Enduring effects of a computer-assisted training program for cognitive behavioral therapy: A 6-month follow-up of CBT4CBT

doi:10.1016/j.drugalcdep.2008.09.015

Drug and Alcohol Dependence

Volume 100, Issues 1–2, 1 February 2009, Pages 178-181

https://doi.org/10.1016/j.drugalcdep.2008.09.015 Get rights and content

Abstract

Objectives

To evaluate the durability of effects of a computer-assisted version of cognitive behavioral therapy (CBT) as treatment for substance dependence through a 6-month follow-up.

Methods

Following a randomized clinical trial in which 73 individuals seeking outpatient treatment for substance dependence in an outpatient community setting were randomized to either standard treatment-as-usual (TAU) or TAU with 8 weeks of biweekly access to computer-based training for CBT (CBT4CBT), participants were interviewed 1, 3, and 6 months after the termination of study treatments.

Results

Sixty of the 73 participants were reached for follow-up (82%); follow-up rates and availability of data were comparable across treatment conditions. Random regression analyses of use across time indicated significant differences between groups, such that those assigned to TAU increased their drug use across time while those assigned to CBT4CBT tended to improve slightly. The durability of the CBT4CBT effect remained even after controlling for treatment retention, treatment substance use outcomes, and exposure to other treatment during the follow-up period.

Conclusions

Computerized CBT4CBT appears to have both short-term and enduring effects on drug use.

Introduction

Cognitive behavioral therapy (CBT) has a comparatively strong level of empirical support among substance use disorders (Carroll and Onken, 2005, DeRubeis and Crits-Christoph, 1998, Dutra et al., 2008, Irvin et al., 1999) and its effects appear to be particularly durable. For example, a 1-year follow-up of cocaine-dependent individuals treated with CBT indicated that they continued to make significant reductions in use, even after controlling for exposure to other treatments (Carroll et al., 1994). This ‘sleeper’ effect has since been replicated in several studies (Carroll et al., 2006, Epstein et al., 2003, Rawson et al., 2002). However, despite strong empirical support for CBT, it is still rarely implemented in community-based settings. Among the barriers to the implementation of CBT in clinical settings are the relative complexity of the approach itself; high caseloads resulting in limited opportunities for clinicians to provide individual therapy to patients; the time and cost of training as well as the high rates of turnover among substance use clinicians; and the relative lack of established CBT training programs and ongoing supervision for clinicians. To address this issue, we developed a six-module, multimedia computer-based version of CBT (“CBT4CBT”) and conducted a randomized clinical trial demonstrating its efficacy as an adjunct to standard outpatient treatment among a heterogeneous group of drug-dependent individuals (Carroll et al., 2008). During the 8-week treatment period, participants assigned to the CBT4CBT condition had significantly longer periods of abstinence and submitted significantly fewer drug-positive urine specimens than those assigned to TAU.

However, an important and rarely studied question regarding computer-assisted training methods is the durability of their effects. If the emerging promise of computer-assisted treatments (Tumur et al., 2007) is to be realized, it is crucial that these approaches be demonstrated to have clinically meaningful and sustained effects. The few existing studies evaluating the durability of effects from computer-assisted treatment have been positive, but limited by loss to follow-up and reliance on self-reported outcomes (Andersson et al., 2005, Spek et al., 2008, Wright et al., 2005). In this report we describe main outcomes from a 6-month follow-up study of a randomized clinical trial of CBT4CBT. Based on the existing literature supporting the durability of CBT effects (Carroll et al., 1994), the primary hypothesis was that individuals assigned to CBT4CBT would maintain reduced frequency of substance use and submit fewer positive urine toxicology screens than those randomized to TAU.

Section snippets

Participants

Participants were recruited from individuals seeking treatment at a community-based outpatient substance abuse treatment provider in Bridgeport, CT. Participants were English-speaking adults who met DSM-IV criteria for any current substance dependence disorder. Exclusion criteria were minimized to facilitate recruitment of a clinically representative group of individuals seeking treatment in community settings. The CONSORT diagram,¹

Follow-up sample

Of the 73 who were exposed to their study treatment, 60 were followed at least once. There were no significant differences by condition in rates of follow-up, data availability or length of time covered during the follow-up (mean 154.4 days for CBT4CBT and 146.6 for TAU, F(1) = 0.51, p = .48). One participant in the TAU condition died during the follow-up period. There were no significant differences between those who were reached for follow-up and those who were not reached in terms of baseline

Discussion

This 6-month follow-up of a computer-assisted training program in CBT for addictions demonstrated that the CBT4CBT program was associated with enduring benefit detectable up to 6 months after the end of treatment. Evidence for the enduring efficacy of CBT4CBT relative to standard treatment was detectable not only in self-report but also through biological measures (urine specimens at 1 month). Participants assigned to CBT4CBT tended to maintain or increase the gains they had achieved during

Conflict of interest

Drs. Carroll and Rounsaville are members of Applied Behavioral Research, which produces clinician training materials unrelated to the CBT4CBT program. The Yale University Office of Cooperative Research has filed a provisional patent application for the program. Drs. Ball, Martino, Nich and Babuscio have no conflicts to declare.

Acknowledgements

We gratefully acknowledge the support of John Hamilton, Cary Ostrow, the staff and leadership of Liberation Programs, Inc., Melissa Gordon and Galina Portnoy of Advanced Behavioral Health, and Patrick Leone, Craig Tomlin, and Doug Forbush of Yale CMI².

Funding source: Support was provided by NIDA grants R37-DA 015969 (KMC), K05-DA00457 (KMC), K05-DA00089 (BJR), and P50-DA09241. NIDA had no further role in study design, in the collection, analysis and interpretation of data in the writing of the

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^☆: A CONSORT diagram for the trial can be viewed by accessing the online version.

^☆☆: Clinical trials.gov ID NCT00350610.

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Short communicationEnduring effects of a computer-assisted training program for cognitive behavioral therapy: A 6-month follow-up of CBT4CBT☆,☆☆

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Participants

Follow-up sample

Discussion

Conflict of interest

Acknowledgements

Internet-based self-help for depression: randomized controlled trial

British Journal of Psychiatry

Application of hierarchical linear models to assessing change

Psychological Bulletin

A Cognitive-Behavioral Approach: Treating Cocaine Addiction

Computer-assisted cognitive-behavioral therapy for addiction. A randomized clinical trial of ‘CBT4CBT’

American Journal of Psychiatry

The use of contingency management and motivational/skills-building therapy to treat young adults with marijuana dependence

Journal of Consulting and Clinical Psychology

Behavioral therapies for drug abuse

American Journal of Psychiatry

One year follow-up of psychotherapy and pharmacotherapy for cocaine dependence: delayed emergence of psychotherapy effects

Archives of General Psychiatry

Empirically supported individual and group psychological treatments for adult mental disorders

Journal of Consulting and Clinical Psychology

A meta-analytic review of psychosocial interventions for substance use disorders

American Journal of Psychiatry

Short communication
Enduring effects of a computer-assisted training program for cognitive behavioral therapy: A 6-month follow-up of CBT4CBT☆,☆☆