Group treatment for substance use disorder in adults: A systematic review and meta-analysis of randomized-controlled trials

Journal of Substance Abuse Treatment 99 (2019) 104–116

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Journal of Substance Abuse Treatment journal homepage: www.elsevier.com/locate/jsat

Group treatment for substance use disorder in adults: A systematic review and meta-analysis of randomized-controlled trials

T

Gianluca Lo Cocoa, ,1, Francesco Melchiorib,1, Veronica Oienid, Maria Rita Infurnab, Bernhard Straussc, Dominique Schwartzec, Jenny Rosendahlc, Salvatore Gulloa ⁎

a

University of Palermo, Department of Psychology, Educational Sciences and Human Movement, Palermo, Italy University Niccolò Cusano, Faculty of Psychology, Rome, Italy c University Hospital Jena, Friedrich Schiller University Jena, Institute of Psychosocial Medicine and Psychotherapy, Jena, Germany d ANDROS clinic, Psychology Unit, Palermo, Italy b

ARTICLE INFO

ABSTRACT

Keywords: Group psychotherapy Substance use disorder Abstinence Systematic review Meta-analysis

Background and aims: From residential programs to outpatient services, group therapy permeates the clinical field of substance misuse. While several group interventions for substance use disorders (SUDs) have demonstrated effectiveness, the existing evidence on group therapy has not been systematically reviewed. The current meta-analysis aims to provide estimates of the efficacy of group therapy for SUDs in adults using rigorous methods. Methods: We included studies comparing group psychotherapy to no treatment control groups, individual psychotherapy, medication, self-help groups, and other active treatments applying no specific psychotherapeutic techniques for patients with substance use disorder. The primary outcome was abstinence, and the secondary outcomes were frequency of substance use and symptoms of substance use disorder, anxiety, depression, general psychopathology, and attrition. A comprehensive search was conducted in Medline, Web of Science, CENTRAL, and PsycINFO, complemented by a manual search. Random-effects meta-analyses were run separately for different types of control groups. Results: Thirty-three studies were included. Significant small effects of group therapy were found on abstinence compared to no treatment, individual therapy, and other treatments. Effects on substance use frequency and SUD symptoms were not significant, but significant moderately sized effects emerged for mental state when group therapy was compared to no treatment. There were no differences in abstinence rates between group therapy and control groups. These results were robust in sensitivity analyses and there was no indication of publication bias. Conclusions: The current findings represent the best available summary analysis of group therapy for SUDs in adults, however cautious interpretation is warranted given the limitations of the available data.

1. Introduction Substance use is a problem affecting a large portion of the global population (Degenhardt & Hall, 2015; Gowing et al., 2015; Griffiths & Meacham, 2008), and the World Health Organization assumes the global burden of disease related to drug and alcohol issues to be 5.4% worldwide (WHO, 2014). In the U.S., the National Survey on Drug Use and Health estimated that 21.5 million Americans aged 12 and older battled a substance use disorder in 2014 (Center for Behavioral Health Statistics and Quality, 2015). Substance use disorder (SUD) is defined in the DSM-5 (APA, 2013) by a cluster of cognitive, behavioral, and

physiological symptoms indicating that an individual continues to use a substance despite experiencing significant substance-related problems. In many cases there is a comorbidity between substance use disorders and psychiatric or personality disorders in adults (Conner, Pinquart, & Gamble, 2009; van Dam, Ehring, Vedel, & Emmelkamp, 2013; Weiss et al., 2007). The prevalence of psychiatric comorbidity has been estimated between 30% and 45% for individuals with alcohol and drug dependence, respectively (Farrell et al., 1998; Worley, Trim, Tate, Hall, & Brown, 2010), and individuals with co-occurring disorders typically have a prolonged course of substance dependence (Hasin et al., 2002). High rates of co-occurrence of drug and alcohol problems were also

Corresponding author. E-mail address: [email protected] (G. Lo Coco). 1 Contributed equally. ⁎

https://doi.org/10.1016/j.jsat.2019.01.016 Received 25 July 2018; Received in revised form 21 January 2019; Accepted 22 January 2019 0740-5472/ © 2019 Elsevier Inc. All rights reserved.

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reported, for example, alcohol use disorders are detected in 38% and 45% of opiate and stimulant-using treatment seekers, respectively (Hartzler, Donovan, & Huang, 2010; Hartzler, Donovan, & Huang, 2011). SUDs are chronic or long-term disorders for a significant proportion of adult patients (McLellan, Lewis, O'Brien, & Kleber, 2000; Morgenstern & McKay, 2007). Standard remission rates have been reported to vary considerably between 19.6% and 95.7%, with a pooled mean estimate of 51.7%, 54%, and 60.0% for alcohol, heroin and polysubstance use disorders, respectively (Fleury et al., 2016). Notably, individuals with mental health problems and SUD co-morbidity are said to be more difficult to treat than individuals with either condition alone, and poor retention in treatment programs and poorer treatment adherence have been reported (Broome, Flynn, & Simpson, 1999). A number of psychosocial interventions for SUDs in adults have demonstrated effectiveness, including coping skills training, relapse prevention, contingency management, motivational interviewing, behavioral couple therapy and motivational enhancement therapy (Carroll & Onken, 2005; Gates, Sabioni, Copeland, Le Foll, & Gowing, 2016; Knapp, Soares, Farrell, & Silva de Lima, 2007; Magill & Ray, 2009; Powers, Vedel, & Emmelkamp, 2008). Most of these SUD-specific treatments are provided in a group format and have received widespread clinical acceptance in the last decades (Wendt & Gone, 2017). Reasons for the clinical predominance of group therapy are the increased focus on cost containment (Spitz, 2001) as well as the influence of mutual support groups such as Alcoholics Anonymous, Cocaine Anonymous, and Twelve-Step Facilitation Therapy in treatment programs for substance use (Brown, Seraganian, Tremblay, & Hannis, 2002; Donovan & Wells, 2007). There are also some important clinical reasons for the adoption of the group format in SUD treatment facilities. A group setting provides a basis for influencing patient's behavior in terms of social support and social pressure to change (Sobell & Sobell, 2011). Furthermore, patients with SUDs can benefit from developing interpersonal relationships with others, learning to identify and communicate psychological needs and identifying maladaptive patterns of behavior (Weiss, Jaffee, de Menil, & Cogley, 2004). A great variety of group treatments for SUD with different formal change approaches have been included in the literature under the umbrella term “group therapy.” For example, group drug counseling is designed to educate patients about the concept of addiction recovery and to provide a supportive group climate (Crits-Christoph et al., 1999). Relapse prevention groups aim to instruct patients about substance use and focus on situations that represent a high risk for relapse, while communication skills training focuses on communication and behavioral skills that can be used to handle risky situations (Monti & Rohsenow, 1999). Motivational groups help patients tip the balance in favor of changing addictive behavior by finding more motivating alternatives (Sobell & Sobell, 2011), while mindfulness group programs such as Mindfulness-Based Relapse Prevention (MBRP, Bowen et al., 2009) enhance coping abilities for relapse triggers and interrupting the previous cycle of automatic substance use behavior (Grant et al., 2017). Twelve-Step Facilitation Therapy (TSF) was adapted from that used in project MATCH (Project MATCH Research Group, 1997) and for delivery in a group format (Donovan et al., 2013). It promotes abstinence from substances by helping participants better understand the core principles of Twelve-Step approaches, facilitating acceptance and surrender of their addiction (Timko, DeBenedetti, & Billow, 2006). In contrast to TSF, Twelve-Step meetings are not therapist-led and include group discussion of the Twelve-Step philosophy (Wells, Peterson, Gainey, Hawkins, & Catalano, 1994). Adoption of the group format in SUD treatment facilities is also supported by clinical evidence for effectiveness (Burlingame, Strauss, & Joyce, 2013; Weiss et al., 2004). Weiss et al. (2004) narratively reviewed 24 studies of group treatment outcomes for SUD and provided support for the effectiveness of the group approach. It was found that group therapy can be effective when added to treatment-as-usual or

