were receiving methadone. Based on DSM-IV Axis I criteria, participants were categorized into three groups: (1) absence of mood/anxiety disorder (ND, n = 29), (2) primary mood disorder (MD, n = 39), or (3) primary anxiety disorder (AD, n = 38). Demographically, the groups were similar. The MD group was significantly more likely to be positive for drugs while in treatment compared with both the ND and AD groups. The MD and AD groups had more psychosocial impairment and higher incidence of suicidal ideation compared with the ND group. Interestingly, the AD group spent more days in treatment compared with the ND or MD group. These findings highlight the need to treat co-occurring Axis I disorders, particularly given the higher relapse risk for those with mood disorders.

Psychopathology is associated with completion of residential treatment in drug dependent women

This study characterized drug dependent women based on current psychopathology (MCMI-III) and then examined the relationship between psychopathology and treatment retention. Participants included 97 pregnant (88%), African-American (78%), single (90%) 30-year old women enrolled in a 6-month residential drug treatment program for women and children. Clustering on personality test scores using Ward's technique identified three subgroups with mild (24%), moderate (59%) and severe (18%) psychopathology. Treatment completion rates varied by group (66%, 45% and 29%), with half of the high severity group leaving against medical advice (AMA) within 60 days. Although the majority of low severity women completed the program as scheduled, they may also have done well in a less intensive treatment modality. Conversely, it appears that women with severe psychopathology may require a more flexible, psychiatrically-oriented approach than is found in most residential settings including greater emphasis on psychiatric issues, individual psychotherapy, and pharmacotherapy.

Psychopathology influences treatment retention among drug-dependent women

Three subgroups of drug dependent women (N = 78) were identified through cluster analysis on MCMI-II scores. Group 1 (26%) presented a relatively benign clinical picture. In contrast, Group 2 (37%) evidenced severe addiction, psychiatric (Axis I), and personality (Axis II) problems. Group 3 (37%) was characterized by fewer Axis I problems, prominent addiction and externalizing (Cluster B) personality deficits. Group membership was significantly associated with retention in a gender-specific day treatment program. Group 2 experienced rapid attrition, with only 36% completing treatment, compared to 57% for Group 1 and 76% for Group 3. Results indicate that drug-dependent women with externalizing psychopathology can be retained in treatment when environmental barriers are removed and an adequate "holding environment" is maintained. However, women with severe psychiatric problems, unstable mood, and interpersonal deficits are less likely to complete treatment. Early identification of women at risk for drop-out affords an opportunity to intervene to prevent its occurrence.

Determining predictors of attrition in an outpatient substance abuse program

Determining pre-treatment variables that predict attrition in an outpatient cocaine abuse program is critically important in efforts to enhance retention and ultimately improve client outcome. Potential predictors have been identified, such as treatment history, deviant behaviors, and level of drug use; however there is not widespread agreement on their applicability across treatments and populations. This study examines the relationship of demographic, drug use severity, and psychosocial factors with treatment attrition and the time of dropout. One hundred and sixty-five individuals from the Houston area, seeking treatment for cocaine dependence, completed a pre-treatment assessment battery prior to starting 12 weeks of outpatient treatment. A series of regression analyses showed that treatment dropouts were more likely to be separated from their spouses, have poorer family/social functioning, have fewer years of education, and to be female. Those participants with higher education levels and those with poorer psychiatric functioning tended to remain in treatment longer. The implications of these findings are discussed.

Depressive symptomatology and early attrition from intensive outpatient substance use treatment

This study examines the relationship between depressive symptoms and attrition from outpatient treatment in a Veterans Affairs facility that had recently moved to intensive outpatient-only treatment for substance abuse. This article focuses on 126 consecutively admitted patients who were enrolled on their last day of a 3- to 4-day outpatient detoxification. Results indicate that severe depressive symptomatology presenting at treatment entry is a significant risk factor for early attrition from intensive outpatient substance use treatment but not later attrition. These data indicate that retention efforts should be directed toward the assessment and management of depressive symptoms early in the treatment process, with interventions targeted to those who report severe symptomatology. The results also indicate that future research should focus on potential distinguishing characteristics between early and later attrition.

The relationship between the quality of drug user treatment and program completion: understanding the perceptions of women in a prison-based program

To determine why some women offenders complete prison-based drug user treatment and others leave early, clients' (N = 101) perceptions of various aspects of the quality of the treatment experience were compared. Analyses of both quantitative and qualitative data indicate that clients who completed the program had a more favorable perception of staff and felt empowered by the experience in treatment. Most of the clients who left early did so because of conflicts or disagreements with the program's rules. We discuss how a supportive approach to personal development may enhance client perceptions of program quality and increase retention rates.

