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Psychological treatment for methamphetamine use and associated psychiatric symptom outcomes: A systematic review
Journal Pre-proof Psychological treatment for methamphetamine use and associated psychiatric symptom outcomes: A systematic review
Alexandra M. Stuart, Amanda L. Baker, Alexandra M.J. Denham, Nicole K. Lee, Alix Hall, Chris Oldmeadow, Adrian Dunlop, Jenny Bowman, Kristen McCarter PII:
S0740-5472(19)30259-4
DOI:
https://doi.org/10.1016/j.jsat.2019.09.005
Reference:
SAT 7934
To appear in:
Journal of Substance Abuse Treatment
Received date:
30 April 2019
Revised date:
2 August 2019
Accepted date:
9 September 2019
Please cite this article as: A.M. Stuart, A.L. Baker, A.M.J. Denham, et al., Psychological treatment for methamphetamine use and associated psychiatric symptom outcomes: A systematic review, Journal of Substance Abuse Treatment(2019), https://doi.org/10.1016/ j.jsat.2019.09.005
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© 2019 Published by Elsevier.
Journal Pre-proof PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE Psychological treatment for methamphetamine use and associated psychiatric symptom outcomes: A systematic review
Revised 27 July 2019 Alexandra M. Stuart1, Amanda L. Baker2, Alexandra M. J. Denham2, Nicole K. Lee3, Alix Hall4, Chris Oldmeadow4, Adrian Dunlop2, Jenny Bowman1, Kristen McCarter2
School of Psychology, Faculty of Science, University of Newcastle, University Drive,
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Callaghan, NSW, 2308 2
School of Medicine and Public Health, Faculty of Health and Medicine, University of
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Newcastle, PO BOX 833, Newcastle, New South Wales 2300, Australia Faculty of Health Sciences, Curtin University, Bentley, Western Australia 6102 Australia
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Hunter Medical Research Institute and Faculty of Health and Medicine, University of
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Newcastle, LOT 1 Kookaburra Circuit, New Lambton Heights, New South Wales 2305,
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Australia
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Word count: 6330
PO Box 833
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Corresponding Author: Dr Kristen McCarter
Newcastle, NSW 2300 Australia
Email: [email protected] Phone: +61 2 4033 5721 Fax: +61 2 4033 5692 Declarations of interest: none. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Abstract Background: Regular methamphetamine use is associated with increased rates of psychiatric symptoms. Although there has been a substantial body of research reporting on the effectiveness of psychological treatments for reducing methamphetamine use, there is a paucity of research examining the effects of these treatments on co-occurring psychiatric symptoms. We addressed this gap by undertaking a systematic review of the evidence of the effectiveness of psychological treatments for methamphetamine use on psychiatric symptom outcomes in randomized controlled
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trials. Methods: A narrative synthesis of studies was conducted following the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement to inform methodology. Eight electronic peer-reviewed
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databases were searched. Ten eligible studies were assessed.
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Results: Most studies found an overall reduction in levels of methamphetamine use and psychiatric
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symptoms among samples as a whole. Although brief interventions were effective, there is evidence that more intensive interventions have greater impact on methamphetamine use and/or psychiatric
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symptomatology. Intervention attendance was variable.
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Conclusions: The evidence suggests that a variety of psychological treatments are effective in reducing levels of methamphetamine use and improving psychiatric symptoms. Future research
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should consider how psychological treatments could maximize outcomes in the co-occurring domains of methamphetamine use and psychiatric symptoms, with increasing treatment attendance as a focus.
PROSPERO registration number: CRD42016043657 Key words: methamphetamine, psychological, treatment, intervention, systematic review, psychiatric symptomsIntroduction In recent years methamphetamine use has become a major global health concern with an estimated 35 million past year users worldwide in 2015 (United Nations Office on Drugs and Crime, 2017). Although use of methamphetamine has decreased in some countries, including
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Australia, harms associated with methamphetamine use continue to increase, partly driven by increases in purity and a change in preference from the powdered form to the high purity crystalline form (Scott, Caulkins, Ritter, Quinn, & Dietze, 2015; Australian Institute of Health and Welfare [AIHW], 2017). In Australia, frequency of use of crystalline methamphetamine has increased significantly (AIHW, 2017), with an associated rise in levels of dependence (Degenhardt et al., 2016). Hospitalizations, ambulance attendances, overdose and deaths related to methamphetamine use have all increased as a consequence (NSW Ministry of Health, 2015; Sindicich, Stafford, &
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Breen, 2016; AIHW, 2017). Methamphetamine associated deaths have doubled in Australia between 2009 and 2015 due to an increase in heart disease and stroke, with 1649 deaths in that period, 43% due to drug toxicity (Darke, Kaye, & Duflou, 2017).
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Regular methamphetamine use can be associated with a range of psychiatric symptoms,
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particularly psychosis, anxiety, and depression (Akindipe, Wilson, & Stein, 2014; McKetin,
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Lubman, Lee, Ross, & Slade, 2011; McKetin et al., 2016). It is more likely to induce psychotic symptoms than other illicit drugs and exhibits a higher dependence liability than other
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psychostimulants (Darke, Kaye, McKetin, & Duflou, 2008; Glasner-Edwards et al., 2008).
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Although vulnerability to psychotic symptoms varies among people who use methamphetamine, these symptoms are more apparent in people who use methamphetamine on a regular basis (Darke
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et al., 2008). In Australia, hospitalizations due to psychosis tripled in the years between 2009 and 2013, especially in the age groups with the highest rate of methamphetamine use (AIHW, 2017). Psychiatric symptoms, including psychosis, anxiety and depression, affect response to methamphetamine treatment (Glasner-Edwards et al., 2008; Glasner-Edwards et al., 2010b; KayLambkin, Baker, McKetin, & Lee, 2010; Newton, De La Garza, Kalechstein, Tziortzis, & Jacobsen, 2009; Rose & Grant, 2008). For example, people who experience depressive symptoms and who use methamphetamine have a poorer prognosis for both conditions (Darke, Kaye, Duflou, & Lappin, 2019; McKetin et al., 2011). Depressive symptoms may also contribute to more frequent use of methamphetamine through negative reinforcement, consequently impacting on treatment outcomes (Glasner-Edwards et al., 2010b; Newton et al., 2009). Additionally, the high rates of
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depression are associated with increased risk of suicidal ideation and attempted suicide (Darke et al., 2008; McKetin et al., 2011). Psychotic symptoms associated with methamphetamine use can produce symptoms almost indistinguishable from schizophrenia and the lack of a validated symptom profile for methamphetamine-induced psychiatric symptoms can be associated with suboptimal care of underlying psychiatric disorders. (McKetin et al., 2016). No pharmacotherapy has been found to be broadly effective for the treatment of methamphetamine use (Lee, Jenner, Harney, & Cameron, 2018). Similarly, there is no evidence to
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suggest that drug treatments can reduce psychological distress or symptomatology associated with methamphetamine use (Anderson et al., 2015; Brensilver, Heinzerling, & Shoptaw, 2013; Ciketic, Hayatbakhsh, Doran, Najman, & McKetin, 2011; Darke & Farrell, 2016; Elkashef et al., 2008;
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Karila et al., 2010; Lile, Stoops, Glaser, Hays, & Rush, 2011; Rose & Grant, 2008). The current
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evidence suggests treating methamphetamine-related psychiatric symptoms in line with guidelines
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for similar disorders that are not drug induced (Hellem, Lundberg, & Renshaw, 2015; Kay-Lambkin et al., 2010). For example, a review of the limited research into the pharmacological treatment of
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methamphetamine-related psychosis reported that antipsychotic medications reduced symptoms of
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methamphetamine psychosis (Knapp, 2007; Shoptaw, Kao, & Ling, 2009). Psychological therapy for methamphetamine dependence continues to be the first line
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treatment option (Colfax et al., 2010; Hellem et al., 2015; Suvanchot, Somrongthong, & Phukhao, 2012) and is effective in reducing methamphetamine use (Degenhardt et al., 2008; Drake, O'Neal, & Wallach, 2008; Karila et al., 2010; Manning et al., 2017; Rawson et al., 2004; Wisdom, Manuel, & Drake, 2011). However, less is known about psychiatric symptom outcomes from these treatments or which psychological interventions are effective for reducing both methamphetamine use and psychiatric symptoms (Barrowclough et al., 2009; Rawson et al., 2004; Wisdom et al., 2011). Although a number of reviews of psychological treatment for methamphetamine use have been conducted (Ciketic et al., 2011; Cohen, Huguet, Cohen, Vera, & Dardennes, 2017; Lee & Rawson, 2008; Rose & Grant, 2008; Shoptaw et al., 2009), none have examined the effects of
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psychological interventions for methamphetamine use and psychiatric symptoms. One recent review by Hellem et al. (2015) examined integrated treatment for methamphetamine and cooccurring symptoms of depression and found a reduction in methamphetamine use but not psychiatric symptoms. The question remains whether methamphetamine specific psychological interventions can impact on psychiatric symptoms. As psychiatric symptoms are increasingly common and increasing in severity among people who use methamphetamine, there is a need for research on the effectiveness of psychological interventions for methamphetamine use and co-
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occurring psychiatric symptomatology. Clinically, this is important in the alcohol and other drug sector where practitioners are specialists in alcohol and other drug treatment but may not have mental health training.
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The present systematic review will determine and summarize the characteristics,
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methodological quality and effectiveness of studies whilst examining the effectiveness of
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psychological interventions for methamphetamine use. We also report on intervention outcomes for co-occurring psychiatric symptoms or disorders. Secondary outcomes related to methamphetamine
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2. Material and methods
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and psychiatric symptom outcomes will also be summarized (where reported, specified below).
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A systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (Moher, Liberati, Tetzlaff, Altman, & PRISMA Group, 2010). The methodology is described in detail in Stuart et al. (2017) and the protocol is registered with PROSPERO (registration number CRD42016043657). 2.1 Information sources A systematic search using PsycINFO, Medline, EMBASE, CINAHL and Scopus was conducted for eligible studies up until November 2018. Registration databases were also searched, including the Cochrane Central Register of Clinical Trials, US Government Website of Clinical Trials and WHO International Clinical Trials Registry. 2.2 Search strategy
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Search terms (see supplementary file S1) were developed from existing reviews of psychological interventions (Anderson et al., 2015; Colfax et al., 2010; Hellem et al., 2015; Lile et al., 2011). Publications were limited to human studies, were available in English, and no limits were placed on publication year. Reference lists of included articles and systematic reviews were also searched manually to find further papers. 2.3 Study selection Studies were included if they tested a psychological intervention and measured the following
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outcomes: i) methamphetamine use and (ii) psychiatric symptoms and/or disorders at baseline and post-treatment. Participants included were adults (over 18), using methamphetamine alone or in
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combination with other substances (poly-drug use). Interventions could be delivered in any setting
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including inpatient units (drug and alcohol rehabilitation or hospital settings), community or prison settings. Psychological interventions included one or more psychological strategies (such as
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cognitive or behavioral strategies) designed to modify methamphetamine use. Only randomized
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controlled trials were eligible. Interventions were compared with active controls (e.g. other psychological interventions), treatment as usual (TAU) or minimal care control conditions (e.g.
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self-help booklets). Interventions were of any duration, delivery, frequency and intensity. Primary
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outcomes were: i) any outcome measure reporting change (reduction/increase) between baseline and follow-up assessment occasion/s in methamphetamine use or abstinence from methamphetamine use; and ii) any outcome measure reporting change between baseline and followup occasion/s (reduction/increase) in psychiatric symptoms or diagnoses. Secondary outcomes of interest were treatment engagement and changes from baseline to follow-up in other drug use, blood-borne virus (BBV) risk-taking behavior, physical health, quality of life using validated measures and global or social levels of functioning. Outcomes reflected any time frame (e.g. shortterm, long-term) and were rated by clients or clinicians, in the form of an assessment by objective or subjective measures. Studies were excluded if they met any of the following criteria: a) were not peer reviewed journal articles; b) did not use a controlled design; c) did not include a psychological intervention;
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d) did not include relevant behavior change outcome measures associated with methamphetamine use and psychiatric outcomes; or e) were case control, cross-over trials, one-arm trials, nonrandomized trials, cross sectional studies or cohort studies. 2.4 Data extraction The Cochrane Handbook for Systematic Reviews (Higgins & Green, 2011) was used to guide data extraction. A data extraction form was developed to organise information. Extraction forms were pre-tested in 10% of the identified articles to ensure functionality. AMS and AMJD
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independently assessed the full-text of the relevant articles. Discrepancies were resolved via discussion and consensus. Data extracted included participant information, methods of each study,
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type of intervention, primary and secondary outcomes and associated results of studies.
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2.5 Risk of bias
The Cochrane Collaboration’s Risk of Bias tool was used to measure risk of bias (Higgins &
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2.6 Grading the strength of evidence
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Green, 2011) with items judged as ‘low’, ‘high’ or ‘unclear’ risk.
The overall quality of evidence of primary outcomes was assessed using the Grades of
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Recommendation, Assessment, Development and Evaluation (GRADE) approach (Higgins &
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Green, 2011), at four levels: ‘very low’, ‘low’, ‘moderate’ and ‘high’. This involved contemplation of directness of evidence, risk of bias, heterogeneity and risk of publication bias. Quality ratings were performed independently by AMS and AMJD, with discrepancies resolved by consensus. 2.7 Data synthesis Due to the low number of included studies and heterogeneity in the outcome measures and data reported, meta-analysis was not possible. A narrative approach to data synthesis was therefore adopted.
3. Results 3.1 Search results and study selection
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The database search returned 1688 results (Figure 1), providing 1142 unique citations after duplicates were removed. A further 1070 studies were excluded at the title-abstract stage. For the remaining 72, the full paper was screened. Of these, 10 studies from 14 manuscripts were included in the review (Baker et al., 2001a, 2001b; Baker et al., 2006; Baker, Bucci, Lewin, Richmond, & Carr, 2005; Baker et al., 2004; Baker, Lee, et al., 2005; Baker et al., 2002a, 2002b; McDonell et al., 2013; Peck, Reback, Yang, Rotheram-Fuller, & Shoptaw, 2005; Polcin et al., 2014; Rawson et al., 2004; Rawson et al., 2006; Smout et al., 2010) .
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3.2 Study characteristics Table 1 summarizes characteristics of the 10 randomized controlled trials included in the
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review. Five studies were conducted in Australia (Baker et al., 2001a, 2001b; Baker et al., 2006;
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Baker, Bucci, et al., 2005; Baker et al., 2004; Baker, Lee, et al., 2005; Baker et al., 2002a, 2002b; Smout et al., 2010) and five in the United States of America (USA) (McDonell et al., 2013; Peck et
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al., 2005; Polcin et al., 2014; Rawson et al., 2004; Rawson et al., 2006). The studies were published
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between 2001 and 2014 and reported on samples ranging in size from 64 to 978 participants. Key inclusion criteria varied, with some samples being: i) users of methamphetamine; ii) users of
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psychostimulants (a sub-sample of whom used methamphetamine); or iii) diagnosed with severe
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mental illness (a sub-sample of whom used methamphetamine). Of the 10 randomized controlled trials, six were conducted among entire samples using methamphetamine (Baker et al., 2001a, 2001b; Baker et al., 2004; Baker, Lee, et al., 2005; Peck et al., 2005; Polcin et al., 2014; Rawson et al., 2004; Smout et al., 2010). One study among people using various psychostimulants included a sub-sample of people using methamphetamine (around 10%; 17/171) (Rawson et al., 2006). Three trials recruited people with severe mental illness, reporting on sub-samples using methamphetamine (Baker et al., 2006; Baker, Bucci et al., 2005; Baker et al., 2002a, 2002b; McDonell et al., 2013). See Table 1 for details. Measures used in studies to assess methamphetamine consumption and psychiatric symptomatology are listed in Table 1. Self-report instruments employed to assess methamphetamine use were as follows: the Drug Use Scale of the Opiate Treatment Index (OTI;
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Darke, Hall, Heather, Wodak, & Ward, 1992) (used in four studies (Baker et al., 2001a, 2001b; 2002a, 2002b; Baker, Bucci et al., 2005; 2006; Baker, Lee et al., 2004, 2005), the Addiction Severity Index (ASI) (McLellan, Luborsky, Woody, & O'Brien, 1980) or ASI-Lite (used in five studies (McDonell et al, 2013; Peck et al, 2005; Polcin et al, 2014; Rawson et al, 2004; Rawson et al, 2006) and a specially devised semi-structured interview (Smout et al, 2010). Biochemical verification of self-reported methamphetamine use / abstinence was conducted in seven studies (Baker, Lee et al., 2004, 2005; McDonell et al 2013; Peck et al, 2005; Polcin et al, 2014; Rawson et
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al, 2004; Rawson et al 2006; Smout et al 2010). Of these studies, six used urinalyses and one (Smout et al, 2010) used hair analyses. Self-report measures of psychiatric symptomatology included more general measures of psychiatric distress such as the General Health Questionnaire
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(GHQ) (Goldberg & Hillier, 1979) (used by Baker et al., 2001a, 2001b); the Brief Symptom
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Inventory (BSI; Derogatis & Melisaratos, 1983) (used in three studies, Baker et al, 2002a, 2002b;
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Baker et al., 2004; Baker, Lee et al, 2005; McDonell et al 2013), the ASI psychiatric status score (McLellan et al., 1980) (used in four studies, McDonell et al, 2013; Polcin et al, 2014; Rawson et
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al., 2004, 2005) and the Short-Form 12 (SF12; Ware, Kosinski, & Keller, 1996) (used in Smout et
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al, 2010). Level of depression was assessed by the Beck Depression Inventory I (BDI-I; Beck, 1967) in two studies (Peck et al., 2013; Rawson et al., 2006) and the Beck Depression Inventory II
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(BDI-II; Beck, Steer, & Brown, 1996) in three studies (Baker et al., 2004; Baker, Lee et al., 2005; Baker et al., 2006; Baker, Bucci et al., 2005; Smout et al., 2010). Psychotic symptomatology was assessed in two studies conducted among people diagnosed with severe mental illness via the Brief Psychiatric Rating Scale (BPRS; Ventura et al., 1993) (Baker et al, 2006; Baker, Bucci et al., 2005) and the Positive and Negative Syndrome Scale (PANSS; Kay, Fiszbein, & Opler, 1987) (McDonell et al., 2013). As seen in Table 1, some studies used multiple self-report instruments to assess psychiatric symptomatology. As shown in Table 1, participants were predominantly male, with mean ages ranging from 28 to 43 years. Intervention lengths ranged from between one session to 12 sessions (over four months). Studies were single and/or multicentre, and participants were recruited from inpatient and
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outpatient alcohol and other drug services and community mental health centres. Interventions assessed outcomes at pre-treatment, post-treatment and follow-up. The follow-up periods varied from one month to 12-months post-intervention. Psychological interventions were delivered by therapists, psychologists and social workers.
3.3 Primary Outcomes: Methamphetamine use and psychiatric outcomes A summary of treatment outcomes, including effect sizes, increases in abstinence and
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changes in diagnostic status, where reported, can be found in Table 2. Studies are described below, according to whether samples were comprised entirely of users of methamphetamine, users of
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psychostimulants more broadly, or whether participants were diagnosed with a severe mental
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illness.
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3.3.1 Studies reporting outcomes among entire samples of people using methamphetamine Baker and colleagues have reported two randomized controlled trials (Baker et al., 2001a,
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2001b; Baker et al., 2004; Baker, Lee, et al., 2005) evaluating combined motivational interviewing
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(MI) and cognitive behavior therapy (CBT) among users of methamphetamine, guided by a treatment manual (Baker, Kay-Lambkin, Lee, Claire, & Jenner, 2003) describing two and four
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session interventions. The two session intervention consisted of an initial session focused mainly on MI and a second session focused on avoidance of high risk situations. The four session condition added a third session covering coping with cravings and a fourth on relapse prevention. A feasibility trial (Baker et al., 2001a, 2001b), aimed to: determine whether regular users of methamphetamine would attend an intervention as lengthy as four sessions; pilot the interventions; and compare outcomes of the combined intervention conditions (n=32) at six-month follow-up with those of the control condition (a self-help booklet, n=32). The interventions appeared feasible (68.8% of participants assigned to the two-session condition attended both sessions and 56.3% attended three or four sessions) and 81.3% were successfully followed up. Methamphetamine use was measured solely by self-report using the OTI (Darke et al., 1992), which provides scores on
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average use occasions per day in the month proceeding interview (see Table 2 for change scores). Outcomes were promising: the sample as a whole reported a significant reduction in methamphetamine use (by 0.44 effect size units in control vs 1.02 in the intervention group, a moderate difference in effect size). Significantly more participants in the intervention conditions reported abstinence from methamphetamine at six months, largely due to differences between the control and four-session condition (85.7% compared to 21.4%). There were no significant changes over time or between groups in psychiatric symptomatology, as measured by the GHQ-28
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(Goldberg & Hillier, 1979). Given the high feasibility and promising results of the above study, Baker and colleagues (Baker et al., 2004; Baker, Lee, et al., 2005) conducted a larger randomized controlled trial (N=214)
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comparing a self-help booklet with two- or four- sessions of MI plus CBT guided by the treatment
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manual (Baker et al., 2003). As seen in Table 2, similar to the pilot study above, according to the
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OTI self-report measure, there was an overall significant reduction in methamphetamine use. At six months mean daily occasions of methamphetamine use fell 0.76 units among the control condition
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vs 1.04 units among the four-session condition, a small effect size difference. However, the
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likelihood of abstinence from methamphetamine was significantly increased among the intervention conditions, as those who attended two or more sessions had higher rates of abstinence (40.8%),
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compared to the control condition (17.6%). Urinalysis results confirmed self-reported abstinence. Psychiatric distress also fell significantly overall, as measured by the BSI (Derogatis & Melisaratos, 1983) as did level of depression measured by the BDI-II (Beck et al., 1996). However, there was a significant short-term beneficial effect of intervention on depression, with more sessions associated with greater improvement. Over two-thirds of the sample scored in the moderately to severely depressed range at pre-treatment (i.e. BDI-II scores of 20 or above), compared with less than half at post-treatment and at the six month follow-up (see Table 2 for details). A further study adapting the MI and CBT manual developed by Baker et al. (2003) was conducted by a group independent of the manual’s developers. In this study, Smout et al. (2010) compared 12 sessions of Acceptance and Commitment Therapy (ACT) with 12 MI plus CBT
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sessions. A median of three weekly sessions of a possible 12 was attended by participants. Both conditions were associated with significant self-reported reductions in methamphetamine use, dependence and negative consequences as well as level of depression on the BDI-II (Beck et al., 1996) (see Table 2 for details). However, at six-months post-treatment, there was only a significant increase in the proportion of methamphetamine-free hair samples in the MI plus CBT (63.6%) compared to the ACT condition (50%). Furthermore, although there generally were no significant within group changes between 12 and 24 weeks, there was a significant further reduction in the
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negative consequences of methamphetamine use for the MI plus CBT condition. The three remaining trials conducted among entire samples of users of methamphetamine (Rawson et al., 2004; Peck et al., 2005; Polcin et al., 2014) were conducted in the USA (see Table 2
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for details). All reported significant improvements in self-reported methamphetamine use. As in the
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Baker, Lee et al. (2005) study above, two of the studies comparing more intensive treatment with
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less intensive treatment (Rawson et al., 2004; Polcin et al., 2014), found a significant benefit for the
psychiatric symptomatology).
