Copyright 2001 by the American Psychological Association, Inc. 0022-006X/01/S5.00 DOI: 10.1037//0022-006X.69.5.825
Journal of Consulting and Clinical Psychology 2001, Vol. 69, No. 5, 825-830
BRIEF REPORTS
Impact of Psychosocial Treatments on Associated Problems of Cocaine-Dependent Patients Roger D. Weiss and David R. Gastfriend
Paul Crits-Christoph, Lynne Siqueland, and Elizabeth McCalmont
Harvard University
University of Pennsylvania
Arlene Frank
Karla Moras and Jacques P. Barber
Brookside Hospital
University of Pennsylvania
Jack Elaine National Institute on Drug Abuse
Michael E. Thase Western Psychiatric Institute and Clinic/University of Pittsburgh
A previous report from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study (P. Crits-Christoph et al., 1999) found relatively superior cocaine and drug use outcomes for individual drug counseling plus group drug counseling compared with other treatments. Using data from that study, the authors examined the relative efficacy of 4 treatments for cocaine dependence on psychosocial and other addiction-associated problems. The 487 patients were randomly assigned to 6 months of treatment with cognitive therapy, supportive-expressive therapy, or individual drug counseling (each with additional group drug counseling), or to group drug counseling alone. Assessments were made at baseline and monthly for 6 months during the acute treatment phase, with follow-up visits at 9 and 12 months. No significant differences between treatments were found on measures of psychiatric symptoms, employment, medical, legal, familysocial, interpersonal, or alcohol use problems. The authors concluded that the superiority of individual drug counseling in modifying cocaine use does not extend broadly to other addiction-associated problems.
Evidence has emerged for the efficacy of a variety of psychosocial treatments for cocaine dependence (Carroll, Nich, & Rounsaville, 1995; Higgins et al., 1994). However, the effects of these
treatments on the associated problems of cocaine-dependent patients has rarely been examined. Although reduction in cocaine use is the primary concern, the broader impact of treatments also is
Paul Crits-Christoph, Lynne Siqueland, Elizabeth McCalmont, Karla Moras, and Jacques P. Barber, Department of Psychiatry, University of Pennsylvania; Roger D. Weiss and David R. Gastfriend, Department of Psychiatry, Harvard University; Arlene Frank, Brookside Hospital, Nashua, New Hampshire; Jack Blaine, Treatment Research Branch, National Institute on Drug Abuse, Bethesda, Maryland; Michael E. Thase, Department of Psychiatry, Western Psychiatric Institute and Clinic/University of Pittsburgh. The National Institute on Drug Abuse (NIDA) Collaborative Cocaine Treatment Study is a cooperative agreement involving four clinical sites, a coordinating center, and NIDA staff. The coordinating center at the University of Pennsylvania includes Paul Crits-Christoph (Principal Investigator; PI), Lynne Siqueland (Project Coordinator), Karla Moras (Assessment Unit Director), Jesse Chittams, Robert Gallop (Director of Data Management), and Larry Muenz (Statistician). The collaborating scientists at the Treatment Research Branch, Division of Clinical and Research Services, at NIDA include Jack Blaine and Lisa Simon Onken. The four participating clinical sites are the University of Pennsylvania, with Lester Luborsky (PI), Jacques P. Barber (co-principal investigator; CO-PI), and Delinda Mercer (Project Director); Brookside Hospital/Harvard Medical School, with Arlene Frank (PI), Stephen F. Butler (CO-PI/Innovative Training Systems), and Sarah Bishop (Project Director); McLean, Massachusetts General Hospital—Harvard University Medical School, with Roger D. Weiss (PI), David R. Gastfriend (CO-PI), Lisa M. Najavits, and Margaret L. Griffin (Project Directors); and the University of Pittsburgh/
