Effects of brief cognitive behavioral therapy on mental health in substance-related disorder: a randomized controlled trial

Substance Use Disorder (SUD) is among the leading healthcare challenges on a global scale [1]. The International Classification for Disease-11th Revision (ICD-11) by the World Health Organization (WHO) defines opioid dependency as a condition of opioid use regulation arising from recurrent or chronic opioid usage, which is characterized by the patient’s diminished ability to regulate usage, compounded by a growing preference for opioid use over other activities, and continued opioid use despite damage to health or subsequent adverse effects [2]. In North America, the term opioid use disorder, as per the definition in the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) published by the American Psychiatric Association, is commonly referred to as opioid dependency [3]. Since 1990, as a result of population growth and aging, the prevalence of opioid use disorders and age-standardized prevalence of opioid use disorders have increased significantly throughout the world in as such that in 2016, the prevalence of opioid use was 26.8 million cases [4]. Despite anti-SUD programs and policies, the incidence rate of SUD has yet to decrease. Among the various existing narcotic substances, opioid drugs are the most prevalent, severely causing global concern as stated in the global burden of disease (GBD) program report, which indicates that South Asia has one of the most concerning statistical spikes in terms of opioid use [1]. Illicitly manufactured heroin has been the predominant opioid used for non-medical purposes in most countries, except source nations and their bordering neighbors, as best typified by Afghanistan and Iran, where traditionally raw opium usage is a concern, albeit, in recent years, heroin injection has been on the rise in the aforementioned countries [5].

While mental health issues are significant comorbidities among non-medical prescription opioid users [6], anxiety and depression are the most commonly observed mental health problems in opioid use disorder [7].

Cognitive behavioral therapy (CBT) has proved to be an effective solution to a wide range of mental health disorders [8]. This could be attributed to the fact that CBT is a time-limited, multisession strategy that targets cognitive, affective, and environmental risks for substance abuse and teaches behavioral self-control skills to assist a person to achieve and maintain abstinence or reduce the risk of harm [9]. Moreover, CBT can significantly increase the self-esteem and self-efficacy of patients, improve coping skills, and enhance the individuals’ learning of behavioral skills to avoid substance abuse [10‐12]. Previous studies revealed that CBT significantly reduces substance use temptations, the patients’ capability to take responsibility for the consequences of such temptations, and the quantity and frequency of opiate consumption [9, 13].

Brief CBT refers to reducing CBT content and condensing the standard 12–20 session duration into a shorter period of four to eight sessions focusing on a specific patient’s problem. It is believed that time-limited therapy might provide an added impetus for patients and therapists to operate with heightened efficiency and efficacy [14]. Previous studies highlighted the efficacy of brief CBT in different disorders, including anxiety, depression, eating disorders, and schizophrenia [15‐18]. Brief CBT can also aid in alleviating symptoms, such as chronic pain, and has been found to be effective in reducing substance use and mitigating associated negative impacts [19‐21]. International guidelines suggest opioid substitution treatment with long-acting opioids (methadone or buprenorphine) as the first-line pharmacological therapy for opioid dependency [22]. While CBT is the first-line treatment for SUD, pharmacotherapy, and CBT co-treatment are proposed as a gold standard for the treatment of SUD [23].

The forty opioid users were divided into two groups: (a) the control group (n = 20) and (b) the intervention group (n = 20). The mean age for the control group was 37.95 ± 7.64, while the mean age for the intervention group was 43.85 ± 9.92. There was a statistical difference between groups regarding age (p = 0.042). Demographic data is summarized in Table 2. There was no significant statistical difference in terms of gender and levels of education. However, both groups were statistically different regarding marital status and occupation.

There was no statistically significant difference among both groups in terms of all subclasses of GHQ-28 and the total score before the intervention, except in terms of social dysfunction. However, the researchers observed a statistically significant difference in social dysfunction, anxiety, and insomnia, in addition to a difference in the GHQ-28 total score between the control and intervention groups after brief CBT. The results are shown in Table 3.

Due to the statistically significant differences among both groups in terms of occupation, marital status, and social dysfunction, the authors utilized the Poisson regression model. After adjusting the effect of occupation and marital status, the multiple Poisson regression model results revealed no statistically significant difference (p < 0.05) for the mean value of social dysfunction among the control and intervention groups before CBT (Table 4).

Table 5 shows the results of the comparison between each group at the beginning and the end of the survey. The GHQ-28 results showed no significant difference in overall subclasses and total scores in both time intervals. However, the level of anxiety and insomnia showed a statistically significant decline in the intervention group after four sessions of CBT. Other subclasses and the total score showed no statistically significant difference in the intervention group before and after CBT.

The researchers applied a Likert scale for scoring, in which the cut-off score was determined to be 23. There was no statistically significant difference in terms of psychotic and non-psychotic opioid users in the intervention group before and after CBT (Table 6). However, the control and intervention groups statistically differed after CBT.

A significant effect of SUD, which the current researchers focused on, is its impact on psychiatric comorbidities, specifically anxiety and insomnia. Treating individual patients using novel SUD management techniques effectively decreases the susceptibility of society to opiate abuse as a whole and can be utilized as a preventative measure. In recent decades, several clinical trials using traditional treatment methods were carried out, yet they were proven to be ineffective; by contrast, CBT has proven effective in treating various mental disorders, including substance abuse. In the current study, the researchers examined the efficiency of brief CBT on mental disorders in SUD and concluded that the application of the treatment is effective on insomnia and anxiety among opiate users.

