Internet Addiction Management: A Comprehensive Review of Clinical Interventions and Modalities

Internet addiction is a pervasive and complex issue that has gained increasing attention in the digital age. This comprehensive review provides an in-depth exploration of clinical interventions and modalities for managing internet addiction. It begins by examining the diagnostic criteria and assessment tools used to identify internet addiction, highlighting the diverse subtypes and varying degrees of severity. Subsequently, the review delves into various clinical interventions, including psychotherapeutic approaches like cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and mindfulness-based interventions. Pharmacological interventions, technology-based tools, and integrative approaches are also thoroughly analyzed. The review also outlines various treatment settings and modalities such as inpatient treatment centers, outpatient clinics, telehealth, support groups, and prevention programs for schools and communities. Furthermore, it discusses the efficacy and challenges associated with managing internet addiction, emphasizing the need for effective interventions, relapse prevention, ethical considerations, and addressing stigma and access barriers. In conclusion, the review offers practical implications for clinical practice. It emphasizes future research's importance in refining diagnostic criteria, exploring emerging technologies, and adapting interventions to an ever-evolving digital landscape. This comprehensive review is a valuable resource for clinicians, researchers, and policymakers seeking to understand and address the complexities of internet addiction.

Mixed amphetamine salts-extended release (MAS-ER) as a behavioral treatment augmentation strategy for cocaine use disorder: A randomized clinical trial

Psychosocial interventions remain the primary strategy for addressing cocaine use disorder (CUD), although many individuals do not benefit from these approaches. Amphetamine-based interventions have shown significant promise and may improve outcomes among individuals continuing to use cocaine in the context of behavioral interventions. One hundred forty-five adults (122 males) who used cocaine a minimum of 4 days in the prior month and met the criteria for a CUD enrolled in a two-stage intervention. All participants received a computer-delivered skills intervention and contingency management for reinforcing abstinence for a 1-month period. Participants demonstrating less than 3 weeks of abstinence in the first month were randomized to receive mixed amphetamine salts-extended release (MAS-ER) or placebo (80 mg/day) for 10 weeks under double-blind conditions. All participants continued with the behavioral intervention. The primary outcome was the proportion of individuals who achieved 3 consecutive weeks of abstinence as measured by urine toxicology confirmed self-report at the study end. The proportion of participants demonstrating 3 consecutive weeks of abstinence at study end did not differ between the medication groups: MAS-ER = 15.6% (7/45) and placebo = 12.2% (5/41). Participants who received MAS-ER reported greater reductions in the magnitude of wanting cocaine, although no group differences were noted in either the perceived improvement or the frequency of wanting cocaine. Retention rates were greater for both medication groups compared to behavioral responders. Overall, augmenting a behavioral intervention with MAS-ER did not significantly increase the abstinence rate among individuals continuing to use cocaine following a month of behavioral therapy alone. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Relapse Rates With Paliperidone Palmitate in Adult Patients With Schizophrenia: Results for the 6-Month Formulation From an Open-label Extension Study Compared to Real-World Data for the 1-Month and 3-Month Formulations

BACKGROUND

The 3 paliperidone palmitate (PP) long-acting injectable antipsychotic formulations, PP 1-month (PP1M), PP 3-month (PP3M), and PP 6-month (PP6M), have shown to reduce the risk of relapse in schizophrenia. The current phase-4 study constructed external comparator arms (ECAs) using real-world data for PP3M and PP1M and compared relapse prevention rates with PP6M from an open-label extension (OLE) study in adult patients with schizophrenia.

METHODS

PP6M data were derived from a single-arm, 24-month, OLE study (NCT04072575), which included patients with schizophrenia who completed a 12-month randomized, double-blind, noninferiority, phase-3 study (NCT03345342) without relapse. Patients in the PP3M and PP1M ECAs were identified from the IBM® MarketScan® Multistate Medicaid Database based on similar eligibility criteria as the PP6M cohort.

RESULTS

A total of 178 patients were included in each cohort following propensity score matching. Most patients were men (>70%; mean age: 39-41 years). Time to relapse (primary analysis based on Kaplan-Meier estimates) was significantly delayed in the PP6M cohort (P < .001, log-rank test). The relapse rate was lower in the PP6M cohort (3.9%) vs PP3M (20.2%) and PP1M (29.8%) cohorts. Risk of relapse decreased significantly (P < .001) by 82% for PP6M vs PP3M (HR = 0.18 [95% CI = 0.08 to 0.40]), 89% for PP6M vs PP1M (HR = 0.11 [0.05 to 0.25]), and 35% for PP3M vs PP1M (HR = 0.65 [0.42 to 0.99]; P = .043). Sensitivity analysis confirmed findings from the primary analysis. Although the ECAs were matched to mimic the characteristics of the PP6M cohort, heterogeneity between the groups could exist due to factors including prior study participation, unmeasured confounders, variations in data capture and quality, and completeness of clinical information.

CONCLUSIONS

In a clinical trial setting, PP6M significantly delayed time to relapse and demonstrated lower relapse rates compared with PP3M and PP1M treatments in real-world settings among adult patients with schizophrenia.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04072575; EudraCT number: 2018-004532-30.

Mindfulness mechanisms in alcohol use: Comparing top-down and bottom-up processes

OBJECTIVE

This study compared two mechanisms by which mindfulness may reduce hazardous drinking: effortful control and craving, "top-down" and "bottom-up" processes, respectively. These relationships were compared in a secondary analysis of a randomized controlled trial of mindfulness-based relapse prevention (MBRP) versus relapse prevention (RP) treatments to explore if they differed based on more explicit versus subtle mindfulness training.

METHOD

A total of 182 individuals (48.4% female; 21-60 years old) who reported drinking > 14/21 drinks/week (for females/males, respectively) in the past 3 months but who wished to quit/reduce their drinking were recruited from Denver and Boulder, CO, United States. Participants were randomly assigned to either 8 weeks of MBRP or RP treatment and completed assessments at baseline, halfway through treatment, and at the end of treatment. The Five-Factor Mindfulness Questionnaire-Short Form, Alcohol Urge Questionnaire, and Effortful Control Scale completed halfway through treatment assessed the predictor, dispositional mindfulness, and mediators, craving and effortful control, respectively. The Alcohol Use Disorder Identification Task was completed after treatment and measured hazardous drinking. Cross-group path analyses were conducted including both mediators/treatments in the same model.

RESULTS

Comparing models with and without equality constraints across treatments, no paths significantly differed based on a chi-square test of difference, χ²(5) = 5.11, p = .40, and only the indirect effect of craving was significant (B = -1.01, p = .01).

CONCLUSIONS

Findings suggest mindfulness may be associated with hazardous drinking reductions through craving but not effortful control and this indirect relationship works similarly across treatments engendering mindfulness explicitly and implicitly. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Low-carbohydrate diet as a nutritional intervention in a major depression disorder: focus on relapse prevention

Objectives: Mood disorders are trending to be among the leading causes of years lived with disability. Despite multiple treatment options, around 30% patients with major depressive disorder (MDD) develop treatment resistant depression (TRD) and fail to respond to current pharmacological therapies. This study aimed to explore the potential benefits of nutritional treatment strategies, along with their molecular mechanisms of action, focusing especially on low-carbohydrate diet (LCHD), ketogenic diet (KD) and other strategies based on carbohydrates intake reduction.Methods: A comprehensive literature review was conducted to determine the impact of LCHD on alleviating depressive symptoms in patients with MDD, along with an explanation of its mode of action.Results: The study revealed significant impact of nutritional interventions based on restriction in carbohydrate intake such as LCHD, KD or sugar-sweetened beverages (SSB) exclusion on anxiety or depression symptoms reduction, mood improvement and lower risk of cognitive impairment or depression. The efficacy of these approaches is further substantiated by their underlying molecular mechanisms, mainly brain-derived neurotrophic factor (BDNF) which is a potential key target of sugar restriction diets in terms of neuroplasticity.Discussion: Healthcare professionals may consider implementing LCHD strategies for MDD and TRD patients to modify the disease process, maintain euthymia, and prevent depressive episode relapses. Ranging from the exclusion of SSB to the adherence to rigorous LCHD regimens, these nutritional approaches are safe, straightforward to implement, and may confer benefits for well-being and relapse prevention in this specific patient population.

Factors associated with a positive phosphatidylethanol test during liver transplantation evaluation

BACKGROUND

Early identification of alcohol use is crucial for informing recommendations of appropriate follow-up treatment pre-liver transplant and optimizing post-liver transplant outcomes. The purpose of the study was to investigate whether there are psychosocial factors associated with a positive PEth test.

METHODS

All patients who underwent a routine pre-surgical psychological evaluation for liver transplant listing (all etiologies, including acute liver failure, dual organ, and re-transplantation) at a single health care system in 2020 were included in a retrospective chart review. Data extraction included results from PEth testing and information from the psychological evaluation (i.e., demographic, psychiatric symptoms, and cognitive functioning).