compared to a wait-list control condition, but very few differences were found between group and individual therapy. Moreover, some studies included in that review highlighted limitations such as the absence of a well-defined SUD diagnosis and a lack of randomized-controlled trials (RCTs). Sobell and Sobell (2011) updated the review by Weiss and colleagues and consistently found that there were no differences between the group and individual treatment formats, despite patients significantly improved in their substance use. Another recent narrative review by Burlingame et al. (2013) found that group treatments for substance use show positive effects with minor differences in effectiveness between specific formal change theories. In sum, previous narrative reviews suggested that group treatments produced positive results compared to no treatment, whereas the results were mixed when groups were compared to other active control conditions. However, the great majority of these reported studies on the effectiveness of group treatment are clinical trials with closed groups and the issue regarding the dissemination of results from RCTs to routinely practice which mostly adopts open groups is an ongoing challenge (Wendt & Gone, 2017). It is noteworthy that several SUD-specific treatments were primarily developed for individual therapy and only later the therapeutic components of these individual therapies were effectively extended and validated into a group format, such as the Twelve-Step Facilitation, the Guided Self-Change treatment and the group motivational interviewing (Donovan et al., 2013; Santa Ana, Wulfert, & Nietert, 2007; Sobell & Sobell, 2011). Although the number of well-conducted RCTs on the efficacy of group therapy for SUDs is increasing at a rapid pace, a meta-analysis of the existing evidence on experimental research of group therapy with adult SUD patients is still missing (Wendt & Gone, 2017). A metaanalysis on the efficacy of group treatments for SUDs can allow for an accurate estimation of the effect of group interventions and to examine whether the effects of group therapy differ among specific subgroups of studies. More quantitative evidence regarding the size of these group effects, the possibility of reaching such effects in the short or long term, and the stability of these effects at follow-up and their potential superiority compared to various control conditions is required. The current meta-analysis aims to shed light on these clinically relevant issues in a field characterized by a massive heterogeneity of treatment modalities and a mismatch between research and real-world practice. The primary goal of this meta-analysis is to provide an updated and comprehensive overview of the existing evidence on group therapy for SUDs in adults. It additionally provides an analysis of all available RCTs comparing group treatments for SUDs to no treatment, individual therapy, and other active treatment. We excluded tobacco and nicotine dependence from the current meta-analysis given that the great majority of studies on this substance recruited only individuals without a psychiatric disorder. 2. Methods 2.1. Protocol and registration This systematic review is part of a larger research project summarizing the evidence on group psychotherapy for various mental disorders which was registered at the PROSPERO international register of systematic reviews (CRD42013004419). Results of this research have recently been published for social anxiety disorder (Barkowski et al., 2016), obsessive-compulsive disorder (Schwartze, Barkowski, Burlingame, Strauss, & Rosendahl, 2016), panic disorder with/without agoraphobia (Schwartze, Barkowski, Strauss, Burlingame, et al., 2017), and post-traumatic stress disorder (Schwartze, Barkowsky, Strauss, Knaevelsrud, & Rosendahl, 2017), as well as for comparisons of group and individual psychotherapy across various mental disorders (Burlingame et al., 2016). 105

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2.2. Eligibility criteria

information (gender, age, substance used, comorbidity), intervention (type of group therapy, number of patients per group, number and length of sessions, sessions attended), comparator (type of control group, number and length of sessions, sessions attended), outcomes (type of outcome, assessment, measure used), statistical parameters (means, standard deviations, frequencies, p-values), and risk of bias indicators. A hierarchical approach was used in cases of multiple measures for one reported outcome, for example urinalysis data was preferred over self-reported abstinence. Therefore, only one effect size per outcome and study was extracted. Intent-to-treat (ITT) data were preferred over completer data.