Western Psychiatric Institute and Clinic, with Michael E. Thase (PI), Dennis Daley (CO-PI), Ishan M. Salloum (CO-PI), and Judy Lis (Project Director). The training unit includes heads of the Cognitive Therapy Training Unit Aaron T. Beck (University of Pennsylvania) and Bruce Liese (University of Kansas Medical Center); heads of the Supportive-Expressive Therapy Training Unit Lester Luborsky and David Mark (University of Pennsylvania); head of the Individual Drug Counseling Unit George Woody (Veterans Administration/ University of Pennsylvania Medical School) and heads of the Group Drug Counseling Unit Delinda Mercer (Head), Dennis Daley (Assistant Head; University of Pittsburgh/Western Psychiatric Institute and Clinic), and Gloria Carpenter (Assistant Head; Treatment Research Unit University of Pennsylvania). The monitoring board includes Larry Beutler, Jim Klett, Bruce Rounsaville, and Tracie Shea. The contributions of John Boren and Deborah Grossman, NIDA, the project officers for this cooperative agreement, are also gratefully acknowledged. The preparation of this article was funded in part by NIDA Grants U01-DA07090, U01-DA07663, U01-DA07673, U01-DA07693, and U01DA07085; by National Institute of Mental Health Clinical Research Center Grant P30-MH-45178; and by NIDA Career Development Awards K05DAGO 168 and K02-DA 00326. Correspondence concerning this article should be addressed to Paul Crits-Christoph, 3535 Market Street, Room 650, Philadelphia, Pennsylvania 19104. Electronic mail may be sent to
[email protected].
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important. Reduction in associated medical, legal, and employment problems can diminish societal costs, whereas psychiatric and interpersonal problems may be intertwined with substance use and may serve as triggers of relapse. The few existing studies that have examined the impact of treatments for cocaine dependence on associated problems have generally failed to find treatment differences on these measures, despite the superiority of one of the treatments in reductions in cocaine and drug use. Behavioral therapy with incentives (contingent on cocaine-free urines) was found to produce significantly greater reductions in cocaine use compared with drug counseling, but comparable (not significantly different) improvements in alcohol, family-social, and psychiatric problems (Higgins et al., 1995). Similarly, Higgins et al. (1994) reported that behavioral treatment with incentives was not significantly different at posttreatment from behavioral treatment without incentives on measures of medical, employment, alcohol, legal, family-social, or psychiatric problems, although the incentives condition reduced cocaine use significantly more. In a comparison of relapse prevention with interpersonal psychotherapy, Carroll, Rounsaville, and Gawin (1991) reported no significant differences between treatments on changes in medical, employment, alcohol, legal, and family-social problems, but they reported a significant advantage of relapse prevention on changes in psychological problems. In a 2 X 2 design that involved a psychotherapy factor (relapse prevention vs. clinical management) crossed with a pharmacotherapy factor (desipramine vs. placebo), Carroll et al. (1994) found no treatment effects either on primary (cocaine use) or on secondary (medical, employment, alcohol, legal, family-social, psychological) outcomes at termination. One-year follow-up from this study revealed that relapse prevention resulted in less cocaine use compared with clinical management, but with comparable outcomes in regard to associated problems (medical, alcohol, psychological; Carroll et al., 1994). However, in a subsequent report from this study, Carroll et al. (1995) reported that desipramine reduced depressive symptoms more than placebo did, but cognitivebehavioral relapse prevention therapy was not associated with greater reductions in depressive symptoms compared with clinical management. It is possible that the lack of relative superiority of incentivebased behavior therapy and cognitive-behavioral relapse prevention therapy over various control conditions in reductions in drug use, but not in other outcomes, is a function of the strong emphasis in these treatments on drug use, with little direct attention given to associated problems. In contrast, psychosocial treatments that have a broader focus may yield greater benefits in regard to such associated