The results in Table 3 display the GHQ_28 total score difference between the intervention and control groups. While GHQ-28 scores showed no statistically significant difference among both groups during the study period, the scores for anxiety and insomnia among the intervention group decreased significantly after CBT. The results are summarized in Table 5. It was observed that the difference between the total scores before and after CBT in the intervention group was not statistically significant (p = 0.052), possibly due to the small sample population. According to Table 6, the number of psychotic patients did not show any significant statistical difference among both groups before the intervention. However, after four sessions of CBT, the psychotic patients of the intervention group declined (insignificantly, at a p-value of 0.077, which can also be a result of the small sample size); this in itself resulted in a significant difference among both two groups. An essential aspect of the study was CBT’s effect on psychiatric comorbidities of SUD. The researchers found that patients were significantly less morbid after four sessions of CBT, which could be attributed to the primary effect of CBT and chiefly associated with the effect of CBT on reducing the consumption of opiates.

Sitnikova et al. (2019) studied the effectiveness of six sessions of CBT on patients with undifferentiated somatoform disorder. The study found no difference between CBT and standard care regarding the severity of somatic symptoms [31], which in itself was similar to the current study’s findings. Liu et al. (2019) performed a meta-analysis to investigate the effect of CBT on medically unexplained physical and somatoform symptoms. The results show that CBT can significantly reduce anxiety, depression, and social function [32]. The results of Liu’s study contradicted the findings of the current study (except for anxiety), which could be related to substance withdrawal since other groups of psychological patients were not included in the study.

Zhang et al. (2016) investigated the efficacy of 12 weeks of group CBT among patients with mild depression and found improvement in terms of social functioning, which was in contrast with the current study’s findings [33]. The reason for the discrepancy might be due to different studied illnesses and the duration of CBT.

Kamarzarin et al. (2019) investigated SUD patients and found that depressive behaviors after CBT significantly improved; however, in the present study, such an effect was not observed [34]. The differences between brief and long CBT interventions for depression might explain the variation in depression symptoms in the abovementioned study and the current study. In another study by Bador and Kerekes (2020), the effect of integrated intensive CBT (five days a week within a four-month period) during addiction care was evaluated and revealed that an improvement in the extent of depression among the studied patients occured [35]. The results of Bador’s study directly contrasted the current study’s findings, which might be due to the intensity and duration of the CBT.

Speed et al. (2022) carried out a randomized controlled trial among 21 patients with substance use disorder to compare the efficacy of eight sessions of group-based CBT with nine hours of behavioral health sessions on insomnia. It was observed that insomnia symptoms were reduced in both groups over time; however, the decline rate in the CBT group was higher as compared to the control group (80% versus 25%) [36]. The results were in line with the current study. A pilot investigation was further conducted among veterans identified with cannabis use disorder, whereby it was observed that the utilization of the CBT Coach mobile application (two-week intervention) had positive outcomes in terms of diminishing cannabis consumption and enhancing sleep quality [37], which was in line with the current study.

CBT is also considered to be an effective first-line treatment option for anxiety [38]. Cully et al. (2017) investigated medically ill veterans to study the efficacy of eight sessions of brief CBT. The study revealed that brief CBT improved the symptoms of anxiety among the studied patients [39], which was in line with the current study’s findings. Golshani et al. (2020) carried out a systematic review and meta-analysis of CBT psychiatric effects on Infertile Iranian females before and after CBT. The results prove CBT’s positive effect on anxiety [40], which was in itself aligned with the current study’s findings.

The effect of brief CBT has yet to be investigated extensively. Roos et al. (2020) performed a review study of clinical trials to differentiate CBT’s short-term and long-term effects on SUD patients and evaluate computer-based CBT on brief or long-term outcomes. The results showed that long-term effects on coping skills were more significant than short-term outcomes [41]; hence, the results of the current study can be discussed in light of CBT’s effect on patients’ awareness of themselves and their situation, in addition to an increase in self-esteem and self-efficacy.

The results of the current study show that brief CBT is effective on psychiatric health, especially anxiety and sleep disorders, but not on patients’ depression, somatic symptoms, and social dysfunction. The researchers believe that in the future, brief CBT could aid psychiatrists and psychologists to control anxiety and sleep disorders. The short timeframe of the intervention used in the current study can increase the cooperation of the SUD patients; moreover, controlling anxiety by implementing brief CBT for SUD patients can improve their quality of life.

The main limitation imposed on the current investigation was the low study population. The researchers highly recommend studying CBT efficacy in SUD among larger populations. It is also recommended that future studies focus on the differences between brief and long-term CBT in SUD. The present study has not determined the efficacy of brief CBT on patients’ consumption and recurrence. Another limitation of the current study is the short-term follow-up duration, for which the authors highly recommend a longer follow-up duration for future studies; moreover, computerized CBT should be the pivot for further studies, and these studies should include more female patients in order to investigate the efficacy of brief CBT among women.