Predictors of treatment outcomes in men and women admitted to a therapeutic community

This study compared factors that predict treatment outcomes in men and women randomly assigned to two therapeutic communities differing primarily in length of inpatient and outpatient treatment. Based on the prior research literature comparing treatment outcomes of men and women, we formulated the following research question: Do factors that predict drug use at follow-up, postdischarge arrest, and employment at follow-up differ for men and women? Self-reports and objective measures of criminal activity and substance abuse were collected at pre- and posttreatment interviews. Separate regression analyses were conducted for men and women for each of the three outcome variables. The results showed that the predictors of outcome for men and women were similar. Clients who completed the 12-month treatment programs had better outcomes regardless of gender. Men and women who completed treatment were characterized at follow-up by substantial reductions in drug use and arrests and by increased employment. Results further suggested that the longer residential treatment program had a particularly beneficial impact on women. Number of prior arrests was also associated with postdischarge outcomes for women. Women with more arrests at admission were more likely to have a postdischarge arrest and less likely to be employed at follow-up. This finding provides invaluable information about which women may be at greater risk for relapse and in need of additional services. We conclude that completion of treatment is the key predictor of treatment outcomes for both men and women.

Rural Pregnant Cocaine Users: An in-Depth Sociodemographic Comparison

As part of a prospective, longitudinal study of the effects of prenatal cocaine use on infant outcome, we enrolled 308 women when they first came in for prenatal care or at delivery, in the case of no prenatal care. The 154 women in the cocaine use group, identified by means of drug history and urine testing, were matched to 154 non-cocaine using controls on race, parity, socioeconomic status, and level of prenatal risk. This report presents a summary of the demographic and drug-use information collected at the time of delivery and the psychosocial data measured at delivery including standardized measures of depression, locus of control, self-esteem, concepts of development, life stress, and social support. Between group comparisons revealed that cocaine users were more likely than non-users to be older, to use other drugs, to begin their drug use at an earlier age, to have more depressive symptoms, to have an external locus of control, to have lower self-esteem, to have a more simplistic understanding of child development, and to have higher positive life event impact scores.

Sexual and physical abuse: do they compromise drug treatment outcomes?

Histories of sexual and physical abuse are frequently reported by individuals participating in substance abuse treatment, these experiences may be associated with psychopathology and poor drug treatment outcomes. This paper presents the findings from a longitudinal study of 330 subjects participating in 26 outpatient treatment programs. Sexual abuse among women was associated with higher levels of depression, anxiety, suicidal ideation, suicide attempts, and PTSD, while physical abuse was associated with fewer psychological disturbances. For men, sexual abuse was associated only with anxiety. Physical abuse was associated with depression, anxiety, suicidal ideation, and PTSD. However, no significant association was found between sexual and physical abuse, and lower levels of treatment participation or drug use at follow-up. These findings indicate that there is a complex connection between abuse, psychopathology, treatment participation, and relapse. Clinical and research implications of these findings are discussed.

Predicting length of stay of substance-using pregnant and postpartum women in day treatment

Pregnant and postpartum substance-using women are a special population whose needs do not reflect those of the general substance-using communities. This study examined length of stay in a federally funded day treatment demonstration program in order to identify predictor variables that may help identify pregnant and postpartum substance-using women at high risk for dropping out of treatment. Variables from intake and exit questionnaires on a sample of 163 women were analyzed using multiple regression on both days in treatment and the logarithmic transformation of days in treatment. Few predictor variables were identified, although findings suggest that if a women is younger and self-referred, she may leave treatment sooner. As one of the first sets of published data on pregnant and postpartum women and retention in treatment, this study lays the groundwork for future research on the retention of pregnant and postpartum women in treatment, thereby facilitating the success of these women in overcoming their addiction.

Women and Children in Residential Treatment: Outcomes for Mothers and Their Infants

This paper examines the relationship between the living arrangement of mother and baby in a residential treatment center and measures of self-esteem, depression and parenting sense of competence and a woman's length of stay and completion or non-completion of treatment. Scores on the Bayley Scales of Infant Development (Bayley 1969) are also examined by the amount of time the baby spent with mother, an arrangement that affords the opportunity for the child to participate in the facility's therapeutic child care center. Findings suggest that the earlier a mother's infant resides with her in the treatment setting, the longer her length of stay will be, with an increased opportunity for program completion. In addition, measures of depression were lower and measures of self-esteem were higher for women with their babies than for clients who did not have their infant in the treatment facility. Scores on the Bayley Scales of Infant Development were within normal limits for all infants living with their mothers in treatment.