Study inclusion criteria were specified according to the PICOS guideline, proposed by the PRISMA statement for preferred reporting items for systematic reviews and meta-analyses (Moher, Alessandro, Tetzlaff, & Altman, 2009). All randomized-controlled trials (RCTs) published after 1990 that examined adult patients with substance use disorder (substance abuse or substance dependence) as the primary diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD) were eligible. There were no restrictions related to comorbidity. Eligible interventions were group treatments consisting of at least 3 patients and a therapist who meet regularly for a minimum of 5 sessions with the primary goal of either reducing or eliminating substance use or addressing behaviors related to substance use (see Weiss et al., 2004). Additional treatments were allowed in the case where the group therapy was the primary treatment. Group therapy was compared to either no treatment control groups, individual psychotherapy, or other active treatments such as Twelve-Step Facilitation Therapy, medication or self-help therapy. Although self-help groups are usually conducted by leaders without any professional training who do not apply psychotherapeutic techniques, this intervention modality incorporates some nonspecific elements of treatment such as the interpersonal learning, guidance and altruism (Humphreys et al., 2004). Consequently, self-help therapy was included as “other treatment” comparison in this review. The primary outcome was abstinence, and secondary outcomes were frequency of substance use as a continuous measure, symptoms of SUD as measured with a common questionnaire such as the Addiction Severity Index, anxiety, depression, general psychopathology, and treatment attrition. Treatment attrition was defined as the number of subjects completing treatment divided by number of subjects that were randomized, with completion as defined by the study authors (for example, a certain percentage of attended sessions). Outcomes were assessed at post-treatment and follow-up, and the latest assessment occurred within 12 months of the post-treatment measure.

2.6. Risk of bias in individual studies The Cochrane Risk of Bias Tool (Higgins, Altman, & Sterne, 2011) has been used to judge the internal validity of the included studies. Selection bias refers to inadequate randomization procedure and allocation concealment, reporting bias may be introduced by incomplete reporting of the findings, and attrition bias can be caused by incomplete outcome data. Risk of bias was rated as low, high, or unclear for each study following the recommendations of the Cochrane Collaboration (Higgins et al., 2011). We also evaluated bias introduced by the implementation quality of the group treatment. Bias was considered low if RCTs ensured treatment completion according to the protocol, either by therapists receiving specific training and regular supervision, or verified by conducting adherence checks for fidelity to a treatment manual or a session by session structure with a precise description of treatment methods (Barkowski et al., 2016). 2.7. Summary measures Between-group effect sizes were computed together with 95% confidence intervals. Relative risks (RR) were provided for dichotomous outcomes, and we calculated Hedges' g, a standardized mean difference corrected for small sample bias, for continuous outcomes (Hedges, 1981).

2.3. Information sources and search

2.8. Synthesis of results

An electronic search was conducted in Medline, Web of Science, CENTRAL, and PsycInfo. The search strategy was initially developed for Medline (Supplementary Table 1) and was subsequently adapted for the other databases. We also manually searched for eligible trials by screening the reference lists of the included studies, existing systematic reviews and meta-analyses, and published clinical treatment guidelines (i.e., Carroll & Onken, 2005; Gates et al., 2016; Magill & Ray, 2009; McHugh, Hearon, & Otto, 2010; Roberts, Roberts, Jones, & Bisson, 2016). We used a broad search strategy and also included search terms for smoking cessation and tobacco use, as the search was a part of a larger project (see funding).

Study results were aggregated within the following comparisons: 1) group therapy vs. no treatment, 2) group therapy vs. individual therapy, and 3) group therapy vs. other treatments. Because the number of included studies was rather limited, the effects of anxiety, depression, and general psychopathology were pooled into a single effect size of mental state per study. We used random effects models to aggregate effect sizes across studies, and heterogeneity in effect sizes across studies was quantified using Q-statistics. We also calculated I2, representing the proportion of the total variance in effect sizes due to true differences among treatments above those expected by chance (Higgins, Thompson, Deeks, & Altman, 2003). I2 values of 25%, 50%, and 75% are commonly interpreted as low, moderate, and high heterogeneity, respectively.

2.4. Study selection A team of reviewers first independently screened potential studies by title and abstract based on the inclusion criteria using a conservative approach, with ambiguous studies left included. The full texts of the identified studies were then independently screened for eligibility by reviewers in pairs of two. Disagreements were resolved by discussion within the research team.

2.9. Risk of bias across studies

2.5. Data collection

2.10. Additional analyses

Data were extracted by independent reviewers and validated by a second reviewer. A third party was consulted in case of disagreements. Consistently with the aforementioned eligibility criteria, the following major groups of data were extracted from the included studies: patient

We conducted sensitivity analyses to prove the robustness of the findings by excluding approximated effect sizes and effect sizes set to zero because of insufficient statistical information in the studies, by excluding studies that allowed for comorbidity of mental disorders

Reporting bias and small study effects were visually assessed in funnel plots, and Egger's regression test was run to statistically analyze the relationship between study effect size and standard error (Egger, Davey Smith, Schneider, & Minder, 1997).

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Idenficaon

G. Lo Coco et al.

Records idenfied through database searching (n = 7873)

Addional records idenfied through other sources (n = 26)

Records screened (n = 7612)

Records excluded a!er screening tles and abstracts (n = 6778)

Full-text arcles assessed for eligibility (n = 834)

Full-text arcles excluded, with reasons n = 801 Not meeng inclusion criteria: 532 - No SUD diagnosis 106 - No group therapy 205 - No eligible control group 81 - No available outcome 28 - No RCT design 98 - Secondary publicaon 14

Inclusion

Eligibility

Screening

Records a!er duplicates removed (n = 7612)

Studies included in quantave synthesis (meta-analysis) (n = 31) (+ 2 follow-up reports)

Relevant data for the analysis not found (a!er contacting authors): 9 Smoking cessaon arcles excluded from the analysis of this study: 260

Fig. 1. Flow chart of the study selection process.

trials, and to other treatments in 18 studies. Cognitive-behavioral group therapy was investigated in 21 comparisons, behavioral group therapy in two comparisons, and mindfulness-based programs in three comparisons. Other group treatment approaches such as dialectic behavioral group therapy or integrated treatment were used in eight comparisons. The median number of patients per group was 8, and the median number of sessions was 14, with patients attending an average of 60.9% of the sessions. The median length of a session was 90 min, provided once a week. Group therapy was applied in an inpatient setting in six studies, in an outpatient setting in 21 trials, and within a day treatment program in three studies. Group therapy was part of an acute treatment in 17 studies, it was used within aftercare treatment (relapse prevention) in nine trials, and it was included in acute treatment and relapse prevention in five studies. A baseline treatment was additionally applied to patients in both intervention and control groups in 14 trials (7 treatment as usual, 4 pharmacotherapy, 2 individual therapy, 1 Twelve-Step group). In total, 3951 patients were randomized with 2103 in intervention groups and 1848 in control groups. The mean age of the patients was 38.2 years and 36.2% of the patients were female. SUD was related to alcohol in seven studies, to cocaine in six, to heroin or opioids in three, and to cannabis in one trial. Eleven studies considered patients using mixed substances, while another three studies did not specify the substances used. The included patients had comorbid mental disorders in nine studies, including borderline personality disorder, psychosis, and major depressive disorder.