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more intensive condition in one or more primary domains of interest (methamphetamine use or
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In the largest trial to date, Rawson et al. (2004), reported on the use of the manualized Matrix Model treatment among 978 outpatients dependent on methamphetamine. As described in
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Table 1, the Matrix Model treatment was a multi-component treatment adopting elements of CBT, MI, family and group therapy. It was delivered over 36 weeks and compared to TAU. The latter varied across sites and varied from one to 13 hours of contact per week. Matrix Model participants were significantly more likely to be retained in treatment and were more likely to complete treatment. As described in Table 2, all conditions improved in both self-reported and urine-verified methamphetamine use severity and the psychiatric domains of the ASI (McLellan et al., 1980). There was a potentially clinically important short-term in-treatment increase in urine-verified methamphetamine abstinence of the Matrix Model treatment compared to TAU. During treatment, Matrix participants, compared to TAU, were 31% more likely to have MA-free urine test results (odds ratio = 1.311). However, this improvement did not persist at discharge or six-month follow-
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up. Similar short-term benefits were found in the Rawson et al. (2006) study, with details described in Table 2. Less than 10% of this sample of people using psychostimulants were using methamphetamine, so the results are not considered in further detail here. During treatment, the mean number of stimulant free urines for contingency management (CM) alone or combined with CBT treatment conditions was significantly higher than for CBT only, but during the follow-up period, all three groups had between 67% and 79% stimulant-free samples across all time-points. For psychiatric symptoms, Rawson et al. (2006) found that CM participants also had significantly
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lower psychiatric scores at week 17 than other conditions. Polcin et al. (2014) found both an intensive nine-session MI intervention and a single session motivational interview control (plus eight nutrition sessions) delivered alongside standard
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outpatient group CBT were associated with significant reductions in self-reported
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methamphetamine use and biochemically verified abstinence over six-months (see Table 2). A
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significant reduction in the number of days experiencing depression in a 30-day period for the intensive MI intervention group was found (adjusted effect size -.67). As seen in Table 2,
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attendance was high in both conditions. However, as shown in Table 2, the intensive MI condition
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had higher psychiatric symptom severity scores at baseline and showed significant reductions in
condition did not.
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ASI – Lite (McLellan et al., 1980) severity and days of psychiatric problems whereas the single MI
In the remaining trial conducted among an entire sample of methamphetamine users, Peck et al. (2005) compared four types of intervention; (i) thrice weekly Matrix Model CBT groups; (ii) CM, with vouchers of increasing value for urine samples (collected thrice weekly) showing continuous abstinence from methamphetamine; (iii) a combination of the first two conditions; and (iv) and a Gay-Specific version of the condition. As seen in Table 2, there were significant and sustained reductions in methamphetamine use. There was a general sustained reduction in depression, with the greatest reduction occurring in the month between baseline (M = 14.3) and 4 weeks (M = 6.8). The authors suggested the specific type of behavioral or CBT may be of little consequence over the longer term and that a structured treatment program may be the key to
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successful treatment. Aside from being a gay sample, this sample represented only those who completed a two-week baseline period of assessments before being admitted into the study. As described in Table 2, three studies reported on samples of people with severe mental illness (Baker et al., 2002a, 2002b; Baker et al., 2006; Baker, Bucci et al., 2005; McDonell et al., 2013) with 16.8% (Baker et al., 2002a, 2002b) to 38.5% (McDonell et al., 2013) using methamphetamine. In the Baker et al. (2002a, 2002b) study, inpatients were assigned to either MI or a self-help booklet control, with both conditions showing reductions in OTI methamphetamine
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use scores at 12-month follow-up, such that baseline intervention threshold criteria were no longer met by half of the group follow-up. There was a significant reduction in psychiatric symptomatology over time, with a standardized change in effect size of 0.56, as measured by the
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global severity index of the BSI (Derogatis & Melisaratos, 1983).
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The two studies conducted among people with severe mental illness living in the community
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(Baker et al., 2006; Baker, Bucci et al., 2005; McDonell et al., 2013) showed benefits of MI and CBT. Compared to TAU, Baker, Bucci et al. (2005, 2006) found 10 sessions of MI and CBT were
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associated with a large reduction in self-reported methamphetamine use. Also among those meeting
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methamphetamine use criteria at baseline, the sub-sample assigned to the MI and CBT condition was associated with benefits in terms of lower depression scores (medium effect size) and
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significantly better global functioning, largely due to a deterioration in the control condition.. McDonell et al. (2013) reported TAU plus contingent reinforcement for urine verified stimulant abstinence versus TAU plus reinforcement (for study participation only) was associated with more stimulant free urines during treatment, (see Table 2 for details) and lower levels of psychiatric symptoms on the BSI (Derogatis & Melisaratos, 1983) and PANSS (excitement subscale; Kay et al., 1987) during treatment but not follow-up. During the six months following randomization, compared to the TAU condition (10%), significantly fewer participants receiving contingent reinforcement (2%) were admitted for inpatient psychiatric care. 3.4 Secondary Outcomes
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Table 2 details secondary outcomes, where reported, in each study. There was substantial variability in secondary outcomes reported, with some data on each secondary outcome except for overall quality of life, which was not reported in any study. As seen in Table 2, all 10 studies provided data regarding treatment and follow-up attendance. Overall, studies showed that people using methamphetamine, including those with coexisting psychiatric symptoms or disorders, can be retained in treatment and followed up over 12months. Evidence from three Australian studies showed that when offered, participants were likely
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to complete a brief intervention and attend two-four sessions on average (Baker et al., 2001a, 2001b; Baker et al., 2006; Baker et al., 2004; Baker, Bucci et al., 2005; Baker et al., 2004; Baker, Lee, et al., 2005; Smout et al., 2010), even when more sessions were available. Studies from the
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USA showed much longer treatments were also feasible. Two studies found that more complex
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interventions, such as the Matrix Model compared with TAU or CBT combined with CM compared
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with either treatment alone, produced better treatment attendance (Peck et al., 2005, Rawson et al., 2004). No significant differences were found in attendance for intensive motivational interventions
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compared to TAU (Baker et al., 2004; Baker, Lee, et al., 2005; Polcin et al., 2014). Follow-up
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attendance varied largely across studies, for example, between 19.6% for ACT at six-months (Smout et al., 2010) to 96.9% for TAU at six-months (Baker et al., 2004; Baker, Lee, et al., 2005).
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Seven studies reported reductions in other drug use among samples as a whole (Baker et al., 2001a, 2001b; Baker et al., 2004 ; Baker, Lee, et al., 2005; Baker et al., 2006; Baker, Bucci et al., 2005, Baker et al., 2002a, 2002b; McDonell et al., 2013; Rawson et al., 2004, 2006). The exception was the Smout study (2010) which reported a significant within group reduction among the CBT group but not the ACT group between baseline and 12 weeks. In terms of BBV risk-taking behavior, three studies (Baker et al., 2001a, 2001b; Baker et al., 2004; Baker, Lee, et al., 2005; McDonell et al., 2013) reported changes in BBV risk reduction and associated risk behavior. Two studies reported significant reductions for the sample as a whole in injecting-risk taking behavior from pre to post-treatment (Baker et al., 2004; Baker, Lee, et al., 2005; McDonell et al., 2013). Conversely, Baker et al. (2001a, 2001b) found no significant change
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in levels of injecting risk-taking behavior across CBT and control conditions in their pilot trial but the control condition reported significantly higher risk-taking behavior. Four studies reported on physical health outcomes. Two reported that health scores improved over time for samples as a whole (Baker et al., 2001a, 2001b; Smout et al., 2010) and two reported no change over time in physical health nor between conditions (Rawson et al., 2004, 2006). Six studies (Baker et al., 2001a, 2001b; Baker et al., 2006; Baker, Bucci et al., 2005; Baker
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et al., 2004; Baker, Lee, et al., 2005; Baker et al., 2002a, 2002b; Rawson et al., 2004, 2006) reported on participants’ levels of functioning (global, social or family). Most reported improvements over samples as a whole with no differences between conditions (Baker et al., 2002a,
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2002b; Rawson et al., 2004, 2006), with no change in functioning reported in one study (Baker et
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al., 2001a, 2001b). Baker, Bucci et al. (2005, 2006) found a small but significant improvement in
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global functioning among people with severe mental illness following CBT compared to
Quality of the Evidence
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participants in the TAU condition, whose functioning deteriorated over the 12-month follow-up.
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Using the Cochrane Collaboration’s Risk of Bias tool (supplementary file S2), most information came from studies with low or unclear risk of bias across domains. The results should
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be interpreted with the unclear risk of bias across studies in mind. The domains with most unclear ratings across studies (blinding of participants and researchers and blinding of outcome assessment) should be considered, given that blinding for the primary outcomes (methamphetamine use and mental health) may be critical for objective measurement. The proportion of high risk of bias ratings for allocation concealment was not considered sufficient to seriously affect the interpretation of results. High risk of bias ratings across some studies for incomplete outcome data were considered relatively minor inadequacies as outcome data for primary outcomes was reported well across studies.
Using GRADE (Higgins & Green, 2011), it is evident that the quality of the primary research evidence on which the review is based is relatively low in terms of homogeneity (with evidence of
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substantial heterogeneity, inconsistent comparison groups and outcomes). The level of evidence for primary outcomes was as follows: moderate for methamphetamine use, low for abstinence, and for mental health measures it was moderate for ASI (McLellan et al., 1980) and BSI (Derogatis & Melisaratos, 1983), and low for BDI I (Beck, 1967), II (Beck et al., 1996). (The quality of the primary research evidence is relatively moderate in terms of conduct and reporting. Outcomes were downgraded due to multiple concerns including small participant numbers, gender bias and inconsistency in reporting. Furthermore, studies were based on high income countries such as
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Australia and the USA. Numerous studies excluded participants with a psychiatric diagnosis, even though comorbidity is common among people who use methamphetamine (Darke et al., 2008; Glasner-Edwards et al., 2010a; Suvanchot et al., 2012).
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4. Discussion
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There were consistent findings in five large controlled trials among samples comprised
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entirely of people using methamphetamine (i.e. those that were not feasibility trials) (Baker et al., 2004; Baker, Lee, et al., 2005; Peck et al., 2005; Polcin et al., 2014; Rawson et al., 2004; Smout et
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al., 2010). Significant and clinically important decreases in methamphetamine use and psychiatric
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symptoms occurred across all conditions. Even minimal control conditions involving assessment and self-help booklets were associated with significant reductions in methamphetamine use.
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However, when comparing a more intensive intervention with either a less intensive or minimal intervention comparison condition, three randomized controlled trials (Baker et al., 2004; Baker, Lee, et al., 2005; Polcin et al., 2014; Rawson et al., 2004) reported significant benefits over the comparison condition on methamphetamine abstinence or psychiatric symptoms, providing evidence that more intensive rather than less intensive psychological treatment may be beneficial. There was fairly consistent evidence for the efficacy of interventions for improving drug use in addition to methamphetamine use, levels of social functioning and BBV risk-taking, perhaps indicating generalization of treatment effects. However, there was inconsistent evidence of the benefit of treatment on physical health, with two studies from the USA not reporting such
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improvement. It is possible that access to health care differs between countries and may impact on physical health status following treatment for methamphetamine use. Three of the five randomized controlled trials among methamphetamine users reported significantly better outcomes for specific psychological treatments in increasing rates of abstinence. Rawson et al. (2004) reported that the Matrix Model was more effective during treatment in increasing abstinence from methamphetamine compared to TAU. Baker, Lee, et al. (2004, 2005) reported that 2-4 sessions of MI and CBT doubled abstinence over a minimal care
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control condition. Smout et al. (2010), using hair analysis, found MI plus CBT to be more effective in improving abstinence compared to ACT and the CBT participants reported fewer negative consequences of methamphetamine use at follow up.
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Overall, studies suggest that MI and CBT are feasible and effective among people who use
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methamphetamine regularly (Baker et al., 2001a, 2001b; Baker et al., 2006; Baker et al., 2004;
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Baker, Lee, et al., 2005; Smout et al., 2010). ACT has some preliminary evidence showing it is feasible, although biochemically verified evidence of methamphetamine use reduction needs
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strengthening in further studies. Attendance in ACT and MI plus CBT interventions averaged
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around three sessions even when up to 12 were offered (Smout et al. 2010). Attending a greater number of sessions (specifically four versus two sessions of MI and CBT), was associated with
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greater improvements in depression in the short-term (Baker et al., 2004; Baker, Lee, et al., 2005). All three of the studies examining MI plus CBT were conducted in Australia. The efficacy of ACT, MI and CBT delivered as relatively brief interventions requires replication elsewhere to determine generalizability of these results in countries with different health care systems. Of note is the subset of studies that examined samples among people with severe mental illness. Evidence presented here (Baker et al., 2002a, 2002b) suggests that admission to a psychiatric hospital is associated with a reduction in methamphetamine use that is sustained at follow-up. For people with severe mental illness using methamphetamine in the community, there is evidence that 10 sessions of MI and CBT versus TAU is effective (Baker, Bucci et al., 2005, Baker et al., 2006) and contingent rewards for methamphetamine free urines may be associated with
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reductions in use and hospitalization (McDonell et al., 2013). Given the rise in hospital admissions due to methamphetamine use (NSW Ministry of Health, 2015; AIHW, 2017) there is an urgent need to further investigate the effectiveness of psychological interventions in the community and their role in reducing hospitalization. Contingency management, a component of the Matrix Model study described here (Rawson et al., 2004) and one of the comparator conditions in the Peck et al. (2005) study, may be worthy of further research in contexts outside of the USA. Peck et al. (2005) noted that it was as effective as
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more complex and intensive interventions (CBT plus CM) and that any structured therapy may be effective. Contingency management may be a useful intervention to encourage session attendance across a range of intervention types and is worthy of further research in this regard. In addition,
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considering the effectiveness of relatively brief MI and CBT for abstinence from
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methamphetamine, the CBT based mutual aid groups, SMART Recovery (Beck et al., 2016), or
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other mutual aid programs that incorporate elements of CBT are also worthy of further research.
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4.1 Limitations
Not all studies provided biochemical verification of self-reported measures of
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methamphetamine. Of the seven studies (Baker et al., 2004, Baker, Lee et al., 2005; McDonell et
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al., 2013; Peck et al., 2005; Polcin et al., 2014; Rawson et al., 2004; Rawson et al., 2006; Smout et al., 2010) using biochemical measures, the six studies using urine samples reported results consistent with self-reported methamphetamine use. Only the Smout et al. (2010) study, which used hair analysis, reported a discrepancy, with hair samples but not self-reported methamphetamine use favouring CBT over ACT. There was a relatively small number of randomized controlled trials examining methamphetamine and psychiatric outcomes, specifically psychosis. There was substantial variability between all studies in terms of the experimental and control conditions used, duration of treatment received, outcomes assessed, and measures used. Thus, a meta-analysis was not possible. Although there are too few studies to recommend specific outcome assessment instruments, this review has shown that self-reported methamphetamine use largely accords with biochemically
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verified measures. Measures of depression showed overall and group differences (e.g., Baker, Bucci et al., 2005, Baker et al., 2006; Polcin et al., 2014). Measures of psychosis such as the BPRS (Ventura et al., 1993) and its mania sub-scale (as reported by Baker et al., 2006) and the excitement sub-scale of the PANSS (Kay et al., 1987) (McDonell et al., 2013) were shown to distinguish between groups. Only Polcin et al. (2014) specifically reported on anxiety symptoms. Given that the comorbidity of anxiety disorders and methamphetamine use can influence treatment outcomes
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(Glasner-Edwards et al., 2010a), studies reporting on anxiety outcomes and investigating treatment options for this comorbidity are warranted. There were no eligible studies employing potentially helpful therapies such as Dialectical Behavior Therapy, Schema Therapy or Mindfulness-Based
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larger sample sizes to increase generalizability.
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CBT, representing a gap in the literature. Finally, future well-designed studies would benefit from
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5. Conclusions
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There is evidence that a variety of psychological treatments are effective for methamphetamine use, with accumulating evidence that more intensive treatment is more effective
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than minimal or less intensive comparison conditions in reducing methamphetamine use and
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improving psychiatric symptoms. Randomized controlled trials show psychological interventions reduce methamphetamine use and co-occurring psychiatric symptoms (psychotic symptoms and depression) compared to control conditions, during treatment and, in some studies, at follow-up. Given that treatment completion is at least as important as length of treatment, brief interventions may be more feasible and effective in some circumstances and could be considered as a first line option, especially for those whose motivation for long term engagement is low. There is much scope for developing the evidence base in this area. As methamphetamine dependence is a global public health burden, and considering pharmacotherapies do not show significant promise, it is imperative that further studies with strong methodological quality are conducted among people who use methamphetamine to guide future development of psychological interventions. As it has been several years since the last study examining methamphetamine use and psychological outcomes was
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published, there is an urgent need to conduct further studies examining promising approaches such as MI plus CBT, CM and ACT as well as other psychotherapies. References
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Full-text articles excluded, with reasons (n = 62) 17 Wrong study design 14 No measure of MA use 9 Wrong outcomes 4 No MH outcome measures 4 Protocol. Study incomplete 4 No comparison group 2 Pharmacological Additional records intervention identified through other patient population 2 Wrong Records identified through sources2 Unable to find database searching (n = 2 (Smout et2al.Conference 2010) abstract (n = 1688) Full-text articles Descriptive study (Baker et al. 12001) Records Records after duplicates removed Records excluded assessed forscreened eligibility 1 Not published (n(n==1142) (n = 1070) 72)
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Figure 1 PRISMA flow diagram
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Studies included in narrative synthesis (n = 10 studies from 14 articles)
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Table 1. Intervention details REVISED 27 JULY 2019 Study Design Recruitment Period Location Number of participants (N) Baker et al., 2001a; Baker et al., 2001b RCT July to December 1998 Newcastle, Australia
Aims
N = 64
100% used MA at least monthly.
Participant inclusion/exclusion criteria
Participant details
Healthcare Providers
Intervention
Inclusion: At least monthly use of MA. Poly-drug use and enrolment in MMT did not exclude people from the study provided they reported regular MA use.
87.5% unemployed
Two research assistants with four years training in psychology.
Four or two X 30-60 min sessions, weekly. Focus of session 1 was on MI, session 2 on avoiding high risk situations, session 3 on reducing cravings, session 4 on relapse prevention. In the 2 session condition the procedure and content was the same as for the 4 session condition. CBT strategies reflecting some of the content of the remaining sessions of the longer intervention were discussed in session 2. All participants were provided with a self-help booklet on reducing MA use and related harms.
The aim of the study was to: (1) identify whether brief MI/CBT interventions were feasible among regular MA users; (2) assess the effectiveness of the intervention overall; and (3) to pilot two- and foursession interventions.
62.5% post school qualification Mean years of education (SD) 10.65 (1.72) Mean age (SD) 31.02 (8.27)
Examine the effectiveness of MI among hospitalized psychiatric patients with comorbid substance use.
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22.5% used MA weekly or more in the month preceding baseline.
76.3% receiving pension or benefits
To replicate and extend the small pilot study of a MI/CBT intervention to reduce MA related harms in a sample of regular MA users (described in Baker et al, 2001a,b, above).
Inclusion: At least weekly use of MA. Poly-drug use and enrolment in MMT did not exclude people from the study provided they reported regular MA use.
74.8% unemployed
100% used MA at least
Four psychologists.
8.8% completed upper high school
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MA use measures/ Biochemical verification of selfreport
Self-help booklet on reducing MA use and related harms.
Pre-treatment and six-months following baseline.
Drug Use Scale of the OTI.
n = 32
No biochemical verification.
GHQ-28.
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n = 32 One inpatient MI 30 - 45 min session, with discussion of cognitive behavioural coping strategies. n = 79
Mean age (SD) 30.88 (10.23)
Brief advice on alcohol and other drug use, and a selfhelp booklet on alcohol and other drug services.
Pre-treatment and at three-, six- and 12month followups
Drug Use Scale of the OTI
BSI
No biochemical verification
Pre-treatment, post-treatment (five weeks), six-month follow-up
Drug Use Scale of the OTI
n = 81
SCID (substance use disorders)
Male % (n) 75% (120)
49.1% post school qualifications Mean age leaving school 16.14 (5.16)
Exclusion: suicidality or acute psychosis, acquired cognitive
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Inclusion: Inpatient in a psychiatric hospital; capable of interview; likely to be a local resident over the next 12 months; meeting diagnostic criteria for current substance abuse or dependence, weekly illicit drug use, or alcohol consumption > 4 drinks a day for men and 2 for women.
N = 160
Baker, Lee, et al., 2004, 2005 RCT Oct 2001 to Sep 2002 Newcastle and Brisbane,
Time points Psychiatric symptom measure/s
% users of MA
Male % (n) 59% (38)
Baker et al., 2002a; Baker et al., 2002b RCT September 1996 to July 1998 Newcastle, Australia
Control / comparison
Mean age (SD)
Three psychologists and one social worker
Four or two X 45-60 min sessions, weekly. Focus of session 1 was on MI, session 2 on avoiding high risk situations, session 3 on reducing cravings, session 4 on relapse prevention. In the two session condition the procedure and content of the first two sessions was the same as for the four session condition. All participants were provided with a self-help booklet on
Self-help booklet n = 74
BSI, BDI-II
SDS Pre-treatment only SCID (substance use disorder)
PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE Journal Pre-proof Australia
weekly.
impairment, current enrolment in treatment for MA use.
N = 214
Baker, Bucci et al., 2005,2006 RCT August 2000 to June 2002
Compared the effectiveness between MI/CBT compared to usual care at reducing MA use and improving symptomatology and global functioning.
Hunter region, Australia
16.8% used MA at least weekly. 42% reported MA abuse/dependence in the last 12 months.
N = 130
McDonell et al., 2013 RCT
Recruitment period not reported Seattle, USA N = 176
Whether the addition of CM for psycho-stimulant drug abstinence would be successful in reducing stimulant use. 100% dependent on stimulants; 38.6% MA
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30.22 (7.83)
reducing MA use and related harms.
Male % (n) 62.6% (134)
Two sessions n = 74 Four sessions n = 66
Inclusion: alcohol consumption .> 4 drinks a day for men and 2 for women, or at least weekly use of cannabis or amphetamines; aged at least 15 years; ability to speak English; and having a confirmed ICD–10 psychotic disorder.
88.2% receiving welfare support
Exclusion: failure to meet at least one of the specified substance use thresholds; had an organic brain impairment; or intended to move from the geographical area within the subsequent 12 months.