Acute dually diagnosed inpatients: the use of self-report symptom severity instruments in persons with depressive disorders and cocaine dependence

A total of 84 adult inpatient dual-diagnosis (cocaine dependence and unipolar depressive disorder) patients' charts were reviewed. Patients were administered the BDI, SCL-90-R with Additional Items for Major Depressive Syndrome, and the DAST-20 within 5 days of admission as standard assessment practice in a hospital program. Depression scores for the BDI and the SCL-90-R were generally consistent, respectively, across each of the depressive disorder diagnostic groups with the exception of organic (cocaine-induced) mood disorder, which had lower mean scores on both instruments. BDI mean score differences were statistically significant regarding the depressive and organic (substance-induced) patients. DAST-20 mean scores were consistent across the diagnostic groups (substantial drug abuse range). Results suggest potential discriminating ability of the BDI in particular in distinguishing genuine unipolar depressive disorders from organically (cocaine) induced mood symptomology when assessments are done rapidly following cocaine cessation.

Does depression predict relapse in the 6 months following treatment for men with alcohol dependence?

OBJECTIVE

To investigate whether depression measured at the time of treatment predicts relapse of alcohol dependence in the 6 months following treatment of alcohol-dependent men.

METHOD

Ninety-three subjects with moderate-severe alcohol dependence (DSM-III-R), recruited from a 3-week, abstinence-focused therapeutic program, were assessed for current and lifetime major depression using the SCID-P and baseline depressive symptoms using the SCL-90, and then followed up for 6 months. Drinking outcomes were based on multiple sources of data.

RESULTS

Relapse was not associated with either lifetime major depression, or baseline depressive symptoms; inadequate numbers of subjects with a current major depression precluded statistical analysis of this variable.

CONCLUSIONS

Neither lifetime major depression, nor the degree of depressive symptoms in alcohol-dependent men at the time of treatment, compromise drinking outcomes in the 6 months following treatment.

Background and overview of mental health and substance abuse treatment systems: meeting the needs of women who are pregnant or parenting

Women with a psychiatric disorder who also abuse alcohol or other drugs have historically encountered barriers to integrated treatment for both disorders. Substance abuse treatment services and mental illness treatment services are usually organized independently of each other and few are designed to meet the needs of pregnant and parenting women. This chapter reviews the developmental histories of treatment systems for psychiatric and substance abuse disorders; the structural barriers that impede the delivery of services to individuals with co-occurring psychiatric and substance abuse disorders; the prevalence of dual disorders; issues related to diagnosis and assessment, types of diagnoses and addictions; treatment issues specific to women who are pregnant or parenting; models of service delivery; and initiatives directed at changing treatment systems.

Predicting treatment retention of women dependent on cocaine

The purpose of this research was (a) to assess differences in retention patterns and discharge status across three program settings; and (b) to examine selected pretreatment characteristics that might help predict treatment retention, which was operationalized as length of time in treatment. Three groups of pretreatment characteristics were examined. They included demographic factors, drug use and treatment history, and psychological status and symptomology. Clients in the intensive day treatment program tended to stay longer and were more likely to successfully complete the program than either clients in the outpatient or the traditional residential programs. In general, pretreatment client characteristics were not helpful in predicting length of time in treatment regardless of program type. Few pretreatment characteristics were related to retention within programs and significant predictors differed across treatment settings.

Treatment retention in women's residential chemical dependency treatment: the effect of admission with children

In the United States there has been an increased interest in the development of treatment programs that admit chemically dependent women with their children. The Salvation Army Family Treatment Services in Honolulu, Hawaii has had a long history of admitting women both with and without their children to long-term residential treatment. This has provided an opportunity to study the differences in treatment retention between these two groups. Subjects were 130 females who participated in treatment between 1988 and 1993. Analyses were conducted to determine whether there were different outcomes for women with children in treatment and women without children in treatment, with regard to type of discharge and length of time in treatment. Results were significant and clearly indicated better retention rates for women who participated in treatment with their children.

Therapeutic community retention among Alaska Natives. Akeela house

The purpose of the study was to determine whether a change in the treatment program at Akeela House Incorporated a therapeutic community in Anchorage. Alaska, significantly increased the time in treatment for Alaska Native residents. The change in treatment involved implementation of culturally sensitive approaches that incorporated and reinforced Native lifestyles. Data were obtained from the Alaska Management Information System on all treatment admissions from January 1988 to January 1995. Prior to implementation, Alaska native residents had significantly shorter times in treatment that Black or White residents. After implementation of the change in the treatment program, Alaska Native residents' times in treatment were no longer significantly different from those of Black or White residents and all three ethnic groups had significantly longer times in treatment than before the intervention.

