Randomized Clinical Trial of Computerized and Clinician-Delivered CBT in Comparison With Standard Outpatient Treatment for Substance Use Disorders: Primary Within-Treatment and Follow-Up Outcomes.

OBJECTIVE Previous trials have demonstrated the efficacy and durability of computer-based cognitive-behavioral therapy (CBT4CBT) as an add-on to standard outpatient care in a range of treatment-seeking populations. In this study, the authors evaluated the efficacy and safety of CBT4CBT as a virtual stand-alone treatment, delivered with minimal clinical monitoring, and clinician-delivered cognitive-behavioral therapy (CBT) compared with treatment as usual in a heterogeneous sample of treatment-seeking outpatients with substance use disorders. METHOD This was a randomized clinical trial in which 137 individuals who met DSM-IV-TR criteria for current substance abuse or dependence were randomly assigned to receive treatment as usual, weekly individual CBT, or CBT4CBT with brief weekly monitoring. RESULTS Rates of treatment exposure differed by group, with the best retention in the CBT4CBT group and the poorest in the individual CBT group. Participants who received CBT or CBT4CBT reduced their frequency of substance use significantly more than those who received treatment as usual. Six-month follow-up outcomes indicated continuing benefit of CBT4CBT (plus monitoring) over treatment as usual, but not for clinician-delivered CBT over treatment as usual. Analysis of secondary outcomes indicated that participants in the CBT4CBT group demonstrated the best learning of cognitive and behavioral concepts, as well as the highest satisfaction with treatment. CONCLUSIONS This first trial of computerized CBT as a virtual stand-alone intervention delivered in a clinical setting to a diverse sample of patients with current substance use disorders indicated that it was safe, effective, and durable relative to standard treatment approaches and was well-liked by participants. Clinician-delivered individual CBT, while efficacious within the treatment period, was unexpectedly associated with a higher dropout rate and lower effects at follow-up.

[1]  H. Kranzler,et al.  The validity of self-reported cocaine use in two groups of cocaine abusers. , 1999, Journal of Consulting and Clinical Psychology.

[2]  J. McKay.  Making the hard work of recovery more attractive for those with substance use disorders , 2017, Addiction.

[3]  N. Petry,et al.  Single versus multiple drug focus in substance abuse clinical trials research. , 2003, Drug and alcohol dependence.

[4]  Philippe Ravaud,et al.  Quality of reporting of noninferiority and equivalence randomized trials. , 2006, JAMA.

[5]  P. Cuijpers,et al.  Internet interventions for adult illicit substance users: a meta‐analysis , 2017, Addiction.

[6]  S. Hollon,et al.  Defining empirically supported therapies. , 1998, Journal of consulting and clinical psychology.

[7]  Per Carlbring,et al.  Guided Internet‐based vs. face‐to‐face cognitive behavior therapy for psychiatric and somatic disorders: a systematic review and meta‐analysis , 2014, World psychiatry : official journal of the World Psychiatric Association.

[8]  W. Miller,et al.  A structured approach to medical management: a psychosocial intervention to support pharmacotherapy in the treatment of alcohol dependence. , 2005, Journal of studies on alcohol. Supplement.

[9]  N. Petry,et al.  Combining cognitive behavioral therapy and contingency management to enhance their effects in treating cannabis dependence: less can be more, more or less. , 2012, Addiction.

[10]  P. Rutigliano,et al.  The timeline followback reports of psychoactive substance use by drug-abusing patients: psychometric properties. , 2000, Journal of consulting and clinical psychology.

[11]  K. Carroll,et al.  Client satisfaction with three therapies in the treatment of alcohol dependence: results from project MATCH. , 2002, The American journal on addictions.

[12]  H. Riper,et al.  Internet and computer based interventions for cannabis use: a meta-analysis. , 2013, Drug and alcohol dependence.

[13]  R. Schwartz.  Urine testing in the detection of drugs of abuse. , 1988, Archives of internal medicine.