Mean age (SD) 28.83 (10.27)
Inclusion: Used stimulants in the last 30 days; met MINI Criteria for MA, amphetamine or cocaine dependence as well as criteria for schizophrenia, schizoaffective disorder, bipolar I or II disorder, or major recurrent depressive disorder.
Employment rates not reported but 65.3% were homeless or in unstable housing
Exclusion: organic brain disorder, dementia, or medical disorders or psychiatric symptoms severe enough to compromise safe participation in the study.
Mean age (SD) 43.01 (9.27 Contingent CM) 42.45 (9.97 Noncontingent Control, NCC)
65.5% reported receiving postschool qualifications
Three state registered psychologists with a minimum of two years postgraduate clinical training
Male % (n) 78.2% (93)
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Male % (n) 65.3% (115)
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n = 65
TAU - self-help booklet on substance use.
Baseline, 15 weeks, six- and 12 months
n = 65
BDI-II, BPRS. Pre-treatment only ICD-10 diagnosis via the Diagnostic Interview for Psychosis
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Multi-site community mental health and addiction treatment agencies
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Education not reported
10 weekly, 60 min individual outpatient sessions of MI/CBT.
Both groups received TAU, which consisted of mental health, chemical dependency, housing and vocational services. CM: received three months of CM for stimulant abstinence (stimulant negative urine test). Missing or drug positive samples resulted in no delivery of reinforcement.
NCC – Noncontingent rewards for study participation only plus TAU. Number of opportunities were equalled, however, the ability to gain extra reimbursement was not included.
n = 91 n = 85
At weeks four, eight, 12, 16 and 24 ASI-Lite, BSI, PANSS
Urine samples were collected from 17.4% (19 of 109) of the participants who attended faceto-face interviews at the six-month follow-up. Drug Use Scale of the OTI SCID (substance use disorders) No biochemical verification
Urine samples were collected thrice weekly during treatment and monthly during follow up; ASI-Lite
PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE Journal Pre-proof Peck, et al. 2005 RCT 1996 to 2001 Los Angeles, USA N = 162
Aimed to evaluate the severity and prevalence of depressive symptoms at various time points after behavioural interventions among MA-dependent gay and bisexual men. The temporal association between MA use and depression scores during treatment was also tested.
Inclusion: seeking treatment for their current MA use problem; diagnosed with MA dependence; self-identified gay or bisexual men; aged 18 - 65; and willing to provide informed consent.
Employment rates not reported 95.7% completed at least high school 41% completed a 4-year degree
Healthcare providers are not described but the study was conducted in an outpatient research clinic.
Mean age (SD) 36.6 (6.4)
CBT: using the Matrix Model. Thrice weekly groups for 16 weeks.
See description of the four intervention conditions.
n = 40 CM: vouchers of increasing value for continuous abstinence as indicated by urine samples.
CBT + CM
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Gay-Specific CBT: a culturally sensitiveversion of Matrix Model CBT, plus education, booklets and materials about HIV-related sexual risk behaviours. Thrice weekly groups for 16 weeks.
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n = 40
Polcin et al., 2014 RCT Recruitment period not reported Northern California, USA N = 217
To assess MA outcomes of individuals assigned to intensive MI versus a comparison single session MI condition plus standard outpatient group treatment three times a week. 100% reported MA dependence
Inclusion: 18 years or older; met DSM-IV criteria for 12-month MA dependenc; and comfortable participating in English.
Employment rates not reported but 34.9% of Standard MI and 36.0% of Intensive MI participants were homeless during the study.
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42.8% had completed high school or less
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57.2% had completed some college or more Mean age (SD) Mean age ranged from 37.5 (Intensive MI males) to 39.3 (Intensive MI women). Overall mean, SD not reported. Male % (n) 50.7% (110)
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Three therapists.
Intensive MI plus TAU – weekly individual therapy sessions for nine weeks. TAU consisted of thrice weekly CBT groups focusing on craving management for up to 12 weeks. n = 111
Urine samples were collected thrice weekly during treatment ASI
Pretreatment only: SCID for DSM-IV diagnosis of major depressive disorder.
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n = 40
Baseline, weekly during treatment and at 16, 26 and 52 weeks follow-up BDI-I
n = 42
Male % (n) 100% (162)
100% reported MA dependence
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Standard MI plus TAU– single session of standard MI, 8 sessions of nutrition education to match intervention group on time. n = 106
Baseline and 2, 4-, and 6month followup ASI-lite
Timeline followback (TLFB) was used to record MA use (self-report). Administered weekly for the 9 weeks of treatment and on follow-up occasions. ASI-Lite Urine samples were used to assess concordance with self-reprorted MA use.
PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE Journal Pre-proof Rawson et al., 2004 RCT 1999 to 2001 8 sites in USA N = 978
To compare the Matrix Model with TAU in 8 community outpatient setttings for reducing MA dependence. 100% reported MA dependence
Inclusion: 18 years +; MAdependent as determined by a DSM-IV checklist; willing to complete forms and provide urine samples; can understand scales and instructions; can understand English; and able to participate in all aspects of the treatment condition.
69% employed M = 12.2 years of education Mean age (SD) 32.8 (SD not reported)
N = 177
To compare the effectiveness of CM and CBT alone and in combination for reducing stimulant use.
Inclusion: diagnosed as MA or cocaine dependent based on DSM-IV criteria; evidence of cocaine or MA use during 2-week screening period.
9.6% (17) MA dependent 90.4% (160) cocaine dependent
Exclusion: dependent on alcohol or benzodiazepines requiring medically supervised withdrawal, or if court mandated to treatment.
Matrix model – 16 weeks of CBT (36 sessions), family education groups (12 sessions), social support groups (four sessions) and individual counselling (four sessions) combined with weekly breath and urine testing. n = 489
Male % (n) 45% (440)
Exclusion: medical and/or psychiatric condition which precluded safe participation; requiring medical detoxification from opioids/alcohol/other drugs; not having used MA in the last 30 days; having been enrolled in another treatment program in the last 30 days; and having medical, legal, housing and/or transportation issues precluding consent.
Rawson, et al. 2006 RCT Recruitment period not reported USA
Clinical staff trained to deliver Matrix Model.
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9% unemployed over last three years 96% reported having a high school degree or equivalent.
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Mean age (SD) 36.2 (SD not reported) Male % (n) 76% (135) 160 – cocaine dependent. 17 – MA dependent.
Baseline, discharge and six- and 12months postadmission
Weekly urine screens during treatment and at six month follow up ASI
ASI
n = 489
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CBT therapist with a masters degree in Marriage and Family Therapy and a CM technician with a BA degree.
TAU – varied widely across the 8 sites, with the intensive phase of treatment ranging from four to16 weeks. Expected contact time with the treatment program ranged from one to 13 hours per week.
All interventions lasted 16 weeks. CM – Participants required to provide three monitored urine samples per week and meet briefly (two-five min) with a CM technician. The voucher value was based on an escalating schedule.
Three intervention conditions were compared.
Baseline, 17, 26 and 52weeks followup BDI-I, ASI
Urine samples were collected thrice weekly during treatment And at each follow up ASI
n= 60 (7 MA) CBT group – Three groups per week for 16 weeks (48 sessions), 90 min each. n = 58 (5 MA) CBT + CM –group interventions simultaneously. n = 59 (5 MA)
PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE Journal Pre-proof Smout, et al. 2010 Preliminary RCT March 2004 to May 2006. South Australia N = 104
To compare treatment attendance, reduction in MA use and related harms following ACT or CBT. 100% MA abuse or dependence
Inclusion: Aged 16 - 65 years; met DSM-IV criteria for MA abuse or dependence according to the Mini-International Psychiatric Interview (MINI) substance use module; MA was their drug of choice; reported average MA use of at least 2 days per week in the past 3 months; willing to provide hair samples; and were available to attend appointments. Exclusion: Reported unstable dose of antidepressant, antipsychotic or mood stabiliser; had psychiatric or medical condition requiring hospitalisation.
39% unemployed 39% employed 12% student 17% vocational education 25% 7-10 yrs education 49% 11-13 yrs education
Two doctoral or Masters level psychologists provided both ACT and CBT.
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12 weekly 60 min individual CBT or ACT sessions. CBT: Building motivation, coping skills, decision-making, relapse prevention and CBT for psychosocial problems impacting on drug use. n = 53
Mean age (SD) 30.9 (SD = 6.5)
ACT: Sessions included reviewing drug use from the previous week, learning new skills associated with ACT and mindfulness/acceptance exercises.
Male % (n) 60.5% (63)
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n = 51
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Compared two interventions.
Baseline, four, eight and 24 weeks postentry for interview. Self-report instruments and hair samples were collected at baseline, 12 and 24 weeks.
Self-reported MA use assessed through semistructured interview.Not previously validated or pilot tested Bioverification with hair analysis Leeds Dependence Questionnaire
BDI-II, SF-12
Note. ACT = Acceptance and Commitment Therapy, ASI-Lite = Addiction Severity Index, BDI = Beck Depression Inventory, BPRS = Brief Psychiatric Rating Scale, BSI = Brief Symptom Inventory, CBT = Cognitive Behavior Therapy, CM = Contingency Management, GAF = Global Assessment of Functioning, GHQ = General Health Questionnaire, ICD-10 = International Classification of Diseases, IPDEQ = International Personality Disorder Examination Questionnaire, MA = methamphetamine, MMT = Methadone Maintenance Treatment, N = number of participants for whole sample, n = number of participants in subgroups, OTI = Opiate Treatment Index (mean score reflects average number of use occasions per day in the previous month), PNSS = Positive and Negative Symptom Scale, RCT = randomized controlled trial, SCID/ I NP = Structured Clinical Interview for Diagnostic and Statistical Manual (DSM-IV) – research version, SD = standard deviation, SDS = Severity of Dependence Scale, SF-12 = Short Form Health Survey-12, SMI = Standard Motivational Interviewing, SMI = Severe Mental Illness, TLFB = Timeline Follow-Back
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Table 2. Outcomes of psychological interventions for methamphetamine use REVISED 27 JULY 2019
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Study
Attrition (rates of follow-up/session attendance)
Results for primary and secondary outcomes (where reported)
Baker et al., 2001a; Baker et al., 2001b
N = 64
MA use: Fell significantly for the sample as a whole (F(1,48) = 17.80, p<0.001). From baseline to six-months mean daily occasions of MA use fell from 0.83 (SD 1.03) to 0.39 (SD 0.62) (0.44 units) in control vs 1.20 (SD 1.65) to 0.18 (SD 0.52) (1.02 units) in the intervention group as a whole (effect size units of 0.40 versus 0.93 respectively, a difference of over half a SD, representing a moderate effect size). % abstinent at 6-month follow-up: control group 21.4%; two sessions 33.3%; four sessions 85.7%. Abstinence rate of the control condition was significantly lower than that of the four-session group (𝜒2 (1) = 10.27; 𝑝 < 0.01).
81.3% followed up at six-months Two session 81.8%, 4 session 77.8%, control 87.5%
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Four session MI/CBT initial = 16 Attended all 4 sessions = 9/16 (56.3%) Two session MI/CBT initial = 16 Attended both sessions = 11/16 (68.8%)
Secondary outcomes: Other drug use: Reflecting the significant reduction in MA use among the sample as a whole, there was a significant overall reduction in polydrug use from baseline M = 4.71 (SD 1.27) to six-months M = 3.96 (SD 1.61) (F(1,48) = 12.71, p<0.01) for the overall sample, with no difference between groups, falling by 0.68 units in control vs 0.86 units in the intervention group (effect size units of 0.46 versus 0.56 respectively). There was no significant change in cannabis (F(1,31)= 3.54, NS] or tobacco use [F(1,44)= 2.67, NS] over time, nor any differential change by group. Health: Mean OTI health scores significantly improved for the sample as a whole, from a mean score (SD not reported) of 20.15 to 16.04 (F(1,48) =8.43, p<0.01), with no differential changes in health across groups. BBV risk: No significant change in levels of injecting risk-taking behavior on the OTI, however, the control group had significantly higher injecting risk-taking overall compared to intervention groups [9.02 vs. 5.34, F(1,48) = 9.24, p < 0.01], particularly when compared to the two-session intervention group [9.02 vs. 3.89, F(1,48) = 11.37, p < .01) Social functioning: No significant differences between groups or changes over time on the OTI (statistics not reported).
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70.0% followed up at three-months (69.6% MI, 70.4% control) 73.1% followed up at six-months 71.9% followed up at 12-months 55.6% completed all follow up phases (54.4% MI, 56.8% control)
N = 214 72.4% attended post-treatment assessment 71.5% followed up at six-months 56.5% completed all follow-up phases (Newcastle site 70.4%; Brisbane site 44.8%) Intervention condition attendance
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N = 160
All participants received the inpatient MI or self-help booklet (control)
Baker, Lee, et al., 2004, 2005
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Psychiatric symptoms: No significant differences between groups or changes over time in GHQ-28 scores (change in mean scores not reported).
MA use: No significant main effects for time nor group effects for MA use with M (SD) scores at baseline, three-, six- and 12-months for controls and MI respectively: 0.95 (0.93), 0.01 (0.03), 0.17 (0.35), 0.03 (0.05) vs 0.51 (0.89), 0.32 (1.05), 0.14 (0.31), 0.06 (0.17). % abstinent at follow-up not reported. % meeting SCID abuse/dependence criteria at baseline and six- and 12-month follow-up for controls and MI respectively: 8/8 (100%), 4/8 (50%), 3/8 (37.5%) vs 11/11 (100%), 4/11 (36.4%), 1/11 (9.1%). Threshold for intervention was halved at 12months (22.5% at baseline vs 12.2%). Psychiatric symptoms: There was a significant reduction over time in overall psychiatric distress on the BSI F(3,76) = 15.67, p < 0.001), with a an effect size of 0.56 between baseline and three-months. There were no statistically significant differences between groups on the BSI with M (SD) scores at baseline, three-, six- and 12-months for controls and MI respectively: 1.61 (0.88), 1.18 (0.87), 1.03 (0.80), 1.12 (0.84) vs 1.77 (0.98), 1.05 (0.87), 0.92 (0.77), 1.01 (0.85). Secondary outcomes: Other drug use. Polydrug use, alcohol and cannabis use fell significantly for the sample as a whole between pretreatment and three-month follow-up (F(1,105) = 9.52, p < 0.01;F (1,60) = 8.07, p < 0.01; F(1,71) = 7.87, p< 0.01, respectively with effect sizes for polydrug use: 0.50, alcohol: 0.63, cannabis: 0.49. The mean number of drug classes used during the month prior to assessment fell 0.42 units among the control group v 0.83 units among the MI group. Reduction in polydrug use was greater in the MI group (M = 0.93, SD = 1.29) compared to the control group (M = 0.42, SD 1.34) at three-months (F(1, 105) = 4.47, p = 0.04). Social functioning. Progressive significant improvement in social functioning over time (F(2,92) = 5.78, p<0.01), with significant improvement between pre-treatment (M = 18.46, SD 5.98) and six-month follow up (M = 17.04, SD 5.31) (p<0.01) and between pre-treatment and 12-month follow up (M = 16.58, SD 5.01) (p < 0.01), for the sample as a whole. MA use: Fell significantly between baseline; M use occasions per day (1.41, SD 1.51) and post-treatment (0.70, SD 1.01) (F (1,148) = 22.64, p < 0.001) and between baseline (1.38, SD 1.47) and six-month follow-up (0.62, SD 1.09) (F(1,146) = 22.11, p < 0.001). No difference between post-treatment (0.58, SD 0.79) and six-month follow-up scores (0.53, SD 0.99). At six-months, mean daily occasions of MA use fell 0.76 units among the control condition vs. 1.04 units among the four session condition (effect size units of 0.55 versus 0.75 respectively, representing a small effect size). % abstinent at six-month follow-up: control group: 17.6% abstinent; two sessions: 33.8% abstinent, AOR = 2.94, p < 0.01; and four sessions: 37.9% abstinent, AOR = 3.08, p < 0.01). All urine samples collected were consistent with self-reported use of MA (on 10 occasions use was reported and detected, on five occasions no use was reported and nil was detected, and on four occasions
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use in the past month was reported but not detected). Four session MI/CBT initial = 66 Attended three or four sessions = 68.2%
Severity of dependence decreased significantly over time for the sample as a whole between pre-treatment (M= (mean 8.10, SD 3.73) and six-month follow-up (M = 6.24, SD 4.25) (F1,146 = 43.60, p<0.001).
Two session MI/CBT initial = 74 Attended both sessions = 75.7%
Psychiatric symptoms: There was a significant reduction over time in overall psychiatric distress on the BSI between pre-treatment (M = 1.43, SD 0.76) and post-treatment (M= 1.18, SD 0.77) (F (1,148) = 22.26, p<0.001) and pre-treatment (M = 1.49, SD 0.78) to six-month follow-up (M = 1.08, SD 0.79) (F(1,142 = 45.90, p<0.001). There were no statistically significant differences between groups on the BSI.
Females (83.3%) significantly more likely than males (60.5%) to complete all treatment sessions allocated (p<0.01)
Significant improvement in depression levels (BDI-II) between pre-treatment (M = 27.19, SD 13.20) and post-treatment (M = 19.35, SD 13.09) (F(1, 148) = 48.61, p <0.001) and between pre-treatment (M = 27.87, SD 13.09) and six-month follow-up (M = 17.95, SD 13.05) (F1,146 = 51.77, p<0.001). No difference between post-treatment (M = 19.22, SD 13.69) and six-month follow-up (M = 17.74, SD 13.42). Extent of reduction in depression was significantly greater at post-treatment with higher number of sessions attended (F(1,148) = 12.49, p<0.001). Over two-thirds of the sample (152 of 214, 71.0%) scored in the moderately to severely depressed range at pre-treatment (i.e. BDI-II scores of 20 or above), compared with less than half at post-treatment (66 of 155, 42.6%) and a similar proportion at the 6-month follow-up (60 of 153, 39.2%).
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N = 130 Intervention condition follow-up assessments 15-weeks n = 60 (92.3%). Six-months n = 60 (92.3%). 12-months n = 49 (75.3%). Control condition follow-up assessments 15-weeks n = 61 (93.8%). Six-months n = 63 (96.9%). 12-months n = 55 (84.6%).
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Secondary outcomes: Other drug use. Significant reduction in benzodiazepine use between pre-treatment (M = 3.34, SD 3.97) and posttreatment (M = 1.03, SD 2.05) (F(1,36) 15.28, p<0.001) and at six-month follow-up (M = 0.57, SD 4.40) (F(1,33) = 10.45, p <0.001), no difference between groups. Polydrug use. Overall reduction from pre-treatment (M = 4.30, SD 1.47) to post-treatment (M = 3.83, SD 1.33) (F(1,148) = 10.96, p<0.001) and to 6-month follow-up (M = 3.44, SD 1.46) (F(1,146) = 30.04, p<0.001). Tobacco. There was a significant overall reduction in cigarettes per day between pre-treatment (M = 17.81, SD 12.47) and six-month follow-up (M = 14.68, SD 11.57) (F(1, 146) = 15.58, p<0.001). There were no other significant changes in use of individual classes of drugs among those using them at least weekly at pretreatment. BBV risk: Overall significant decrease in injecting risk-taking behavior from pre-treatment (M = 7.33, SD 5.28) to post-treatment (M = 4.53, SD 4.44) (F(1,138) = 25.65, p<0.001) and from pre-treatment (M = 6.71, SD 5.04) to six-month follow-up (M = 3.71, SD 4.35) (F(1,136) = 29.14, p<0.001). No significant reductions in sexual risk-taking behavior.. MA use: Differential (baseline v. six months) reduction in MA use in intervention condition compared with control ( F(1,18) = .4.70,p = 0.04). Mean daily number of occasions of MA use fell from M = 2.39 (SD 3.71) to M = 0.19 (SD 0.41) in the intervention condition by 1.33 units compared with -0.40 for control, from M = 0.56 (SD 0.60) to M = 1.47 (SD 2.28), representing differential change of 1.73 standardised units (a large effect size). The effect was still strong at 12 months.
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MI/CBT group 8 people completed 0 sessions (12.3%); 11 completed some sessions (16.9%); and 46 completed all 10 sessions (70.7%)
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Psychiatric symptoms: There was a significant overall improvement between baseline and the 12-month assessment on the BPRS mania factor with M (SD) scores for treatment vs control respectively 6.79 (3.77) and 6.07 (1.63) vs 7.39 (3.51) and 5.94 (2.26), representing an overall effect size of 0.44, (F(1,95) = 8.46, p<0.01). There was significant overall improvement between baseline and each of the follow up assessments on BPRS negative symptoms for treatment and controls, with baseline and 12-month M (SD) respectively 7.02 (2.96) and 6.86 (1.36) vs 7.54 (3.41) and 6.58 (2.35) (all F’s >13, p<0.001), representing an overall effect size of 0.51. BDI–II depression scores were also significantly lower at each of the follow up assessments than at baseline, with a significantly more marked reduction between baseline and six-month assessment for intervention than for control, with respective M (SD) 23.47 (12.94) and 14.10 (11.38) vs 13.30 (11.28) and 9.92 (9.29)(0.78 v. 0.28 standardized units, or a half a standard deviation of differential impact, p<.01). Secondary outcomes: Other drug use. Significant time effects for alcohol and polydrug use but no group main effects. Alcohol consumption and polydrug use decreased significantly for sample as a whole, at 15 weeks, six- and 12-month follow ups for the treatment and the control groups. Reduction in alcohol consumption (M, SD) between baseline and 12-month follow up for treatment and control conditions was respectively 6.15 (4.94) to 3.58 (4.80) vs 6.30 (4.49) to 2.19 (3.04), equivalent to an overall effect size change of 0.80 units. Respective M (SD) scores for polydrug use were 3.17 (1.05) to 2.84 (1.18) vs 2.64 (0.90) to 2.19 (1.12) (all F’s > 9, p<0.01), equivalent to an overall effect size change of 0.31 units. Mean daily cannabis decreased by 0.36 standardized units for treatment compared with -0.02 for control (NS). Significant interaction for group x time with deterioration in global functioning between baseline and 12-month assessment for control (M = 71.64 (SD 12.72) to M = 66.28 (SD 11.21) and small improvement in CBT/MI group (M = 66.41 (SD 11.97) to M = 68.45 (SD 9.98), a
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differential impact of over half a standard deviation (0.58) (a moderate effect size).
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McDonell, et al. 2013
N = 176
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Stimulant use: CM (M = 0.91, SD 2.40) reported significantly fewer days of stimulant use during treatment compared to NCC (M = 4.67, SD 7.69 (𝛽 = 2.70, 95% CI = 0.91–4.31, p<.05). At follow-up, CM (M = 1.83, SD 4.94) continued to report lower scores than NCC (M = 3.65, SD 7.15 𝛽 = 2.16, 95% CI=0.18–3.24, p<.05).
