1R01MH097703 (Esposito-Smythers/Spirito, Multiple PIs)
National Institute of Mental Health
Role: Multiple PI with Anthony Spirito, Ph.D.
Co-Investigators: Jennifer Wolff, Ph.D., Daniel Dickstein, M.D., Shirley Yen, Ph.D., Bob Stout, Ph.D.
A significant subgroup of suicidal adolescents continues to demonstrate suicidal ideation and behavior after discharge from emergent psychiatric care. These adolescents are typically high utilizers of expensive follow-up psychiatric care after discharge from inpatient psychiatric settings. This group of adolescents is the focus of this application. At the time of this grant submission, there were only 6 RCTs with suicidal adolescents, two using family therapy, two using group therapy, one using Multisystemic Therapy, and a study by our group using individual adolescent Cognitive Behavioral Therapy (CBT; Donaldson et al, 2005). Only one of these six studies reported a reduction in suicide attempts at follow-up. We completed a study (Esposito-Smythers et al., 2011) using an integrated adolescent and parent CBT protocol for adolescents with depression, suicidality, and a substance use disorder. At follow-up, our protocol resulted in fewer suicide attempts, re-hospitalizations, ED (Emergency Department) evaluations, and residential placements relative to standard care. These data are remarkable for the cost savings in the experimental group if ED evaluations, repeat inpatient psychiatric hospitalizations and residential placements are considered. In addition, our 5% rate of repeat attempts in the experimental condition over 18 months is very low compared to naturalistic studies and other treatment studies. Our protocol required two therapists per family – one for the adolescent and one for the parent(s) due to the acuity and severity of these adolescents. Not all suicidal adolescents will need an intensive treatment protocol such as ours but many being discharged from inpatient psychiatric care will need such services. In this application, depressed, suicidal adolescents seeking emergency care in an ED or who are psychiatrically hospitalized were eligible for our study if they have at least one additional risk factor: a prior suicide attempt, nonsuicidal self-injury (NSSI), and/or a substance use disorder, because these factors are related to increased risk for continued suicidal behavior and expensive contacts with the health care system after discharge. These risk factors were also chosen for scientific reasons because they share common underlying mechanisms – affect regulation and impulse control - that can be addressed in an intensive treatment protocol. The purpose of this application was to conduct a two group randomized controlled trial to test the primary aim that an intensive protocol designed to treat depressed, suicidal adolescents with an additional complicating risk factor will produce better treatment outcomes compared to standard care at the end of the active treatment (6 months), end of maintenance treatment (12 months), and at the final follow-up point (18 months). This application’s clinical significance lies in its addressing a critical barrier to the field: how to best treat the highest risk, depressed and suicidal adolescents. We are in the process of collecting the remainder of the 18-month follow-up data.
R01MH087520 (Brown, PI)
National Institute of Mental Health
PI: Larry Brown, M.D., Brown University
Youth and young adults in the juvenile justice system have a high prevalence of concurrent psychiatric and substance use disorders and are also at high risk for HIV. However, even when the disorders and risks are recognized, most programs do not address all of these important problems and long-term efficacy for all outcomes simultaneously has yet to be demonstrated for these multi-problem youth. Adverse outcomes for youth include partially treated or relapsing psychiatric disorders, continued substance abuse, unchanged HIV risk, and further legal problems. This project, in collaboration with the Rhode Island Family Court and the Fairfax County Juvenile Court, addressed these issues by implementing an Integrated Treatment Program (ITP) that targets mental health/substance abuse disorders and HIV risk. ITP is novel by targeting multiple adolescent problems simultaneously, involving parents to augment change, and its delivery within family/juvenile courts. This study will extend our previous efficacious interventions among youth with psychiatric disorders to court-involved youth. Adolescents and their parents were enrolled from the Rhode Island Family Court Mental Health Clinic and the Fairfax County Juvenile Court, where youth aged 13-17 are referred by judges or court staff for assessment and/or referral for treatment. This randomized controlled trial tested the efficacy, among 153 court-involved youth who needed outpatient treatment, of the novel, integrated treatment (ITP) as compared to enhanced standard care in community outpatient services (ESC) over an 18-month period (6 months of ITP or ESC and 12 months of follow-up). ITP consists of three components: 1) individual cognitive behavioral therapy which includes a motivational interviewing component and is modular-based to address concurrent mental health and substance abuse issues; 2) family and parent training sessions to address parental communication and monitoring to support risk reduction among youth; 3) multifamily group workshops to address HIV risk, family communication and peer resistance skills. Youth in both conditions (ITP and ESC) received similar case management services from the court or study staff and psychiatric medication management (if needed) from a study psychiatrist. ITP was compared to ESC on reductions in sexual risk behavior, substance use, symptoms of psychiatric disorders, and legal offenses. The main outcome paper for this study is currently underway.
1R01AA016854 (Esposito-Smythers, PI)
National Institute on Alcohol Abuse and Alcoholism
Role: Principal Investigator
Co-Investigators: Larry Brown, M.D., Wendy Hadley, Ph.D., Jerome Short, Ph.D., Patrick McKnight, Ph.D.