problems, particularly for those patients that initially have relatively more problems that might be most amenable to psychotherapy (e.g., psychiatric, interpersonal, social problems). The current report presents changes in a variety of associated problems for cocaine-dependent patients who participated in the National Institute of Drug Abuse Collaborative Cocaine Treatment Study (Crits-Christoph et al., 1997, 1999), a multicenter project investigating the efficacy of four psychosocial treatments: cognitive therapy (CT) plus group drug counseling (GDC), supportive-expressive (SE) psychotherapy plus GDC, individual drug counseling (IDC) plus GDC, and GDC. A previous report presented the results of the primary efficacy measures (drug and cocaine use; Crits-Christoph et al., 1999). All treatments were found to decrease drug use substantially, with cocaine use in the
past 30 days improving from a mean of 10.4 days (SD = 7.8; Mdn = 8.0) at baseline to a mean of 3.4 days (SD = 6.5; Mdn = 0.0) at the 12-month assessment. However, contrary to study hypotheses, the IDC+GDC group was found to yield statistically and clinically superior outcomes compared with the other treatments. By Month 6, 39% of patients in the IDC+GDC group reported use of cocaine in the past month, whereas 57% of patients in CT+GDC, 49% in SE+GDC, and 52% in GDC alone reported use. This report describes analyses of secondary outcome measures, including changes in family-social, legal, medical, interpersonal, and psychiatric problems, as well as in alcohol use. In addition to examining differences between treatment modalities (main effects), we explored the hypothesis that professional psychotherapy (cognitive or SE psychotherapy) would particularly produce changes in the associated problems (especially psychiatric, interpersonal, social problems) of cocaine-dependent patients for those patients with relatively higher levels of initial psychiatric symptomatology.
Method Patients A total of 487 patients, recruited from five sites in the northeast United States, were randomized to treatment. Patients were recruited by advertisements in newspapers or flyers (46%), referrals from substance abuse treatment centers (22%), friends or acquaintances (18%), mental health centers (8%), and private mental health providers (6%). To be included in the study, patients (ages 18-60 years) needed to have received a principal Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) diagnosis of cocaine dependence (current or in early partial remission) and report having used cocaine in the past 30 days. Principal diagnosis was determined using a 9-point severity rating scale adapted from the Anxiety Disorders Interview Schedule—Revised (DiNardo & Barlow, 1988) that reflects the diagnostician's judgment of subjective distress and functional impairment due to each disorder. After telephone screening, eligible patients were invited for an intake visit that initiated an orientation-assessment phase and included informed consent procedures. During the orientation-assessment phase, the patient was required to attend three clinic visits within 14 days, including one group session and two case management visits. Group counselors met with patients during clinic visits and suggested attendance at self-help groups such as Cocaine or Alcoholics Anonymous, promoted HIV risk reduction, and addressed housing, job, or financial needs. Following completion of baseline assessments, patients were randomized to treatment from the central coordinating center using an urn randomization procedure, with gender, marital status, employment status, mode of cocaine use, psychiatric severity, and antisocial personality traits scores used to balance the treatment conditions on these potential prognostic factors within each site.
Therapists Details of the procedures for selection, training, certification, and competence evaluation of therapists and counselors in an initial training phase have been described elsewhere (Crits-Christoph et al., 1998, 1999). A total of 15 CT therapists, 13 SE therapists, 12 individual drug counselors, and 10 group drug counselors participated in the clinical trial.