RESULTS

There were 158 patients (73.8%) who had a PEth test, of whom 21.5% had a positive result (n = 34). Younger age was associated with a positive PEth (p < .001). ALD status and type of ALD (hepatitis vs. cirrhosis) were also associated with a positive PEth test. Other demographic characteristics and psychiatric symptoms were not associated with a positive PEth result (p > .05).

CONCLUSION

Younger age was the only significant demographic variable associated with a positive PEth test. Given the difficulty of predicting who may be using alcohol, it may be useful to use PEth testing for all patients during the pre-liver transplant evaluation and while patients are listed for liver transplant. Early identification of alcohol use through routine PEth testing will help identify patients who are using alcohol and need further treatment for alcohol use to optimize health and post-transplant outcomes.

Relapse prevention therapy for internet gaming disorder in Swedish child and adolescent psychiatric clinics: a randomized controlled trial

Objectives

To evaluate the effectiveness of relapse prevention (RP) as a treatment for internet gaming disorder (IGD).

Design

Randomized controlled trial.

Setting

Three child and adolescent psychiatry (CAP) units in Region Skåne, Sweden.

Participants

Children aged 13-18 years, coming for their first visit to CAP during 2022, were screened for gaming behavior. Those who met the proposed DSM-5 criteria for IGD were offered participation in the trial, if they had the capacity to provide written informed consent and if they spoke Swedish. A total of 111 CAP patients agreed to participate. Out of those, 11 patients were excluded due to incorrect inclusion such as young age (n = 1), or due to the absence of responses to follow-up measures (n = 9). After exclusion, 102 participants remained (intervention = 47, control = 55).

Interventions

The intervention, RP, is based on cognitive behavioral treatment (CBT) and was provided individually, comprising of five to seven 45-min sessions over a period of 5 to 7 weeks versus treatment as usual.

Outcome measures

Participants were assessed with Game Addiction Scale for Adolescents pre-treatment (GASA) (baseline), post-treatment (treatment group only), and 3 months after baseline (follow-up).

Results

The repeated measures ANOVA showed a significant interaction effect between treatment and time. Both the control group and treatment group lowered their mean GASA score from baseline to follow-up significantly, but the improvement was greater in the treatment group (mean difference in control group -5.1, p < 0.001, 95% CI = - 3.390 to -6.755, mean difference in treatment group -9.9, p < 0.001, 95% CI = -11.746 to -8.105).

Conclusion

RP was found to be superior to treatment as usual in terms of reduction of IGD symptoms. Future research should address which aspects within a given treatment are effective, who benefits from treatment, in what aspects, and why.

Trial registration number

ClinicalTrials.gov, NCT05506384 https://clinicaltrials.gov/ct2/show/NCT05506384.

Pilot study of attentional retraining for postpartum smoking relapse

Introduction

Tobacco smoking is a leading cause of preventable death worldwide. The perinatal period provides a unique opportunity for intervention, as many smokers quit smoking during pregnancy but relapse postpartum. Novel relapse prevention interventions that reduce the burden of treatment attendance in this population are needed. Attentional retraining (AR) has been shown to reduce attentional biases toward smoking-related stimuli, a cognitive process implicated in smoking, AR has not been applied to perinatal smokers, and the effect of AR on craving and smoking is not clear. The goal of this study was to evaluate the delivery of AR for smoking cues in perinatal smokers utilizing a mobile intervention.

Methods

This pilot study utilized Ecological Momentary Assessment (EMA) methodology delivered on a mobile device to examine the relapse process and evaluate the utility of AR in former smokers attempting to remain abstinent postpartum. AR (or Control Training) was administered to abstinent smokers (N = 17) for up to 2 weeks both before and after delivery.

Results

All 17 participants completed the study. There was evidence that AR reduced attentional bias in the AR group (vs. Controls). There was no evidence that AR reduced craving. An exploratory analysis revealed that there was no evidence that AR reduced smoking during the study period.

Discussion

AR using EMA methodology via a mobile device is feasible in perinatal smokers. Further research using larger samples is required to evaluate the utility of mobile AR in reducing craving and smoking.

Congruency of multimodal data-driven personalization with shared decision-making for StayFine: individualized app-based relapse prevention for anxiety and depression in young people

Tailoring interventions to the individual has been hypothesized to improve treatment efficacy. Personalization of target-specific underlying mechanisms might improve treatment effects as well as adherence. Data-driven personalization of treatment, however, is still in its infancy, especially concerning the integration of multiple sources of data-driven advice with shared decision-making. This study describes an innovative type of data-driven personalization in the context of StayFine, a guided app-based relapse prevention intervention for 13- to 21-year-olds in remission of anxiety or depressive disorders (n = 74). Participants receive six modules, of which three are chosen from five optional modules. Optional modules are Enhancing Positive Affect, Behavioral Activation, Exposure, Sleep, and Wellness. All participants receive Psycho-Education, Cognitive Restructuring, and a Relapse Prevention Plan. The personalization approach is based on four sources: (1) prior diagnoses (diagnostic interview), (2) transdiagnostic psychological factors (online self-report questionnaires), (3) individual symptom networks (ecological momentary assessment, based on a two-week diary with six time points per day), and subsequently, (4) patient preference based on shared decision-making with a trained expert by experience. This study details and evaluates this innovative type of personalization approach, comparing the congruency of advised modules between the data-driven sources (1-3) with one another and with the chosen modules during the shared decision-making process (4). The results show that sources of data-driven personalization provide complementary advice rather than a confirmatory one. The indications of the modules Exposure and Behavioral Activation were mostly based on the diagnostic interview, Sleep on the questionnaires, and Enhancing Positive Affect on the network model. Shared decision-making showed a preference for modules improving positive concepts rather than combating negative ones, as an addition to the data-driven advice. Future studies need to test whether treatment outcomes and dropout rates are improved through personalization.

Validation of a Measure Helping Relapse Prevention in the Treatment of Alcohol Use Disorders

Background: Relapse Prevention (RP) is a cognitive-behavioral approach that aims to identify situations at high risk of relapse and to support patients with alcohol use disorders (AUDs) in developing coping strategies for the maintenance of desired behavioral changes. Based on this framework, the present study aims to assess and validate the psychometric properties of the MANEMOS, a 24-item inventory of alcohol relapse triggering situations. Methods: The internal consistency and factor structure of the MANEMOS were analyzed in a sample of 313 (27.7% women) in-patients and out-patients, attending alcohol treatment programs in Italian addiction treatment facilities. Results: The results support the internal reliability and validity of the measure. A confirmative factor analysis has revealed the existence of eight distinct dimensions measuring relapse risk situations: namely, Pleasant emotions, Unpleasant emotions, Craving, Conflicts with others, Occasions, Social Pressure, Personal Control, and Physical Discomfort. The patients' assessment of the riskiness of the situation showed some significant differences depending on gender and on type of treatment received. Conclusions: The findings indicate that MANEMOS is a valid measure for identifying and reflecting on patients' high relapse-risk situations. This easy and flexible assessment measure may have important implications for prevention and clinical intervention.

Relapse prevention through health technology program reduces hospitalization in schizophrenia

BACKGROUND

Psychiatric hospitalization is a major driver of cost in the treatment of schizophrenia. Here, we asked whether a technology-enhanced approach to relapse prevention could reduce days spent in a hospital after discharge.

METHODS

The Improving Care and Reducing Cost (ICRC) study was a quasi-experimental clinical trial in outpatients with schizophrenia conducted between 26 February 2013 and 17 April 2015 at 10 different sites in the USA in an outpatient setting. Patients were between 18 and 60 years old with a diagnosis of schizophrenia, schizoaffective disorder, or psychotic disorder not otherwise specified. Patients received usual care or a technology-enhanced relapse prevention program during a 6-month period after discharge. The health technology program included in-person, individualized relapse prevention planning with treatments delivered via smartphones and computers, as well as a web-based prescriber decision support program. The main outcome measure was days spent in a psychiatric hospital during 6 months after discharge.

RESULTS

The study included 462 patients, of which 438 had complete baseline data and were thus used for propensity matching and analysis. Control participants (N = 89; 37 females) were enrolled first and received usual care for relapse prevention followed by 349 participants (128 females) who received technology-enhanced relapse prevention. During 6-month follow-up, 43% of control and 24% of intervention participants were hospitalized (χ2 = 11.76, p<0.001). Days of hospitalization were reduced by 5 days (mean days: b = -4.58, 95% CI -9.03 to -0.13, p = 0.044) in the intervention condition compared to control.

CONCLUSIONS

These results suggest that technology-enhanced relapse prevention is an effective and feasible way to reduce rehospitalization days among patients with schizophrenia.

Perspectives on relapse prevention following intensive treatment of anorexia nervosa: A focus group study

OBJECTIVE

Including the perspectives of individuals with lived experience of mental health issues is a critical step in research and treatment development. Focus groups with patients with a history of treatment for anorexia nervosa (AN) were conducted in anticipation of a clinical trial of Relapse Prevention and Changing Habits (REACH+).

METHODS

Seven female adults (23-51 years) who had previously received inpatient treatment for AN, now in remission, participated in one of two semistructured focus groups. Rapid qualitative analysis was used to examine participants' contributions and identify common topics.