Follow-up CM = 52 (57.1%). NCC = 55 (64.7%). Overall, 60.8% of participants completed follow-up measures. During Treatment Significantly fewer CM (38/91, 42%) than NCC control group (55/85, 65%) participants were retained throughout the 12 weeks (p<0.05). Retention: CM 42%, control 65% CM participants retained for fewer weeks (mean= 7.25, SD 4.25) than those in the NCM control group (mean=9.33, SD 3.98)
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Participants in CM group were 2.4 times (95% CI = 1.9–3.0, p <.05) as likely as those in NCC group to submit a stimulant-negative urine sample during the treatment period (three urine tests submitted per week, for 12 weeks). Participants in CM more likely than those in NCC to submit stimulant negative urine test during follow up (46%, 35% respectively; odds ratio = 1.4, 95% CI=1.0–1.9, p<0.05).
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Psychiatric symptoms: BSI. CM (M = 1.04, SD 0.79) reported significantly lower scores during treatment than NCC (M = 1.24, SD 0.71) (𝛽 = 0.25, 95% CI = 0.08–0.43, p<0.05) but not at follow-up, CM (M = 1.17, SD 0.85) vs NCC (M = 1.25, SD 0.79). PANSS. CM group (M = 10.60, SD 2.58) reported significantly lower excitement subscale scores during treatment than NCC (M = 11.69, SD = 3.42) ( 𝛽 = 0.86, 95% CI = 0.11–1.60, p<0.05) but not at follow-up, CM (M = 11.17, SD 3.18) vs NCC (M = 11.57, SD 3.01). Psychiatric hospitalization: Significantly fewer CM (2%) than NCC (10%) participants were admitted during the six months following randomization (𝜒2 = 5.4, df=1, p = 0.02). Secondary outcomes: Days of alcohol use. CM (M = 1.84, SD 4.77) reported significantly fewer use days during treatment compared to NCC (M = 4.32, SD 8.43) (𝛽 = 2.44, 95% CI = 0.60–4.29, p<0.05) but not at follow-up CM (M = 3.60, SD 7.92) vs NCC (M = 4.21, SD 7.86). HIV risk behavior. Injecting drug use. CM were less than one-third as likely to report engaging in injecting drug use during treatment compared to NCC (odds ratio = 3.3, 95% CI = 1.8–5.9, p<0.05) but not during follow-up.
PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE Journal Pre-proof Peck, et al. 2005
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N = 155 (seven SCID interviews were missing, resulting in a final sample of 155 interviews upon which analyses of SCID and BDI total scores were tested).
MA use: Across all treatments, significant reductions in recent self-reported days of MA use were observed across all time points. Baseline (M = 9.6 days; SD 7.4) to week 16 (M = 2.4 days, SD 5.3), week 26 (M = 2.2 days, SD 4.8), and week 52 (M = 3.6 days, SD 6.4; (F (3, 505) = 44.1, p <.0001). (Urine samples were only taken during treatment).
CBT – attended 40.8% of 48 possible sessions.
Psychiatric symptoms: BDI at baseline indicated at least mild depressive symptoms for 73.2% of participants. Of 153 baseline BDI scores, 44 (28.5%) were in the moderate to severe range (M = 25.0, SD 5.6); 69 (44.8%) mild to moderate range (M = 13.7, SD 2.3); and 41 (26.6%) depression to minimal depression range (M = 5.5, SD 2.7). No statistically significant differences between treatment conditions for severity of reported depressive symptoms at baseline, 16, or 26 weeks. At 52-week follow-up, CBT condition had higher BDI scores (M=10.3, SD 7.8) than participants in other conditions (but had higher scores at baseline). All participants reported significant decreases in depressive symptoms from baseline to end of treatment. Most of the decrease occurred in the first month, with the largest drop in BDI scores being in the period between baseline and the first week (t(139) = 9.1, p<0.001).
CM – Average amount earned per participant was $415 (potential was $1277) CBT + CM – 73.8% of total possible CBT sessions and earned $662 in vouchers (potential was $1277).
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Gay-CBT – attended 55.8% of total possible sessions.
The criteria for life-time mood disorder (based on SCID scores) was met in more than one-half (52.9%) of participants, with 28.4% of the sample meeting criteria for a lifetime major depressive disorder (MDD).
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Urine samples indicating recent use of MA predicted future high BDI scores and samples documenting recent prior abstinence of MA predicted future low BDI scores (F (1, 968) = 18.6, p<.0001). BDI scores did not predict future MA use. Secondary outcomes: None reported. Polcin, et al. 2014
Two-month follow-up Intensive MI = 91.5% Standard MI = 94.6%
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Four-month follow-up Intensive MI = 91.5% Standard MI = 88.3% Six-month follow-up Intensive MI = 91.5% Standard MI = 93.7% Sessions attended (M, SD) Intensive MI Outpatient sessions (TAU) = 14.3 (1.0) MI sessions = 5.3 (0.3) Standard MI Outpatient sessions (TAU) =14.7 (1.1) MI sessions = 4.2 (0.3)
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MA use: Percent of days abstinent increased significantly in both groups across all time points. In the Standard MI group, average baseline scores (M = 0.55, SE 0.04) increased at two months (M = 0.74, SE 0.04), at four months (M = 0.76, SE 0.03) and increased at six months (M = 0.78, SE 0.03) (p<0.001). Similar changes were found in the Intensive MI group at baseline (M = 0.56, SE 0.04), two months (M = 0.74, SE 0.03), four months (M = 0.75, SE 0.03) and six months (M = 0.75, SE 0.03) (p<0.001). There were no differences between treatment conditions. Similarly, average ASI Drug Scores fell significantly from baseline to each follow-up occasion for both conditions, (Adjusted r for SMI = -0.08, p<0.001, IMI = -0.06, p<0.002) with no differential reduction between the two intervention conditions. Concordance between self-reported drug use and urine screens ranged from 86.5% to 90% across data collection time points.
N = 217 completed
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Psychiatric symptoms: ASI psychiatric status score was significantly reduced from baseline to follow-ups for IMI condition (-0.06, p<.0.05) but not for the SMI condition (Adjusted r = -0.01). Similarly, there was a significant reduction in depression for the IMI condition (Adjusted r = -0.67, p<0.01) vs. no reduction in depression for Standard MI.
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(Intensive MI condition attended significantly more MI sessions than Standard MI attended nutrition sessions p<0.01)
Anxiety status. No significant reductions over time and no differences between SMI and IMI groups. Number of days had psychiatric problem: Higher at baseline in IMI than SMI. Scores in SMI group were relatively consistent at baseline (11.40, SE = 1.11), 2-months (11.76, SE = 1.17), 4-months (11.36, SE = 1.14) and 6-months (11.88, SE = 1.27). Scores in IMI group significantly dropped across time points (p<0.01): baseline (15.70, SE = 1.08), 2-months (12.50, SE = 1.18), 4-months (12.72, SE = 1.22) and 6-months (10.80, SE = 1.08). Secondary outcomes: None reported.
PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE Journal Pre-proof Rawson, et al. 2004
Rawson, et al. 2006
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N = 978 During treatment (for total sample): 798 (81.6%) completed discharge interviews. 841 (86%) completed 6-month interviews. 12-month data not available
MA use: Matrix participants provided significantly more MA-free urines in the first 12 weeks of their treatment (4.3 vs 3.3, p< 0.05, statistics not reported). During treatment, Matrix participants, compared to TAU, were 31% more likely to have MA-free urine test results (odds ratio = 1.311). During treatment the Matrix condition had longer mean periods of abstinence than TAU in two of the 8 sites: Site 3 (Matrix M=3.013, SD=4.028 vs TAU M=1.805, SD=1.805, SD=3.763) and Site 5 (Matrix M=3.429, SD=4.467 vs TAU M=1.279, SD=2.274) both p’s <0.05. At discharge, the Matrix Model had 66% MA-free urine samples, and 69% of urine samples were MA-free in TAU. At 6-month follow-up, both groups had 69% MA-free urine samples.
Treatment completion rate Matrix = 40.9% TAU = 34.2% This difference was statistically significant (p <0.05)
Similarly, self-reported MA use was reduced during treatment over time, with no significant differences by treatment condition, mean number of days of MA use at baseline M = 11.3, discharge M = 4.3, 6-month follow-up M = 4.4 and for TAU mean number of days of MA use at baseline M = 11.8, discharge M = 4.4, 6-month follow-up, M = 4.0. (Ftime = 124.43, p <.0001). Overall, self-reported number of days of MA use in the past 30 days was reduced from 11 days at baseline to slightly over 4 days at discharge, and this reduction was maintained at 6-month follow up.
Clinical contacts (M, SD) TAU = 12.7 (14.7) Matrix Model = 26.8 (19.7)
Psychiatric and secondary symptoms; All ASI domains except for the medical scale showed significant improvement across treatment. Significant reductions from baseline were seen at 6-month follow-up in the family, drug, psychiatric and alcohol areas, with no differences between treatment conditions (statistics not reported).
N = 177
MA use: During treatment, the mean number of stimulant free urines for CM and CBT + CM treatment conditions was significantly higher than for CBT only (F = 10.0 (df = 2, 176), p<0.0001). The CBT + CM group gave the most stimulant-free samples (M=28.6), followed by CM (M = 27.6). CBT had the lowest stimulant-free samples (M=15.5) across the 16 weeks. A 3-week criterion of consecutive abstinence revealed significant differences between groups (χ2=15.5, df=2, n=177, p<0.0001) with pairwise comparisons made between CBT (34.5%) vs CM (60.0%; χ2 =14.9, df = 1, n = 97, <0 .0001) and CBT vs CBT + CM conditions (69.5%; χ2=18.4, df=1,n=97, p<0.0001). In comparing the CM and CM+CBT conditions, no significant differences in abstinence were found. During the follow-up period, all three groups had between 67% and 79% stimulant-free samples across all time-points, with no differences between conditions.
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Discharge, 26 and 52-week follow-up rates n (%) CM – 45 (75.0%), 46 (76.7%), 45 (75.0%) CBT – 47 (81.0%), 44 (75.9%), 45 (77.6%) CM + CBT 46 (78.0%), 49 (83.1%), 48 (81.4%) There were no significant differences between groups in followup rates.
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There was a significant main effect for all three treatment groups with regard to the reduction in the mean number of days participants reported using MA from the month preceding admission interviews to the month preceding the treatment-end (week 17) interviews (F=3.9, df=3, n= 106, p < 0.01). There were no between group differences.
Mean (SD) weeks retained in treatment CM = 12.6 (5.2) 63% completed 16 weeks.
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CBT = 9.0 (6.5), 40% completed 16 weeks CM+CBT = 12.0 (5.6), 59% completed 16 weeks
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Mean numbers completing treatment were significantly higher in the CM and CM + CBT groups compared to CBT (p<0.05)
Participants in the CM + CBT group attended more CBT sessions (26.5, 15.3) compared to CBT only (19.0, 15.4), p<0.01 Mean number of sessions attended = 19.0, SD = 15.4
Psychiatric and secondary outcomes: At week 17 study participants reported statistically significant overall reductions in problems related to employment, alcohol, drugs, family/social, and psychiatric domains, but not in the legal or medical scales. CM participants had significantly lower psychiatric scores at week 17 than those in CM or CBT + CM conditions (CM: M = 0.12, SD=0.2; CBT: M = 0.22, SD=0.2; CBT + CM: M = 0.24, SD=0.2; p < .05 (statistics not given)). Sustained treatment effects were seen at the later follow-ups in drug use, psychiatric severity and family scores, with no significant differences between groups.
PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE Journal Pre-proof Smout, et al. 2010
N = 104
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MA use: Significant within-group reductions in self-reported MA use for CBT Baseline: median = 5.7, SD = 9.3; 12 weeks: median = 0.3, SD = 1.0, 24 weeks: median = 0.4, SD = 2.9) and for ACT (Baseline: median = 6.0, SD = 7.0, 12 weeks: median = 0.2 SD = 3.0, 24 weeks: median = 0.8, 1.8). Significant within-group reductions in MA dependence and negative consequence scores (CBT: Baseline, median = 107.0, SD = 117.0, 12 weeks: median = 15.0 SD = 30.0), 24 weeks, median = 4.5 SD = (15.0)) in both groups (ACT: Baseline, median = 103.0 SD = 99.0, 12 weeks, median = 12.0 SD = 29.0, 24 weeks, median = 6.0 SD = 39.0) from baseline to 12 weeks. Statistical significance for CBT group for MAfree hair samples (%). CBT: Baseline: 96.2%, 12 weeks: 57.1%, 24 weeks: 63.6%. ACT: Baseline: 86.3%, 12 weeks: 66.7%, 24 weeks: 50%). Between 12 and 24 weeks there were no significant within group changes except for a significant further reduction in negative consequences for the CBT condition (t(107) = 2.2, p = 0.03), and showed only a trend toward improvement for ACT (t(107) = 1.8, p = 0.08).
In-Treatment and Follow-up data: Four-weeks: CBT = 41.5% ACT = 37.3% 8-weeks CBT = 26.4% ACT = 13.7%
Psychiatric symptoms: BDI-II scores were significantly reduced across time CBT: Baseline: M = 25.7, SD = 11.2, 12 weeks: M = 17.7, SD = 12.2, 24 weeks: M = 14.1, SD = 14.8, ACT: Baseline: M = 27.8, SD = 10.3, 12 weeks: M = 15.4, SD = 13.6, 24 weeks: M =16.9, SD = 16.3 from baseline to 12 weeks (F (2, 51) = 32.16, p < .01). There were no significant changes between 12 and 24 weeks. SF-12 scores significantly reduced across time, (CBT: Baseline: M = 30.5, SD = 9.7, 12 weeks: M = 40.8, SD = 11.6, 24 weeks: M = 40.9, SD = 15.4. ACT: Baseline: M = 30.3, SD = 8.1, 12 weeks: M = 44.3, SD = 10.4, 24 weeks, M = 44.2, SD = 12.7) from baseline to 12 weeks (F (2, 52) = 28.59, p<0.01).
Post-intervention: CBT = 32.1% ACT = 27.5%
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24-week follow-up: CBT = 28.3% ACT = 19.6%
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Secondary outcomes: There were significant changes between baseline and follow-up for the sample as a whole in the physical scale scores of the SF12 (F(1, 52) =4.81, p < 0.05), and, for the CBT group, in the self-reported number of other drugs used.
Provided any post-intervention data (overall) - 29.8%
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61% of treatment starters attended at least 4 sessions
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Note: ACT = Acceptance and Commitment ASI = Addiction Severity Index, BBV = Blood Borne Virus, BDI-II = Beck Depression Inventory, BPRS = Brief Psychiatric Rating Scale, BSI = Brief Symptom Inventory, CBT = Cognitive Behaviour Therapy, CM = Contingency Management, GAF = Global Assessment of Functioning, GCBT = Gay specific Cognitive Behaviour Therapy, GHQ-28 = General Health Questionnaire, GSI = Global Severity Index, HIV = Human Immunodeficiency Virus, IMI = Intensive Motivational Interviewing, ITT = Intention to Treat Analysis, M = mean, MA = methamphetamine, MI = Motivational Interviewing, NCC = non-contingent control condition, OTI = Opiate Treatment Index, PNSS = Positive and Negative Symptom Scale, SCID = Structured Clinical Interview, SD = standard deviation, SE = standard error, SMI = Standard Motivational Interviewing, TAU = treatment as usual
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Journal Pre-proof PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE
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Highlights Regular methamphetamine use is associated with psychiatric symptoms A variety of psychological treatments are effective in reducing levels of methamphetamine use and improving psychiatric symptoms in this population There is accumulating evidence that more intensive treatment is more effective than minimal or less intensive comparison conditions in reducing methamphetamine use and improving psychiatric symptoms.
Figure 1
Alexandra M. Stuart, Amanda L. Baker, Alexandra M.J. Denham, Nicole K. Lee, Alix Hall, Chris Oldmeadow, Adrian Dunlop, Jenny Bowman, Kristen McCarter PII:
S0740-5472(19)30259-4
DOI:
https://doi.org/10.1016/j.jsat.2019.09.005
Reference:
SAT 7934
To appear in:
Journal of Substance Abuse Treatment
Received date:
30 April 2019
Revised date:
2 August 2019
Accepted date:
9 September 2019
Please cite this article as: A.M. Stuart, A.L. Baker, A.M.J. Denham, et al., Psychological treatment for methamphetamine use and associated psychiatric symptom outcomes: A systematic review, Journal of Substance Abuse Treatment(2019), https://doi.org/10.1016/ j.jsat.2019.09.005
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2019 Published by Elsevier.
Journal Pre-proof PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE Psychological treatment for methamphetamine use and associated psychiatric symptom outcomes: A systematic review
Revised 27 July 2019 Alexandra M. Stuart1, Amanda L. Baker2, Alexandra M. J. Denham2, Nicole K. Lee3, Alix Hall4, Chris Oldmeadow4, Adrian Dunlop2, Jenny Bowman1, Kristen McCarter2
School of Psychology, Faculty of Science, University of Newcastle, University Drive,
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Callaghan, NSW, 2308 2
School of Medicine and Public Health, Faculty of Health and Medicine, University of
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Newcastle, PO BOX 833, Newcastle, New South Wales 2300, Australia Faculty of Health Sciences, Curtin University, Bentley, Western Australia 6102 Australia
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Hunter Medical Research Institute and Faculty of Health and Medicine, University of
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Newcastle, LOT 1 Kookaburra Circuit, New Lambton Heights, New South Wales 2305,
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Australia
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Word count: 6330
PO Box 833
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Corresponding Author: Dr Kristen McCarter
Newcastle, NSW 2300 Australia
Email: [email protected] Phone: +61 2 4033 5721 Fax: +61 2 4033 5692 Declarations of interest: none. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Abstract Background: Regular methamphetamine use is associated with increased rates of psychiatric symptoms. Although there has been a substantial body of research reporting on the effectiveness of psychological treatments for reducing methamphetamine use, there is a paucity of research examining the effects of these treatments on co-occurring psychiatric symptoms. We addressed this gap by undertaking a systematic review of the evidence of the effectiveness of psychological treatments for methamphetamine use on psychiatric symptom outcomes in randomized controlled
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trials. Methods: A narrative synthesis of studies was conducted following the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement to inform methodology. Eight electronic peer-reviewed
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databases were searched. Ten eligible studies were assessed.
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Results: Most studies found an overall reduction in levels of methamphetamine use and psychiatric
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symptoms among samples as a whole. Although brief interventions were effective, there is evidence that more intensive interventions have greater impact on methamphetamine use and/or psychiatric
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symptomatology. Intervention attendance was variable.
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Conclusions: The evidence suggests that a variety of psychological treatments are effective in reducing levels of methamphetamine use and improving psychiatric symptoms. Future research
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should consider how psychological treatments could maximize outcomes in the co-occurring domains of methamphetamine use and psychiatric symptoms, with increasing treatment attendance as a focus.
PROSPERO registration number: CRD42016043657 Key words: methamphetamine, psychological, treatment, intervention, systematic review, psychiatric symptomsIntroduction In recent years methamphetamine use has become a major global health concern with an estimated 35 million past year users worldwide in 2015 (United Nations Office on Drugs and Crime, 2017). Although use of methamphetamine has decreased in some countries, including
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Australia, harms associated with methamphetamine use continue to increase, partly driven by increases in purity and a change in preference from the powdered form to the high purity crystalline form (Scott, Caulkins, Ritter, Quinn, & Dietze, 2015; Australian Institute of Health and Welfare [AIHW], 2017). In Australia, frequency of use of crystalline methamphetamine has increased significantly (AIHW, 2017), with an associated rise in levels of dependence (Degenhardt et al., 2016). Hospitalizations, ambulance attendances, overdose and deaths related to methamphetamine use have all increased as a consequence (NSW Ministry of Health, 2015; Sindicich, Stafford, &
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Breen, 2016; AIHW, 2017). Methamphetamine associated deaths have doubled in Australia between 2009 and 2015 due to an increase in heart disease and stroke, with 1649 deaths in that period, 43% due to drug toxicity (Darke, Kaye, & Duflou, 2017).
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Regular methamphetamine use can be associated with a range of psychiatric symptoms,
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particularly psychosis, anxiety, and depression (Akindipe, Wilson, & Stein, 2014; McKetin,
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Lubman, Lee, Ross, & Slade, 2011; McKetin et al., 2016). It is more likely to induce psychotic symptoms than other illicit drugs and exhibits a higher dependence liability than other
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psychostimulants (Darke, Kaye, McKetin, & Duflou, 2008; Glasner-Edwards et al., 2008).
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Although vulnerability to psychotic symptoms varies among people who use methamphetamine, these symptoms are more apparent in people who use methamphetamine on a regular basis (Darke
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et al., 2008). In Australia, hospitalizations due to psychosis tripled in the years between 2009 and 2013, especially in the age groups with the highest rate of methamphetamine use (AIHW, 2017). Psychiatric symptoms, including psychosis, anxiety and depression, affect response to methamphetamine treatment (Glasner-Edwards et al., 2008; Glasner-Edwards et al., 2010b; KayLambkin, Baker, McKetin, & Lee, 2010; Newton, De La Garza, Kalechstein, Tziortzis, & Jacobsen, 2009; Rose & Grant, 2008). For example, people who experience depressive symptoms and who use methamphetamine have a poorer prognosis for both conditions (Darke, Kaye, Duflou, & Lappin, 2019; McKetin et al., 2011). Depressive symptoms may also contribute to more frequent use of methamphetamine through negative reinforcement, consequently impacting on treatment outcomes (Glasner-Edwards et al., 2010b; Newton et al., 2009). Additionally, the high rates of
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depression are associated with increased risk of suicidal ideation and attempted suicide (Darke et al., 2008; McKetin et al., 2011). Psychotic symptoms associated with methamphetamine use can produce symptoms almost indistinguishable from schizophrenia and the lack of a validated symptom profile for methamphetamine-induced psychiatric symptoms can be associated with suboptimal care of underlying psychiatric disorders. (McKetin et al., 2016). No pharmacotherapy has been found to be broadly effective for the treatment of methamphetamine use (Lee, Jenner, Harney, & Cameron, 2018). Similarly, there is no evidence to
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suggest that drug treatments can reduce psychological distress or symptomatology associated with methamphetamine use (Anderson et al., 2015; Brensilver, Heinzerling, & Shoptaw, 2013; Ciketic, Hayatbakhsh, Doran, Najman, & McKetin, 2011; Darke & Farrell, 2016; Elkashef et al., 2008;
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Karila et al., 2010; Lile, Stoops, Glaser, Hays, & Rush, 2011; Rose & Grant, 2008). The current
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evidence suggests treating methamphetamine-related psychiatric symptoms in line with guidelines
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for similar disorders that are not drug induced (Hellem, Lundberg, & Renshaw, 2015; Kay-Lambkin et al., 2010). For example, a review of the limited research into the pharmacological treatment of
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methamphetamine-related psychosis reported that antipsychotic medications reduced symptoms of
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methamphetamine psychosis (Knapp, 2007; Shoptaw, Kao, & Ling, 2009). Psychological therapy for methamphetamine dependence continues to be the first line
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treatment option (Colfax et al., 2010; Hellem et al., 2015; Suvanchot, Somrongthong, & Phukhao, 2012) and is effective in reducing methamphetamine use (Degenhardt et al., 2008; Drake, O'Neal, & Wallach, 2008; Karila et al., 2010; Manning et al., 2017; Rawson et al., 2004; Wisdom, Manuel, & Drake, 2011). However, less is known about psychiatric symptom outcomes from these treatments or which psychological interventions are effective for reducing both methamphetamine use and psychiatric symptoms (Barrowclough et al., 2009; Rawson et al., 2004; Wisdom et al., 2011). Although a number of reviews of psychological treatment for methamphetamine use have been conducted (Ciketic et al., 2011; Cohen, Huguet, Cohen, Vera, & Dardennes, 2017; Lee & Rawson, 2008; Rose & Grant, 2008; Shoptaw et al., 2009), none have examined the effects of
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psychological interventions for methamphetamine use and psychiatric symptoms. One recent review by Hellem et al. (2015) examined integrated treatment for methamphetamine and cooccurring symptoms of depression and found a reduction in methamphetamine use but not psychiatric symptoms. The question remains whether methamphetamine specific psychological interventions can impact on psychiatric symptoms. As psychiatric symptoms are increasingly common and increasing in severity among people who use methamphetamine, there is a need for research on the effectiveness of psychological interventions for methamphetamine use and co-
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occurring psychiatric symptomatology. Clinically, this is important in the alcohol and other drug sector where practitioners are specialists in alcohol and other drug treatment but may not have mental health training.