Treatments Treatment involved a 6-month active phase and a 3-month booster phase. Individual treatment sessions (50 min) occurred twice per week
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BRIEF REPORTS during the first 12 weeks, weekly during Weeks 13 to 24, and monthly during the booster phase. GDC sessions (1.5 hr) were held once a week during the 6-month active phase. During the booster phase, patients in GDC alone met for a half hour with the group counselor each month. The treatment approaches are described in greater detail elsewhere (Crits-Christoph et al., 1997, 1998). In brief, CT was administered according to a manual for CT for substance abuse or dependence (Beck, Wright, Newman, & Liese, 1993). This model assumes that substance-use disorders are related to individuals' maladaptive beliefs and related thought processes. Treatment uses a collaborative model in conjunction with cognitive and behavioral techniques such as Socratic questioning, advantagesdisadvantages analysis, monitoring of drug-related beliefs, activity monitoring and scheduling, behavioral experiments, and role plays. SE psychodynamic psychotherapy followed a general SE treatment manual (Luborsky, 1984) supplemented with a more specific variant of it developed for cocaine abusers (Mark & Luborsky, 1992). Within this model, problems associated with cocaine use and with its cessation are examined in the context of an understanding of the person's interpersonal and intrapsychic functioning as formulated in terms of the Core Conflictual Relationship Theme (CCRT; Luborsky & Crits-Christoph, 1998). Supportive and interpretive techniques are used, particularly interpretations related to aspects of patients' CCRTs that most interfere with the achievement of patients' goals. The IDC manual (Mercer & Woody, 1999) focuses primarily on helping patients achieve and maintain abstinence by encouraging behavioral changes, such as avoiding drug triggers, structuring one's life, and engaging in healthy behaviors (e.g., exercise). This model is consistent with the philosophy of the 12-step approach, specifically with the perspective that addiction is a disease that damages the person physically, emotionally, and spiritually and that recovery is a gradual process. Participation in outside self-help groups (e.g., Alcoholics Anonymous) is strongly encouraged. Manual-guided GDC (Mercer, Carpenter, Daley, Patterson, & Volpicelli, 1994) consisted of a 3-month initial phase emphasizing education about the stages of recovery from addiction and encouragement of participation in 12-step programs. The second 3-month phase involved open discussion with a focus on patients' helping each other solve problems in recovery. As reported previously (Crits-Christoph et al., 1999), patients in IDC+GDC attended significantly fewer individual sessions compared with patients in SE and CT (IDC+GDC, M = 11.9, SD = 10.5; CT+GDC, M = 15.5, SD = 10.6; SE+GDC, M = 15.7, SD = 11.3). Across all conditions, the average patient attended about nine group sessions. Assessments of treatment fidelity and discrimination were obtained during both the therapist training phase and the main trial with independent audiotapes ratings. Training phase data indicated that the treatments were implemented as intended and the treatment conditions could be readily discriminated (Barber, Krakauer, Calvo, Badgio, & Faude, 1997; Barber, Mercer, Krakauer, & Calvo, 1996).
Assessments Assessments were completed at intake, postorientation (approximately 2 weeks later and prior to randomization), and then monthly for 6 months.-, Follow-up assessments were conducted at 9 and at 12 months postrandomization. A variety of measures were used to assess psychiatric, interpersonal, social, medical, legal, and employment problems that may occur in conjunction with substance dependence. Measures used included the 17item Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960), the Beck Depression Inventory (BDI; Beck, Steer, & Garbin, 1988), the Beck Anxiety Inventory (BAI; Beck, Epstein, & Brown, 1988), the Inventory of Interpersonal Problems (IIP; Horowitz, Rosenberg, Baer, Ureno, & Villasenor, 1988), the Brief Symptom Inventory Global Severity Index (BSI; Derogatis, 1992), and the Medical, Legal, Family-Social, Alcohol, Psychiatric, and Employment composite scores of the Addiction Severity Index (ASI; McLellan et al., 1992). Because of nonnormal distributions for many of the variables (especially accumulation of scores of 0 for ASI
subscales), transformations were applied to raw scores, including a squareroot transformation for the BDI and the HRSD, shifted-logarithmic transformation with a shift of 0.001 for the ASI subscales, the BSI, and the BAI, and a shifted-logarithmic transformation with a shift of 1 for the IIP. Following the procedure in the previous publication (Crits-Christoph et al., 1999) for examining interactions of treatment condition with initial psychiatric symptomatology, a composite baseline psychiatric severity measure was created by summing standardized scores on the HRSD, the BAI, the BSI, and the ASI Psychiatric Severity subscale. As described previously (Crits-Christoph et al., 1999), data collection was relatively successful despite the high levels of attrition from treatment that occurred. The average patient attended 4.5 (SD = 1.9) of the 6 postbaseline monthly assessments during the active phase of treatment.