Alcohol and other drug (AOD) abuse/dependence, suicidal behavior, and HIV infection constitute three significant public health problems. Adolescents seeking treatment for mental health problems are at significantly greater risk for the development of AOD abuse/dependence, suicidal behavior, and risky sexual behavior compared to non-psychiatric adolescent samples. Prevention programs that target these three often inter-related self-destructive behaviors among youth seeking community mental health treatment have not been tested. The primary purpose of this proposal is to develop a family-based cognitive behavioral protocol designed to prevent AOD use disorder, suicidal behavior, and HIV risk behaviors among teens receiving community mental health services and then evaluate it in a randomized Stage I trial. This protocol, referred to as ASH-P, was developed by integrating key elements from two federally funded intervention protocols, Dr. Esposito-Smythers' (PI) cognitive behavioral individual and family based protocol for the treatment of adolescent alcohol abuse and suicidality and Dr. Brown's (PI) HIV prevention program for teens in mental health treatment. There were three primary aims in this project: 1) develop a manualized AOD, suicide, and HIV prevention protocol for adolescents receiving community mental health treatment; 2) pilot and refine the prevention protocol with 12 families; and 3) test this prevention protocol in a small randomized pilot trial. A two group ran-domized design was used to compare ASH-P to an assessment only control (AO-C). Participants included 81 adolescents and a parent. Assessments were completed at pre-intervention as well as 1, 6, and 12-months post-enrollment, and included measures of family-based mechanisms and high-risk behaviors. ASH-P relative to AO-C was associated less deliberate self-harm (suicidal and/or non-suicidal self-injury) and greater refusal of sex to avoid a sexually transmitted infection. It also had a moderate effect on odds of binge drinking. No differences were found in suicidal ideation, alcohol use, or sexual intercourse. ASH-P showed initial promise in preventing multiple high-risk behaviors (Esposito-Smythers et al., 2017). Further testing of prevention protocols that target multiple high-risk behaviors in clinical samples is warranted.
National Institute of Child Health and Human Development /Adolescent Medicine Trials Network for HIV/AIDS (ATN) (Brown, PI)
PI: Larry Brown, M.D., Brown University
HIV infected adolescents report particularly high rates of substance abuse. In a study conducted with 323 HIV-infected adolescents, the frequency of use of alcohol and/or marijuana was greater than the national samples (Murphy, 2001). Approximately 25% of youth reported using alcohol or marijuana more than weekly, and a quarter of these youth failed activities on a weekly basis because of their substance use. Hosek, Harper & Domanico (2005) found that among HIV-infected youth, 56% reported having used marijuana in the previous month, with a mean use on 6 of 30 days. For those that are HIV-positive, substance use can impede their judgment in protecting sexual partners from subsequent infection. Substance abuse can also interfere with treatment for HIV. For example, substance use is positively correlated with medication non-adherence. Mellins et al. (2002) found in a study of 128 HIV-infected mothers that psychiatric problems and substance abuse were the best predictors of medication non-adherence. Also, Power et al. (2003) found that there was a significant relationship between using substances to help cope with HIV-related stress and medication non-adherence.
Despite the fact that substance abuse is prevalent among HIV-infected youth, and may yield serious consequences including non-adherence to medical care and sexual risk behavior, efficacious substance abuse treatments tailored for HIV infected youth that can be delivered within HIV clinic settings have not been developed. The purpose of this grant was to develop and test a combined Cognitive Behavioral Treatment and Contingency Management (CBT/CM) intervention for alcohol and/or marijuana abuse for use with HIV-infected adolescents and young adults ages 16 to 24, in order to reduce substance use and sexual risk behaviors and increase adherence to medical treatment. This intervention was created by modifying an NIH funded cognitive behavioral protocol for the treatment of adolescent substance abuse and mental health problems with initial demonstrated efficacy (Esposito-Smythers et al., 2011). Specifically, this protocol was tailored to the unique needs of HIV-positive adolescents and integrated with a clinic administered contingency management program targeting adolescent substance abuse, treatment attendance, and adherence to HIV medical care.
Seventeen participants (ages 18–24) were recruited from three HIV community clinics across the United States. Assessments were completed at pre-and post-treatment as well as 3-month follow-up. Eighty percent of participants were retained in the study. Results suggest that the CBT/CM intervention was acceptable, feasible, and could be delivered with ﬁdelity. Further, participants reported signiﬁcant reductions in alcohol use, withdrawal symptoms, dependence symptoms and related problems, as well as co-occurring depressive symptoms and delinquent behavior across assessment periods. A trend was evident for reductions in marijuana use and related problems (Esposito-Smythers et al., 2014). Overall, these preliminary results suggest that a substance abuse CBT/CM intervention tailored to YPLH is acceptable, feasible, and holds promise for symptomatic improvement. Further testing of this type of protocol is warranted.