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The present systematic review will determine and summarize the characteristics,
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methodological quality and effectiveness of studies whilst examining the effectiveness of
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psychological interventions for methamphetamine use. We also report on intervention outcomes for co-occurring psychiatric symptoms or disorders. Secondary outcomes related to methamphetamine
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2. Material and methods
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and psychiatric symptom outcomes will also be summarized (where reported, specified below).
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A systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (Moher, Liberati, Tetzlaff, Altman, & PRISMA Group, 2010). The methodology is described in detail in Stuart et al. (2017) and the protocol is registered with PROSPERO (registration number CRD42016043657). 2.1 Information sources A systematic search using PsycINFO, Medline, EMBASE, CINAHL and Scopus was conducted for eligible studies up until November 2018. Registration databases were also searched, including the Cochrane Central Register of Clinical Trials, US Government Website of Clinical Trials and WHO International Clinical Trials Registry. 2.2 Search strategy
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Search terms (see supplementary file S1) were developed from existing reviews of psychological interventions (Anderson et al., 2015; Colfax et al., 2010; Hellem et al., 2015; Lile et al., 2011). Publications were limited to human studies, were available in English, and no limits were placed on publication year. Reference lists of included articles and systematic reviews were also searched manually to find further papers. 2.3 Study selection Studies were included if they tested a psychological intervention and measured the following
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outcomes: i) methamphetamine use and (ii) psychiatric symptoms and/or disorders at baseline and post-treatment. Participants included were adults (over 18), using methamphetamine alone or in
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combination with other substances (poly-drug use). Interventions could be delivered in any setting
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including inpatient units (drug and alcohol rehabilitation or hospital settings), community or prison settings. Psychological interventions included one or more psychological strategies (such as
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cognitive or behavioral strategies) designed to modify methamphetamine use. Only randomized
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controlled trials were eligible. Interventions were compared with active controls (e.g. other psychological interventions), treatment as usual (TAU) or minimal care control conditions (e.g.
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self-help booklets). Interventions were of any duration, delivery, frequency and intensity. Primary
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outcomes were: i) any outcome measure reporting change (reduction/increase) between baseline and follow-up assessment occasion/s in methamphetamine use or abstinence from methamphetamine use; and ii) any outcome measure reporting change between baseline and followup occasion/s (reduction/increase) in psychiatric symptoms or diagnoses. Secondary outcomes of interest were treatment engagement and changes from baseline to follow-up in other drug use, blood-borne virus (BBV) risk-taking behavior, physical health, quality of life using validated measures and global or social levels of functioning. Outcomes reflected any time frame (e.g. shortterm, long-term) and were rated by clients or clinicians, in the form of an assessment by objective or subjective measures. Studies were excluded if they met any of the following criteria: a) were not peer reviewed journal articles; b) did not use a controlled design; c) did not include a psychological intervention;
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d) did not include relevant behavior change outcome measures associated with methamphetamine use and psychiatric outcomes; or e) were case control, cross-over trials, one-arm trials, nonrandomized trials, cross sectional studies or cohort studies. 2.4 Data extraction The Cochrane Handbook for Systematic Reviews (Higgins & Green, 2011) was used to guide data extraction. A data extraction form was developed to organise information. Extraction forms were pre-tested in 10% of the identified articles to ensure functionality. AMS and AMJD
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independently assessed the full-text of the relevant articles. Discrepancies were resolved via discussion and consensus. Data extracted included participant information, methods of each study,
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type of intervention, primary and secondary outcomes and associated results of studies.
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2.5 Risk of bias
The Cochrane Collaboration’s Risk of Bias tool was used to measure risk of bias (Higgins &
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2.6 Grading the strength of evidence
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Green, 2011) with items judged as ‘low’, ‘high’ or ‘unclear’ risk.
The overall quality of evidence of primary outcomes was assessed using the Grades of
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Recommendation, Assessment, Development and Evaluation (GRADE) approach (Higgins &
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Green, 2011), at four levels: ‘very low’, ‘low’, ‘moderate’ and ‘high’. This involved contemplation of directness of evidence, risk of bias, heterogeneity and risk of publication bias. Quality ratings were performed independently by AMS and AMJD, with discrepancies resolved by consensus. 2.7 Data synthesis Due to the low number of included studies and heterogeneity in the outcome measures and data reported, meta-analysis was not possible. A narrative approach to data synthesis was therefore adopted.
3. Results 3.1 Search results and study selection
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The database search returned 1688 results (Figure 1), providing 1142 unique citations after duplicates were removed. A further 1070 studies were excluded at the title-abstract stage. For the remaining 72, the full paper was screened. Of these, 10 studies from 14 manuscripts were included in the review (Baker et al., 2001a, 2001b; Baker et al., 2006; Baker, Bucci, Lewin, Richmond, & Carr, 2005; Baker et al., 2004; Baker, Lee, et al., 2005; Baker et al., 2002a, 2002b; McDonell et al., 2013; Peck, Reback, Yang, Rotheram-Fuller, & Shoptaw, 2005; Polcin et al., 2014; Rawson et al., 2004; Rawson et al., 2006; Smout et al., 2010) .
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3.2 Study characteristics Table 1 summarizes characteristics of the 10 randomized controlled trials included in the
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review. Five studies were conducted in Australia (Baker et al., 2001a, 2001b; Baker et al., 2006;
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Baker, Bucci, et al., 2005; Baker et al., 2004; Baker, Lee, et al., 2005; Baker et al., 2002a, 2002b; Smout et al., 2010) and five in the United States of America (USA) (McDonell et al., 2013; Peck et
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al., 2005; Polcin et al., 2014; Rawson et al., 2004; Rawson et al., 2006). The studies were published
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between 2001 and 2014 and reported on samples ranging in size from 64 to 978 participants. Key inclusion criteria varied, with some samples being: i) users of methamphetamine; ii) users of
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psychostimulants (a sub-sample of whom used methamphetamine); or iii) diagnosed with severe
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mental illness (a sub-sample of whom used methamphetamine). Of the 10 randomized controlled trials, six were conducted among entire samples using methamphetamine (Baker et al., 2001a, 2001b; Baker et al., 2004; Baker, Lee, et al., 2005; Peck et al., 2005; Polcin et al., 2014; Rawson et al., 2004; Smout et al., 2010). One study among people using various psychostimulants included a sub-sample of people using methamphetamine (around 10%; 17/171) (Rawson et al., 2006). Three trials recruited people with severe mental illness, reporting on sub-samples using methamphetamine (Baker et al., 2006; Baker, Bucci et al., 2005; Baker et al., 2002a, 2002b; McDonell et al., 2013). See Table 1 for details. Measures used in studies to assess methamphetamine consumption and psychiatric symptomatology are listed in Table 1. Self-report instruments employed to assess methamphetamine use were as follows: the Drug Use Scale of the Opiate Treatment Index (OTI;
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Darke, Hall, Heather, Wodak, & Ward, 1992) (used in four studies (Baker et al., 2001a, 2001b; 2002a, 2002b; Baker, Bucci et al., 2005; 2006; Baker, Lee et al., 2004, 2005), the Addiction Severity Index (ASI) (McLellan, Luborsky, Woody, & O'Brien, 1980) or ASI-Lite (used in five studies (McDonell et al, 2013; Peck et al, 2005; Polcin et al, 2014; Rawson et al, 2004; Rawson et al, 2006) and a specially devised semi-structured interview (Smout et al, 2010). Biochemical verification of self-reported methamphetamine use / abstinence was conducted in seven studies (Baker, Lee et al., 2004, 2005; McDonell et al 2013; Peck et al, 2005; Polcin et al, 2014; Rawson et
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al, 2004; Rawson et al 2006; Smout et al 2010). Of these studies, six used urinalyses and one (Smout et al, 2010) used hair analyses. Self-report measures of psychiatric symptomatology included more general measures of psychiatric distress such as the General Health Questionnaire
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(GHQ) (Goldberg & Hillier, 1979) (used by Baker et al., 2001a, 2001b); the Brief Symptom
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Inventory (BSI; Derogatis & Melisaratos, 1983) (used in three studies, Baker et al, 2002a, 2002b;
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Baker et al., 2004; Baker, Lee et al, 2005; McDonell et al 2013), the ASI psychiatric status score (McLellan et al., 1980) (used in four studies, McDonell et al, 2013; Polcin et al, 2014; Rawson et
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al., 2004, 2005) and the Short-Form 12 (SF12; Ware, Kosinski, & Keller, 1996) (used in Smout et
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al, 2010). Level of depression was assessed by the Beck Depression Inventory I (BDI-I; Beck, 1967) in two studies (Peck et al., 2013; Rawson et al., 2006) and the Beck Depression Inventory II
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(BDI-II; Beck, Steer, & Brown, 1996) in three studies (Baker et al., 2004; Baker, Lee et al., 2005; Baker et al., 2006; Baker, Bucci et al., 2005; Smout et al., 2010). Psychotic symptomatology was assessed in two studies conducted among people diagnosed with severe mental illness via the Brief Psychiatric Rating Scale (BPRS; Ventura et al., 1993) (Baker et al, 2006; Baker, Bucci et al., 2005) and the Positive and Negative Syndrome Scale (PANSS; Kay, Fiszbein, & Opler, 1987) (McDonell et al., 2013). As seen in Table 1, some studies used multiple self-report instruments to assess psychiatric symptomatology. As shown in Table 1, participants were predominantly male, with mean ages ranging from 28 to 43 years. Intervention lengths ranged from between one session to 12 sessions (over four months). Studies were single and/or multicentre, and participants were recruited from inpatient and
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outpatient alcohol and other drug services and community mental health centres. Interventions assessed outcomes at pre-treatment, post-treatment and follow-up. The follow-up periods varied from one month to 12-months post-intervention. Psychological interventions were delivered by therapists, psychologists and social workers.
3.3 Primary Outcomes: Methamphetamine use and psychiatric outcomes A summary of treatment outcomes, including effect sizes, increases in abstinence and
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changes in diagnostic status, where reported, can be found in Table 2. Studies are described below, according to whether samples were comprised entirely of users of methamphetamine, users of
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psychostimulants more broadly, or whether participants were diagnosed with a severe mental
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illness.
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3.3.1 Studies reporting outcomes among entire samples of people using methamphetamine Baker and colleagues have reported two randomized controlled trials (Baker et al., 2001a,
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2001b; Baker et al., 2004; Baker, Lee, et al., 2005) evaluating combined motivational interviewing
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(MI) and cognitive behavior therapy (CBT) among users of methamphetamine, guided by a treatment manual (Baker, Kay-Lambkin, Lee, Claire, & Jenner, 2003) describing two and four
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session interventions. The two session intervention consisted of an initial session focused mainly on MI and a second session focused on avoidance of high risk situations. The four session condition added a third session covering coping with cravings and a fourth on relapse prevention. A feasibility trial (Baker et al., 2001a, 2001b), aimed to: determine whether regular users of methamphetamine would attend an intervention as lengthy as four sessions; pilot the interventions; and compare outcomes of the combined intervention conditions (n=32) at six-month follow-up with those of the control condition (a self-help booklet, n=32). The interventions appeared feasible (68.8% of participants assigned to the two-session condition attended both sessions and 56.3% attended three or four sessions) and 81.3% were successfully followed up. Methamphetamine use was measured solely by self-report using the OTI (Darke et al., 1992), which provides scores on
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average use occasions per day in the month proceeding interview (see Table 2 for change scores). Outcomes were promising: the sample as a whole reported a significant reduction in methamphetamine use (by 0.44 effect size units in control vs 1.02 in the intervention group, a moderate difference in effect size). Significantly more participants in the intervention conditions reported abstinence from methamphetamine at six months, largely due to differences between the control and four-session condition (85.7% compared to 21.4%). There were no significant changes over time or between groups in psychiatric symptomatology, as measured by the GHQ-28
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(Goldberg & Hillier, 1979). Given the high feasibility and promising results of the above study, Baker and colleagues (Baker et al., 2004; Baker, Lee, et al., 2005) conducted a larger randomized controlled trial (N=214)
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comparing a self-help booklet with two- or four- sessions of MI plus CBT guided by the treatment
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manual (Baker et al., 2003). As seen in Table 2, similar to the pilot study above, according to the
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OTI self-report measure, there was an overall significant reduction in methamphetamine use. At six months mean daily occasions of methamphetamine use fell 0.76 units among the control condition
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vs 1.04 units among the four-session condition, a small effect size difference. However, the
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likelihood of abstinence from methamphetamine was significantly increased among the intervention conditions, as those who attended two or more sessions had higher rates of abstinence (40.8%),
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compared to the control condition (17.6%). Urinalysis results confirmed self-reported abstinence. Psychiatric distress also fell significantly overall, as measured by the BSI (Derogatis & Melisaratos, 1983) as did level of depression measured by the BDI-II (Beck et al., 1996). However, there was a significant short-term beneficial effect of intervention on depression, with more sessions associated with greater improvement. Over two-thirds of the sample scored in the moderately to severely depressed range at pre-treatment (i.e. BDI-II scores of 20 or above), compared with less than half at post-treatment and at the six month follow-up (see Table 2 for details). A further study adapting the MI and CBT manual developed by Baker et al. (2003) was conducted by a group independent of the manual’s developers. In this study, Smout et al. (2010) compared 12 sessions of Acceptance and Commitment Therapy (ACT) with 12 MI plus CBT
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sessions. A median of three weekly sessions of a possible 12 was attended by participants. Both conditions were associated with significant self-reported reductions in methamphetamine use, dependence and negative consequences as well as level of depression on the BDI-II (Beck et al., 1996) (see Table 2 for details). However, at six-months post-treatment, there was only a significant increase in the proportion of methamphetamine-free hair samples in the MI plus CBT (63.6%) compared to the ACT condition (50%). Furthermore, although there generally were no significant within group changes between 12 and 24 weeks, there was a significant further reduction in the
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negative consequences of methamphetamine use for the MI plus CBT condition. The three remaining trials conducted among entire samples of users of methamphetamine (Rawson et al., 2004; Peck et al., 2005; Polcin et al., 2014) were conducted in the USA (see Table 2
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for details). All reported significant improvements in self-reported methamphetamine use. As in the
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Baker, Lee et al. (2005) study above, two of the studies comparing more intensive treatment with
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less intensive treatment (Rawson et al., 2004; Polcin et al., 2014), found a significant benefit for the
psychiatric symptomatology).
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more intensive condition in one or more primary domains of interest (methamphetamine use or
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In the largest trial to date, Rawson et al. (2004), reported on the use of the manualized Matrix Model treatment among 978 outpatients dependent on methamphetamine. As described in
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Table 1, the Matrix Model treatment was a multi-component treatment adopting elements of CBT, MI, family and group therapy. It was delivered over 36 weeks and compared to TAU. The latter varied across sites and varied from one to 13 hours of contact per week. Matrix Model participants were significantly more likely to be retained in treatment and were more likely to complete treatment. As described in Table 2, all conditions improved in both self-reported and urine-verified methamphetamine use severity and the psychiatric domains of the ASI (McLellan et al., 1980). There was a potentially clinically important short-term in-treatment increase in urine-verified methamphetamine abstinence of the Matrix Model treatment compared to TAU. During treatment, Matrix participants, compared to TAU, were 31% more likely to have MA-free urine test results (odds ratio = 1.311). However, this improvement did not persist at discharge or six-month follow-
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up. Similar short-term benefits were found in the Rawson et al. (2006) study, with details described in Table 2. Less than 10% of this sample of people using psychostimulants were using methamphetamine, so the results are not considered in further detail here. During treatment, the mean number of stimulant free urines for contingency management (CM) alone or combined with CBT treatment conditions was significantly higher than for CBT only, but during the follow-up period, all three groups had between 67% and 79% stimulant-free samples across all time-points. For psychiatric symptoms, Rawson et al. (2006) found that CM participants also had significantly
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lower psychiatric scores at week 17 than other conditions. Polcin et al. (2014) found both an intensive nine-session MI intervention and a single session motivational interview control (plus eight nutrition sessions) delivered alongside standard
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outpatient group CBT were associated with significant reductions in self-reported
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methamphetamine use and biochemically verified abstinence over six-months (see Table 2). A
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significant reduction in the number of days experiencing depression in a 30-day period for the intensive MI intervention group was found (adjusted effect size -.67). As seen in Table 2,
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attendance was high in both conditions. However, as shown in Table 2, the intensive MI condition
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had higher psychiatric symptom severity scores at baseline and showed significant reductions in
condition did not.
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ASI – Lite (McLellan et al., 1980) severity and days of psychiatric problems whereas the single MI
In the remaining trial conducted among an entire sample of methamphetamine users, Peck et al. (2005) compared four types of intervention; (i) thrice weekly Matrix Model CBT groups; (ii) CM, with vouchers of increasing value for urine samples (collected thrice weekly) showing continuous abstinence from methamphetamine; (iii) a combination of the first two conditions; and (iv) and a Gay-Specific version of the condition. As seen in Table 2, there were significant and sustained reductions in methamphetamine use. There was a general sustained reduction in depression, with the greatest reduction occurring in the month between baseline (M = 14.3) and 4 weeks (M = 6.8). The authors suggested the specific type of behavioral or CBT may be of little consequence over the longer term and that a structured treatment program may be the key to
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successful treatment. Aside from being a gay sample, this sample represented only those who completed a two-week baseline period of assessments before being admitted into the study. As described in Table 2, three studies reported on samples of people with severe mental illness (Baker et al., 2002a, 2002b; Baker et al., 2006; Baker, Bucci et al., 2005; McDonell et al., 2013) with 16.8% (Baker et al., 2002a, 2002b) to 38.5% (McDonell et al., 2013) using methamphetamine. In the Baker et al. (2002a, 2002b) study, inpatients were assigned to either MI or a self-help booklet control, with both conditions showing reductions in OTI methamphetamine
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use scores at 12-month follow-up, such that baseline intervention threshold criteria were no longer met by half of the group follow-up. There was a significant reduction in psychiatric symptomatology over time, with a standardized change in effect size of 0.56, as measured by the
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global severity index of the BSI (Derogatis & Melisaratos, 1983).
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The two studies conducted among people with severe mental illness living in the community
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(Baker et al., 2006; Baker, Bucci et al., 2005; McDonell et al., 2013) showed benefits of MI and CBT. Compared to TAU, Baker, Bucci et al. (2005, 2006) found 10 sessions of MI and CBT were
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associated with a large reduction in self-reported methamphetamine use. Also among those meeting
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methamphetamine use criteria at baseline, the sub-sample assigned to the MI and CBT condition was associated with benefits in terms of lower depression scores (medium effect size) and
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significantly better global functioning, largely due to a deterioration in the control condition.. McDonell et al. (2013) reported TAU plus contingent reinforcement for urine verified stimulant abstinence versus TAU plus reinforcement (for study participation only) was associated with more stimulant free urines during treatment, (see Table 2 for details) and lower levels of psychiatric symptoms on the BSI (Derogatis & Melisaratos, 1983) and PANSS (excitement subscale; Kay et al., 1987) during treatment but not follow-up. During the six months following randomization, compared to the TAU condition (10%), significantly fewer participants receiving contingent reinforcement (2%) were admitted for inpatient psychiatric care. 3.4 Secondary Outcomes
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Table 2 details secondary outcomes, where reported, in each study. There was substantial variability in secondary outcomes reported, with some data on each secondary outcome except for overall quality of life, which was not reported in any study. As seen in Table 2, all 10 studies provided data regarding treatment and follow-up attendance. Overall, studies showed that people using methamphetamine, including those with coexisting psychiatric symptoms or disorders, can be retained in treatment and followed up over 12months. Evidence from three Australian studies showed that when offered, participants were likely
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to complete a brief intervention and attend two-four sessions on average (Baker et al., 2001a, 2001b; Baker et al., 2006; Baker et al., 2004; Baker, Bucci et al., 2005; Baker et al., 2004; Baker, Lee, et al., 2005; Smout et al., 2010), even when more sessions were available. Studies from the
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USA showed much longer treatments were also feasible. Two studies found that more complex
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interventions, such as the Matrix Model compared with TAU or CBT combined with CM compared
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with either treatment alone, produced better treatment attendance (Peck et al., 2005, Rawson et al., 2004). No significant differences were found in attendance for intensive motivational interventions
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compared to TAU (Baker et al., 2004; Baker, Lee, et al., 2005; Polcin et al., 2014). Follow-up
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attendance varied largely across studies, for example, between 19.6% for ACT at six-months (Smout et al., 2010) to 96.9% for TAU at six-months (Baker et al., 2004; Baker, Lee, et al., 2005).