(dual diagnosis), and by excluding studies that did not apply a baseline treatment to all patients. We also tested whether results change when only studies comparing equivalent treatment approaches were considered and when studies with a high or unclear risk of bias were excluded. Subgroup analyses were not executed because of the small number of included studies and the low heterogeneity found in the majority of analyses. We further conducted post-hoc power analyses to test if our meta-analyses have sufficient power to detect differences between group psychotherapy and control groups with α = 0,05 (twotailed) considering average group sizes of the included studies and the degree of heterogeneity across studies (Hedges & Pigott, 2001). 3. Results 3.1. Study selection Our electronic search revealed 7873 records. After screening all records and assessing the relevant full texts for eligibility, 31 primary studies and two secondary publications reporting follow-up results met our inclusion criteria (Fig. 1). 3.2. Study characteristics The characteristics of the included studies are summarized in Table 1. The included studies allowed for 34 comparisons between group therapy and a control group. Group therapy was compared to no treatment control groups in nine studies, to individual therapy in seven 107

USA

USA

Spain

USA

Easton et al. (2007)

Epstein, Hawkins, Covi, Umbricht, and Preston (2003)

Estopiñán, Poza, Martín, and Garcia (2009)

Garland, Gaylord, Boettiger, and Howard (2010)

Canada

Brown et al. (2002)

Germany

USA

Bowen et al. (2014)

Burtscheidt et al. (2002)

USA

Bowen et al. (2009)

USA

Patients with SUD (cocaine, heroin, marijuana) and severe persistent mental illness Age: 43 34% female Patients with SUD (alcohol only or polysubstance use) Age: 41 36% female Patients with SUD (alcohol only or polysubstance use) Age: 38 20% female Patients with SUD (alcohol only or polysubstance use) Age: 38 31% female Veterans with SUD (alcohol, cannabinol or stimulants) and major depressive disorder Age: 49 8% female Patients with SUD (alcohol) Age: 42 30% female Men with SUD (alcohol) and cooccurring interpersonal violence Age: 38 0% female Patients with SUD (cocaine) Age: 39 43% female Patients with SUD (alcohol) Age: 45 29% female Patients with SUD (alcohol) living in a therapeutic community for > 18 months

USA

Bellack, Bennet, Gearon, Brown, and Yang (2006)

Brown et al. (2006) Lydecker et al. (2010)

Population Age % female

Country

Author(s) and publication year

Table 1 Characteristics of the included studies.

108 Mindfulness-based group therapy

Cognitive-behavioral group therapy

Cognitive-behavioral group therapy

Cognitive-behavioral group therapy

a) Cognitive-behavioral group therapy b) Coping skills training

Cognitive-behavioral group therapy combining treatment for depression and coping Skills training for SUD

Cognitive-behavioral relapse prevention aftercare program

a) Cognitive-behavioral relapse prevention b) Mindfulness-based relapse prevention

Mindfulness-Based Relapse Prevention (MBRP)

Behavioral group therapy

Group treatment

27

14

48

10

14

n.r.

10

6

40 40

6

n.r.

40

48

6

8

103 126

8

8

5

No. of patients per group

88

93

103

n

10/120

7/90

12/90

12/90

26/100

26/100

36/60

10/90

8/120

8/120

8/120

52/n.r.

No. of sessions/ length in minutes

Social-support group

TAU

Social-support group

TSF (Twelve-Step Facilitation Therapy; therapist-guided)

TAU

TSF (Twelve-Step Facilitation Therapy; therapist-guided)

TSF (Twelve-Step Facilitation Therapy; therapist-guided)

TAU (Twelve-Steps)

TAU (Twelve-Steps)

Supportive group discussion

Comparison treatment

26

10

49

38

40

42

140

95

75

72

n

No

No

No

No

No

Standard pharmacotherapy

No

No

No

No

Baseline

(continued on next page)

Attrition, mental state, SUD symptoms,

Attrition, abstinence

Attrition, abstinence, substance use

Attrition, abstinence, SUD symptoms

Attrition, abstinence

Attrition, abstinence, mental state, SUDsymptoms

Attrition, frequency, SUDsymptoms

Attrition, abstinence, substance use

Attrition, Substance use, SUD-symptoms

Attrition, abstinence, substance use

Outcomes

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109

USA

USA

Ireland

Linehan et al. (2002)

Madigan et al. (2013)

Spain

Lanza, Garcia, Lamelas, and GonzalezMenendez (2014)

Linehan et al. (1999)

USA

Kushner et al. (2013)

Canada

USA

Hunter et al. (2012)

Li, Armstrong, Chaim, Kelly, and Shenfeld (2007)

USA

Hien et al. (2009)

USA

Germany

Gouzoulis-Mayfrank et al. (2015)

Lehman, Herron, Schwartz, and Myers (1993)

Country

Author(s) and publication year

Table 1 (continued)

Patients with SUD (alcohol, cannabis) and severe mental illness Age: 31 26% female Patients with SUD (mixed substances) and their partners Age: 42 26% female Women with SUD (mixed substances) and borderline personality disorder Age: 30 100% female Women with SUD (heroin) and borderline personality disorder Age: 36 100% female Patients with SUD (cannabis) and Psychosis

Age: 40 21% female Patients with SUD (mixed substances) and Psychosis Age: 31 16% female Women with SUD (mixed substances) and PTSD Age: 39 100% female Patients with SUD and depressive symptoms Age: 35 48% female Patients with SUD (alcohol) and anxiety disorder Age: 39 40% female Incarcerated women with SUD Age: 33 100% female

Population Age % female

Cognitive-behavioral group therapy and motivational interviewing

Dialectical behavior group therapy

Dialectical behavior group therapy

Multiple couples therapy (integrated treatment)

a) Cognitive-behavioral group therapy (Acceptance and Commitment therapy) b) Cognitive-behavioral group therapy (traditional program) Supportive group therapy (Being sober group) + intensive case management

Cognitive-behavioral group therapy

Cognitive-behavioral group therapy

Cognitive-behavioral group therapy (Seeking Safety)

Integrated treatment including disorder-specific group therapy

Group treatment

59

11

12

30

29

n.r.

n.r.

n.r.