Results The final patient sample (N = 487) was 77% male and 58% Caucasian, 40% African American, and 2% Hispanic. The average age at intake was 34 years old. The majority of patients lived alone (70%), were employed (60%), and had completed on average 13 years of schooling. The majority were crack cocaine smokers (81%), and the remaining (19%) were intranasal users. At the time of intake, on average, patients had used cocaine 10 days and alcohol 7 days in the previous month. The average length of cocaine use was 7 years (SD = 4.8). Thirty-three percent of the patients met criteria for alcohol dependence, 4% for cannabis dependence, and 17% for cannabis abuse. Twenty-eight percent of patients met criteria for a cocaine-induced mood disorder and 5% for a cocaine-induced anxiety disorder. Fourteen percent of patients met criteria for both antisocial personality disorder (ASP) as an adult and conduct disorder as a child, whereas an additional 32% met criteria for ASP as an adult with no history of childhood conduct disorder. The statistical analysis for the outcome measures was a general mixed-model analysis of variance approach that examined average outcome over all postbaseline assessments (Months 1-6, 9, and 12), rather than assuming a linear slope over time. Main effects for treatment and time were modeled, as well as a Treatment X Psychiatric Severity interaction (the latter term testing the hypothesis that professional psychotherapies achieve better results than drug counseling with patients who have initially higher levels of psychiatric severity). Preliminary models also examined Treatment X Site interactions and Treatment X Phase, with phase indicating acute treatment (Months 1-6) versus booster and follow-up phase (Months 9 and 12 assessments). The mixed-model analysis retains all nonmissing observations, and time intervals are considered fixed; baseline scores for each outcome measure were entered as covariates in the models. There were no significant Treatment X Site or Treatment X Phase interactions on any measure, and therefore these interactions were dropped from the model. No significant treatment condition main effects were found (Table 1). In addition, tests of the hypothesis that psychotherapy would be particularly useful for those with initially high psychiatric severity failed to find any supportive evidence on any measure (p values for all Treatment X Psychiatric Severity interactions were all nonsignificant). Although there were no significant treatment effects, all variables, with the exception of ASI Medical and Employment composites, evidenced significant reductions from baseline over time, as evidenced by a significant main effect for time in the mixed model (see Table 1). Pre-post effect sizes, calculated as baseline
BRIEF REPORTS
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Table 1 Baseline and Months 3, 6, 9, and 12 Observed Means on Outcome Measures That Evidenced a Significant Decrease Over Time Baseline Variable and treatment ASI-Alcohol IDC CT SE GDC ASI-Family IDC CT SE GDC ASI-Legal IDC CT SE GDC ASI-Psych IDC CT SE GDC BAI IDC CT SE
GDC BDI IDC CT SE GDC BSI IDC CT SE GDC HRSD IDC CT SE GDC IIP
IDC CT SE
GDC
Month 3
Month 6
Month 9
Month 12
Time effect
Treatment effect
M
SD
M
SD
M
SD
M
SD
M
SD
F
df
p
F
df
p
0.20 0.23 0.24 0.22
0.22 0.23 0.23 0.23
0.12 0.13 0.15 0.13