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Seven studies reported reductions in other drug use among samples as a whole (Baker et al., 2001a, 2001b; Baker et al., 2004 ; Baker, Lee, et al., 2005; Baker et al., 2006; Baker, Bucci et al., 2005, Baker et al., 2002a, 2002b; McDonell et al., 2013; Rawson et al., 2004, 2006). The exception was the Smout study (2010) which reported a significant within group reduction among the CBT group but not the ACT group between baseline and 12 weeks. In terms of BBV risk-taking behavior, three studies (Baker et al., 2001a, 2001b; Baker et al., 2004; Baker, Lee, et al., 2005; McDonell et al., 2013) reported changes in BBV risk reduction and associated risk behavior. Two studies reported significant reductions for the sample as a whole in injecting-risk taking behavior from pre to post-treatment (Baker et al., 2004; Baker, Lee, et al., 2005; McDonell et al., 2013). Conversely, Baker et al. (2001a, 2001b) found no significant change
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in levels of injecting risk-taking behavior across CBT and control conditions in their pilot trial but the control condition reported significantly higher risk-taking behavior. Four studies reported on physical health outcomes. Two reported that health scores improved over time for samples as a whole (Baker et al., 2001a, 2001b; Smout et al., 2010) and two reported no change over time in physical health nor between conditions (Rawson et al., 2004, 2006). Six studies (Baker et al., 2001a, 2001b; Baker et al., 2006; Baker, Bucci et al., 2005; Baker
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et al., 2004; Baker, Lee, et al., 2005; Baker et al., 2002a, 2002b; Rawson et al., 2004, 2006) reported on participants’ levels of functioning (global, social or family). Most reported improvements over samples as a whole with no differences between conditions (Baker et al., 2002a,
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2002b; Rawson et al., 2004, 2006), with no change in functioning reported in one study (Baker et
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al., 2001a, 2001b). Baker, Bucci et al. (2005, 2006) found a small but significant improvement in
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global functioning among people with severe mental illness following CBT compared to
Quality of the Evidence
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participants in the TAU condition, whose functioning deteriorated over the 12-month follow-up.
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Using the Cochrane Collaboration’s Risk of Bias tool (supplementary file S2), most information came from studies with low or unclear risk of bias across domains. The results should
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be interpreted with the unclear risk of bias across studies in mind. The domains with most unclear ratings across studies (blinding of participants and researchers and blinding of outcome assessment) should be considered, given that blinding for the primary outcomes (methamphetamine use and mental health) may be critical for objective measurement. The proportion of high risk of bias ratings for allocation concealment was not considered sufficient to seriously affect the interpretation of results. High risk of bias ratings across some studies for incomplete outcome data were considered relatively minor inadequacies as outcome data for primary outcomes was reported well across studies.
Using GRADE (Higgins & Green, 2011), it is evident that the quality of the primary research evidence on which the review is based is relatively low in terms of homogeneity (with evidence of
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substantial heterogeneity, inconsistent comparison groups and outcomes). The level of evidence for primary outcomes was as follows: moderate for methamphetamine use, low for abstinence, and for mental health measures it was moderate for ASI (McLellan et al., 1980) and BSI (Derogatis & Melisaratos, 1983), and low for BDI I (Beck, 1967), II (Beck et al., 1996). (The quality of the primary research evidence is relatively moderate in terms of conduct and reporting. Outcomes were downgraded due to multiple concerns including small participant numbers, gender bias and inconsistency in reporting. Furthermore, studies were based on high income countries such as
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Australia and the USA. Numerous studies excluded participants with a psychiatric diagnosis, even though comorbidity is common among people who use methamphetamine (Darke et al., 2008; Glasner-Edwards et al., 2010a; Suvanchot et al., 2012).
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4. Discussion
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There were consistent findings in five large controlled trials among samples comprised
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entirely of people using methamphetamine (i.e. those that were not feasibility trials) (Baker et al., 2004; Baker, Lee, et al., 2005; Peck et al., 2005; Polcin et al., 2014; Rawson et al., 2004; Smout et
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al., 2010). Significant and clinically important decreases in methamphetamine use and psychiatric
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symptoms occurred across all conditions. Even minimal control conditions involving assessment and self-help booklets were associated with significant reductions in methamphetamine use.
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However, when comparing a more intensive intervention with either a less intensive or minimal intervention comparison condition, three randomized controlled trials (Baker et al., 2004; Baker, Lee, et al., 2005; Polcin et al., 2014; Rawson et al., 2004) reported significant benefits over the comparison condition on methamphetamine abstinence or psychiatric symptoms, providing evidence that more intensive rather than less intensive psychological treatment may be beneficial. There was fairly consistent evidence for the efficacy of interventions for improving drug use in addition to methamphetamine use, levels of social functioning and BBV risk-taking, perhaps indicating generalization of treatment effects. However, there was inconsistent evidence of the benefit of treatment on physical health, with two studies from the USA not reporting such
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improvement. It is possible that access to health care differs between countries and may impact on physical health status following treatment for methamphetamine use. Three of the five randomized controlled trials among methamphetamine users reported significantly better outcomes for specific psychological treatments in increasing rates of abstinence. Rawson et al. (2004) reported that the Matrix Model was more effective during treatment in increasing abstinence from methamphetamine compared to TAU. Baker, Lee, et al. (2004, 2005) reported that 2-4 sessions of MI and CBT doubled abstinence over a minimal care
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control condition. Smout et al. (2010), using hair analysis, found MI plus CBT to be more effective in improving abstinence compared to ACT and the CBT participants reported fewer negative consequences of methamphetamine use at follow up.
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Overall, studies suggest that MI and CBT are feasible and effective among people who use
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methamphetamine regularly (Baker et al., 2001a, 2001b; Baker et al., 2006; Baker et al., 2004;
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Baker, Lee, et al., 2005; Smout et al., 2010). ACT has some preliminary evidence showing it is feasible, although biochemically verified evidence of methamphetamine use reduction needs
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strengthening in further studies. Attendance in ACT and MI plus CBT interventions averaged
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around three sessions even when up to 12 were offered (Smout et al. 2010). Attending a greater number of sessions (specifically four versus two sessions of MI and CBT), was associated with
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greater improvements in depression in the short-term (Baker et al., 2004; Baker, Lee, et al., 2005). All three of the studies examining MI plus CBT were conducted in Australia. The efficacy of ACT, MI and CBT delivered as relatively brief interventions requires replication elsewhere to determine generalizability of these results in countries with different health care systems. Of note is the subset of studies that examined samples among people with severe mental illness. Evidence presented here (Baker et al., 2002a, 2002b) suggests that admission to a psychiatric hospital is associated with a reduction in methamphetamine use that is sustained at follow-up. For people with severe mental illness using methamphetamine in the community, there is evidence that 10 sessions of MI and CBT versus TAU is effective (Baker, Bucci et al., 2005, Baker et al., 2006) and contingent rewards for methamphetamine free urines may be associated with
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reductions in use and hospitalization (McDonell et al., 2013). Given the rise in hospital admissions due to methamphetamine use (NSW Ministry of Health, 2015; AIHW, 2017) there is an urgent need to further investigate the effectiveness of psychological interventions in the community and their role in reducing hospitalization. Contingency management, a component of the Matrix Model study described here (Rawson et al., 2004) and one of the comparator conditions in the Peck et al. (2005) study, may be worthy of further research in contexts outside of the USA. Peck et al. (2005) noted that it was as effective as
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more complex and intensive interventions (CBT plus CM) and that any structured therapy may be effective. Contingency management may be a useful intervention to encourage session attendance across a range of intervention types and is worthy of further research in this regard. In addition,
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considering the effectiveness of relatively brief MI and CBT for abstinence from
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methamphetamine, the CBT based mutual aid groups, SMART Recovery (Beck et al., 2016), or
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other mutual aid programs that incorporate elements of CBT are also worthy of further research.
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4.1 Limitations
Not all studies provided biochemical verification of self-reported measures of
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methamphetamine. Of the seven studies (Baker et al., 2004, Baker, Lee et al., 2005; McDonell et
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al., 2013; Peck et al., 2005; Polcin et al., 2014; Rawson et al., 2004; Rawson et al., 2006; Smout et al., 2010) using biochemical measures, the six studies using urine samples reported results consistent with self-reported methamphetamine use. Only the Smout et al. (2010) study, which used hair analysis, reported a discrepancy, with hair samples but not self-reported methamphetamine use favouring CBT over ACT. There was a relatively small number of randomized controlled trials examining methamphetamine and psychiatric outcomes, specifically psychosis. There was substantial variability between all studies in terms of the experimental and control conditions used, duration of treatment received, outcomes assessed, and measures used. Thus, a meta-analysis was not possible. Although there are too few studies to recommend specific outcome assessment instruments, this review has shown that self-reported methamphetamine use largely accords with biochemically
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verified measures. Measures of depression showed overall and group differences (e.g., Baker, Bucci et al., 2005, Baker et al., 2006; Polcin et al., 2014). Measures of psychosis such as the BPRS (Ventura et al., 1993) and its mania sub-scale (as reported by Baker et al., 2006) and the excitement sub-scale of the PANSS (Kay et al., 1987) (McDonell et al., 2013) were shown to distinguish between groups. Only Polcin et al. (2014) specifically reported on anxiety symptoms. Given that the comorbidity of anxiety disorders and methamphetamine use can influence treatment outcomes
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(Glasner-Edwards et al., 2010a), studies reporting on anxiety outcomes and investigating treatment options for this comorbidity are warranted. There were no eligible studies employing potentially helpful therapies such as Dialectical Behavior Therapy, Schema Therapy or Mindfulness-Based
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larger sample sizes to increase generalizability.
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CBT, representing a gap in the literature. Finally, future well-designed studies would benefit from
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5. Conclusions
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There is evidence that a variety of psychological treatments are effective for methamphetamine use, with accumulating evidence that more intensive treatment is more effective
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than minimal or less intensive comparison conditions in reducing methamphetamine use and
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improving psychiatric symptoms. Randomized controlled trials show psychological interventions reduce methamphetamine use and co-occurring psychiatric symptoms (psychotic symptoms and depression) compared to control conditions, during treatment and, in some studies, at follow-up. Given that treatment completion is at least as important as length of treatment, brief interventions may be more feasible and effective in some circumstances and could be considered as a first line option, especially for those whose motivation for long term engagement is low. There is much scope for developing the evidence base in this area. As methamphetamine dependence is a global public health burden, and considering pharmacotherapies do not show significant promise, it is imperative that further studies with strong methodological quality are conducted among people who use methamphetamine to guide future development of psychological interventions. As it has been several years since the last study examining methamphetamine use and psychological outcomes was
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published, there is an urgent need to conduct further studies examining promising approaches such as MI plus CBT, CM and ACT as well as other psychotherapies. References
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Akindipe, T., Wilson, D., & Stein, D. J. (2014). Psychiatric disorders in individuals with methamphetamine dependence: Prevalence and risk factors. Metabolic Brain Disease, 29(2), 351-357. Anderson, A. L., Li, S.-H., Markova, D., Holmes, T. H., Chiang, N., Kahn, R., . . . Elkashef, A. M. (2015). Bupropion for the treatment of methamphetamine dependence in non-daily users: A randomized, double-blind, placebo-controlled trial. Drug and Alcohol Dependence, 150, 170-174. Australian Institute of Health and Welfare. (2017). National drug strategy household survey 2016: Detailed findings. Drug Statistics Series (Cat. no. PHE 214 ed.). Canberra: AIHW. Baker, A., Boggs, T. G., & Lewin, T. (2001a). Characteristics of regular amphetamine users and implications for treatment. Drug and Alcohol Review, 20(1), 49-56. Baker, A., Boggs, T. G., & Lewin, T. J. (2001b). Randomized controlled trial of brief cognitivebehavioural interventions among regular users of amphetamine. Addiction, 96(9), 12791287. Baker, A., Bucci, S., Lewin, T. J., Kay-Lambkin, F., Constable, P., & Carr, V. J. (2006). Cognitivebehavioural therapy for substance use disorders in people with psychotic disorders. British Journal of Psychiatry, 188(5), 439-448. Baker, A., Bucci, S., Lewin, T. J., Richmond, R., & Carr, V. J. (2005). Comparisons between psychosis samples with different patterns of substance use recruited for clinical and epidemiological studies. Psychiatry Research, 134(3), 241-150. Baker, A., Kay-Lambkin, F., Lee, N., Claire, M., & Jenner, L. (2003). A brief cognitive-behavioural intervention for regular amphetamine users: A treatment guide. Canberra: Commonwealth of Australia. Baker, A., Lee, N. K., Claire, M., Lewin, T. J., Grant, T., Pohlman, S., . . . Carr, V. J. (2004). Drug use patterns and mental health of regular amphetamine users during a reported ‘heroin drought’. Addiction, 99(7), 875-884. Baker, A., Lee, N. K., Claire, M., Lewin, T. J., Grant, T., Pohlman, S., . . . Carr, V. J. (2005). Brief cognitive behavioural interventions for regular amphetamine users: a step in the right direction. Addiction, 100(3), 367-378. Baker, A., Lewin, T., Reichler, H., Clancy, R., Carr, V., Garrett, R., . . . Terry, M. (2002a). Evaluation of a motivational interview for substance use within psychiatric in-patient services. Addiction, 97(10), 1329-1337. Baker, A., Lewin, T., Reichler, H., Clancy, R., Carr, V., Garrett, R., . . . Terry, M. (2002b). Motivational interviewing among psychiatric in-patients with substance use disorders. Acta Psychiatrica Scandinavica, 106(3), 233-240. Barrowclough, C., Haddock, G., Beardmore, R., Conrod, P., Craig, T., Davies, L., . . . Wykes, T. (2009). Evaluating integrated MI and CBT for people with psychosis and substance misuse: Recruitment, retention and sample characteristics of the MIDAS trial. Addictive Behaviors, 34(10), 859-866. Beck, A. T. (1967) Depression. Philadelphia, PA: University of Pennsylvania Press. Beck, A. K., Baker, A., Kelly, P. J., Deane, F. P., Shakeshaft, A., Hunt, D., . . . Kelly, J. F. (2016). Protocol for a systematic review of evaluation research for adults who have participated in the ‘SMART recovery’ mutual support programme. BMJ Open, 6(5), e009934. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation. Brensilver, M., Heinzerling, K. G., & Shoptaw, S. (2013). Pharmacotherapy of amphetamine-type stimulant dependence: An update. Drug and Alcohol Review, 32(5), 449-460.
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Ciketic, S., Hayatbakhsh, M. R., Doran, C. M., Najman, J. M., & McKetin, R. (2011). A review of psychological and pharmacological treatment options for methamphetamine dependence. Journal of Substance Use, 17(4), 363-383. Cohen, J. Y., Huguet, G., Cohen, J., Vera, L., & Dardennes, R. (2017). Cognitive-behavioural therapies and motivational interviewing for methamphetamine use disorders: A systematic review. Journal of Addiction Medicine and Therapy, 5(2), 1030. Colfax, G., Santos, G.-M., Chu, P., Vittinghoff, E., Pluddeman, A., Kumar, S., & Hart, C. (2010). Amphetamine-group substances and HIV. Lancet, 376 (9739), 458-474. Darke, S., & Farrell, M. (2016). Which medications are suitable for agonist drug maintenance? Addiction, 111(5), 767-774. Darke, S., Hall, W., Heather, N., Wodak, A., & Ward, J. (1992) Development and validation of a multidimensional instrument for assessing outcome of treatment among opioid users: The Opiate Treatment Index, British Journal of Addiction, 87(5), 733– 742. Darke, S., Kaye, S., & Duflou, J. (2017). Rates, characteristics and circumstances of methamphetamine-related death in Australia: A national 7-year study. Addiction, 112(12), 2191-2201. Darke, S., Kaye, S., Duflou, J., & Lappin, J. (2019). Completed suicide among methamphetamine users: A national study. Suicide and Life-Threatening Behavior, 49(1), 328-337. Darke, S., Kaye, S., McKetin, R., & Duflou, J. (2008). Major physical and psychological harms of methamphetamine use. Drug and Alcohol Review, 27(3), 253-262. Degenhardt, L., Roxburgh, A., Black, E., Bruno, R., Campbell, G., Kinner, S., & Fetherston, J. (2008). The epidemiology of methamphetamine use and harm in Australia. Drug and Alcohol Review, 27(3), 243-252. Degenhardt, L., Sara, G., McKetin, R., Roxburgh, A., Dobbins, T., Farrell, M., . . . Hall, W. D. (2016). Crystalline methamphetamine use and methamphetamine-related harms in Australia. Drug and Alcohol Review, 36(2), 160-170. Derogatis, L. R., & Melisaratos, N. (1983). The brief symptom inventory: An introductory report. Psychological Medicine, 13(3), 595-605. Drake, R. E., O'Neal, E. L., & Wallach, M. A. (2008). A systematic review of psychosocial research on psychosocial interventions for people with co-occurring severe mental and substance use disorders. Journal of Substance Abuse Treatment, 34(1), 123-138. Elkashef, A. M., Rawson, R. A., Anderson, A. L., Li, S.-H., Holmes, T., Smith, E. V., . . . Weis, D. (2008). Bupropion for the treatment of methamphetamine dependence. Neuropsychopharmacology, 33(5), 1162-1170. Glasner-Edwards, S., Mooney, L., Marinelli-Casey, P., Hillhouse, M., Ang, A., & Rawson, R. (2010a). Anxiety disorders among methamphetamine dependent adults: Association with post-treatment functioning. The American Journal on Addictions / American Academy of Psychiatrists in Alcoholism and Addictions, 19(5), 385-390. Glasner-Edwards, S., Mooney, L. J., Marinelli-Casey, P., Hillhouse, M., Ang, A., & Rawson, R. (2008). Clinical course and outcomes of methamphetamine-dependent adults with psychosis. Journal of Substance Abuse Treatment, 35(4), 445-450. Glasner-Edwards, S., Mooney, L. J., Marinelli-Casey, P., Hillhouse, M., Ang, A., & Rawson, R. A. (2010b). Psychopathology in methamphetamine-dependent adults 3 years after treatment. Drug and Alcohol Review, 29(1), 12-20. Goldberg, D. P., & Hillier, V. F. (1979). A scaled version of the General Health Questionnaire. Psychological medicine, 9(1), 139-145. Hellem, T. L., Lundberg, K. J., & Renshaw, P. F. (2015). A review of treatment options for cooccurring methamphetamine use disorders and depression. Journal of Addictions Nursing, 26(1), 14-23. Higgins, J. P. T., Green, S. (Eds). (2011). Cochrane handbook for systematic reviews of interventions version 5.1.0: updated March 2011. The Cochrane Collaboration. Available from http://www.cochrane-handbook.org
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Karila, L., Weinstein, A., Aubin, H. J., Benyamina, A., Reynaud, M., & Batki, S. L. (2010). Pharmacological approaches to methamphetamine dependence: A focused review. British Journal of Clinical Pharmacology, 69(6), 578-592. Kay, S. R., Fiszbein, A., Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276. Kay-Lambkin, F. J., Baker, A. L., McKetin, R., & Lee, N. (2010). Stepping through treatment: Reflections on an adaptive treatment strategy among methamphetamine users with depression. Drug and Alcohol Review, 29(5), 475-482. Knapp, W. P. S., Farrell, M. B., Silva de Lima, M. . (2007). Psychosocial interventions for cocaine and psychostimulant amphetamines related disorders (Review). The Cochrane Database of Systematic Reviews, 3, Cd003023. Lee, N. K., Jenner, L., Harney, A., & Cameron, J. (2018). Pharmacotherapy for amphetamine dependence: A systematic review. Drug and Alcohol Dependence. 191, 309-337. Lee, N. K., & Rawson, R. A. (2008). A systematic review of cognitive and behavioural therapies for methamphetamine dependence. Drug and Alcohol Review, 27(3), 309-317. Lile, J., Stoops, W., Glaser, P., Hays, L., & Rush, C. (2011). Physiological and subjective effects of acute intranasal methamphetamine during extended-release alprazolam maintenance. Drug and Alcohol Dependence, 119(3), 187-193. Manning, V., Garfield, J., Best, D., Berends, L., Room, R., Mugavin, J., . . . Lubman, D. I. (2017). Substance use outcomes following treatment: Findings from the Australian Patient Pathways Study. Australian and New Zealand Journal of Psychiatry, 51(2), 177-189. McDonell, M. G., Srebnik, D., Angelo, F., McPherson, S., Lowe, J. M., Sugar, A., . . . Ries, R. K. (2013). Randomized controlled trial of contingency management for stimulant use in community mental health patients with serious mental illness. American Journal of Psychiatry, 170(1), 94-101. McKetin, R., Dawe, S., Burns, R. A., Hides, L., Kavanagh, D. J., Teesson, M., . . . Saunders, J. B. (2016). The profile of psychiatric symptoms exacerbated by methamphetamine use. Drugand Alcohol Dependence, 161, 104-109. McKetin, R., Lubman, D. I., Lee, N. M., Ross, J. E., & Slade, T. N. (2011). Major depression among methamphetamine users entering drug treatment programs. Medical Journal of Australia, 195(S3), S51-S55. McLellan, A. T., Luborsky, L., Woody, G. E., & O'Brien, C. P. (1980). An improved diagnostic evaluation instrument for substance abuse patients: The Addiction Severity Index. The Journal of Nervous and Mental Disease, 168(1), 26-33. Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & PRISMA Group. (2010). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. International Journal of Surgery, 8(5), 336-341. Newton, T. F., De La Garza, R., Kalechstein, A. D., Tziortzis, D., & Jacobsen, C. A. (2009). Theories of addiction: Methamphetamine users' explanations for continuing drug use and relapse. The American Journal on Addictions, 18(4), 294-300. NSW Ministry of Health (2015). Crystalline methamphetamine. Background paper — NSW data. September 2015 (revised). Sydney: NSW MoH, 2015. Retrieved from http://www.health.nsw.gov.au/crystallinemethamphetamine/Publications/backgroundpaper.p df Peck, J., Reback, C., Yang, X., Rotheram-Fuller, E., & Shoptaw, S. (2005). Sustained reductions in drug use and depression symptoms from treatment for drug abuse in methamphetaminedependent gay and bisexual men. Journal of Urban Health :Bulletin of the New York Academy of Medicine, 82(S1), i100-108. Polcin, D., Bond, J., Korcha, R., Nayak, M., Galloway, G., & Evans, K. (2014). Randomized trial of intensive motivational interviewing for methamphetamine dependence. Journal of Addictive Diseases 33(3), 253-265. Rawson, R., Marinelli-Casey, P., Anglin, M., Dickow, A., Frazier, Y., Gallagher, C., . . . Zweben, J. (2004). A multi-site comparison of psychosocial approaches for the treatment of methamphetamine dependence. Addiction, 99(6), 708-717.