[14]  I. Scott.  Non‐inferiority trials: determining whether alternative treatments are good enough , 2009, The Medical journal of Australia.

[15]  Brian D. Kiluk,et al.  Measures of outcome for stimulant trials: ACTTION recommendations and research agenda. , 2016, Drug and alcohol dependence.

[16]  K. Preston,et al.  Assessment of cocaine use with quantitative urinalysis and estimation of new uses. , 1997, Addiction.

[17]  Alan E Kazdin,et al.  Addressing the treatment gap: A key challenge for extending evidence-based psychosocial interventions. , 2017, Behaviour research and therapy.

[18]  I. Marks,et al.  Brief scheduled phone support from a clinician to enhance computer-aided self-help for obsessive-compulsive disorder: randomized controlled trial. , 2005, Journal of clinical psychology.

[19]  Brian D. Kiluk,et al.  Computer-assisted delivery of cognitive-behavioral therapy: efficacy and durability of CBT4CBT among cocaine-dependent individuals maintained on methadone. , 2014, The American journal of psychiatry.

[20]  W. Ling,et al.  A comparison of contingency management and cognitive-behavioral approaches during methadone maintenance treatment for cocaine dependence. , 2002, Archives of general psychiatry.

[21]  Brian D. Kiluk,et al.  Randomized Trial of Computerized Cognitive Behavioral Therapy for Alcohol Use Disorders: Efficacy as a Virtual Stand-Alone and Treatment Add-On Compared with Standard Outpatient Treatment. , 2016, Alcoholism, clinical and experimental research.

[22]  Brian D. Kiluk,et al.  Toward empirical identification of a clinically meaningful indicator of treatment outcome: features of candidate indicators and evaluation of sensitivity to treatment effects and relationship to one year follow up cocaine use outcomes. , 2014, Drug and alcohol dependence.

[23]  R L Stout,et al.  Ensuring balanced distribution of prognostic factors in treatment outcome research. , 1994, Journal of studies on alcohol. Supplement.

[24]  Brian D. Kiluk,et al.  Technology-based interventions for the treatment and recovery management of substance use disorders: a JSAT special issue. , 2014, Journal of substance abuse treatment.

[25]  B. Rounsaville,et al.  Computer-assisted delivery of cognitive-behavioral therapy for addiction: a randomized trial of CBT4CBT. , 2008, The American journal of psychiatry.

[26]  Steve Martino,et al.  A methodological analysis of randomized clinical trials of computer-assisted therapies for psychiatric disorders: toward improved standards for an emerging field. , 2011, The American journal of psychiatry.

[27]  K. Bucholz,et al.  DSM-5 criteria for substance use disorders: recommendations and rationale. , 2013, The American journal of psychiatry.

[28]  B. Rounsaville,et al.  Efficacy of disulfiram and cognitive behavior therapy in cocaine-dependent outpatients: a randomized placebo-controlled trial. , 2004, Archives of general psychiatry.

[29]  B. Rounsaville,et al.  One-year follow-up of psychotherapy and pharmacotherapy for cocaine dependence. Delayed emergence of psychotherapy effects. , 1994, Archives of general psychiatry.

[30]  B. Rounsaville,et al.  One-year follow-up of disulfiram and psychotherapy for cocaine-alcohol users: sustained effects of treatment. , 2000, Addiction.

[31]  B. Rounsaville,et al.  Enduring effects of a computer-assisted training program for cognitive behavioral therapy: a 6-month follow-up of CBT4CBT. , 2009, Drug and alcohol dependence.

[32]  B. Rounsaville,et al.  A general system for evaluating therapist adherence and competence in psychotherapy research in the addictions. , 2000, Drug and alcohol dependence.

[33]  C. Easton,et al.  The use of contingency management and motivational/skills-building therapy to treat young adults with marijuana dependence. , 2006, Journal of consulting and clinical psychology.

[34]  K. Carroll,et al.  Cost-effectiveness of computer-assisted training in cognitive-behavioral therapy as an adjunct to standard care for addiction. , 2010, Drug and alcohol dependence.