RESULTS

Transcript analysis yielded three topics related to relapse prevention: (1) recovery aids, including a sense of agency in treatment decisions and finding new interests/passions, (2) recovery hindrances, such as lack of access to care, and (3) identification of members of support system. Aspects of REACH+ received positive feedback, such as continuity of care from the inpatient setting and the use of telehealth. Viewpoints differed with respect to the helpfulness of obtaining patient weights in treatment. The REACH+ online platform received positive comments regarding content and usability, as well as suggestions for additional content.

DISCUSSION

Qualitative feedback from patients with a history of AN highlighted the value of engaging patients in their own treatment decisions, as well as in treatment design and innovation. Within this small group, there were differences of opinion about treatment components, specifically weight assessment, that suggest the need for further data. User-centered design provides opportunities to improve the acceptability and, therefore, dissemination of novel treatments.

PUBLIC SIGNIFICANCE

Relapse prevention is a critical treatment need for patients with anorexia nervosa, as this illness too often follows a protracted course. There are challenges in both obtaining specialized care and in retaining patients in treatment. Here, patient perspectives on these challenges offer input to allow for optimization of relapse prevention treatment. Shared decision-making may be particularly valuable to support an individual's sense of agency and engagement in care.

Long-term safety and effectiveness of eculizumab in patients with aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder: a 2-year interim analysis of post-marketing surveillance in Japan

Background

The terminal complement C5 inhibitor eculizumab is approved in Japan for relapse prevention in aquaporin-4 antibody-positive (AQP4+) neuromyelitis optica spectrum disorder (NMOSD) and is undergoing mandatory post-marketing surveillance (PMS) of clinical use.

Objectives

The objective of the study is to assess the real-world, long-term safety and effectiveness of eculizumab in Japanese patients with AQP4+ NMOSD.

Design

Regulatory-mandated PMS analysis implemented as an all-case surveillance of all patients with AQP4+ NMOSD who have been treated with eculizumab in Japan since its approval in November 2019.

Methods

This PMS interim analysis assessed the safety and effectiveness of eculizumab in Japanese patients with AQP4+ NMOSD from November 2019 to April 2022.

Results

Of 147 patients treated with eculizumab who consented to publication, 71 had at least one case report form collected and locked at the interim analysis data cut-off, constituting the safety analysis set; three patients from PREVENT (NCT01892345) were excluded from the effectiveness analysis set. Twelve and 10 patients in the safety and effectiveness analysis sets discontinued, respectively. In the safety analysis set, 67/71 patients (94.4%) were female, mean illness duration was 6.8 [standard deviation (SD): 6.2] years, mean age at eculizumab initiation was 50.7 (SD: 13.3) years, and mean eculizumab treatment duration was 44.6 (SD: 23.7) weeks. At diagnosis of NMOSD, 34/71 patients (47.9%) and 35/71 patients (49.3%) in the safety analysis set had symptoms of optic neuritis and transverse myelitis, respectively. In the safety analysis set, 19/71 patients (26.8%) reported adverse events, 10/71 (14.1%) reported adverse drug reactions (ADRs), and 7/71 (9.9%) reported serious ADRs; no meningococcal infections were observed. In the effectiveness analysis set, 64/68 patients (94.1%) were female, mean disease duration was 6.9 (SD: 6.3) years, mean age at eculizumab initiation was 50.6 (SD: 13.2) years, and 27/68 (39.7%) were tested for C5 genetic polymorphism (all negative). In the 2 years before eculizumab, 51/68 patients (75.0%) experienced relapse. Relapse rate was 0.02/patient-year after eculizumab initiation versus 0.74/patient-year in the 2 years before eculizumab. Overall, 37/68 patients (54.4%) were prescribed immunosuppressants in the 6 months before and 19/40 (47.5%) in the 6-12 months after starting eculizumab treatment. The proportion of patients taking >10 mg/day of prednisolone decreased from 45.6% at 24-20 weeks before to 23.1% and 0% at 48-52 and 100-104 weeks after eculizumab, respectively.

Conclusion

This article reports interim PMS data for Japanese patients and provides updated real-world evidence for the safety of eculizumab and its effectiveness at preventing relapses in patients with AQP4+ NMOSD. Safety and effectiveness results are consistent with those from PREVENT.

Mediating Effects of Thought Suppression in the Relationship Between Mindfulness and Substance Use Craving

Background: Substance use disorder (SUD) is a significant issue in the United States, characterized by chronic relapse following periods of abstinence. One of the primary precursors to relapse is craving. Findings from several studies have shown a negative association between trait mindfulness and craving in clinical samples; however, further research is needed to understand mechanisms underlying this relationship. Purpose/Objectives: The current study assessed thought suppression as a partial mediator of the relationship between trait mindfulness and craving. Methods: The current study used data from a previous randomized controlled trial of adults (N = 244) enrolled in community-based treatment for substance use disorder (SUD). Results: Analyses showed a significant moderate positive association between thought suppression and craving, a significant moderate negative association between thought suppression and trait mindfulness, and a significant moderate negative association between trait mindfulness and craving. Subsequent analyses confirmed a partial mediating role of thought suppression in the relationship between trait mindfulness and craving, indicating the inverse relationship between trait mindfulness and craving was partially explained by thought suppression. Conclusions/importance: These findings may inform treatment for SUD. Specifically, targeting thought suppression through mindfulness-based treatment approaches may be a mechanism through which craving can be reduced.

Does selective inhibition training reduce relapse rates when added to standard treatment of alcohol use disorder? A randomized controlled trial

BACKGROUND

Alcohol-dependent individuals tend to selectively approach alcohol cues in the environment, demonstrating an alcohol approach bias. Because approach bias modification (ApBM) training can reduce the approach bias and decrease relapse rates in alcohol-dependent patients when added to abstinence-focused treatment, it has become a part of regular treatment. Moreover, in selective inhibition (SI) training, responses to one category of stimuli (i.e., alcohol stimuli) are selectively inhibited in an adapted Go/No-Go task. SI-Training has been found to effectively devalue the inhibited category and to reduce consumption of alcohol among social drinkers. This study investigated whether SI-Training can further improve the effects of treatment as usual that includes ApBM, and if so, whether the effect is mediated by a devaluation of the inhibited alcohol stimuli.

METHODS

Abstinent alcohol-dependent inpatients (N=434) were randomly assigned to receive 6 sessions of either active (n = 214, 32% female) or sham (n = 220, 38% female) SI-Training, in addition to standard treatment that includes active ApBM. Ratings were used to assess changes in the evaluation of alcohol stimuli after the training. Relapse rates were assessed 3 and 12 months after treatment discharge.

RESULTS

Alcohol stimuli were rated negatively before and after the training, and the training did not influence these ratings. Evaluation of nonalcoholic drinks became more positive after active SI-Training. Both ApBM and SI-Training showed the expected training effects on reaction times. Contrary to expectations, SI-Training conditions did not yield different abstinence rates 3 or 12 months after treatment.

CONCLUSIONS

We found no evidence supporting the hypothesis that SI-Training amplifies the relapse-preventing effect of ApBM. Moreover, alcohol stimuli were rated negatively before and after treatment and were not influenced by SI-Training.

Meta-Analysis: Relapse Prevention Strategies for Depression and Anxiety in Remitted Adolescents and Young Adults

OBJECTIVE

Depression and anxiety cause a high burden of disease and have high relapse rates (39%-72%). This meta-analysis systematically examined effectiveness of relapse prevention strategies on risk of and time to relapse in youth who remitted.

METHOD

PubMed, PsycInfo, Embase, Cochrane, and ERIC databases were searched up to June 15, 2021. Eligible studies compared relapse prevention strategies to control conditions among youth (mean age 13-25 years) who were previously depressed or anxious or with ≥30% improvement in symptoms. Two reviewers independently assessed titles, abstracts, and full texts; extracted study data; and assessed risk of bias and overall strength of evidence. Random-effects models were used to pool results, and mixed-effects models were used for subgroup analyses. Main outcome was relapse rate at last follow-up (PROSPERO ID: CRD42020149326).

RESULTS

Of 10 randomized controlled trials (RCTs) that examined depression, 9 were eligible for analysis: 4 included psychological interventions (n = 370), 3 included antidepressants (n = 80), and 2 included combinations (n = 132). No RCTs for anxiety were identified. Over 6 to 75 months, relapse was half as likely following psychological treatment compared with care as usual conditions (k = 6; odds ratio 0.56, 95% CI 0.31 to 1.00). Sensitivity analyses including only studies with ≥50 participants (k = 3), showed similar results. Over 6 to 12 months, relapse was less likely in youth receiving antidepressants compared with youth receiving pill placebo (k = 3; OR 0.29, 95% CI 0.10 to 0.82). Quality of studies was suboptimal.

CONCLUSION

Relapse prevention strategies for youth depression reduce risk of relapse, although adequately powered, high-quality RCTs are needed. This finding, together with the lack of RCTs on anxiety, underscores the need to examine relapse prevention in youth facing these common mental health conditions.

