From the Editor

More than ever, we are talking about substance use problems. But as with other mental health services, people struggle to get care, particularly evidence-based therapies.

In the first selection, we consider a new paper from The American Journal of Psychiatry, published last week. Yale University’s Brian Kiluk and his co-authors compare traditional CBT (done with a therapist and in-person) with a computer-based therapy program, CBT4CBT. They conclude: “This computerized version of CBT thus appears to be an engaging and attractive approach for persons with substance use disorders.”

typingTyping to Treat Substance Use?

In the second selection, we consider an essay by The Globe and Mail’s André Picard who asks a simple question: How many people actually suffer from mental illness? Picard cautions us on “pathologizing normal emotions.”



Substance and Therapy

“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”

Brian D. Kiluk, Charla Nich, Matthew B. Buck, Kathleen A. Devore, Tami L. Frankforter, Donna M. LaPaglia, Srinivas B. Muvvala, Kathleen M. Carroll

The American Journal of Psychiatry, 24 May 2018 Online First

Drug and alcohol use are among the most costly public health problems in the United States. Limited availability, uptake, and fidelity of evidence-based treatments have led to increased interest in web-based interventions, which can provide greater accessibility and standardization as well as potential cost savings. Meta-analyses suggest a significant but modest effect of these approaches in decreasing substance use in varied populations. However, interpretation is complex because of the varied level of rigor in the trials included, with common limitations including weak comparison conditions (waiting list or assessment only), inadequate treatment exposure, and low rates of follow-up. Moreover, evaluations of unguided “stand-alone” web-based interventions are often conducted in populations with less severe use disorders (nonclinical populations, risky drinkers), and they rarely conduct well-specified, rigorous comparisons with validated clinician-delivered versions of the same treatment.

We previously reported on the efficacy, durability, and cost-effectiveness of computer-based training for cognitive-behavioral therapy (CBT4CBT) as an add-on to standard treatment for substance use in outpatient and methadone maintenance settings. However, these trials did not address the efficacy of CBT4CBT alone, an important step in establishing its efficacy and utility in the health care system. Here, we describe primary outcomes from a randomized clinical trial evaluating CBT4CBT as a virtual stand-alone treatment as well as clinician-delivered cognitive-behavioral therapy (CBT), each compared with standard outpatient treatment for a heterogeneous group of individuals seeking treatment for substance use disorders. The primary hypothesis was that individuals assigned to receive either form of CBT (clinician-delivered or CBT4CBT) would reduce their substance use relative to those receiving standard treatment. Based on previous work, we also hypothesized that the effects of either form of CBT would be durable relative to treatment as usual through a 6-month follow-up.

eea8dd39-0bd9-454f-95ed-98c6d2f64b30_w01Brian D. Kiluk

So opens a new paper by Yale University’s Kiluk et al.

Here’s what they did:

  • Participants were people seeking care from the Substance Abuse Treatment Unit of the Connecticut Mental Health Center in New Haven between January 2012 and October 2016. They were English speaking.
  • Participants met DSM-IV criteria for cocaine, marijuana, opioid, or alcohol abuse or dependence.
  • Exclusion criteria included psychotic disorders.
  • Participants were randomized to three groups. Standard treatment as usual. Participants had weekly groups or individual therapy at the clinic. Clinician-delivered CBT. Participants had 12 weekly therapy sessions. CBT4CBT plus monitoring. “Participants were asked to complete one CBT4CBT module each week as their principal form of treatment, in conjunction with brief (10 minutes) in-person weekly clinical monitoring provided by a doctoral-level clinician.”
  • Primary outcome measure was days of any drug or alcohol use by week; secondary outcomes included knowledge of CBT concepts and treatment satisfaction.

Here’s what they found:

  • There were 137 participants.
  • Demographically, they were predominantly male (75%); many were African American (49%); most were unemployed (75%). In terms of use: marijuana (49%) and cocaine (29%) were the two most common primary substances. Most participants (81.8%) used both drugs and alcohol.
  • In terms of adverse events, one patient suicided (in the clinician-delivered CBT group).
  • “For the intent-to-treat sample, analyses of data collected during the treatment phase indicated reduction in frequency of any substance use over time by week for the whole sample during the 12-week treatment period… and also confirmed the two primary hypotheses: greater reductions in frequency of any drug or alcohol use over time for clinician-delivered CBT compared with treatment as usual… and for CBT4CBT plus monitoring compared with treatment as usual…” Six-month follow-up outcomes showed ongoing benefit for CBT4CBT over treatment as usual, but not for clinician-delivered CBT over treatment as usual. See figure below.
  • “Among the participants who reported drug use at baseline (N=132), the percentage of drug-free urine specimens was highest in the CBT4CBT plus monitoring group (37%), lowest in the clinician-delivered CBT group (33.1%), and intermediate in the treatment-as-usual group (34.3%), but these differences were not statistically significant.”
  • “Treatment retention was significantly higher in the CBT4CBT condition (a mean of 62 days completed, of 84), lowest in the clinician-delivered CBT condition (43 days), and intermediate in the treatment-as-usual condition (55 days).”
  • In terms of understanding CBT concepts (based on a 40-item test), “those assigned to CBT4CBT plus monitoring had the largest gain in percent correct over time.”
  • And in terms of treatment satisfaction: “a larger proportion of participants assigned to CBT4CBT plus monitoring responded with the highest possible level (“very satisfied”) (82.4%) compared with those assigned to clinician-delivered CBT (63.9%) or treatment as usual (60.0%), although the difference fell short of significance…”


