SUD Treatment: Why Patients Drop Out, How to Re-Engage in Recovery

What’s happening – A qualitative study looked at ways people think about their treatment for substance use disorder (SUD). Researchers interviewed 30 patients who were enrolled in a year-long, residential recovery program about their motivations for continuing treatment. Researchers used the Health Belief Model – which includes the six constructs of perceived susceptibility, severity, benefits, barriers, cue to action, and self-efficacy – as a framework for understanding patient attitudes. They found that treatment engagement was related to participants’ beliefs about the severity of their SUD, the treatment program’s ability to help them avoid a relapse, and their ability to use the strategies they had learned during treatment.

Why it’s complicated – Staying engaged with treatment can be a challenge, and for some, the idea of moderation or being “California sober” (that is, not abstinent), has gained popularity in recent years. Earlier this month, singer Demi Lovato revealed in a documentary that she is not completely sober following her 2018 near-fatal overdose. In response to backlash about her following a “California sober” approach, Lovato dismissed the criticism last week, saying that the topic is between her and her treatment team.

Reports & Perspectives

  • Group motivational interviewing (MI) was found to keep patients engaged in treatment as well as lower alcohol and drug use in a study of 118 veterans with SUD by Santa Ana et al.
  • A review of wearable biosensors and their applications for alcohol use disorder (AUD) describes the current and potential uses for sensors, looking beyond identifying intoxication to possibly monitoring abstinence and engaging in treatment interventions.
  • Peer-recovery coaches were associated with increased patient engagement with SUD treatment, including engagement with buprenorphine treatment (which can now be more widely prescribed thanks to HHS guidelines updated April 28) and opioid abstinence, and hospitalizations and ER visits were reduced in a study by Magidson et al.

The conversation

  • @DrSarahWakeman (last author on the Magidson et al study) tweeted “Pre-print of our new eval of #recoverycoach program. People w/lived experience as essential, non-clinical members of SUD care teams so valuable. We found decreased hospitalizations & ED visits, improved outpt engagement & bupe outcomes….”
  • @DrugPolicyOrg (the nonprofit Drug Policy Alliance) tweeted “Demi Lovato’s new album #DWTDTAOSO dropped today and her song ‘California Sober’ addresses her time in drug treatment. Recovery looks different for everyone – thank you @ddlovato for telling your story” and shared their article on SUD treatment

In practice – More on motivational interviewing practice; using MAT to treat AUD, and how to administer buprenorphine for opioid use disorder (OUD). See also our Psy-Q on responding to clients who want to try “California sober” or moderation approach to SUD treatment with Dr. Collin M. Reiff.

Psy-Q Challenge

My SUD patient wants to try a “California sober” treatment approach. How should I respond?

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Alzheimer’s Disease and Dementia Risk High in Those with Persistent Midlife Loneliness

What’s happening – Persistent loneliness during midlife (ages 45 to 64) was associated with a higher risk of dementia and Alzheimer’s disease later in life according to a study by Akhter‐Khan et al in Alzheimer’s & Dementia. Additionally, people who overcame feelings of loneliness appeared to have a lower risk than those who reported no loneliness. Researchers looked at data from the Framingham Heart Study (2,880 participants) who responded twice to a question about loneliness on the Center for Epidemiologic Studies Depression Scale (CES-D), taken about 3 years apart.

Responses were categorized as feeling no loneliness, transient (loneliness at one but not a subsequent survey), incident (loneliness in the second survey but not the first), and persistent (loneliness at both assessments). The researchers suggest that the lower risk of later dementia seen in those who had transient loneliness over those who reported no loneliness could point to the importance of psychological resilience.

Why it’s complicated – Loneliness and social isolation in older adults are associated with serious health risks besides dementia and Alzheimer’s, including heart disease, stroke, depression, anxiety, and suicide, and most research focuses on older people. The Akhter-Khan et al study, looking at adults at midlife and its findings of resilience, offers hope to concerns about the ongoing social isolation and loneliness caused by the pandemic.