Implementation of a relapse prevention program among smokers undergoing arthroplasty: lessons learned

BACKGROUND

Surgery is a potent motivator to help people quit smoking to reduce the risk of complications. Many patients who smoke receive tobacco cessation counseling prior to surgery and are able to quit, but do not receive the same resources after surgery and often resume smoking.

METHODS

We present a case study describing the recruitment process, study components, and lessons learned from StayQuit, a comprehensive relapse prevention program designed to prevent relapse after arthroplasty. Lessons learned were examined post hoc to determine challenges related to program implementation, using existing study procedures and information collected.

RESULTS

While a comprehensive postoperative relapse prevention program may be beneficial to patients, implementation of StayQuit is unlikely to be feasible under current circumstances. The primary challenges to successful implementation of StayQuit focused on themes of lack of engagement in the preoperative Orthopedic Surgery Quit Smoking Program (OSQSP) and an environment unfavorable to in-person enrollment on the day of surgery.

CONCLUSIONS

Postoperative relapse prevention programs may be beneficial for patients who quit smoking prior to elective surgery. To help guide implementation, it is important to consider surgeon behavior, the collaboration of clinical and non-clinical teams, and best practices for study enrollment in surgical settings.

A randomized controlled clinical trial of prazosin for alcohol use disorder in active duty soldiers: Predictive effects of elevated cardiovascular parameters

BACKGROUND

Excessive noradrenergic signaling contributes to aversive symptoms of alcohol withdrawal that interfere with abstinence or reductions in harmful use.

METHODS

To address this aspect of alcohol use disorder, 102 active-duty soldiers participating in command-mandated Army outpatient alcohol treatment were randomized to also receive the brain-penetrant alpha-1 adrenergic receptor antagonist prazosin or placebo for 13 weeks. Primary outcomes were scores on the Penn Alcohol Craving Scale (PACS), standard drink units (SDUs) per day averaged over each week, % days of any drinking per week, and % days of heavy drinking per week.

RESULTS

PACS declines did not differ significantly between the prazosin and placebo groups in the overall sample. In the subgroup with comorbid PTSD (n = 48), PACS declines were significantly greater in the prazosin than in the placebo condition (p < 0.05). Baseline alcohol consumption was markedly reduced by the pre-randomization outpatient alcohol treatment program, but the addition of prazosin treatment produced a greater slope of decline in SDUs per day compared to placebo (p = 0.01). Preplanned subgroup analyses were performed in soldiers with elevated baseline cardiovascular measures consistent with increased noradrenergic signaling. In soldiers with elevated standing heart rate (n = 15), prazosin reduced SDUs per day (p = 0.01), % days drinking (p = 0.03), and % days heavy drinking (p = 0.001) relative to placebo. In soldiers with elevated standing systolic blood pressure (n = 27), prazosin reduced SDUs per day (p = 0.04) and tended to reduce % days drinking (p = 0.056). Prazosin also reduced depressive symptoms and the incidence of emergent depressed mood more than placebo (p = 0.05 and p = 0.01, respectively). During the final 4 weeks of prazosin vs. placebo treatment that followed completion of Army outpatient AUD treatment, alcohol consumption in soldiers with elevated baseline cardiovascular measures increased in those receiving placebo but remained suppressed in those receiving prazosin.

CONCLUSIONS

These results extend reports that higher pretreatment cardiovascular measures predict beneficial effects of prazosin, which may be useful for relapse prevention in patients with AUD.

Relapse Prevention Therapy for Problem Gaming or Internet Gaming Disorder in Swedish Child and Youth Psychiatric Clinics: Protocol for a Randomized Controlled Trial

BACKGROUND

Although gaming is a common arena where children socialize, an increasing number of children are exhibiting signs of problem gaming or internet gaming disorder. An important factor to the development of problem gaming is parent-child relationships. A cognitive behavioral therapy-based form of treatment, labeled relapse prevention, has been developed as a treatment for child and adolescent problem gaming or internet gaming disorder. However, no study has evaluated the effect of this treatment among Swedish children and youth nor the role of the parent-child relationships in this treatment.

OBJECTIVE

This study aims (1) to evaluate a relapse prevention treatment for patients showing signs of problem gaming or internet gaming disorder recruited from child and youth psychiatric clinics and (2) to test whether the quality of parent-child relationships plays a role in the effect of relapse prevention treatment and vice versa-whether the relapse prevention treatment has a spillover effect on the quality of parent-child relationships. Moreover, we explore the carer's attitudes about parent-child relationships and child gaming, as well as experiences of the treatment among the children, their carers, and the clinicians who carried out the treatment.

METHODS

This study is a 2-arm, parallel-group, early-stage randomized controlled trial with embedded qualitative components. Children aged 12-18 years who meet the criteria for problem gaming or internet gaming disorder will be randomized in a 1:1 ratio to either intervention (relapse prevention treatment) or control (treatment as usual), with a total of 160 (80 + 80) participants. The primary outcomes are measures of gaming and gambling behavior before and after intervention, and the secondary outcomes include child ratings of parent-child communication and family functioning. The study is supplemented with a qualitative component with semistructured interviews to capture participants' and clinicians' experiences of the relapse prevention, as well as attitudes about parent-child relationships and parenting needs in carers whose children completed the treatment.

RESULTS

The trial started in January 2022 and is expected to end in December 2023. The first results are expected in March 2023.

CONCLUSIONS

This study will be the first randomized controlled trial evaluating relapse prevention as a treatment for child and adolescent problem gaming and internet gaming disorder in Sweden. Since problem behaviors in children interact with the family context, investigating parent-child relationships adjacent to the treatment of child problem gaming and internet gaming disorder is an important strength of the study. Further, different parties, ie, children, carers, and clinicians, will be directly or indirectly involved in the evaluation of the treatment, providing more knowledge of the treatment and its effect. Limitations include comorbidity in children with problem gaming and internet gaming disorder and challenges with the recruitment of participants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05506384 (retrospectively registered); https://clinicaltrials.gov/ct2/show/NCT05506384.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44318.

The development and internal evaluation of a predictive model to identify for whom Mindfulness-Based Cognitive Therapy (MBCT) offers superior relapse prevention for recurrent depression versus maintenance antidepressant medication

Depression is highly recurrent, even following successful pharmacological and/or psychological intervention. We aimed to develop clinical prediction models to inform adults with recurrent depression choosing between antidepressant medication (ADM) maintenance or switching to Mindfulness-Based Cognitive Therapy (MBCT). Using data from the PREVENT trial (N=424), we constructed prognostic models using elastic net regression that combined demographic, clinical and psychological factors to predict relapse at 24 months under ADM or MBCT. Only the ADM model (discrimination performance: AUC=.68) predicted relapse better than baseline depression severity (AUC=.54; one-tailed DeLong's test: z=2.8, p=.003). Individuals with the poorest ADM prognoses who switched to MBCT had better outcomes compared to those who maintained ADM (48% vs. 70% relapse, respectively; superior survival times [z=-2.7, p=.008]). For individuals with moderate-to-good ADM prognosis, both treatments resulted in similar likelihood of relapse. If replicated, the results suggest that predictive modeling can inform clinical decision-making around relapse prevention in recurrent depression.

What Kind of Therapy Works With Juveniles Who Have Sexually Offended? A Randomized-Controlled Trial of Two Versions of a Specialized Cognitive Behavioral Outpatient Treatment Program

There is ongoing debate about whether specialized treatment is effective to reduce sexual recidivism in juveniles who have sexually offended (JSOs). Although most treatment programs are based on cognitive behavioral therapy principles for preventing sexual offending, accordant scientific evidence is poor. Following CONSORT guidelines, the present study aimed to evaluate two versions of a short-term outpatient treatment program for JSOs in Switzerland: (a) the Therapy Program for Adequate Sexual Behaviors Version 1 (ThePaS-I), which included offending-specific skills training; (b) the ThePaS-II, which included general socioemotional skills training. Based on changes in self-reported mental health, sexual behaviors, victim empathy, and therapist-rated risk, as well as comprehensive data on sexual and general recidivism, we found some similarities regarding the effects of the two treatments. ThePaS-II showed better short-term changes in self-reported mental health than the ThePaS-I. However, JSOs in the ThePaS-I showed lower rates of sexual reoffending (but not general reoffending) after treatment than those in the ThePaS-II. Despite some methodological limitations, the current findings favor offending-specific skills-based therapy over general skills-based ones for preventing sexual reoffenses. The findings may encourage further methodologically sound studies to examine different treatment approaches for juveniles and adults who have committed criminal offenses.