The authors write:

The results strongly support the safety, feasibility, and efficacy for CBT4CBT provided with minimal clinical monitoring. Participants assigned to this condition consistently achieved the best outcomes in terms of treatment retention, engagement, and substance use in comparison to an active control condition. Although a direct comparison (i.e., noninferiority) was not tested here, CBT4CBT plus monitoring appeared to outperform clinician-delivered CBT on all outcomes evaluated. There were no indications that CBT4CBT plus monitoring was not ‘at least as good’ as clinician-delivered CBT; in addition to greater reductions in substance use and indicators of clinical significance, those assigned to CBT4CBT plus monitoring showed the greatest increase in knowledge of CBT concepts and were most likely to report the highest levels satisfaction with treatment. This computerized version of CBT thus appears to be an engaging and attractive approach for persons with substance use disorders.

A few thoughts:

  1. This is a good study.
  1. Wow.
  1. I’ll say that again: wow.
  1. It should be noted that the CBT4CBT participants did better on several measures, but that the results weren’t always statistically significant. Still, the computerized CBT intervention was effective in terms of engagement and decreased substance use.
  1. Why were retention rates so problematic for people in the traditional CBT? For the record, the CBT was manualized and provided by doctoral-level and predoctoral level fellows. And it doesn’t seem to be a matter of quality. From the paper: “All CBT sessions were recorded; 104 of them (52%) were rated using a validated adherence and competence monitoring tool, and ongoing feedback was provided to clinicians by an expert supervisor. Ratings indicated high adherence and competence; the mean adherence score (possible ratings ranged from 1, did not occur, to 7, covered extensively and in great depth) for the six core CBT items (functional analysis, coping skills training, reviewing practice exercises, explaining CBT concepts, assigning homework, and agenda setting) was above 3 for all items, and the mean quality score (where possible ratings ranged from 1, very poor, to 7, outstanding) was above 4 for all six items.”
  1. The authors didn’t do an economic analysis, but clearly the computerized CBT would be highly cost-effective compared to traditional CBT.


Illness and Mental Health

“How many people actually suffer from mental illness?”

André Picard

The Globe and Mail, 22 May 2018

Half of Canadians – 49 per cent to be precise – have ‘experienced a mental health issue’ at some point in their lives, according to a new national survey.

That includes a whopping 63 per cent of millennials, 50 per cent of Gen Xers and 41 per cent of ‘late boomers’.

‘The numbers speak for themselves,’ says Jacques Goulet, president of Sun Life Financial Canada, the company that commissioned the poll.

‘From work-related stress to living with schizophrenia, mental illness crosses all boundaries and touches people at every stage of life,’ Sun Life says in a news release.

Mental illness does affect a lot of people, across a broad swath of society. But numbers rarely, if ever, speak for themselves. They need context and unpacking.

Polls like this one are problematic for a host of reasons.

picardAndré Picard

So begins a short essay by The Globe’s Picard. The piece is short, and doesn’t require much of a summary here.

Picard argues that: “What the poll tells us, more than anything else, is that we are pathologizing normal emotions. It’s normal to be anxious in certain situations – like driving on a busy highway, or having to give a speech in front of strangers.”

He continues:

  • “It is also important to make a distinction between mental-health problems, acute mental illness and severe mental illness. About one in five people will suffer from an acute mental illness, such as a mild, moderate or severe depression. But it’s often temporary and treatable.”
  • “A small percentage of people – roughly 4 per cent – suffer from severe mental illnesses. Often these are intractable, largely untreatable and ultimately life-threatening.”
  • “We do ourselves a grave disservice when we lump everyone into the same basket.”

A few thoughts:

  1. This is a good essay.
  1. Picard makes good points.
  1. Historically, we as a society didn’t discuss mental illness. Is there a danger that we could over-discuss mental illness?
  2. CMAJ Deputy Editor Kirsten Patrick takes issue with Picard’s argument in a short and entertaining blog, “Why I called André Picard’s column on mental illness a nothingburger.” Dr. Patrick writes about her experience with depression, and argues that more awareness about mental illness is critically important. “Are physicians being inundated by scores of patients reporting sort-of-mental-health-issues and demanding care? Are physicians confused and overwhelmed because they can’t tell who’s really sick and who isn’t? Er, no, I don’t think this is our main problem.”Regardless of where you find yourself on the Picard-Patrick divide, we can marvel at this moment, when the country’s most prominent health reporter crosses swords with the deputy editor of its most prominent journal on the topic of how best to help those with mental illness. (You can find her blog here:


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.