8

n.r.

n.r.

n.r.

18 19

3

n.r.

n.r.

n.r.

No. of patients per group

171

47

176

50

n

12/n.r.

n.r./150

n.r./120

8/90

n.r./60

16/90

16/90

6/60

18/120

12/75–90

n.r./120

No. of sessions/ length in minutes

No (additional) treatment

Individual comprehensive validation therapy + Twelve-Steps groups

TAU

Individual couple therapy (integrated treatment)

No (additional) treatment

No treatment (Waitlist control)

Progressive relaxation training

No (additional) treatment

Women's health education group

TAU

Comparison treatment

29

12

15

24

25

13

173

26

177

50

n

Attrition, substance use, mental state

Attrition, abstinence

Attrition, abstinence

Attrition, SUD symptoms

SUD symptoms

Abstinence, SUD symptoms, mental state

Attrition, abstinence, mental state, substance use

Attrition, abstinence, mental state

Attrition, abstinence, substance use

Attrition, abstinence, substance use

Outcomes

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TAU (care from a multidisciplinary team in the local service)

Pharmacotherapy (opiate agonist medication)

No

No

TAU (usual mental health center and rehabilitation services)

No

Residential TAU (Twelve-Steps)

TAU based on Twelve-Steps and Matrix Model

Standard SUD treatment

No

Baseline

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110

USA

Brazil

USA

USA

China

Spain

USA

USA

USA

USA

USA

Marlowe et al. (2003)

Marques and Formigoni (2001)

Maude-Griffin et al. (1998)

Milby et al. (1996)

Min et al. (2011).

Monras et al. (2000)

O'Farrel, Schumm, Dunlap, Murphy, and Muchowsky (2016)

Rawson et al. (2001)

Rawson et al. (2002)

Schmitz et al. (1997).

Weinstein, Gottheil, and Sterling (1997); Gottheil, Weinstein, Sterling, Lundy, and Serota (1998)

Patients with SUD (cocaine) Age: n.r. % female n.r.

Patients with SUD (alcohol) Age: n.r. 24% female Patients with SUD (alcohol) and their heterosexual partners without SUD Age: 48 30% female Patients with SUD (opioid) Age: 33 40% female Patients with SUD (cocaine) Age: 44 48% female Patients with SUD (cocaine) Age: 35 50% female

Age: 28 22% female Patients with SUD (cocaine) Age: 34 22% female Patients with SUD (alcohol or drugs) Age: 32 8% female Veterans with SUD (cocaine) Age: n.r. 2% female Homeless persons with SUD Age: 31 19% female Men with SUD (heroin) Age: 36 0% female

Population Age % female

Integrated group treatment including behavioral, exploratory, supportive, and expressive techniques

Cognitive-behavioral group therapy

Cognitive-behavioral group therapy

Cognitive-behavioral group therapy + individual sessions

Group behavioral couples therapy

Motivational enhancement group therapy

Cognitive-behavioral relapse prevention

Group oriented day treatment (multimodal)

Cognitive-behavioral group therapy

Cognitive-behavioral group therapy

Cognitive-behavioral group oriented day treatment

Group treatment

142

24

30

40

50

45

50

89

59

78

40

n

n.r.

5

6

n.r.

8

10

12

n.r.

n.r.

7

n.r.

No. of patients per group

36/180

12/60

48/90

n.r./90

11/90

nr/60

20/90

24/n.r.

36/n.r.

17/n.r.

n.r.

No. of sessions/ length in minutes

Individual counseling

Cognitive-behavioral individual therapy

No (additional) treatment

No (additional) treatment

Individual behavioral couples therapy

No (additional) treatment

No (additional) treatment

TAU (Twelve-Steps, individual and group counseling)

TSF (Twelve-Step Facilitation Therapy; therapist-guided)

Cognitive-behavioral individual therapy

No (additional) treatment

Comparison treatment

144

23

30

41

51

43

50

87

69

77

39

n

No

No

Pharmacotherapy (standard methadone tx)

TAU: Detoxification + Pharmacotherapy (naltrexone)

Twelve-Steps Group (without partner)

TAU (individual visits + pharmacological treatment if necessary)

TAU (rehabilitation program)

No

Individual counseling

No

Individual cognitive-behavioral addiction counseling + interpersonal problem solving groups

Baseline

n.r. = not reported; PTSD = posttraumatic stress disorder; SUD = substance use disorder; TAU = treatment as usual; TSF = Twelve-Step Facilitation Therapy.

Country

Author(s) and publication year

Table 1 (continued)

Attrition, abstinence, substance use, SUD symptoms, mental state Attrition, abstinence, substance use, SUD symptoms, Mental state

Abstinence

Abstinence, SUD symptoms, mental state

Attrition, abstinence, substance use

Attrition, abstinence, SUD symptoms, mental state Attrition, abstinence

Attrition, abstinence

Attrition, abstinence, substance use, SUD symptoms Abstinence

Attrition, abstinence

Outcomes

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3.3. Risk of bias within studies

studies with dual diagnoses (Supplementary Table 4). Results for studies comparing equivalent treatment approaches and for trials with low risk of bias were similar to findings including all studies. Results dropped to zero when we included only trials applying a baseline treatment to all patients for comparisons of group therapy and no treatment. Post-hoc power analyses revealed that for the primary outcome abstinence all meta-analyses are adequately powered with 1 − β = 0,81 for comparisons against no treatment control groups, 0,93 for comparisons against individual therapy, and 0,98 for comparisons against other active treatments. Since effects and/or number of studies were smaller for analyses on the secondary outcomes, these analyses are mainly underpowered (1 − β < 0,80) except for mental state in comparisons against no treatment control groups (1 − β = 0,99) and frequency of use in comparisons against individual therapy (1 − β = 0,95).

