Steps Through Amphetamines
Cognitive behaviour therapy (CBT) for regular amphetamine use and depression: a stepped care approach

• Formalise a stepped care model of treatment incorporating a range of psychological interventions shown in previous research to be effective in reducing amphetamine use and depressive symptomatology.
• Trial the stepped care model of treatment among a target group of 20 people who are both regular users of amphetamines and who currently report moderate symptoms of depression. Provision of treatment in this group will be contingent on their response (amphetamine use and depression) to a previously provided step in treatment.
• Compare the ‘stepped care’ group with a ‘standard’ treatment group of 20 people who are both regular users of amphetamines and who currently report moderate symptoms of depression. All people in this group will receive all components of treatment regardless of response.
• Compare outcomes for amphetamine use, depression, general functioning, etc. between groups

  Design and Method

  
  

Regular amphetamine users with comorbid depression were recruited across two sites (Sydney and Newcastle). Participants had to be using amphetamine at least once a week for the month prior to entry to the study, and reporting moderate levels of depression for the two weeks prior to entry.
Sydney site:
All participants had access to integrated psychological treatment with a dual focus on depression and amphetamine use according to the following schedule:

1. A detailed mental health and drug/alcohol assessment (initial assessment)
2. A brief (1-session) feedback and goal setting treatment session and the provision of self-help material [Step 1 as per the control treatment in 5].
3. A 5-week assessment (5-weeks post-initial assessment).
4. Up to 4-sessions of intervention with an integrated focus [Step 2, as per 6].
5. A 10-week assessment (10-weeks post-initial assessment).
6. Up to 4-sessions of intervention with an integrated focus [Step 3, using 5].
7. A 15-week assessment (15-weeks post-initial assessment).
8. Up to 4-sessions of intervention with an integrated focus [Step 4, using 5]
9. A 20-week assessment (20-weeks post-initial assessment).

Newcastle site:
Trial of a stepped care intervention with provision of treatment contingent on response to a previous intervention:

1. Initial assessment
2. Provision of the Step 1 intervention to all participants [as per 5].
3. A 5-week assessment.
4. Provision of Step 2 intervention where indicated, with an amphetamine, depression or integrated focus [as per 6]. Those who ‘responded’ to Step 1 had the option of entering the monitoring phase and proceeding straight to the next assessment.
5. A 10-week assessment.
6. Provision of Step 3 intervention where indicated, with an amphetamine, depression or integrated focus [as per 6]. ‘Responders’ had the option of entering the monitoring phase and proceeding straight to the next assessment.
7. A 15-week assessment.
8. Provision of Step 4 intervention and/or referral to other services where indicated, with an amphetamine, depression or integrated focus [as per 6]. ‘Responders’ had the option of entering the monitoring phase and proceeding straight to the next assessment.
9. A 20-week assessment.

Stepping Up and Stepping Down:
The decision to step treatment up (offer the next level) or down (offer a previous step or move onto monitoring) was based on the following factors:

• Client preference,
• Clinical judgement, and
• Assessment results relative to baseline and/or previous assessment
  - Improvements or otherwise in amphetamine use only,
  - Improvements or otherwise in depression only, or
  - Improvements or otherwise in both depression and amphetamine use.

Participants at the Newcastle site could also elect a singular focus on amphetamine use, on depression or an integrated treatment targeting both depression and amphetamine use.

Benefits

This pilot study has provided important information regarding the willingness of amphetamine users with depression to participate in a stepped care intervention. In general, participants did not like receiving the one-session Step 1 intervention and then no contact until the 5-week interim assessment. Much of the study dropout occurred at this point. Future replications should consider altering this first step to incorporate more sessions.
Given the choice, Newcastle participants selected a sole focus on amphetamine use as their Step 2 intervention, and then opted for integrated treatment targeting both amphetamine use and depression simultaneously as subsequent steps in treatment. Depression was never selected as the singular focus of treatment, despite reported levels of depression in the severe range at the initial assessment for this group. Although not statistically significant, this approach seemed to benefit the Newcastle participants, who reported lower depression and amphetamine use relative to their Sydney counterparts who received a predetermined integrated treatment at every step.
On average, participants at both sites attended three treatment sessions and three assessment occasions over the study period. Higher (although not statically significantly higher) attendance occurred at the Newcastle site where participants and clinicians were able to tailor the focus and frequency of sessions within the stepped care framework. In general, heavier amphetamine users attended (and reported benefit from) a higher number of sessions across both sites.
It would appear that stepped care is feasible within this population, however a flexible schedule of sessions over a lengthy period may be helpful to heavier users with co-existing depression. Amphetamine users with depression will attend treatment over the longer term, although flexibility and assertive outreach is required by treatment providers.

Output

Preliminary results have been reported at the following national conference:

• APSAD (Australian Professional Society for Alcohol and other Drugs) Annual Conference: November, 2008 (Sydney, NSW)

Preliminary results have been reported at the following international conference:

• World Congress on Congress on Behavioural and Cognitive Therapies Bi-annual Conference: July, 2007 (Barcelona, Spain)

One journal article is currently in preparation summarising the outcomes of this pilot trial. This will be submitted to Drug and Alcohol Review, one of the leading journals in the Drug and Alcohol field.

Funding

NSW Health 2006/7 NSW Comorbidity Research Grants Program ($75,780)