Conversation & Perspectives

  • A paper by Hwang et al looks at pandemic loneliness in older people, arguing that it was a “behavioral epidemic” even before COVID-19 and that more should be done to improve the well-being of this population.
  • An article by the AARP examines how loneliness and isolation during the pandemic could lead to dementia.
  • An editorial in JAMDA discusses loneliness and isolation in long-term care during the pandemic, with ideas for how to reduce loneliness in residents.
  • Another study looking at middle age focused on sleep patterns and the risk of dementia in later years, finding that sleeping for 6 hours or less in their 50s and 60s made people more likely to be diagnosed with dementia later in life. The association between poor sleep and sleep duration and dementia in older people has been frequently studied, but the connection remains unclear. This study is unique in that it had a longer follow-up period than most (30 years vs. 10 years or less), and it concentrated on midlife rather than on participants who are 65-plus.
  • @Eddy_Elmer (a gerontology PhD candidate) tweeted “Persistent loneliness in midlife increases dementia risk over time. ‘Human beings are social and need social interaction…[We think] without interaction, the brain can lose external stimulation, which can increase Alzheimer’s risk.’” quoting the study’s last author in a UPI article.
  • @RouchLaure (Laure Rouch, PharmD, PhD) tweeted about the Akhter-Khan et al study, “Persistent #loneliness in midlife is an independent risk factor for #dementia and AD, whereas recovery from loneliness suggests #resilience to dementia risk.”

In practice – Inside the mental health impact of COVID on long-term care residents. More on hypersomnia treatment.

Frequent Suicidal Ideation Assessments May Help Predict Suicidal Behavior

What’s happening – Frequent assessments of suicidal thinking were used by Wang et al to study how real-time monitoring could improve predictions of short-term post-hospitalization suicidal behavior. During inpatient care, 83 participants received smartphone prompts to take the ecological momentary assessment (EMA) surveys of suicidal thinking 4 to 6 times each day. Subject reported on suicide attempts at 2 and 4 weeks after discharge, which the research term noted is the highest-risk period for suicide attempts. The assessment data were analyzed with machine learning algorithms to predict post-hospital suicide attempts. Additionally, the noncompletion of surveys was considered a predictor of post-discharge suicide attempts.

Why it’s complicated – Predicting suicidal behavior remains difficult, according to a meta-analysis of 50 years-worth of research (which included 365 studies and 3,428 total risk factor effect sizes) by Franklin et al. This frequently cited study from the APA’s Psychological Bulletin concluded that research should focus less on risk factors and more on machine learning-based risk algorithms.

Conversation & Perspectives

  • A recent study from Chen et al used a machine learning approach that was applied to Swedish national registry data to predict suicidal behavior and death within 30 and 90 days of inpatient and outpatient psychiatric care. The authors found that combining four machine learning methods provided more accurate predictions than using the four models individually.
  • Adolescents received daily surveys measuring suicidal ideation for 4 weeks after hospitalization for suicide attempt or suicidal ideation in a study by Czyz et al. Daily fluctuations in ideation were observed, and the authors suggest that promoting a sense of connectedness to others is a potential target for intervention in high-risk youth.
  • A poignant essay by developmental psychologist Dr. Pamela Morris for the New York Times shares how her teenage daughter’s suicide led her to think about new possibilities for prevention. She compares the decades-long nationwide effort to encourage seatbelt use with a possible new effort to recognize and respond to suicidal thinking, imagining a world where routine discussion by doctors, parents, employers, and religious leaders is a normal part of life. Just as putting on a seatbelt has become automatic, perhaps one day we’ll think similarly about openly discussing preventing suicide and supporting those who are struggling, Morris suggests.
  • @pamela_a_morris (author of the NYT essay) tweeted “Thank you @nytopinion for helping me get the word out about #suicideprevention. And thanks to all of you who have been brave enough to begin this tough conversation. If just one more teen has someone to talk with about #suicide, that will be a good thing.”
  • @Mad_In_America tweeted “Can a Harry Potter-Themed Wellbeing Program Help Middle Schoolers Cope? A school-based, #HarryPotter themed and #CBT informed program for middle schoolers enhances #wellbeing and reduces suicidality.” Read their article and the original study by Klim-Conforti et al in the Journal of Affective Disorders.

In practice – Coming this May, watch for Psycom Pro’s special report on putting mental health on an equal playing field with medical health, featuring a multidisciplinary expert panel. See also, suicide risk screening, suicide risk screening tools, treating adolescents in the pandemic for teen depression and anxiety and teen anxiety in the ER.

Last Updated: May 7, 2021