The random allocation was adequate in 13 studies (low risk of bias), two studies were evaluated as high risk, and 18 studies had an unclear risk of bias. The risk of selection bias due to inadequate allocation concealment was judged as low in eight studies, while it was unclear in 25. The risk of reporting bias was rated as low in six studies, high in one study, and unclear in 26 trials. We determined that the risk of bias due to lack of implementation quality was low in 23 studies, while it was unclear in 10 studies because of missing information (Supplementary Table 2). The risk of attrition bias due to incomplete outcome data was judged as low for 53% of the outcomes, while it was rated as high for 37%, and as unclear for 10%. Finally, none of the primary studies accounted for the dependence of data, such as the correlation of data within groups by considering the intraclass correlation coefficient (ICC) in the analysis (Baldwin, Murray, & Shadish, 2005).

4. Discussion

3.4. Results of individual studies and synthesis of results

Little is known about the efficacy of psychosocial treatment for substance-related disorders conducted in the group format, despite the widespread implementation of group therapy in most treatment facilities (Crits-Christoph, Johnson, Connolly Gibbons, & Gallop, 2013; Fletcher, 2013). The current meta-analysis examined 33 studies including 34 treatment conditions and 3951 patients. The results indicated that the pooled effect sizes for short-term efficacy were significant but small on the primary outcome abstinence in each comparison. Group intervention effects remained evident for abstinence at post-treatment when studies with a high risk of bias, without a baseline treatment, or with dual diagnosis were excluded. A visual inspection of the funnel plot for the primary outcome suggested no indication of publication bias. Taken together, these findings provide some evidence for the general efficacy of group treatment on abstinence at post-treatment. The observed effect sizes ranged from the small to moderate level and are consistent with the results of previous metaanalyses (for example, Burke, Arkowitz, & Menchola, 2003; Magill & Ray, 2009) as well as with research suggesting that the public nature of group therapy can represent a more powerful incentive to avoid relapse by providing a robust source of external control that can counterbalance a disorder characterized by the breakdown of internalized control mechanisms (Khantzian, 2004). A moderate heterogeneity in effect sizes was found when group treatment was compared to other treatments. In the reviewed studies, various “other treatments” were contrasted with group therapy by including both therapist-led and not therapist-led interventions, such as the mutual self-help groups. Thus, this statistical heterogeneity seems to reflect the variety of helpful approaches for SUDs, with the challenge of crafting an effective treatment tailored to the specific need of the patient (Mack, Brady, Miller, & Frances, 2016). It is often argued that a limited number of included studies in the single analyses might be related to a lack of statistical power. Therefore, we conducted post-hoc power analyses. Although the number of studies was small in most analyses, for the primary outcome abstinence all meta-analyses were adequately powered to detect differences between study groups. This refers to one of the primary aims of meta-analyses: increasing statistical power that is usually not given in the primary studies, particularly when active treatment groups are compared (Cuijpers, 2016). It is worth noting that group therapy performed well at mental state improvement (defined as improvement in symptoms of depression, anxiety, or overall distress) with a moderate effect when compared to no treatment. However, there was no significant effect on mental state outcome when group treatment was compared to individual psychotherapy or other active treatments. Additionally, group therapy was not effective in reducing the frequency of substance use and symptoms of SUD across all comparisons. This may be due to a higher heterogeneity and the small number of analyzed studies reporting frequency

3.4.1. Post-treatment The results of the included studies on the primary and secondary outcomes as well as the pooled results (Hedges' g with 95% confidence intervals) according to the type of control group are shown in Table 2. We found significant, small effects of group therapy on abstinence in each comparison, classified as group therapy compared to either no treatment, individual therapy, or other treatments. While study results were homogeneous for comparisons against no treatment and individual therapy, moderate effects were seen when group therapy was compared to other treatments. The effects on frequency of substance use and symptoms of SUD were non-significant. We found a significant medium effect for mental state when group therapy was compared to no treatment, but the effects for comparisons against individual therapy and other treatments were small and non-significant. Attrition in group therapy was 32%, and 34% in control groups. Differences in attrition between group psychotherapy and control treatments were non-significant for all of the subgroups: vs. no treatment, RR = 0,96, 95% CI [0,83; 1,12], k = 5; vs. individual therapy, RR = 1,01, 95% CI [0,82; 1,23], k = 5; and vs. other treatments, RR = 1,03, 95% CI [0,94; 1,13], k = 15. 3.4.2. Follow-up We considered results of the latest reported follow-up assessment within 12 months of treatment completion. The results are summarized in Supplementary Table 3. Results for the primary outcome abstinence increased over time for comparisons against no treatment but decreased for comparisons against individual and other treatments. The number of studies reporting follow-up results for the other outcomes was small, preventing a clear interpretation of the effects. 3.5. Risk of bias across studies We examined the risk of bias across studies by including all studies in one analysis because of the small number of included studies within the three types of comparisons. A visual inspection of the funnel plot for the primary outcome abstinence did not reveal any substantial asymmetry (Supplementary Fig. 1). Egger's regression test also indicated no significant evidence of small-study effects (p = 0,403). We did not run the Egger test for the other outcomes because it should be used only when there are at least 10 studies included in the meta-analysis (Sterne, Egger, & Moher, 2011). 3.6. Additional analyses Results of sensitivity analyses demonstrated the robustness of the findings on abstinence at post-treatment. The effects and conclusions remained stable when excluding outliers, approximated effect sizes, or 111

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Table 2 Meta-analytic results for different comparisons at post-treatment. Study

Group vs. no treatment Hunter 2012 Lanza 2014 Lehman 1993 Marlowe 2003 Min 2011 Monras 2000 Rawson 2001 Rawson 2002 Total effect Heterogeneity I2 Group vs. individual therapy Linehan 2002 O'Farrel 2016 Schmitz 1997 Weinstein 1997 Total effect Heterogeneity I2 Group vs. other active treatments Bellack 2006 Bowen 2009 Bowen 2014 Brown 2006 Burtscheidt 2002 Calvo Estopinan 2008 Easton 2007 Epstein 2003 Garland 2010 Gouzoulis-Mayfrank 2015 Hien 2009 Kushner 2013 Linehan 1999 Maude-Griffin 1998 Milby 1996 Total effect Heterogeneity I2