Self-interpellation in narratives about craving: Multiple and unitary selves

The concept of addiction seeks to explain why people act contrary to their own best interest. At the centre stage of addiction discourse is craving, conceptualised as a strong urge to use substances. This article analyses how talk therapies such as relapse prevention and self-help groups shape identity constructions and understandings of craving among clients. Drawing upon interviews with individuals who have engaged in talk therapies in Sweden, we analyse how craving is made up through 'self-interpellation', that is, personal narratives about past, present or future thoughts, feelings and actions. The main 'self-interpellation' included multiple selves, where craving was elided by the true self and only felt by the inauthentic self. Less dominant were narratives which drew on a unitary self that remained stable over time and had to fight craving. The notion of multiple selves appeared as a master narrative that the participants were positioned by in their identity constructions. We conclude that this multiplicity seems ontologically demanding for people who try to recover from substance use problems. A demystification of craving, in which neither substance effects nor malfunctioning brains are blamed for seemingly irrational thoughts and actions, may reduce the stigmatisation of those who have developed habitual substance use.

A Randomized Clinical Trial to Assess the Efficacy of a Psychological Treatment to Quit Smoking Assisted with an App: Study Protocol

Numerous studies have shown the efficacy of smoking cessation interventions. However, some challenges, such as relapse rates, remain. The availability of information technologies (ICTs) offers promising opportunities to address such challenges. The aim of this paper is to describe the protocol followed to assess the efficacy of a face-to-face cognitive-behavioral intervention for smoking cessation using a smartphone application as a complement, compared with a control group. A single blind, two-arm, randomized controlled trial is proposed (NCT04765813). The participants will be smokers over 18 years old, who smoke at least eight cigarettes per day. Participants will be randomized to one of two conditions, using a 1:1 allocation ratio: (1) cognitive-behavioral smoking cessation treatment along with an App with active therapeutic components (SinHumo App); or (2) cognitive-behavioral treatment along with the use of a control App (without active components). The experimental App will be used during the eight treatment sessions and for 12 months after the end of treatment. The primary outcome measures will be 7-days point-prevalence abstinence at 12-months follow-up. We expect the experimental App to obtain higher abstinence rates at the end of treatment and at one-year post-treatment follow-ups and lower relapse rates, compared to the control App.

Relapse prevention for alcohol use disorders: combined acamprosate and cue exposure therapy as aftercare

AIMS

Many patients with alcohol use disorders are challenged by cravings leading to repeated relapses. Both cue exposure therapy (CET) and acamprosate target alcohol cravings and are often combined (CET + acamprosate). The main aim of this study was to investigate whether aftercare treatment consisting of CET combined with acamprosate is equivalent to (A) CET as monotherapy, (B) aftercare as usual (AAU) as monotherapy or (C) AAU combined with acamprosate.

METHODS

Patients were randomized to receive either CET with urge-specific coping skills (USCS) as aftercare or AAU. Acamprosate prescription data were extracted from patient case records. Alcohol consumption, cravings, and USCS were assessed at pre-aftercare, post-aftercare, and 6-month follow-up.

RESULTS

Overall, patients increased their alcohol consumption during and following aftercare treatment, thereby relapsing despite any treatment. However, CET + acamprosate achieved greater abstinence compared to AAU + acamprosate at follow-up (p=.047). CET + acamprosate also reduced number of drinking days (p=.020) and number of days with excessive drinking (p=.020) at post-aftercare, when compared to AAU monotherapy. CET monotherapy increased sensible drinking at post-aftercare compared to AAU monotherapy (p=.045) and AAU + acamprosate (p=.047). Only CET monotherapy showed improvement in cravings, when compared to AAU at follow-up (mean urge level: p=.032; peak urge level: p=.014).

CONCLUSION

The study showed that CET both as monotherapy and combined with acamprosate was superior to AAU monotherapy and AAU + acamprosate in reducing alcohol consumption. Only CET + acamprosate was capable of reducing alcohol consumption in the longer term, indicating that anti-craving medication may not impede CET from exerting an effect on alcohol consumption. Trial registration: ClinicalTrials.gov ID: NCT02298751 (24/11-2014).

Using Remotely Supervised At-Home TES for Enhancing Mental Resilience

We are in the midst of a mental health crisis with major depressive disorder being the most prevalent among mental health disorders and up to 30% of patients not responding to first-line treatments. Noninvasive Brain Stimulation (NIBS) techniques have proven to be effective in treating depression. However, there is a fundamental problem of scale. Currently, any type of NIBS treatment requires patients to repeatedly visit a clinic to receive brain stimulation by trained personnel. This is an often-insurmountable barrier to both patients and healthcare providers in terms of time and cost. In this perspective, we assess to what extent Transcranial Electrical Stimulation (TES) might be administered with remote supervision in order to address this scaling problem and enable neuroenhancement of mental resilience at home. Social, ethical, and technical challenges relating to hardware- and software-based solutions are discussed alongside the risks of stimulation under- or over-use. Solutions to provide users with a safe and transparent ongoing assessment of aptitude, tolerability, compliance, and/or misuse are proposed, including standardized training, eligibility screening, as well as compliance and side effects monitoring. Looking into the future, such neuroenhancement could be linked to prevention systems which combine home-use TES with digital sensor and mental monitoring technology to index decline in mental wellbeing and avoid relapse. Despite the described social, ethical legal, and technical challenges, the combination of remotely supervised, at-home TES setups with dedicated artificial intelligence systems could be a powerful weapon to combat the mental health crisis by bringing personalized medicine into people’s homes.

Optimizing relapse prevention and changing habits (REACH+) in anorexia nervosa

INTRODUCTION

Relapse rates in anorexia nervosa (AN) are high, even after full weight restoration. This study aims to develop a relapse prevention treatment that specifically addresses persistent maladaptive behaviors (habits). Relapse Prevention and Changing Habits (REACH+) aims to support patients in developing routines that promote weight maintenance, encourage health, and challenge habits that perpetuate illness. The clinical trial design uses the Multiphase Optimization STrategy (MOST) framework to efficiently identify which components of treatment contribute to positive outcomes.

METHODS

Participants will be 60 adults with AN who have achieved weight restoration in an inpatient setting. Treatment will consist of 6 months of outpatient telehealth sessions. REACH+ consists of behavior, cognitive, and motivation components, as well as food monitoring and a skill consolidation phase. A specialized online platform extends therapy between sessions. Participants will be randomly assigned to different versions of each component in a fractional factorial design. Outcomes will focus on maintenance of remission, measured by rate of weight loss and end-of-trial status. Interventions that contribute to remission will be included in an optimized treatment package, suitable for a large-scale clinical trial of relapse prevention in AN.

Alter Game: A Study Protocol on a Virtual "Serious Game" for Relapse Prevention in Patients With Gambling Disorder

Cognitive behavioral therapy (CBT) is the most successful protocol in gambling disorder (GD) treatment. However, it presents some weaknesses, especially concerning relapse prevention (RP). RP is one of the most important therapeutic steps, aiming at managing cravings and to avoid future relapse increasing perceived self-efficacy. Encouraging results come from the blending of psychotherapy and virtual reality (VR), containing gambling cues. The goal of Alter Game (approved by the Ethical Commission, Prot. No. 69346) is verifying the efficacy of an innovative psychological treatment for GD based on the integration of traditional CBT therapy and an immersive VR cue exposure therapy using a serious virtual game, which is a game designed for purposes other than entertainment. RP in virtual cue-exposure therapy allows pathological gamblers to manage the urge to gamble and to avoid relapse by becoming aware of which internal and external triggers are related to craving. We hypothesize that the integrated intervention will be more effective than simple CBT with regard to self-efficacy, craving, and gambling-related distortions. Four virtual ecological environments were developed, and a virtual app, Exludo, interfaced with a computerized multiparametric acquisition system for biofeedback, was created. A sample of about 60 patients aged between 18 and 65 with GD referring to the Addiction Medicine Unit of Verona (Rossi Hospital) will be recruited. Patients will be randomly assigned to the CBT group (16 CBT sessions) or the CBT + VR group (8 CBT sessions + 8 VR cue-exposure therapy sessions). The MCMI-III, the BIS-11, and the SOGS will be used to evaluate inclusion and exclusion criteria, while the Gambling Related Cognitions Scale and the Multidimensional Gambling Self-Efficacy Scale will be used to verify changes as a function of the treatment. Craving will be evaluated through VAS, and psychophysiological variables will be assessed through biofeedback. A pre-test/post-test experimental design with a 1-month follow-up will be conducted. This study will examine an innovative psychotherapeutic protocol for GD treatment, and it will help in identifying new virtual tools to increase the efficacy of traditional therapeutic approaches that could also be applied to treat other addictions.

A 12-session relapse prevention program vs psychoeducation in the treatment of Japanese alcoholic patients: A randomized controlled trial

Aim

Alcoholism is the most prevalent substance use disorder in Japan; the estimated number of patients and high‐risk drinkers is in the millions. Although studies in the West have shown that cognitive behavioral therapy (CBT) is one of the most effective treatment strategies for alcoholic patients, there is a dearth of efficacy studies of CBT‐based intervention for those patients in the non‐Western setting. The aim of this study is to investigate the efficacy of a 12‐session CBT‐based relapse prevention program for Japanese alcoholic patients.