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Rawson, R., McCann, M., Flammino, F., Shoptaw, S., Miotto, K., Reiber, C., & Ling, W. (2006). A comparison of contingency management and cognitive-behavioral approaches for stimulantdependent individuals. Addiction 101(2), 267-274. Rose, M. E., & Grant, J. E. (2008). Pharmacotherapy for methamphetamine dependence: a review of the pathophysiology of methamphetamine addiction and the theoretical basis and efficacy of pharmacotherapeutic interventions. Annals of Clinical Psychiatry, 20(3), 145-155. Scott, N., Caulkins, J. P., Ritter, A., Quinn, C., & Dietze, P. (2015). High-frequency drug purity and price series as tools for explaining drug trends and harms in Victoria, Australia. Addiction, 110(1), 120-128. Shoptaw, S., Kao, U., & Ling, W. (2009). Treatment for amphetamine psychosis. Cochrane Database of Systematic Reviews, 4, CD003026. Sindicich, N., Stafford, J., & Breen, C. (2016). Australian trends in ecstasy and related drug markets 2015. Findings from the Ecstasy and Related Drugs Reporting System (EDRS). Sydney: National Drug and Alcohol Research Centre. Smout, M. F., Longo, M., Harrison, S., Minniti, R., Wickes, W., & White, J. M. (2010). Psychosocial treatment for methamphetamine use disorders: A preliminary randomized controlled trial of cognitive behavior therapy and acceptance and commitment therapy. Substance Abuse, 31(2), 98-107. Stuart, A., Baker, A., Bowman, J., McCarter, K., Denham, A., Lee, N. K., . . . Dunlop, A. (2017). Protocol for a systematic review of psychological treatment for methamphetamine use: An analysis of methamphetamine use and mental health symptom outcomes. BMJ Open, 7(9), 1-6. Suvanchot, K. S., Somrongthong, R., & Phukhao, D. (2012). Efficacy of group motivational interviewing plus brief cognitive behavior therapy for relapse in amphetamine users with cooccurring psychological problems at Southern Psychiatric Hospital in Thailand. Journal of the Medical Association of Thailand, 95(8), 1075-1080. United Nations Office on Drugs and Crime. World drug report 2017. New York: United Nations Office on Drugs and Crime, 2017:13–20. Ventura, J., Lukoff, D., Nuechterlein, K. H., Liberman, R. P., Green, M. F., Shaner, A. (1993) Appendix 1: Brief Psychiatric Rating Scale (BPRS) Expanded Version (4.0) scales, anchor points and administration manual. International Journal of Methods in Psychiatric Research Psychiatric Research, 3, 227-243. Ware, J., Kosinski, M., & Keller, S. (1996). A 12-Item Short-Form Health Survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34(3), 220-233. Retrieved from http://www.jstor.org/stable/3766749Wisdom, J. P., Manuel, J. I., & Drake, R. E. (2011). Substance use disorder among people with first-episode psychosis: A systematic review of course and treatment. Psychiatric Services, 62(9), 1007-1012.
Full-text articles excluded, with reasons (n = 62) 17 Wrong study design 14 No measure of MA use 9 Wrong outcomes 4 No MH outcome measures 4 Protocol. Study incomplete 4 No comparison group 2 Pharmacological Additional records intervention identified through other patient population 2 Wrong Records identified through sources2 Unable to find database searching (n = 2 (Smout et2al.Conference 2010) abstract (n = 1688) Full-text articles Descriptive study (Baker et al. 12001) Records Records after duplicates removed Records excluded assessed forscreened eligibility 1 Not published (n(n==1142) (n = 1070) 72)
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Figure 1 PRISMA flow diagram
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Studies included in narrative synthesis (n = 10 studies from 14 articles)
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Table 1. Intervention details REVISED 27 JULY 2019 Study Design Recruitment Period Location Number of participants (N) Baker et al., 2001a; Baker et al., 2001b RCT July to December 1998 Newcastle, Australia
Aims
N = 64
100% used MA at least monthly.
Participant inclusion/exclusion criteria
Participant details
Healthcare Providers
Intervention
Inclusion: At least monthly use of MA. Poly-drug use and enrolment in MMT did not exclude people from the study provided they reported regular MA use.
87.5% unemployed
Two research assistants with four years training in psychology.
Four or two X 30-60 min sessions, weekly. Focus of session 1 was on MI, session 2 on avoiding high risk situations, session 3 on reducing cravings, session 4 on relapse prevention. In the 2 session condition the procedure and content was the same as for the 4 session condition. CBT strategies reflecting some of the content of the remaining sessions of the longer intervention were discussed in session 2. All participants were provided with a self-help booklet on reducing MA use and related harms.
The aim of the study was to: (1) identify whether brief MI/CBT interventions were feasible among regular MA users; (2) assess the effectiveness of the intervention overall; and (3) to pilot two- and foursession interventions.
62.5% post school qualification Mean years of education (SD) 10.65 (1.72) Mean age (SD) 31.02 (8.27)
Examine the effectiveness of MI among hospitalized psychiatric patients with comorbid substance use.
l a
22.5% used MA weekly or more in the month preceding baseline.
76.3% receiving pension or benefits
To replicate and extend the small pilot study of a MI/CBT intervention to reduce MA related harms in a sample of regular MA users (described in Baker et al, 2001a,b, above).
Inclusion: At least weekly use of MA. Poly-drug use and enrolment in MMT did not exclude people from the study provided they reported regular MA use.
74.8% unemployed
100% used MA at least
Four psychologists.
8.8% completed upper high school
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MA use measures/ Biochemical verification of selfreport
Self-help booklet on reducing MA use and related harms.
Pre-treatment and six-months following baseline.
Drug Use Scale of the OTI.
n = 32
No biochemical verification.
GHQ-28.
e
n = 32 One inpatient MI 30 - 45 min session, with discussion of cognitive behavioural coping strategies. n = 79
Mean age (SD) 30.88 (10.23)
Brief advice on alcohol and other drug use, and a selfhelp booklet on alcohol and other drug services.
Pre-treatment and at three-, six- and 12month followups
Drug Use Scale of the OTI
BSI
No biochemical verification
Pre-treatment, post-treatment (five weeks), six-month follow-up
Drug Use Scale of the OTI
n = 81
SCID (substance use disorders)
Male % (n) 75% (120)
49.1% post school qualifications Mean age leaving school 16.14 (5.16)
Exclusion: suicidality or acute psychosis, acquired cognitive
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Inclusion: Inpatient in a psychiatric hospital; capable of interview; likely to be a local resident over the next 12 months; meeting diagnostic criteria for current substance abuse or dependence, weekly illicit drug use, or alcohol consumption > 4 drinks a day for men and 2 for women.
N = 160
Baker, Lee, et al., 2004, 2005 RCT Oct 2001 to Sep 2002 Newcastle and Brisbane,
Time points Psychiatric symptom measure/s
% users of MA
Male % (n) 59% (38)
Baker et al., 2002a; Baker et al., 2002b RCT September 1996 to July 1998 Newcastle, Australia
Control / comparison
Mean age (SD)
Three psychologists and one social worker
Four or two X 45-60 min sessions, weekly. Focus of session 1 was on MI, session 2 on avoiding high risk situations, session 3 on reducing cravings, session 4 on relapse prevention. In the two session condition the procedure and content of the first two sessions was the same as for the four session condition. All participants were provided with a self-help booklet on
Self-help booklet n = 74
BSI, BDI-II
SDS Pre-treatment only SCID (substance use disorder)
PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE Journal Pre-proof Australia
weekly.
impairment, current enrolment in treatment for MA use.
N = 214
Baker, Bucci et al., 2005,2006 RCT August 2000 to June 2002
Compared the effectiveness between MI/CBT compared to usual care at reducing MA use and improving symptomatology and global functioning.
Hunter region, Australia
16.8% used MA at least weekly. 42% reported MA abuse/dependence in the last 12 months.
N = 130
McDonell et al., 2013 RCT
Recruitment period not reported Seattle, USA N = 176
Whether the addition of CM for psycho-stimulant drug abstinence would be successful in reducing stimulant use. 100% dependent on stimulants; 38.6% MA
27
30.22 (7.83)
reducing MA use and related harms.
Male % (n) 62.6% (134)
Two sessions n = 74 Four sessions n = 66
Inclusion: alcohol consumption .> 4 drinks a day for men and 2 for women, or at least weekly use of cannabis or amphetamines; aged at least 15 years; ability to speak English; and having a confirmed ICD–10 psychotic disorder.
88.2% receiving welfare support
Exclusion: failure to meet at least one of the specified substance use thresholds; had an organic brain impairment; or intended to move from the geographical area within the subsequent 12 months.
Mean age (SD) 28.83 (10.27)
Inclusion: Used stimulants in the last 30 days; met MINI Criteria for MA, amphetamine or cocaine dependence as well as criteria for schizophrenia, schizoaffective disorder, bipolar I or II disorder, or major recurrent depressive disorder.
Employment rates not reported but 65.3% were homeless or in unstable housing
Exclusion: organic brain disorder, dementia, or medical disorders or psychiatric symptoms severe enough to compromise safe participation in the study.
Mean age (SD) 43.01 (9.27 Contingent CM) 42.45 (9.97 Noncontingent Control, NCC)
65.5% reported receiving postschool qualifications
Three state registered psychologists with a minimum of two years postgraduate clinical training
Male % (n) 78.2% (93)
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Male % (n) 65.3% (115)
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n = 65
TAU - self-help booklet on substance use.
Baseline, 15 weeks, six- and 12 months
n = 65
BDI-II, BPRS. Pre-treatment only ICD-10 diagnosis via the Diagnostic Interview for Psychosis
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Multi-site community mental health and addiction treatment agencies
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Education not reported
10 weekly, 60 min individual outpatient sessions of MI/CBT.
Both groups received TAU, which consisted of mental health, chemical dependency, housing and vocational services. CM: received three months of CM for stimulant abstinence (stimulant negative urine test). Missing or drug positive samples resulted in no delivery of reinforcement.
NCC – Noncontingent rewards for study participation only plus TAU. Number of opportunities were equalled, however, the ability to gain extra reimbursement was not included.
n = 91 n = 85
At weeks four, eight, 12, 16 and 24 ASI-Lite, BSI, PANSS
Urine samples were collected from 17.4% (19 of 109) of the participants who attended faceto-face interviews at the six-month follow-up. Drug Use Scale of the OTI SCID (substance use disorders) No biochemical verification
Urine samples were collected thrice weekly during treatment and monthly during follow up; ASI-Lite
PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE Journal Pre-proof Peck, et al. 2005 RCT 1996 to 2001 Los Angeles, USA N = 162
Aimed to evaluate the severity and prevalence of depressive symptoms at various time points after behavioural interventions among MA-dependent gay and bisexual men. The temporal association between MA use and depression scores during treatment was also tested.
Inclusion: seeking treatment for their current MA use problem; diagnosed with MA dependence; self-identified gay or bisexual men; aged 18 - 65; and willing to provide informed consent.
Employment rates not reported 95.7% completed at least high school 41% completed a 4-year degree
Healthcare providers are not described but the study was conducted in an outpatient research clinic.
Mean age (SD) 36.6 (6.4)
CBT: using the Matrix Model. Thrice weekly groups for 16 weeks.
See description of the four intervention conditions.
n = 40 CM: vouchers of increasing value for continuous abstinence as indicated by urine samples.
CBT + CM
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Gay-Specific CBT: a culturally sensitiveversion of Matrix Model CBT, plus education, booklets and materials about HIV-related sexual risk behaviours. Thrice weekly groups for 16 weeks.
e
n = 40
Polcin et al., 2014 RCT Recruitment period not reported Northern California, USA N = 217
To assess MA outcomes of individuals assigned to intensive MI versus a comparison single session MI condition plus standard outpatient group treatment three times a week. 100% reported MA dependence
Inclusion: 18 years or older; met DSM-IV criteria for 12-month MA dependenc; and comfortable participating in English.
Employment rates not reported but 34.9% of Standard MI and 36.0% of Intensive MI participants were homeless during the study.
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42.8% had completed high school or less
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57.2% had completed some college or more Mean age (SD) Mean age ranged from 37.5 (Intensive MI males) to 39.3 (Intensive MI women). Overall mean, SD not reported. Male % (n) 50.7% (110)
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Three therapists.
Intensive MI plus TAU – weekly individual therapy sessions for nine weeks. TAU consisted of thrice weekly CBT groups focusing on craving management for up to 12 weeks. n = 111
Urine samples were collected thrice weekly during treatment ASI
Pretreatment only: SCID for DSM-IV diagnosis of major depressive disorder.
f o
n = 40
Baseline, weekly during treatment and at 16, 26 and 52 weeks follow-up BDI-I
n = 42
Male % (n) 100% (162)
100% reported MA dependence
28
Standard MI plus TAU– single session of standard MI, 8 sessions of nutrition education to match intervention group on time. n = 106
Baseline and 2, 4-, and 6month followup ASI-lite
Timeline followback (TLFB) was used to record MA use (self-report). Administered weekly for the 9 weeks of treatment and on follow-up occasions. ASI-Lite Urine samples were used to assess concordance with self-reprorted MA use.
PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE Journal Pre-proof Rawson et al., 2004 RCT 1999 to 2001 8 sites in USA N = 978
To compare the Matrix Model with TAU in 8 community outpatient setttings for reducing MA dependence. 100% reported MA dependence
Inclusion: 18 years +; MAdependent as determined by a DSM-IV checklist; willing to complete forms and provide urine samples; can understand scales and instructions; can understand English; and able to participate in all aspects of the treatment condition.
69% employed M = 12.2 years of education Mean age (SD) 32.8 (SD not reported)
N = 177
To compare the effectiveness of CM and CBT alone and in combination for reducing stimulant use.
Inclusion: diagnosed as MA or cocaine dependent based on DSM-IV criteria; evidence of cocaine or MA use during 2-week screening period.
9.6% (17) MA dependent 90.4% (160) cocaine dependent
Exclusion: dependent on alcohol or benzodiazepines requiring medically supervised withdrawal, or if court mandated to treatment.
Matrix model – 16 weeks of CBT (36 sessions), family education groups (12 sessions), social support groups (four sessions) and individual counselling (four sessions) combined with weekly breath and urine testing. n = 489
Male % (n) 45% (440)
Exclusion: medical and/or psychiatric condition which precluded safe participation; requiring medical detoxification from opioids/alcohol/other drugs; not having used MA in the last 30 days; having been enrolled in another treatment program in the last 30 days; and having medical, legal, housing and/or transportation issues precluding consent.
Rawson, et al. 2006 RCT Recruitment period not reported USA
Clinical staff trained to deliver Matrix Model.
29
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9% unemployed over last three years 96% reported having a high school degree or equivalent.
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Mean age (SD) 36.2 (SD not reported) Male % (n) 76% (135) 160 – cocaine dependent. 17 – MA dependent.
Baseline, discharge and six- and 12months postadmission
Weekly urine screens during treatment and at six month follow up ASI
ASI
n = 489
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CBT therapist with a masters degree in Marriage and Family Therapy and a CM technician with a BA degree.
TAU – varied widely across the 8 sites, with the intensive phase of treatment ranging from four to16 weeks. Expected contact time with the treatment program ranged from one to 13 hours per week.
All interventions lasted 16 weeks. CM – Participants required to provide three monitored urine samples per week and meet briefly (two-five min) with a CM technician. The voucher value was based on an escalating schedule.
Three intervention conditions were compared.
Baseline, 17, 26 and 52weeks followup BDI-I, ASI
Urine samples were collected thrice weekly during treatment And at each follow up ASI
n= 60 (7 MA) CBT group – Three groups per week for 16 weeks (48 sessions), 90 min each. n = 58 (5 MA) CBT + CM –group interventions simultaneously. n = 59 (5 MA)
PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE Journal Pre-proof Smout, et al. 2010 Preliminary RCT March 2004 to May 2006. South Australia N = 104
To compare treatment attendance, reduction in MA use and related harms following ACT or CBT. 100% MA abuse or dependence
Inclusion: Aged 16 - 65 years; met DSM-IV criteria for MA abuse or dependence according to the Mini-International Psychiatric Interview (MINI) substance use module; MA was their drug of choice; reported average MA use of at least 2 days per week in the past 3 months; willing to provide hair samples; and were available to attend appointments. Exclusion: Reported unstable dose of antidepressant, antipsychotic or mood stabiliser; had psychiatric or medical condition requiring hospitalisation.
39% unemployed 39% employed 12% student 17% vocational education 25% 7-10 yrs education 49% 11-13 yrs education
Two doctoral or Masters level psychologists provided both ACT and CBT.
30
12 weekly 60 min individual CBT or ACT sessions. CBT: Building motivation, coping skills, decision-making, relapse prevention and CBT for psychosocial problems impacting on drug use. n = 53
Mean age (SD) 30.9 (SD = 6.5)
ACT: Sessions included reviewing drug use from the previous week, learning new skills associated with ACT and mindfulness/acceptance exercises.
Male % (n) 60.5% (63)
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n = 51
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Compared two interventions.
Baseline, four, eight and 24 weeks postentry for interview. Self-report instruments and hair samples were collected at baseline, 12 and 24 weeks.
Self-reported MA use assessed through semistructured interview.Not previously validated or pilot tested Bioverification with hair analysis Leeds Dependence Questionnaire
BDI-II, SF-12
Note. ACT = Acceptance and Commitment Therapy, ASI-Lite = Addiction Severity Index, BDI = Beck Depression Inventory, BPRS = Brief Psychiatric Rating Scale, BSI = Brief Symptom Inventory, CBT = Cognitive Behavior Therapy, CM = Contingency Management, GAF = Global Assessment of Functioning, GHQ = General Health Questionnaire, ICD-10 = International Classification of Diseases, IPDEQ = International Personality Disorder Examination Questionnaire, MA = methamphetamine, MMT = Methadone Maintenance Treatment, N = number of participants for whole sample, n = number of participants in subgroups, OTI = Opiate Treatment Index (mean score reflects average number of use occasions per day in the previous month), PNSS = Positive and Negative Symptom Scale, RCT = randomized controlled trial, SCID/ I NP = Structured Clinical Interview for Diagnostic and Statistical Manual (DSM-IV) – research version, SD = standard deviation, SDS = Severity of Dependence Scale, SF-12 = Short Form Health Survey-12, SMI = Standard Motivational Interviewing, SMI = Severe Mental Illness, TLFB = Timeline Follow-Back
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Table 2. Outcomes of psychological interventions for methamphetamine use REVISED 27 JULY 2019
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Study
Attrition (rates of follow-up/session attendance)
Results for primary and secondary outcomes (where reported)
Baker et al., 2001a; Baker et al., 2001b
N = 64
MA use: Fell significantly for the sample as a whole (F(1,48) = 17.80, p<0.001). From baseline to six-months mean daily occasions of MA use fell from 0.83 (SD 1.03) to 0.39 (SD 0.62) (0.44 units) in control vs 1.20 (SD 1.65) to 0.18 (SD 0.52) (1.02 units) in the intervention group as a whole (effect size units of 0.40 versus 0.93 respectively, a difference of over half a SD, representing a moderate effect size). % abstinent at 6-month follow-up: control group 21.4%; two sessions 33.3%; four sessions 85.7%. Abstinence rate of the control condition was significantly lower than that of the four-session group (𝜒2 (1) = 10.27; 𝑝 < 0.01).
81.3% followed up at six-months Two session 81.8%, 4 session 77.8%, control 87.5%
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Four session MI/CBT initial = 16 Attended all 4 sessions = 9/16 (56.3%) Two session MI/CBT initial = 16 Attended both sessions = 11/16 (68.8%)
Secondary outcomes: Other drug use: Reflecting the significant reduction in MA use among the sample as a whole, there was a significant overall reduction in polydrug use from baseline M = 4.71 (SD 1.27) to six-months M = 3.96 (SD 1.61) (F(1,48) = 12.71, p<0.01) for the overall sample, with no difference between groups, falling by 0.68 units in control vs 0.86 units in the intervention group (effect size units of 0.46 versus 0.56 respectively). There was no significant change in cannabis (F(1,31)= 3.54, NS] or tobacco use [F(1,44)= 2.67, NS] over time, nor any differential change by group. Health: Mean OTI health scores significantly improved for the sample as a whole, from a mean score (SD not reported) of 20.15 to 16.04 (F(1,48) =8.43, p<0.01), with no differential changes in health across groups. BBV risk: No significant change in levels of injecting risk-taking behavior on the OTI, however, the control group had significantly higher injecting risk-taking overall compared to intervention groups [9.02 vs. 5.34, F(1,48) = 9.24, p < 0.01], particularly when compared to the two-session intervention group [9.02 vs. 3.89, F(1,48) = 11.37, p < .01) Social functioning: No significant differences between groups or changes over time on the OTI (statistics not reported).
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Baker et al., 2002a; Baker et al., 2002b
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70.0% followed up at three-months (69.6% MI, 70.4% control) 73.1% followed up at six-months 71.9% followed up at 12-months 55.6% completed all follow up phases (54.4% MI, 56.8% control)
N = 214 72.4% attended post-treatment assessment 71.5% followed up at six-months 56.5% completed all follow-up phases (Newcastle site 70.4%; Brisbane site 44.8%) Intervention condition attendance
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N = 160
All participants received the inpatient MI or self-help booklet (control)
Baker, Lee, et al., 2004, 2005
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Psychiatric symptoms: No significant differences between groups or changes over time in GHQ-28 scores (change in mean scores not reported).
MA use: No significant main effects for time nor group effects for MA use with M (SD) scores at baseline, three-, six- and 12-months for controls and MI respectively: 0.95 (0.93), 0.01 (0.03), 0.17 (0.35), 0.03 (0.05) vs 0.51 (0.89), 0.32 (1.05), 0.14 (0.31), 0.06 (0.17). % abstinent at follow-up not reported. % meeting SCID abuse/dependence criteria at baseline and six- and 12-month follow-up for controls and MI respectively: 8/8 (100%), 4/8 (50%), 3/8 (37.5%) vs 11/11 (100%), 4/11 (36.4%), 1/11 (9.1%). Threshold for intervention was halved at 12months (22.5% at baseline vs 12.2%). Psychiatric symptoms: There was a significant reduction over time in overall psychiatric distress on the BSI F(3,76) = 15.67, p < 0.001), with a an effect size of 0.56 between baseline and three-months. There were no statistically significant differences between groups on the BSI with M (SD) scores at baseline, three-, six- and 12-months for controls and MI respectively: 1.61 (0.88), 1.18 (0.87), 1.03 (0.80), 1.12 (0.84) vs 1.77 (0.98), 1.05 (0.87), 0.92 (0.77), 1.01 (0.85). Secondary outcomes: Other drug use. Polydrug use, alcohol and cannabis use fell significantly for the sample as a whole between pretreatment and three-month follow-up (F(1,105) = 9.52, p < 0.01;F (1,60) = 8.07, p < 0.01; F(1,71) = 7.87, p< 0.01, respectively with effect sizes for polydrug use: 0.50, alcohol: 0.63, cannabis: 0.49. The mean number of drug classes used during the month prior to assessment fell 0.42 units among the control group v 0.83 units among the MI group. Reduction in polydrug use was greater in the MI group (M = 0.93, SD = 1.29) compared to the control group (M = 0.42, SD 1.34) at three-months (F(1, 105) = 4.47, p = 0.04). Social functioning. Progressive significant improvement in social functioning over time (F(2,92) = 5.78, p<0.01), with significant improvement between pre-treatment (M = 18.46, SD 5.98) and six-month follow up (M = 17.04, SD 5.31) (p<0.01) and between pre-treatment and 12-month follow up (M = 16.58, SD 5.01) (p < 0.01), for the sample as a whole. MA use: Fell significantly between baseline; M use occasions per day (1.41, SD 1.51) and post-treatment (0.70, SD 1.01) (F (1,148) = 22.64, p < 0.001) and between baseline (1.38, SD 1.47) and six-month follow-up (0.62, SD 1.09) (F(1,146) = 22.11, p < 0.001). No difference between post-treatment (0.58, SD 0.79) and six-month follow-up scores (0.53, SD 0.99). At six-months, mean daily occasions of MA use fell 0.76 units among the control condition vs. 1.04 units among the four session condition (effect size units of 0.55 versus 0.75 respectively, representing a small effect size). % abstinent at six-month follow-up: control group: 17.6% abstinent; two sessions: 33.8% abstinent, AOR = 2.94, p < 0.01; and four sessions: 37.9% abstinent, AOR = 3.08, p < 0.01). All urine samples collected were consistent with self-reported use of MA (on 10 occasions use was reported and detected, on five occasions no use was reported and nil was detected, and on four occasions
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use in the past month was reported but not detected). Four session MI/CBT initial = 66 Attended three or four sessions = 68.2%
Severity of dependence decreased significantly over time for the sample as a whole between pre-treatment (M= (mean 8.10, SD 3.73) and six-month follow-up (M = 6.24, SD 4.25) (F1,146 = 43.60, p<0.001).