Abstinence g

95% CI

0,26 0,63

−0,34; 0,86 −0,63; 1,88

0,09

−0,34; 0,53

0,17 0,58 0,43 0,28 0%

−0,37; 0,72 −0,06; 1,23 −0,18; 1,03 0,04; 0,52

−0,09 0,36 0,29 0,53 0,34 0%

−0,88; 0,70 −0,03; 0,75 −0,49; 1,07 −0,02; 1,09 0,06; 0,62

0,64

0,26; 1,03

0,33 −0,55 0,06 0,31 0,54

0,01; 0,65 −1,11; 0,01 −0,38; 0,50 −0,57; 1,19 0,07; 1,01

0,18 −0,02

−0,26; 0,61 −0,25; 0,21

0,48 0,29 0,86 0,29 65,09%

−0,26; 1,21 −0,11; 0,68 0,45; 1,26 0,07; 0,50

Frequency of use

SUD symptoms

g

g

95% CI

0,28 −0,26

−0,42; 0,97 −0,97; 0,45

95% CI

Mental state g

95% CI

0,42 0,82

−0,15; 0,99 0,08; 1,55

0,67

0,26; 1,07

0,71

0,22; 1,20

0,68

0,17; 1,19

0,29 59,32%

−0,28; 0,86

0,64 0%

0,38; 0,90

0,74 −0,05 0,31 67,33%

0,04; 1,44 −0,60; 0,49 −0,46; 1,09

−0,30

−0,89; 0,28

0,45

−0,18; 1,09

0,19

−0,06; 0,43

0,13 38,19%

−0,21; 0,46

0,94 0,16 0,52 65,64%

0,23; 1,66 −0,39; 0,71 −0,25; 1,28

0,10 0,00 0,00 0,06 0%

−0,29; −0,67; −0,55; −0,23;

0,49 0,68 0,55 0,34

0,00 0,10 0,16

−0,37; 0,37 −0,24; 0,44 −0,13; 0,44

0,40

0,01; 0,80

−0,43

−0,82; −0,03

0,02 0,04

−0,95; 0,99 −0,16; 0,25

0,01 16,15%

−0,14; 0,16

0,00

−0,48; 0,48

−0,35

−0,98; 0,29

0,07 53,44%

−0,34; 0,49

SUD = substance use disorder.

of use and SUD symptoms. However, there is promising evidence for reduced SUD symptoms at follow up when the group format was compared with the no treatment condition. Additional long-term effects were evaluated, and significant medium effects on abstinence were found in studies comparing group treatment to no treatment, a finding that is consistent with previous randomized trials examining the effectiveness of group therapy for SUD patients (Litt, Kadden, Cooney, & Kabela, 2003; McKay et al., 1997). However, studies comparing group therapy against other active treatments did not yield significant differences on abstinence in the longterm. Overall, our findings on abstinence are promising, given the chronic-relapsing nature of addiction problems highlighted by previous research (McLellan et al., 2000). It is worth noting that we found only a few studies reporting follow-up results for the secondary outcomes. No differences in secondary outcomes were found when group therapy was compared to individual therapy or other active treatments such as Twelve-Step Facilitation Therapy or TAU. This result is consistent with previous research reporting no differences between the outcomes of group and individual therapy in general (Burlingame et al., 2016), and specifically for patients with SUD (Irvin, Bowers, Dunn, & Wang, 1999; Schmitz et al., 1997; Sobell & Sobell, 2011; Weiss et al., 2004) as well as between group therapy and any active therapy comparators for various mental disorders (panic disorder and PTSD: Schwartze et al., 2016, Schwartze, Barkowski, Strauss, Burlingame, et al., 2017, Schwartze, Barkowski, Strauss, Knaevelsrud, et al., 2017; social anxiety disorder: Barkowski et al., 2016). However, this result represents a promising outcome considering that there are several advantages to the group format in substance use treatment (Flores, 2007)

and the efficient use of therapist time achieved by group therapy (Marques & Formigoni, 2001). No differences in attrition were found between group psychotherapy and control treatments. However, the overall attrition rate was high at 34%, especially when compared to previous meta-analyses of psychotherapy efficacy studies (Swift & Greenberg, 2012). This is particularly important considering the increased likelihood of achieving abstinence or intervals of greatly reduced substance use for patients who are able to maintain active participation in formalized treatment (Kleber et al., 2007). Patients with SUD are known to frequently report high rates of treatment discontinuation (Wells, Saxson, Calsyn, Jackson, & Donovan, 2010) and attendance can be poor even when group therapy is mandated such as in methadone or rehab clinics (Joe, Simpson, Greener, & Rowan-Szal, 1999). Further research is needed to determine which group therapeutic strategies can effectively improve treatment adherence. There is some evidence for the efficacy of contingency management procedures such as abstinence-based incentives for reinforcing cocaine abstinence and group therapy attendance (Petry, Martin, & Simcic, 2005) as well as attendance at motivational enhancement and treatment readiness group sessions for opioid-dependent patients (Kidorf et al., 2009). Interestingly, the effects for comparisons against individual therapy and other treatments on abstinence remained significant and moderate once the studies examining patients with dual diagnoses in the sensitivity analysis were excluded. This result confirms the robustness of the findings on the effectiveness of group treatment for SUDs and suggests that group therapy can be implemented and sustained for patients with both a SUD and a comorbid psychiatric disorder. Although previous 112