Methods

Forty‐eight alcoholic patients (M = 36, F = 12) who were admitted to an addiction treatment unit were randomly allocated either to a 12‐session relapse prevention (RP) program (n = 24) or a 12‐session psychoeducation (PE) program (n = 24). Both treatment programs were conducted in a group format once a week for 12 weeks. Other aspects of inpatient treatment (group meetings, etc) were the same in both groups. Self‐rating scales, which measure behavioral and cognitive coping, coping response, self‐efficacy, and cognition of drinking, were administered at pretreatment, mid‐treatment, and posttreatment periods. The proportion of participants who relapsed at 3 and 6 months after discharge was evaluated.

Results

Both RP and PE groups showed significant improvement in self‐efficacy and cognition of drinking at posttreatment. However, there were no significant differences in the self‐rating scales between both groups. In addition, there were no significant differences in relapse rate at 3 and 6 months after discharge between both groups.

Conclusions

The 12‐session CBT‐based relapse prevention program and the psychoeducation program may be equally efficacious for alcoholic patients. Several factors that influenced the results are discussed.

Usage Intensity of a Relapse Prevention Program and Its Relation to Symptom Severity in Remitted Patients With Anxiety and Depression: Pre-Post Study

BACKGROUND

Given that relapse is common in patients in remission from anxiety and depressive disorders, relapse prevention is needed in the maintenance phase. Although existing psychological relapse prevention interventions have proven to be effective, they are not explicitly based on patients' preferences. Hence, we developed a blended relapse prevention program based on patients' preferences, which was delivered in primary care practices by mental health professionals (MHPs). This program comprises contact with MHPs, completion of core and optional online modules (including a relapse prevention plan), and keeping a mood and anxiety diary in which patients can monitor their symptoms.

OBJECTIVE

The aims of this study were to provide insight into (1) usage intensity of the program (over time), (2) the course of symptoms during the 9 months of the study, and (3) the association between usage intensity and the course of symptoms.

METHODS

The Guided E-healTh for RElapse prevention in Anxiety and Depression (GET READY) program was guided by 54 MHPs working in primary care practices. Patients in remission from anxiety and depressive disorders were included. Demographic and clinical characteristics, including anxiety and depressive symptoms, were collected via questionnaires at baseline and after 3, 6, and 9 months. Log data were collected to assess the usage intensity of the program.

RESULTS

A total of 113 patients participated in the study. Twenty-seven patients (23.9%) met the criteria for the minimal usage intensity measure. The core modules were used by ≥70% of the patients, while the optional modules were used by <40% of the patients. Usage decreased quickly over time. Anxiety and depressive symptoms remained stable across the total sample; a minority of 15% (12/79) of patients experienced a relapse in their anxiety symptoms, while 10% (8/79) experienced a relapse in their depressive symptoms. Generalized estimating equations analysis indicated a significant association between more frequent face-to-face contact with the MHPs and an increase in both anxiety symptoms (β=.84, 95% CI .39-1.29) and depressive symptoms (β=1.12, 95% CI 0.45-1.79). Diary entries and the number of completed modules were not significantly associated with the course of symptoms.

CONCLUSIONS

Although the core modules of the GET READY program were used by most of the patients and all patients saw an MHP at least once, usage decreased quickly over time. Most patients remained stable while participating in the study. The significant association between the frequency of contact and the course of symptoms most likely indicates that those who received more support had more symptoms, and thus, it is questionable whether the support offered by the program was sufficient to prevent these patients from relapsing.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12888-019-2034-6.

Prevention of disease flares by risk-adapted stratification of therapy withdrawal in juvenile idiopathic arthritis: results from the PREVENT-JIA trial

Objectives

To investigate the ability of high-sensitivity C-reactive protein (hsCRP) and S100A12 to serve as predictive biomarkers of successful drug withdrawal in children with clinical remission of juvenile idiopathic arthritis (JIA).

Methods

This multicentre trial (PREVENT-JIA) enrolled 119 patients with JIA in clinical remission, and 100 patients reached the intervention phase in which the decision whether to continue or stop treatment was based on S100A12 and hsCRP levels. Patients were monitored for 12 months after stopping medication for flares of disease. Results were compared with withdrawal of therapy without biomarker-based stratification in patients from the German Biologika in der Kinderrheumatologie (BiKeR) pharmacovigilance registry.

Results

In the PREVENT-JIA group, 49 patients had a flare, and 45% of patients stopping medication showed flares within the following 12 months. All patients (n=8) continuing therapy due to permanently elevated S100A12/hsCRP at more than one visit flared during the observation phase. In the BiKeR control group, the total flare rate was 62%, with 60% flaring after stopping medication. The primary outcome, time from therapy withdrawal to first flare (cumulative flare rate after therapy withdrawal), showed a significant difference in favour of the PREVENT-JIA group (p=0.046; HR 0.62, 95% CI 0.38 to 0.99). As additional finding, patients in the PREVENT-JIA trial stopped therapy significantly earlier.

Conclusion

Biomarker-guided strategies of therapy withdrawal are feasible in clinical practice. This study demonstrates that using predictive markers of subclinical inflammation is a promising tool in the decision-making process of therapy withdrawal, which translates into direct benefit for patients.

Trial registration number

ISRCTN69963079.

Acceptability of Texting 4 Relapse Prevention, Text Messaging-Based Relapse Prevention Program for People With Schizophrenia and Schizoaffective Disorder

ABSTRACT

We report process outcomes of the pilot randomized controlled trial of Texting 4 Relapse Prevention (T4RP), a text messaging-based relapse prevention program for people with schizophrenia or schizoaffective disorder (SAD). Forty people were randomized to either the intervention or treatment as usual control group at a 2:1 ratio. Process indicators were collected at 6 months post enrollment.Over 90% of patients agreed or strongly agreed that the text messages were easy to understand, easy to answer, positive, and helped them feel supported. Patient acceptability was positively associated with recovery (β = 0.29, p = <0.001) and patient-provider communication scores (β = 1.04, p < 0.001), and negatively associated with symptoms of the disorder (β = -0.27, p = 0.07). Acceptability was similar by diagnosis (β, SAD diagnosis = 0.40, p = 0.90) and age (β = 0.05, p = 0.67). Findings suggest that a text messaging intervention aimed at preventing relapse is feasible and perceived as beneficial in individuals with schizophrenia and SAD. Future research might include a targeted study of T4RP within the context of hospital discharge when people with schizophrenia/SAD are at highest risk of relapse.

Schema Therapy for Patients with Bipolar Disorder: Theoretical Framework and Application

Bipolar disorder (BD) is a severe mood disorder characterized by episodes of depression and hypomania or mania. Despite its primarily biological roots, the onset and course of the disorder have also been related to psychosocial factors such as early adverse experiences and related maladaptive schemas. Several researchers proposed a schema therapeutic model to treat patients with BD. In this paper, we further develop the theoretical model and elaborate on seven elements that were found effective in the psychosocial interventions with individuals with BD: monitoring mood and early symptoms of relapse, recognizing and management of stressful situations and interpersonal conflicts, creating a relapse prevention plan, stabilizing the sleep/wake cycle and daily routine, encouraging the use of medication, and reducing self-stigma and substance use. Apart from that, we describe the elements of the schema work with patients who suffer from BD. Illustrative clinical cases accompany the theoretical framework. The research of the schema therapy with patients with severe mental illnesses has only recently started developing. The presented paper also aims to encourage further research in this area and highlight potentially beneficial research goals.

Cognitive behavioral treatment for disordered gaming and problem gambling in adolescents: a pilot feasibility study

BACKGROUND

Disordered gaming and problem gambling (DG/PG) are associated with a range of functional impairments as well as psychiatric comorbidity. With the proliferation of digital gaming apps aimed at children and adolescents, which involve in-game purchases, there is increasing evidence that DG/PG are on the rise in this age range. The behavior can be detected in youth presenting at school-based health clinics and community psychiatric clinics. Cognitive behavioral therapy (CBT) is one of several recommended treatments for adults, but little evidence is available for the efficacy of this approach in adolescents with DG/PG.

AIM

To evaluate the acceptability and feasibility of a CBT-based intervention developed for adolescents with DG/PG, which can be delivered in routine psychiatric care facilities.

METHODS

Adolescents who were patients at a child and adolescent psychiatry service were screened for DG/PG. Those aged 12-17 years with pronounced symptoms were invited to participate in a 7-week CBT program called Relapse Prevention. Nine adolescents agreed to participate and five consented to repeated assessments of outcome (pre-, post-treatment, and 6-month follow-up). In addition to acceptability and satisfaction with treatment, symptoms of DG were assessed with standardized interview and self-report measures.

RESULTS

There were no dropouts from the treatment. Participants who completed treatment and all outcome assessments reported satisfaction with the treatment. The participants showed fewer symptoms of DG after treatment, and the proportion who met criteria for computer game addiction decreased from 56 to 0%. There was no reduction in the number of participants who met criteria for PG.

CONCLUSION

This study provides preliminary evidence for the acceptability and feasibility of a CBT-based intervention for DG/PG in adolescents. Preliminary data suggest that the treatment may be effective for DG but not PG. Further studies are needed to evaluate the efficacy of this approach for both conditions.