Two session MI/CBT initial = 74 Attended both sessions = 75.7%
Psychiatric symptoms: There was a significant reduction over time in overall psychiatric distress on the BSI between pre-treatment (M = 1.43, SD 0.76) and post-treatment (M= 1.18, SD 0.77) (F (1,148) = 22.26, p<0.001) and pre-treatment (M = 1.49, SD 0.78) to six-month follow-up (M = 1.08, SD 0.79) (F(1,142 = 45.90, p<0.001). There were no statistically significant differences between groups on the BSI.
Females (83.3%) significantly more likely than males (60.5%) to complete all treatment sessions allocated (p<0.01)
Significant improvement in depression levels (BDI-II) between pre-treatment (M = 27.19, SD 13.20) and post-treatment (M = 19.35, SD 13.09) (F(1, 148) = 48.61, p <0.001) and between pre-treatment (M = 27.87, SD 13.09) and six-month follow-up (M = 17.95, SD 13.05) (F1,146 = 51.77, p<0.001). No difference between post-treatment (M = 19.22, SD 13.69) and six-month follow-up (M = 17.74, SD 13.42). Extent of reduction in depression was significantly greater at post-treatment with higher number of sessions attended (F(1,148) = 12.49, p<0.001). Over two-thirds of the sample (152 of 214, 71.0%) scored in the moderately to severely depressed range at pre-treatment (i.e. BDI-II scores of 20 or above), compared with less than half at post-treatment (66 of 155, 42.6%) and a similar proportion at the 6-month follow-up (60 of 153, 39.2%).
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Baker, Bucci et al., 2005, 2006
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N = 130 Intervention condition follow-up assessments 15-weeks n = 60 (92.3%). Six-months n = 60 (92.3%). 12-months n = 49 (75.3%). Control condition follow-up assessments 15-weeks n = 61 (93.8%). Six-months n = 63 (96.9%). 12-months n = 55 (84.6%).
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Secondary outcomes: Other drug use. Significant reduction in benzodiazepine use between pre-treatment (M = 3.34, SD 3.97) and posttreatment (M = 1.03, SD 2.05) (F(1,36) 15.28, p<0.001) and at six-month follow-up (M = 0.57, SD 4.40) (F(1,33) = 10.45, p <0.001), no difference between groups. Polydrug use. Overall reduction from pre-treatment (M = 4.30, SD 1.47) to post-treatment (M = 3.83, SD 1.33) (F(1,148) = 10.96, p<0.001) and to 6-month follow-up (M = 3.44, SD 1.46) (F(1,146) = 30.04, p<0.001). Tobacco. There was a significant overall reduction in cigarettes per day between pre-treatment (M = 17.81, SD 12.47) and six-month follow-up (M = 14.68, SD 11.57) (F(1, 146) = 15.58, p<0.001). There were no other significant changes in use of individual classes of drugs among those using them at least weekly at pretreatment. BBV risk: Overall significant decrease in injecting risk-taking behavior from pre-treatment (M = 7.33, SD 5.28) to post-treatment (M = 4.53, SD 4.44) (F(1,138) = 25.65, p<0.001) and from pre-treatment (M = 6.71, SD 5.04) to six-month follow-up (M = 3.71, SD 4.35) (F(1,136) = 29.14, p<0.001). No significant reductions in sexual risk-taking behavior.. MA use: Differential (baseline v. six months) reduction in MA use in intervention condition compared with control ( F(1,18) = .4.70,p = 0.04). Mean daily number of occasions of MA use fell from M = 2.39 (SD 3.71) to M = 0.19 (SD 0.41) in the intervention condition by 1.33 units compared with -0.40 for control, from M = 0.56 (SD 0.60) to M = 1.47 (SD 2.28), representing differential change of 1.73 standardised units (a large effect size). The effect was still strong at 12 months.
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MI/CBT group 8 people completed 0 sessions (12.3%); 11 completed some sessions (16.9%); and 46 completed all 10 sessions (70.7%)
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Psychiatric symptoms: There was a significant overall improvement between baseline and the 12-month assessment on the BPRS mania factor with M (SD) scores for treatment vs control respectively 6.79 (3.77) and 6.07 (1.63) vs 7.39 (3.51) and 5.94 (2.26), representing an overall effect size of 0.44, (F(1,95) = 8.46, p<0.01). There was significant overall improvement between baseline and each of the follow up assessments on BPRS negative symptoms for treatment and controls, with baseline and 12-month M (SD) respectively 7.02 (2.96) and 6.86 (1.36) vs 7.54 (3.41) and 6.58 (2.35) (all F’s >13, p<0.001), representing an overall effect size of 0.51. BDI–II depression scores were also significantly lower at each of the follow up assessments than at baseline, with a significantly more marked reduction between baseline and six-month assessment for intervention than for control, with respective M (SD) 23.47 (12.94) and 14.10 (11.38) vs 13.30 (11.28) and 9.92 (9.29)(0.78 v. 0.28 standardized units, or a half a standard deviation of differential impact, p<.01). Secondary outcomes: Other drug use. Significant time effects for alcohol and polydrug use but no group main effects. Alcohol consumption and polydrug use decreased significantly for sample as a whole, at 15 weeks, six- and 12-month follow ups for the treatment and the control groups. Reduction in alcohol consumption (M, SD) between baseline and 12-month follow up for treatment and control conditions was respectively 6.15 (4.94) to 3.58 (4.80) vs 6.30 (4.49) to 2.19 (3.04), equivalent to an overall effect size change of 0.80 units. Respective M (SD) scores for polydrug use were 3.17 (1.05) to 2.84 (1.18) vs 2.64 (0.90) to 2.19 (1.12) (all F’s > 9, p<0.01), equivalent to an overall effect size change of 0.31 units. Mean daily cannabis decreased by 0.36 standardized units for treatment compared with -0.02 for control (NS). Significant interaction for group x time with deterioration in global functioning between baseline and 12-month assessment for control (M = 71.64 (SD 12.72) to M = 66.28 (SD 11.21) and small improvement in CBT/MI group (M = 66.41 (SD 11.97) to M = 68.45 (SD 9.98), a
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differential impact of over half a standard deviation (0.58) (a moderate effect size).
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McDonell, et al. 2013
N = 176
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Stimulant use: CM (M = 0.91, SD 2.40) reported significantly fewer days of stimulant use during treatment compared to NCC (M = 4.67, SD 7.69 (𝛽 = 2.70, 95% CI = 0.91–4.31, p<.05). At follow-up, CM (M = 1.83, SD 4.94) continued to report lower scores than NCC (M = 3.65, SD 7.15 𝛽 = 2.16, 95% CI=0.18–3.24, p<.05).
Follow-up CM = 52 (57.1%). NCC = 55 (64.7%). Overall, 60.8% of participants completed follow-up measures. During Treatment Significantly fewer CM (38/91, 42%) than NCC control group (55/85, 65%) participants were retained throughout the 12 weeks (p<0.05). Retention: CM 42%, control 65% CM participants retained for fewer weeks (mean= 7.25, SD 4.25) than those in the NCM control group (mean=9.33, SD 3.98)
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Participants in CM group were 2.4 times (95% CI = 1.9–3.0, p <.05) as likely as those in NCC group to submit a stimulant-negative urine sample during the treatment period (three urine tests submitted per week, for 12 weeks). Participants in CM more likely than those in NCC to submit stimulant negative urine test during follow up (46%, 35% respectively; odds ratio = 1.4, 95% CI=1.0–1.9, p<0.05).
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Psychiatric symptoms: BSI. CM (M = 1.04, SD 0.79) reported significantly lower scores during treatment than NCC (M = 1.24, SD 0.71) (𝛽 = 0.25, 95% CI = 0.08–0.43, p<0.05) but not at follow-up, CM (M = 1.17, SD 0.85) vs NCC (M = 1.25, SD 0.79). PANSS. CM group (M = 10.60, SD 2.58) reported significantly lower excitement subscale scores during treatment than NCC (M = 11.69, SD = 3.42) ( 𝛽 = 0.86, 95% CI = 0.11–1.60, p<0.05) but not at follow-up, CM (M = 11.17, SD 3.18) vs NCC (M = 11.57, SD 3.01). Psychiatric hospitalization: Significantly fewer CM (2%) than NCC (10%) participants were admitted during the six months following randomization (𝜒2 = 5.4, df=1, p = 0.02). Secondary outcomes: Days of alcohol use. CM (M = 1.84, SD 4.77) reported significantly fewer use days during treatment compared to NCC (M = 4.32, SD 8.43) (𝛽 = 2.44, 95% CI = 0.60–4.29, p<0.05) but not at follow-up CM (M = 3.60, SD 7.92) vs NCC (M = 4.21, SD 7.86). HIV risk behavior. Injecting drug use. CM were less than one-third as likely to report engaging in injecting drug use during treatment compared to NCC (odds ratio = 3.3, 95% CI = 1.8–5.9, p<0.05) but not during follow-up.
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N = 155 (seven SCID interviews were missing, resulting in a final sample of 155 interviews upon which analyses of SCID and BDI total scores were tested).
MA use: Across all treatments, significant reductions in recent self-reported days of MA use were observed across all time points. Baseline (M = 9.6 days; SD 7.4) to week 16 (M = 2.4 days, SD 5.3), week 26 (M = 2.2 days, SD 4.8), and week 52 (M = 3.6 days, SD 6.4; (F (3, 505) = 44.1, p <.0001). (Urine samples were only taken during treatment).
CBT – attended 40.8% of 48 possible sessions.
Psychiatric symptoms: BDI at baseline indicated at least mild depressive symptoms for 73.2% of participants. Of 153 baseline BDI scores, 44 (28.5%) were in the moderate to severe range (M = 25.0, SD 5.6); 69 (44.8%) mild to moderate range (M = 13.7, SD 2.3); and 41 (26.6%) depression to minimal depression range (M = 5.5, SD 2.7). No statistically significant differences between treatment conditions for severity of reported depressive symptoms at baseline, 16, or 26 weeks. At 52-week follow-up, CBT condition had higher BDI scores (M=10.3, SD 7.8) than participants in other conditions (but had higher scores at baseline). All participants reported significant decreases in depressive symptoms from baseline to end of treatment. Most of the decrease occurred in the first month, with the largest drop in BDI scores being in the period between baseline and the first week (t(139) = 9.1, p<0.001).
CM – Average amount earned per participant was $415 (potential was $1277) CBT + CM – 73.8% of total possible CBT sessions and earned $662 in vouchers (potential was $1277).
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Gay-CBT – attended 55.8% of total possible sessions.
The criteria for life-time mood disorder (based on SCID scores) was met in more than one-half (52.9%) of participants, with 28.4% of the sample meeting criteria for a lifetime major depressive disorder (MDD).
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Urine samples indicating recent use of MA predicted future high BDI scores and samples documenting recent prior abstinence of MA predicted future low BDI scores (F (1, 968) = 18.6, p<.0001). BDI scores did not predict future MA use. Secondary outcomes: None reported. Polcin, et al. 2014
Two-month follow-up Intensive MI = 91.5% Standard MI = 94.6%
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Four-month follow-up Intensive MI = 91.5% Standard MI = 88.3% Six-month follow-up Intensive MI = 91.5% Standard MI = 93.7% Sessions attended (M, SD) Intensive MI Outpatient sessions (TAU) = 14.3 (1.0) MI sessions = 5.3 (0.3) Standard MI Outpatient sessions (TAU) =14.7 (1.1) MI sessions = 4.2 (0.3)
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MA use: Percent of days abstinent increased significantly in both groups across all time points. In the Standard MI group, average baseline scores (M = 0.55, SE 0.04) increased at two months (M = 0.74, SE 0.04), at four months (M = 0.76, SE 0.03) and increased at six months (M = 0.78, SE 0.03) (p<0.001). Similar changes were found in the Intensive MI group at baseline (M = 0.56, SE 0.04), two months (M = 0.74, SE 0.03), four months (M = 0.75, SE 0.03) and six months (M = 0.75, SE 0.03) (p<0.001). There were no differences between treatment conditions. Similarly, average ASI Drug Scores fell significantly from baseline to each follow-up occasion for both conditions, (Adjusted r for SMI = -0.08, p<0.001, IMI = -0.06, p<0.002) with no differential reduction between the two intervention conditions. Concordance between self-reported drug use and urine screens ranged from 86.5% to 90% across data collection time points.
N = 217 completed
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Psychiatric symptoms: ASI psychiatric status score was significantly reduced from baseline to follow-ups for IMI condition (-0.06, p<.0.05) but not for the SMI condition (Adjusted r = -0.01). Similarly, there was a significant reduction in depression for the IMI condition (Adjusted r = -0.67, p<0.01) vs. no reduction in depression for Standard MI.
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(Intensive MI condition attended significantly more MI sessions than Standard MI attended nutrition sessions p<0.01)
Anxiety status. No significant reductions over time and no differences between SMI and IMI groups. Number of days had psychiatric problem: Higher at baseline in IMI than SMI. Scores in SMI group were relatively consistent at baseline (11.40, SE = 1.11), 2-months (11.76, SE = 1.17), 4-months (11.36, SE = 1.14) and 6-months (11.88, SE = 1.27). Scores in IMI group significantly dropped across time points (p<0.01): baseline (15.70, SE = 1.08), 2-months (12.50, SE = 1.18), 4-months (12.72, SE = 1.22) and 6-months (10.80, SE = 1.08). Secondary outcomes: None reported.
PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE Journal Pre-proof Rawson, et al. 2004
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N = 978 During treatment (for total sample): 798 (81.6%) completed discharge interviews. 841 (86%) completed 6-month interviews. 12-month data not available
MA use: Matrix participants provided significantly more MA-free urines in the first 12 weeks of their treatment (4.3 vs 3.3, p< 0.05, statistics not reported). During treatment, Matrix participants, compared to TAU, were 31% more likely to have MA-free urine test results (odds ratio = 1.311). During treatment the Matrix condition had longer mean periods of abstinence than TAU in two of the 8 sites: Site 3 (Matrix M=3.013, SD=4.028 vs TAU M=1.805, SD=1.805, SD=3.763) and Site 5 (Matrix M=3.429, SD=4.467 vs TAU M=1.279, SD=2.274) both p’s <0.05. At discharge, the Matrix Model had 66% MA-free urine samples, and 69% of urine samples were MA-free in TAU. At 6-month follow-up, both groups had 69% MA-free urine samples.
Treatment completion rate Matrix = 40.9% TAU = 34.2% This difference was statistically significant (p <0.05)
Similarly, self-reported MA use was reduced during treatment over time, with no significant differences by treatment condition, mean number of days of MA use at baseline M = 11.3, discharge M = 4.3, 6-month follow-up M = 4.4 and for TAU mean number of days of MA use at baseline M = 11.8, discharge M = 4.4, 6-month follow-up, M = 4.0. (Ftime = 124.43, p <.0001). Overall, self-reported number of days of MA use in the past 30 days was reduced from 11 days at baseline to slightly over 4 days at discharge, and this reduction was maintained at 6-month follow up.
Clinical contacts (M, SD) TAU = 12.7 (14.7) Matrix Model = 26.8 (19.7)
Psychiatric and secondary symptoms; All ASI domains except for the medical scale showed significant improvement across treatment. Significant reductions from baseline were seen at 6-month follow-up in the family, drug, psychiatric and alcohol areas, with no differences between treatment conditions (statistics not reported).
N = 177
MA use: During treatment, the mean number of stimulant free urines for CM and CBT + CM treatment conditions was significantly higher than for CBT only (F = 10.0 (df = 2, 176), p<0.0001). The CBT + CM group gave the most stimulant-free samples (M=28.6), followed by CM (M = 27.6). CBT had the lowest stimulant-free samples (M=15.5) across the 16 weeks. A 3-week criterion of consecutive abstinence revealed significant differences between groups (χ2=15.5, df=2, n=177, p<0.0001) with pairwise comparisons made between CBT (34.5%) vs CM (60.0%; χ2 =14.9, df = 1, n = 97, <0 .0001) and CBT vs CBT + CM conditions (69.5%; χ2=18.4, df=1,n=97, p<0.0001). In comparing the CM and CM+CBT conditions, no significant differences in abstinence were found. During the follow-up period, all three groups had between 67% and 79% stimulant-free samples across all time-points, with no differences between conditions.
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Discharge, 26 and 52-week follow-up rates n (%) CM – 45 (75.0%), 46 (76.7%), 45 (75.0%) CBT – 47 (81.0%), 44 (75.9%), 45 (77.6%) CM + CBT 46 (78.0%), 49 (83.1%), 48 (81.4%) There were no significant differences between groups in followup rates.
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There was a significant main effect for all three treatment groups with regard to the reduction in the mean number of days participants reported using MA from the month preceding admission interviews to the month preceding the treatment-end (week 17) interviews (F=3.9, df=3, n= 106, p < 0.01). There were no between group differences.
Mean (SD) weeks retained in treatment CM = 12.6 (5.2) 63% completed 16 weeks.
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CBT = 9.0 (6.5), 40% completed 16 weeks CM+CBT = 12.0 (5.6), 59% completed 16 weeks
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Mean numbers completing treatment were significantly higher in the CM and CM + CBT groups compared to CBT (p<0.05)
Participants in the CM + CBT group attended more CBT sessions (26.5, 15.3) compared to CBT only (19.0, 15.4), p<0.01 Mean number of sessions attended = 19.0, SD = 15.4
Psychiatric and secondary outcomes: At week 17 study participants reported statistically significant overall reductions in problems related to employment, alcohol, drugs, family/social, and psychiatric domains, but not in the legal or medical scales. CM participants had significantly lower psychiatric scores at week 17 than those in CM or CBT + CM conditions (CM: M = 0.12, SD=0.2; CBT: M = 0.22, SD=0.2; CBT + CM: M = 0.24, SD=0.2; p < .05 (statistics not given)). Sustained treatment effects were seen at the later follow-ups in drug use, psychiatric severity and family scores, with no significant differences between groups.
PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE Journal Pre-proof Smout, et al. 2010
N = 104
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MA use: Significant within-group reductions in self-reported MA use for CBT Baseline: median = 5.7, SD = 9.3; 12 weeks: median = 0.3, SD = 1.0, 24 weeks: median = 0.4, SD = 2.9) and for ACT (Baseline: median = 6.0, SD = 7.0, 12 weeks: median = 0.2 SD = 3.0, 24 weeks: median = 0.8, 1.8). Significant within-group reductions in MA dependence and negative consequence scores (CBT: Baseline, median = 107.0, SD = 117.0, 12 weeks: median = 15.0 SD = 30.0), 24 weeks, median = 4.5 SD = (15.0)) in both groups (ACT: Baseline, median = 103.0 SD = 99.0, 12 weeks, median = 12.0 SD = 29.0, 24 weeks, median = 6.0 SD = 39.0) from baseline to 12 weeks. Statistical significance for CBT group for MAfree hair samples (%). CBT: Baseline: 96.2%, 12 weeks: 57.1%, 24 weeks: 63.6%. ACT: Baseline: 86.3%, 12 weeks: 66.7%, 24 weeks: 50%). Between 12 and 24 weeks there were no significant within group changes except for a significant further reduction in negative consequences for the CBT condition (t(107) = 2.2, p = 0.03), and showed only a trend toward improvement for ACT (t(107) = 1.8, p = 0.08).
In-Treatment and Follow-up data: Four-weeks: CBT = 41.5% ACT = 37.3% 8-weeks CBT = 26.4% ACT = 13.7%
Psychiatric symptoms: BDI-II scores were significantly reduced across time CBT: Baseline: M = 25.7, SD = 11.2, 12 weeks: M = 17.7, SD = 12.2, 24 weeks: M = 14.1, SD = 14.8, ACT: Baseline: M = 27.8, SD = 10.3, 12 weeks: M = 15.4, SD = 13.6, 24 weeks: M =16.9, SD = 16.3 from baseline to 12 weeks (F (2, 51) = 32.16, p < .01). There were no significant changes between 12 and 24 weeks. SF-12 scores significantly reduced across time, (CBT: Baseline: M = 30.5, SD = 9.7, 12 weeks: M = 40.8, SD = 11.6, 24 weeks: M = 40.9, SD = 15.4. ACT: Baseline: M = 30.3, SD = 8.1, 12 weeks: M = 44.3, SD = 10.4, 24 weeks, M = 44.2, SD = 12.7) from baseline to 12 weeks (F (2, 52) = 28.59, p<0.01).
Post-intervention: CBT = 32.1% ACT = 27.5%
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24-week follow-up: CBT = 28.3% ACT = 19.6%
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Secondary outcomes: There were significant changes between baseline and follow-up for the sample as a whole in the physical scale scores of the SF12 (F(1, 52) =4.81, p < 0.05), and, for the CBT group, in the self-reported number of other drugs used.
Provided any post-intervention data (overall) - 29.8%
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61% of treatment starters attended at least 4 sessions
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Note: ACT = Acceptance and Commitment ASI = Addiction Severity Index, BBV = Blood Borne Virus, BDI-II = Beck Depression Inventory, BPRS = Brief Psychiatric Rating Scale, BSI = Brief Symptom Inventory, CBT = Cognitive Behaviour Therapy, CM = Contingency Management, GAF = Global Assessment of Functioning, GCBT = Gay specific Cognitive Behaviour Therapy, GHQ-28 = General Health Questionnaire, GSI = Global Severity Index, HIV = Human Immunodeficiency Virus, IMI = Intensive Motivational Interviewing, ITT = Intention to Treat Analysis, M = mean, MA = methamphetamine, MI = Motivational Interviewing, NCC = non-contingent control condition, OTI = Opiate Treatment Index, PNSS = Positive and Negative Symptom Scale, SCID = Structured Clinical Interview, SD = standard deviation, SE = standard error, SMI = Standard Motivational Interviewing, TAU = treatment as usual
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Journal Pre-proof PSYCHOLOGICAL TREATMENT FOR METHAMPHETAMINE
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Highlights Regular methamphetamine use is associated with psychiatric symptoms A variety of psychological treatments are effective in reducing levels of methamphetamine use and improving psychiatric symptoms in this population There is accumulating evidence that more intensive treatment is more effective than minimal or less intensive comparison conditions in reducing methamphetamine use and improving psychiatric symptoms.
Figure 1