0.15 0.17 0.20 0.16
0.15 0.13 0.16 0.13
0.19 0.16 0.19 0.14
0.12 0.14 0.15 0.13
0.16 0.19 0.19 0.16
0.11 0.15 0.15 0.13
0.16 0.18 0.20 0.18
2.9
6,2474
.009
0.7
3, 458
.56
0.24 0.20 0.23 0.20
0.23 0.23 0.23 0.22
0.15 0.15 0.16 0.12
0.21 0.20 0.22 0.19
0.15 0.11 0.13 0.13
0.21 0.17 0.20 0.18
0.14 0.14 0.15 0.15
0.17 0.18 0.18 0.20
0.14 0.15 0.10 0.15
0.17 0.18 0.16 0.19
7.0
6,2451
.0001
0.4
3, 454
.72
0.09 0.10 0.11 0.08
0.16 0.18 0.19 0.17
0.05 0.06 0.05 0.03
0.14 0.14 0.11 0.11
0.04 0.05 0.04 0.06
0.13 0.12 0.12 0.15
0.03 0.04 0.05 0.05
0.09 0.13 0.13 0.14
0.03 0.04 0.05 0.06
0.11 0.13 0.12 0.12
2.4
6,2476
.02
0.6
3, 456
.61
0.18 0.20 0.20 0.18
0.17 0.20 0.21 0.20
0.12 0.13 0.13 0.11
0.18 0.16 0.19 0.18
0.10 0.11 0.15 0.15
0.16 0.17 0.18 0.20
0.12 0.13 0.12 0.12
0.17 0.20 0.16 0.17
0.14 0.13 0.11 0.15
0.19 0.18 0.17 0.20
3.6
6,2500
.002
0.6
3, 458
.64
6.7 6.7
7.3 8.6
2.9 4.9 4.6 3.4
4.2 7.9 8.5 4.7
3.7 4.6 4.1 3.4
7.3 7.9 19.2
5, 1431
.0001
1.0
3,417
.38
5.1 8.1
5.8 9.2 10.0
5.0 6.8
5.7 8.3 6.4 6.5
8.0 9.0
7.8
8.3 9.4 9.4 9.8
6.2
8.7 7.8
8.7 7.1
6.3 6.6
7.6 9.2 7.0 6.5
19.5
6,2080
.0001
2.1
3,436
.10
0.35 0.43 0.38 0.33
0.48 0.56 0.55 0.35
0.37 0.41 0.32 0.34
0.57 0.55 0.39 0.38
11.8
6,2073
.0001
1.7
3,435
.17
6.3
7.5
6.7
6.8
11.6 12.0 12.1 12.5
8.3 9.3 9.1 9.0
8.4 7.4
0.50 0.58 0.51 0.55
0.46 0.57 0.49 0.46
0.27 0.38 0.41 0.32
0.31 0.50 0.58 0.38
0.29 0.40 0.41 0.30
0.51 0.53 0.57 0.48
8.6 9.1 9.2 8.9
5.4 5.9 5.1 5.9
6.3 5.7
6.0 6.7 6.9 7.3
5.7
6.3
5.7 4.9 6.7 5.4
6.7
10.5
5, 1434
.0001
0.5
3, 425
.68
66.7 68.5 64.6 65.5
40.3 35.6 38.3 35.7
39.9 50.1 46.3 47.1
34.4 39.2 35.2 38.0
49.4 49.7 46.1 50.6
46.4 43.0 40.8 44.7
22.1
5, 1427
.0001
1.5
3,420
.21
7.4
7.1 6.2
8.3
6.3 6.1
Note, ns for baseline are 121 for individual drug counseling (IDC) plus group drug counseling (GDC), 119 for cognitive therapy (CT) plus GDC, 124 for supportive-expressive (SE) psychotherapy plus GDC, and 123 for GDC. For Months 1-12, within-treatment ns ranged from 69 to 101. Baseline scores from the relevant outcome scale, site, phase of the study, sociopathic traits as measured by the California Psychological Inventory Socialization Scale, and intake psychiatric severity were used as covariates in the significance testing. Significance testing included data from all monthly (baseline, Months 1-12) assessments. Means for outcome measures not shown (ASI Medical and Employment) and the monthly assessments not shown (Months 1, 2, 4, and 5) can be obtained from Paul Crits-Christoph. ASI = Addiction Severity Index; Psych = psychiatric; BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; BSI = Brief Symptom Inventory Global Severity Index; HRSD = 17-item Hamilton Rating Scale for Depression; IIP = Inventory of Interpersonal Problems. mean minus treatment mean (estimated from the mixed model and averaging over all postbaseline assessments) divided by baseline standard deviation of the transformed scores, were 0.51 for the ASI-Alcohol subscale, 0.36 for the ASI-Family subscale, 0.29 for the ASI-Legal subscale, 0.33 for the ASI-Psychiatric Severity subscale, 0.55 for the BAI, 0.73 for the BDI, 0.60 for the BSI, 0.48 for the HRSD, and 0.63 for the IIP. On the basis of the descriptive cutoffs established for the BAI, BDI, BSI, and HRSD, patients
changed on average from mild levels of symptoms at baseline to nonclinical (normal range) levels during treatment.