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research found evidence regarding certain well-supported treatment methods for adult patients with SUDs (Miller & Wilbourne, 2002; Sobell & Sobell, 2011), the greater efficacy of a single type of treatment modality over another for patients with co-occurring substance use and mental health problems is still a matter of debate (Drake, O'Neal, & Wallach, 2008; Roberts et al., 2016). Our findings suggest that group therapy can be effective for the difficult-to-treat patients. However, this is a preliminary conclusion, given the small number of studies included in the meta-analysis. More studies are needed in order to draw definitive conclusions about the efficacy of group treatment approaches for patients with comorbidities. Nonetheless, the pattern of findings seen in the currently available research is encouraging. To sum up, the current meta-analysis suggests that integrating the results on the efficacy of group therapy RCTs can allow both researchers and clinicians to make an accurate estimation of the effect of group treatment for SUDs. At the same time, we are aware that the “realworld” group treatments for SUDs are often different from those reported in the RCTs. For example, the open-enrolling groups are likely the most frequent modality of group therapy in SUD specialty clinics and are rarely examined in controlled trials (Weiss et al., 2004; Wendt & Gone, 2017) because of methodological difficulties. In the current review none of the 31 studies have explicitly mentioned the inclusion of open-enrolling groups. However, some recent and powerful tools for analyzing data from rolling groups were developed (Tasca et al., 2010) and could be effectively adopted in research with SUDs. Furthermore, there is still a gap in the literature associated with the mismatch between the use of group manualized therapies and the need for high degree of flexibility in treatment delivery to address the complex nature of addiction (Wendt & Gone, 2018). RCTs and meta-analyses have extensively relied on manualized/structured treatments. Although strict treatment adherence is necessary for a well-controlled study, considerable flexibility within structured group therapies is likely required within real-world treatment settings (Wendt & Gone, 2018). Finally, the results of the current meta-analysis provide compelling evidence for the effects of group treatment for SUDs and can help both policy makers and stakeholders to allocate financial resources for improving effective group interventions in SUDs specialty treatments. A precise estimation of the effect of group interventions can improve the evidence-based ground of group therapies, given that most of previous research efforts heavily focused on individual therapy for SUDs (Wendt & Gone, 2017).

patients when the N ranged between 50 and 150. Furthermore, we used a conservative approach by including those studies with a lack of reported number of sessions because in the worst case we would underestimate the real treatment effect as it is quite unlikely to reach a high treatment effect with a small (< 5) number of sessions. The next generation of empirical research on group therapy should consistently report more details concerning the group structure, such as open or closed format or number of patients per each group. In the reviewed studies, the included participants were typically white males. The applicability of the treatments to females, older adults, and non-white individuals is less clear. Few included trials were conducted outside the USA (32%), leaving the applicability of treatments to other countries similarly unclear. We focused on studies of adult individuals with SUD and considered adolescents as a special population that deserved a distinct analysis. Although the diagnostic criteria for drug use are similar for all types of substances and across all ages, the epidemiology and nature of adolescent substance use is related to the unique developmental period of adolescence (Fisher & Roget, 2009). Our findings therefore cannot apply to adolescent substance users, although the behavioral treatment of adolescent substance use is an important area to pursue (Hogue, Henderson, Ozechowski, & Robbins, 2014). To date, the results from controlled studies of treatment for adolescents with SUDs fall well short of yielding definitive conclusions about the treatment approaches that are most effective for this clinical population. However, the recent meta-analytic results on the advantages of group counseling treatment seem promising, with positive and statistically significant improvements in substance use over time (Tanner-Smith, Wilson, & Lipsey, 2013) and tested in a wide array of group interventions including psychoeducation, social learning and motivational interviewing (Burlingame et al., 2013). Finally, we were unable to investigate whether effect sizes differed by specific SUD diagnoses due to the limited number of studies available for inclusion in some subgroup analyses. In the current study, eleven RCTs included patients using mixed substances, which appear to reflect the complexity of group delivery in clinical contexts. 4.2. Conclusions The term group therapy has been used by both clinicians and researchers to describe very different approaches to the treatment of SUDs, with some adopting well-validated group therapy principles and processes (e.g., Yalom & Leszcz, 2005) and others simply promoting dyadic interactions in a group context. Although there are different meanings of the term “group therapy” in the field (Weiss et al., 2004), a large majority of programs for SUDs report that group therapy is a useful treatment modality due to its empirical effectiveness (Weiss et al., 2004; Wendt & Gone, 2018). The current meta-analysis represents an effort to narrow the gap between research and practice in the SUD literature, given that no meta-analyses quantitatively summarizing the efficacy of group therapy for SUDs are currently available. The results of the present meta-analysis provide preliminary evidence that group treatment leads to improved abstinence when compared to either no treatment, individual therapy, or other treatments. However, the effect sizes are small and there are few studies reporting follow-up results. The main findings in this study are supported by sensitivity analyses and a low level of heterogeneity. Although the current findings represent compelling summary analysis of group therapy for SUDs, further research is needed to determine the influence of sociodemographic, psychiatric, and general medical characteristics as well as patient treatment preferences on treatment attrition and outcome (Kadden, Litt, Cooney, Kabela, & Getter, 2001; Sofin, Danker-Hopfe, Gooren, & Neu, 2017). Group studies with long-term prospective designs are also needed, given that only a third to a half of individuals with SUDs achieve remission, occurring after a mean follow-up period of 17 years (Fleury et al., 2016). The current findings could facilitate group clinicians in improving

4.1. Limitations Various limitations related to the characteristics of the included studies may have impacted our findings. Firstly, some studies relied almost entirely on patient self-reports to clinicians, and numerous questions have been raised about their reliability and validity in substance use research (Richter & Johnson, 2001). Secondly, although there was some breadth in the range of included intervention types, the majority of the group therapies implemented in the included studies could be classified as taking the cognitive-behavioral approach (58%). Furthermore, in the present meta-analysis the eligible interventions were group treatments consisting of at least 3 patients and a therapist who meet regularly for a minimum of 5 sessions, consistently to recent reviews on evidence-based group treatments (Burlingame et al., 2013; Weiss et al., 2004). Thus, the estimation of the effect size of group interventions in this meta-analysis excluded some very brief group therapies which are usually delivered in one, two or four sessions such as the motivational enhancement therapy (Miller & Rollnick, 2002) or group motivational interviewing (Santa Ana et al., 2007). Further studies are needed to estimate the effects of these brief group treatments which showed to be viable treatment modalities in clinical settings to enhance treatment outcome for SUDs. Additionally, a number of included studies did not report the number of patients per group or the number of group sessions. We believe it was reasonable to include those studies because it seemed very unlikely for us that groups had < 3 113

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their attitudes toward group therapies by further supporting the efficacy of group treatment protocols, and, at the same time, could help researchers to further address the complexities with group facilitation which are usually under-examined in RCTs with this difficult-to-treat patient population.

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