Feasibility of an Intervention Delivered via Mobile Phone and Internet to Improve the Continuity of Care in Schizophrenia: A Randomized Controlled Pilot Study

Schizophrenia is a severe mental illness associated with a heavy symptom burden and high relapse rates. Digital interventions are increasingly suggested as means to facilitate continuity of care, relapse prevention, and long-term disease management for schizophrenia spectrum disorders. In order to investigate the feasibility of a mobile and internet-based aftercare program, a 2-arm randomized controlled pilot study was conducted. The program could be used by patients for six months after inpatient treatment and included psychoeducation, an individual crisis plan, optional counseling via internet chat or phone and a supportive monitoring module. Due to the slow pace of enrollment, recruitment was stopped before the planned sample size was achieved. Reasons for the high exclusion rate during recruitment were analyzed as well as attitudes, satisfaction, and utilization of the program by study participants. The data of 25 randomized patients suggest overall positive attitudes towards the program, high user satisfaction and good adherence to the monitoring module. Overall, the results indicate that the digital program might be suitable to provide support following discharge from intensive care. In addition, the study provides insights into specific barriers to recruitment which may inform future research in the field of digital interventions for severe mental illness.

Psychological interventions as an alternative and add-on to antidepressant medication to prevent depressive relapse: systematic review and meta-analysis

BACKGROUND

After remission, antidepressants are often taken long term to prevent depressive relapse or recurrence. Whether psychological interventions can be a viable alternative or addition to antidepressants remains unclear.

AIMS

To compare the effectiveness of psychological interventions as an alternative (including delivered when tapering antidepressants) or addition to antidepressants alone for preventing depressive relapse.

METHOD

Embase, PubMed, the Cochrane Library and PsycINFO were searched from inception until 13 October 2019. Randomised controlled trials (RCTs) with previously depressed patients in (partial) remission where preventive psychological interventions with or without antidepressants (including tapering) were compared with antidepressant control were included. Data were extracted independently from published trials. A random-effects meta-analysis on time to relapse (hazard ratio, HR) and risk of relapse (risk ratio, RR) at the last point of follow-up was conducted. PROSPERO ID: CRD42017055301.

RESULTS

Among 11 included trials (n = 1559), we did not observe an increased risk of relapse for participants receiving a psychological intervention while tapering antidepressants versus antidepressants alone (RR = 1.02, 95% CI 0.84-1.25; P = 0.85). Psychological interventions added to antidepressants significantly reduced the risk of relapse (RR = 0.85, 95% CI 0.74-0.97; P = 0.01) compared with antidepressants alone.

CONCLUSIONS

This study found no evidence to suggest that adding a psychological intervention to tapering increases the risk of relapse when compared with antidepressants alone. Adding a psychological intervention to antidepressant use reduces relapse risk significantly versus antidepressants alone. As neither strategy is routinely implemented these findings are relevant for patients, clinicians and guideline developers.

Effectiveness of Mindfulness-Based Relapse Prevention in Individuals with Substance Use Disorders: A Systematic Review

OBJECTIVES

This systematic review aimed to understand the current state of the art about the effectiveness of mindfulness-based relapse prevention (MBRP) on individuals with substance use disorders (SUD), taking into account not only SUD variables (e.g., cravings, frequency of use) but also other relevant clinical variables (e.g., anxiety and depressive symptoms, quality of life).

METHODS

A comprehensive search of electronic databases was conducted to identify studies that investigate MBRP interventions on individuals with SUD. Studies that met the inclusion criteria were synthesized and assessed using systematic review methods.

RESULTS

Thirteen studies were included in the present review. The methodological quality of the included studies was moderately strong. Nine studies (69.2%) used the traditional 16 h MBRP program. Six studies (46.1%) chose to use a co-intervention treatment ranging from the treatment as usual (TAU) to cognitive behavioral therapy. All but one study indicated that their interventions produced positive effects on at least one addiction outcome measure. None of the interventions were evaluated across different settings or populations.

CONCLUSIONS

Despite some heterogeneity regarding the type of MBRP program used, results support the effectiveness of these interventions in the SUD population, especially in reducing cravings, decreasing the frequency of use, and improving depressive symptoms.

Health professionals' attitudes toward medications for opioid use disorder

BACKGROUND

Research has shown that medications, especially opioid agonist treatments, are an effective way to treat opioid use disorder (OUD); however, negative attitudes held by health professionals contribute to their underutilization. Methods: A 23-year review of studies that examined health professionals' attitudes toward medications for OUD (MOUD) was conducted to describe the current state of knowledge and to inform future research and interventions. Results: Studies examined attitudes toward the use of methadone, buprenorphine, and naltrexone among various types of health professionals: prescribers, non-prescribing clinicians, pharmacists, and administrators. The characteristics and findings of the included studies were reviewed and synthesized. Findings indicate that attitudes toward MOUD affect access and utilization by influencing prescribing practices, referrals, and adoption within programs. Exposure, knowledge, and treatment orientation were found to be important factors related to attitudes toward MOUD across multiple studies of various types of health professionals. Conclusions: To increase access and utilization, continued efforts are needed to increase positive attitudes toward MOUD among various types of health professionals. Findings indicate that interventions should seek to increase knowledge about MOUD and foster interprofessional communication related to MOUD, especially between prescribers and behavioral health providers.

Using implementation intentions to prevent relapse after remission from psychological treatment for depression: The SMArT intervention

OBJECTIVE

To provide evidence of the effectiveness of a brief relapse prevention intervention using implementation intentions (Self-Management after Therapy, SMArT), following remission from depression and to identify effective relapse prevention strategies.

METHOD

The SMArT intervention was provided to 107 patients who were recovered after psychological therapy for depression. Relapse events were calculated as reliable and clinically significant increases in PHQ-scores. Sixteen patients receiving the intervention and eight practitioners providing it were interviewed. Framework Analysis identified seven themes which highlighted effective relapse prevention strategies and effective implementation of the SMArT intervention.

RESULTS

Relapse rates at the final SMArT session (four months after the end of acute stage therapy) were 11%. Seven themes were identified that supported effective self-management: (1) Relationship with the practitioner-feeling supported; (2) Support networks; (3) Setting goals, implementing plans and routine; (4) Changing views of recovery; (5) The SMArT sessions-mode, content, timing, duration; (6) Suitability for the person; and (7) Suitability for the service.

CONCLUSION

The study provides some support for the effectiveness of the SMArT intervention, although a randomized controlled trial is required; and identifies important relapse prevention strategies.

Alcohol use disorder and the liver

Alcohol use disorders (AUD) cause a range of physical harms, but the major cause of alcohol-related mortality is alcohol-related liver disease (ALD), in some countries accounting for almost 90% of alcohol-related deaths. The risk of ALD has an exponential relationship with increasing alcohol consumption, but is also associated with genetic factors, other life-style factors and social deprivation. ALD includes a spectrum of progressive pathology, from liver steatosis to fibrosis and liver cirrhosis. There are no specific treatments for liver cirrhosis, but abstinence from alcohol is key to limit progression of the disease. Over time, cirrhosis can progress (often silently) to decompensated cirrhosis and hepatocellular carcinoma (HCC). Liver transplantation may be suitable for patients with decompensated liver cirrhosis and may also be used as a curative intervention for HCC, but only for a few selected patients, and complete abstinence is a prerequisite. Patients with AUD are also at risk of developing alcoholic hepatitis, which has a high mortality and limited evidence for effective therapies. There is a strong evidence base for the effectiveness of psychosocial and pharmacological interventions for AUD, but very few of these have been trialled in patients with comorbid ALD. Integrated specialist alcohol and hepatology collaborations are required to develop interventions and pathways for patients with ALD and ongoing AUD.

Relapse risk after in-ward electroconvulsive therapy for acute polymorphic psychotic disorder

PURPOSE

Acute polymorphic psychotic disorder (APPD) without symptoms of schizophrenia is a serious psychiatric condition. APPD can be effectively treated with electroconvulsive therapy (ECT), but little is known about relapse prevention after ECT for APPD.

MATERIALS AND METHODS

This was a retrospective register-based study conducted with 97 patients with APPD (ICD-10 diagnosis F23.0). We estimated the rates of readmission and suicide, and the prognostic factors of these outcomes after ECT. We combined data from several national Swedish registers and used Cox's regression analysis to identify demographic factors, disease characteristics, and relapse preventive treatments that predicted time to readmission or suicide (relapse). Data registered between 2011 and 2016 were used in the study.

RESULTS

Twenty percent of cases relapsed within a year. Thereafter, relapse rate was low. Two cases died during follow-up, whereof one by suicide. Anxiolytic treatment, lamotrigine treatment, and having more than four previous psychiatric hospital admissions were associated with shorter time to relapse. The most robust of these associations was between anxiolytics and relapse risk.

CONCLUSIONS

The first year after discharge from APPD is the period associated with the highest risk of relapse. Having many previous admissions was associated to relapse risk after ECT for APPD. The associations between anxiolytics, lamotrigine, and relapse are uncertain and might be influenced by indication bias.