Prediction of attrition from day hospital treatment in lower socioeconomic cocaine-dependent men

This study attempted to identify predictors of completion of a 27 h/week 4-week day hospital program for cocaine dependence. The research subjects were 95 lower socioeconomic, primarily African American male veterans. Of a wide range of predictor variables available at baseline, including sociodemographic and historical information, Addiction Severity Index data, psychiatric diagnoses, SCL-90 measures, and measures of craving and familial alcoholism, only the cocaine urine toxicology result and self report of days of cocaine use in the past 30 days (log transformed) were significant predictors. The urine toxicology result was the more powerful predictor with 73 percent with a negative urine completing treatment, as contrasted with 36 percent with a positive urine. Three additional measures obtained at the end of treatment week 1 further increased ability to predict treatment completion/attrition. Two of these measures were based on counsellor ratings and one was based on the patient's report of psychiatric treatment services received during the first treatment week. Thus, patients at high risk for dropout can be identified fairly early. Whether treatments can be adapted to retain such patients is an important question for the field.

Postpartum women in outpatient drug abuse treatment: correlates of retention/completion

This article examines correlates of retention/completion for low-income court-ordered and voluntary postpartum women in two types of outpatient drug abuse treatment: day treatment (an intensive seven-day-a-week, neurobehavioral treatment model program) and traditional outpatient treatment (a conventional five-day-a-week program). Instruments used in this study to assess factors in retention/completion include the Addiction Severity Index, the Brief Symptom Inventory, the Beck Depression Inventory, the Hudson's Index of Self-Esteem, the Coping Strategies Inventory, the Social Support Questionnaire, and a Barriers to Treatment measure specifically designed for this study. It was found that the women in this study had relatively normal psychosocial profiles, and that their support systems, while small, were relatively satisfying. Very few psychosocial profile elements were found to be predictors, but social support was marginally related to length of stay in treatment. Program type, infant custody, and number of children in the home appeared to be the strongest predictors of treatment retention/completion.

Self-reported depression as a predictor of dropout in a hierarchical therapeutic community

Studies of the importance of depression for treatment outcome in hierarchical therapeutic communities are scarce. Therefore, a total of 144 substance abusers consecutively entering Phoenix House in Oslo were followed prospectively through an entire 18-month program. Using a structured interview and two self-report instruments, Million Clinical Multiaxial Inventory and Symptom Checklist-90, 69% of the clients were depressive cases at the time of application. However, depression alone did not predict dropout during the following 1-year inpatient phase. Of the 36 clients who completed the drug-free inpatient year, 19% were depressive cases at this point. Thus being depressed after 1 year increased the risk for dropout five times compared to being nondepressed. The study demonstrates the need for a modification of the treatment model, which might include the use of antidepressant and/or individual psychotherapy, at least in the outpatient phase.

Effectiveness of a specialized intervention for women in a methadone program

Over the past 20 years, specialized programming for chemically dependent women has been recommended for improving psychosocial functioning and retention in treatment. This study examined the impact of a structured, six-week assertiveness and sexuality workshop for women at three community-based methadone maintenance programs. Results indicated that women who participated frequently in the women's groups (four to six sessions) showed greater increases in self-esteem and knowledge compared to women who participated infrequently (one to three sessions). In addition, level of participation was positively associated with length of stay in the treatment program after completing the workshop.

Changes concurrent with initiation of abstinence from cocaine abuse

In an exploration of changes that occur with initiation of cocaine abstinence, this study examined treatment outcomes in four domains--behavior (cocaine use), affect (depression), cognition (schematic self-representations), and psychophysiology (reactivity to drug cues). Nineteen patients initially entered this 8-week outpatient psychopharmacotherapy trial for the treatment of cocaine dependence. Thirteen completed treatment, and eleven maintained abstinence during the last four weeks of the study. In addition to a demonstrated change in their cocaine-using behavior, these "abstainers" reported reduced depression, increased congruency with "ideal" self-schemas, increased discrepancy with "addict" self-schemas, and generally more positive self-representations. In addition, "abstainers" reported reduced posttreatment craving in the presence of cocaine cues, but evidenced no change in physiological reactivity. Implications of these findings for research and treatment are discussed.