Discussion Contrary to our initial hypotheses, these analyses failed to reveal superiority of professional psychotherapy over drug counseling on associated features of substance dependence. Because of the gen-
BRIEF REPORTS erally low level of psychiatric problems in particular in this sample, an advantage for professional psychotherapy might only be expected with a subgroup of the sample (those with more severe problems). However, there was also no evidence of an interaction of Treatment X Psychiatric Severity initial level (i.e., psychotherapy did not fare relatively better with those patients with initially higher levels of psychiatric problems). Furthermore, on the basis of the unexpected finding of the relative superiority of IDC (plus GDC) on measures of drug and cocaine use (Crits-Christoph et al., 1999), it might have been expected that IDC (plus GDC) would also have a more successful impact on addiction-related problems. If such problems are a consequence of cocaine use, reducing cocaine use would potentially also improve the associated problems. However, there was no evidence in support of findings in this direction either. Our findings are generally consistent with previous studies (Carroll et al., 1994; Higgins et al., 1994, 1995) that found superiority of one treatment in reductions in cocaine use but that failed to find superiority of these treatments in associated problems. This is not to say, however, that these treatments did not affect such associated problems, as changes from baseline (particularly on measures of psychiatric, interpersonal, family-social, and alcohol problems) were typically significant (although modest in effect size) in our study and in other studies across treatments. However, the lack of differences in change in associated addiction problems among the four treatments examined suggests that IDC (plus GDC), with its superior results on measures of drug and cocaine use, continues to be the treatment of choice among those studied. This conclusion, however, needs qualification. First, the current study was an efficacy study that included therapists and counselors who were highly selected and trained for this project. Consequently, the generalizability of our findings to typical addiction counselors in the community is an open question. The second qualification is that the inclusion-exclusion criteria (e.g., patients on psychotropic medication were excluded) may have truncated the range of associated problems, particularly psychiatric and interpersonal problems. At more extreme levels of comorbid psychopathology, the expertise of professional psychotherapists may lead to greater changes on psychiatric, social, and interpersonal problems. A third qualification is that the design of the study involved an extended (2 week) initial orientation-assessment period that may also limit the generalizability of the findings to clinical practice. In summary, the "efficacy" features of the study's design (highly selected-trained counselors, restrictive inclusion-exclusion criteria, selected sample) limit the relevance of the findings to current treatments, providers, and patients in the community. Another consideration is that psychotherapy may not produce benefits in the associated symptoms of cocaine-dependent patients until considerable time has elapsed, as was found in a previous study (Carroll et al., 1995). For example, patients may need a prolonged period of abstinence before trust and intimacy is restored with friends and family members and interpersonal-social relationships improve. This raises the clinical issue of sequencing of treatments. IDC (plus GDC) may be the most appropriate initial treatment to reduce the primary problem (cocaine use) and improve problems that are a consequence of cocaine use. If a patient continues to display psychiatric or interpersonal problems, other forms of psychosocial or pharmacological treatments might be indicated. Future research can address such sequencing issues.
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Received September 11, 2000 Revision received February 12, 2001 Accepted February 28, 2001