Long-Term Effects of Short-Term Music Therapy for Prison Inmates: Six-Year Follow-Up of a Randomized Controlled Trial

For most interventions to reduce criminal recidivism, long-term effects are uncertain. Music therapy has shown effects on possible precursors of recidivism, but direct evidence on long-term effects is lacking. In an exploratory parallel randomized controlled trial, 66 inmates in a Norwegian prison were allocated to music therapy or standard care and followed up over a median of 6 years, using state registry data. Median time to relapse was 5 years, with no differences between the interventions. The imprisonment of most participants was too short to provide a sufficient number of therapy sessions. Sufficiently powered studies are needed to examine the long-term effects of appropriate doses of therapy.

A systematic review of interventions to support transitions from intensive treatment for adults with anorexia nervosa and/or their carers

AIM

In the short term, intensive treatment focusing on restoring weight for anorexia nervosa can remediate many symptoms. However, there is a high level of relapse after discharge. This paper examines interventions developed to bridge the transition from intensive to less intensive forms of treatment for adult anorexia nervosa.

METHOD

We undertook a systematic review of the literature on interventions aimed at providing transition support. The Template for Intervention Description and Replication was used to describe components of the transition interventions. Patient's drop-out rates, weight, eating disorder psychopathology and mood data were extracted at end of treatment and follow-up to describe preliminary efficacy.

RESULTS

Fourteen studies were selected: nine used psychological interventions delivered through face-to-face talking therapy or guided self-help, three examined the use of fluoxetine and two assessed stepped-care approaches. Transition support was delivered to patients in 11 studies, to patients and carers in two studies, and carers alone in another study.

CONCLUSIONS

There was a great heterogeneity in the content and structure of the transition interventions evaluated. Overall, drop-out rates were lower for psychological support than pharmacological interventions or stepped-care approaches. Changes in eating disorder outcomes and mood were small to moderate throughout for studies that included a comparison group.

Feasibility of an Integrated Treatment Approach for Youth with Depression, Suicide Attempts, and Substance Use Problems

Depression, suicidal behaviors and substance use problems frequently co-occur, and treatment for youth with these co-occurring problems is often fragmented and challenging. An integrated cognitive-behavioral treatment approach that builds upon a relapse prevention framework and applies common core skills, language, and approach for treating these related problems may be clinically beneficial. Following a description of the integrated approach, we present results of a pilot trial (n = 13) to examine the acceptability and feasibility of the Cognitive-Behavioral Therapy - Relapse Prevention (CBT-RP) intervention plus enhanced treatment as usual (TAU) compared to enhanced TAU alone. The feasibility of the CBT-RP + TAU intervention was reflected by high rates of retention (86%). The acceptability was reflected in positive evaluations regarding the helpfulness of the intervention by adolescents and families. The majority of youth in both CBT-RP + TAU and TAU alone groups evidenced reductions in depression and suicide ideation from study entry to Week 20. Patterns of reduction were more consistent, however, for youth receiving CBT-RP + TAU, and reductions were slower to emerge for some youth receiving TAU alone. Reductions in alcohol and marijuana problems were similar, but half of the youth in TAU alone (and none in the CBT-RP + TAU group) had emergency department visits related to psychiatric crises or substance related problems. These findings, although based on a small sample, underscore the feasibility and acceptability of an integrated cognitive-behavioral relapse prevention approach for youth with depression, suicide attempt histories, and substance use problems.

User pathways of e-cigarette use to support long term tobacco smoking relapse prevention: a qualitative analysis

BACKGROUND AND AIMS

E-cigarettes are the most popular consumer choice for support with smoking cessation in the United Kingdom. However, there are concerns that long-term e-cigarette use may sustain concurrent tobacco smoking or lead to relapse to smoking in ex-smokers. We aimed to explore vaping trajectories, establishing e-cigarette users' perspectives on continued e-cigarette use in relation to smoking relapse or abstinence.

DESIGN

Qualitative longitudinal study collecting detailed subjective data at baseline and ~12 months later.

SETTING

United Kingdom.

PARTICIPANTS

E-cigarette users (n = 37) who self-reported that they had used e-cigarettes to stop smoking at baseline.

MEASUREMENTS

Semi-structured qualitative interviews (face-to-face or telephone) collected self-reported patterns of e-cigarette use. Thematic analysis of transcripts and a mapping approach of individual pathways enabled exploration of self-reported experiences, motives, resources, and environmental and social influences on vaping and any concurrent tobacco smoking.

FINDINGS

Three broad participant pathways were identified: 'maintainer' (e-cigarette use and not smoking), 'abstainer' (neither smoking nor using e-cigarettes), and 'relapser' (dual-using, or relapsed back to tobacco smoking only). In each pathway, individual experiences with vaping nicotine appeared to play an important role and appeared to be related to psychological and social factors. A social context supportive of vaping was important for the maintainers, as was a belief in the need to overcome nicotine addiction for the abstainers, and dislike of the 'vaping culture' expressed by some in the relapser group. Dual-users held beliefs such as a need for cigarettes at time of acute stress that affirmed dependence on tobacco.

CONCLUSIONS

In a sample of UK e-cigarette users who report having used e-cigarettes to quit smoking, a social context that supports continued vaping was perceived to be helpful in preventing relapse to smoking.

Tafenoquine: a toxicity overview

Introduction: A century-long history in 8-aminoquinolines, the only anti-malaria drug class preventing malaria relapse, has resulted in the approval of tafenoquine by the U.S. Food and Drug Administration (FDA) and the Australian Therapeutic Goods Administration (TGA) and to date registration in Brazil and Thailand. Tafenoquine is an alternative anti-relapse treatment for vivax malaria and malaria prophylaxis. It should not be given in pregnancy, during lactation of infants with glucose-6-phosphate dehydrogenase (G6PD) unknown or deficient status, and in those with G6PD deficiency or psychiatric illness.Areas covered: This systematic review assesses tafenoquine associated adverse events in English-language, human clinical trials. Meta-analysis of commonly reported adverse events was conducted and grouped by comparison arms.Expert opinion: Tafenoquine, either for radical cure or prophylaxis, is generally well tolerated in adults. There is no convincing evidence for neurologic, ophthalmic, and cardiac toxicities. Psychotic disorder which has been attributed to higher doses is a contraindication for the chemoprophylaxis indication and psychiatric illness is a warning for the radical cure indication. Pregnancy assessment and quantitative G6PD testing are required. The optimal radical curative regimen including the tafenoquine dose along with its safety for parts of Southeast Asia, South America, and Oceania needs further assessment.

Evaluation of a Blended Relapse Prevention Program for Anxiety and Depression in General Practice: Qualitative Study

BACKGROUND

Existing studies have yet to investigate the perspectives of patients and professionals concerning relapse prevention programs for patients with remitted anxiety or depressive disorders in primary care. User opinions should be considered when optimizing the use and implementation of interventions.

OBJECTIVE

This study aimed to evaluate the GET READY relapse prevention programs for patients with remitted anxiety or depressive disorders in general practice.

METHODS

Semistructured interviews (N=26) and focus group interviews (N=2) with patients and mental health professionals (MHPs) in the Netherlands were performed. Patients with remitted anxiety or depressive disorders and their MHPs who participated in the GET READY study were interviewed individually. Findings from the interviews were tested in focus group interviews with patients and MHPs. Data were analyzed using thematic analysis.

RESULTS

Participants were positive about the program because it created awareness of relapse risks. Lack of motivation, lack of recognizability, lack of support from the MHP, and symptom severity (too low or too high) appeared to be limiting factors in the use of the program. MHPs play a crucial role in motivating and supporting patients in relapse prevention. The perspectives of patients and MHPs were largely in accordance, although they had different perspectives concerning responsibilities for taking initiative.

CONCLUSIONS

The implementation of the GET READY program was challenging. Guidance from MHPs should be offered for relapse prevention programs based on eHealth. Both MHPs and patients should align their expectations concerning responsibilities in advance to ensure optimal usage. Usage of blended relapse prevention programs may be further enhanced by diagnosis-specific programs and easily accessible support from MHPs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12888-019-2034-6.

A Mixed-Methods Evaluation of Usability and Acceptability of Web-Based Relapse Prevention and Self-Monitoring Program: Secondary Analysis of a Pilot Randomized Controlled Trial

This secondary analysis of a pilot randomized controlled trial assessed the usability and acceptability of a web-based relapse prevention and self-monitoring program, which was newly developed for Japanese drug users. We analyzed quantitative and qualitative data using a mixed-method approach among 43 study participants. We assessed the usability of the programs using the Web Usability Scale (WUS) and satisfaction and acceptance using the Client Satisfaction Questionnaire 8-item version (CSQ-8). We also collected qualitative feedback using semi-structured open-ended questions. The results of WUS indicated that the usability of the programs was sufficient. According to the CSQ-8 results, the self-monitoring program had less satisfaction, while the web-based relapse prevention program met satisfaction. Some possible improvements for a future version of the web-based programs were suggested based on participants' feedback.