Psychosocial interventions for psychostimulant misuse.
BACKGROUND
Psychostimulant misuse is a continuously growing medical and social burden. There is no evidence proving the efficacy of pharmacotherapy. Psychosocial interventions could be a valid approach to help patients in reducing or ceasing drug consumption.


OBJECTIVE
To assess the effects of psychosocial interventions for psychostimulant misuse in adults.


METHODS
We searched the Cochrane Drugs and Alcohol Group Specialised Register (via CRSLive); Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science and PsycINFO, from inception to November 2015. We also searched for ongoing and unpublished studies via ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (apps.who.int/trialsearch/).All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies.


METHODS
We included randomised controlled trials comparing any psychosocial intervention with no intervention, treatment as usual (TAU) or a different intervention in adults with psychostimulant misuse or dependence.


METHODS
We used the standard methodological procedures expected by Cochrane.


RESULTS
We included a total of 52 trials (6923 participants).The psychosocial interventions considered in the studies were: cognitive behavioural therapy (19 studies), contingency management (25 studies), motivational interviewing (5 studies), interpersonal therapy (3 studies), psychodynamic therapy (1 study), 12-step facilitation (4 studies).We judged most of the studies to be at unclear risk of selection bias; blinding of personnel and participants was not possible for the type of intervention, so all the studies were at high risk of performance bias with regard to subjective outcomes; the majority of studies did not specify whether the outcome assessors were blind. We did not consider it likely that the objective outcomes were influenced by lack of blinding.The comparisons made were: any psychosocial intervention versus no intervention (32 studies), any psychosocial intervention versus TAU (6 studies), and one psychosocial intervention versus an alternative psychosocial intervention (13 studies). Five of included studies did not provide any useful data for inclusion in statistical synthesis.We found that, when compared to no intervention, any psychosocial treatment: reduced the dropout rate (risk ratio (RR): 0.83, 95% confidence interval (CI) 0.76 to -0.91, 24 studies, 3393 participants, moderate quality evidence); increased continuous abstinence at the end of treatment (RR: 2.14, 95% CI 1.27 to -3.59, 8 studies, 1241 participants, low quality evidence); did not significantly increase continuous abstinence at the longest follow-up (RR: 2.12, 95% CI 0.77 to -5.86, 4 studies, 324 participants, low quality evidence); significantly increased the longest period of abstinence: (standardised mean difference (SMD): 0.48, 95% CI 0.34 to 0.63, 10 studies, 1354 participants, high quality evidence). However, it should be noted that the in the vast majority of the studies in this comparison the specific psychosocial treatment assessed in the experimental arm was given in add on to treatment as usual or to another specific psychosocial or pharmacological treatment which was received by both groups. So, many of the control groups in this comparison were not really untreated. Receiving some amount of treatment is not the same as not receiving any intervention, so we could argue that the overall effect of the experimental psychosocial treatment could be smaller if given in add on to TAU or to another intervention than if given to participants not receiving any intervention; this could translate to a smaller magnitude of the effect of the psychosocial intervention when it is given in add on.When compared to TAU, any psychosocial treatment reduced dropout rate (RR: 0.72, 95% CI 0.59 to 0.89, 6 studies, 516 participants, moderate quality evidence), did not increase continuous abstinence at the end of treatment (RR: 1.27, 95% CI 0.94 to 1.72, 2 studies, 224 participants, low quality evidence), did not increase longest period of abstinence (MD -3.15 days, 95% CI -10.35 to 4.05, 1 study, 110 participants, low quality evidence). No studies in this comparison assessed the outcome of continuous abstinence at longest follow-up.There were few studies comparing two or more psychosocial interventions, with small sample sizes and considerable heterogeneity in terms of the types of interventions assessed. None reported significant results.None of the studies reported harms related to psychosocial interventions.


CONCLUSIONS
The addition of any psychosocial treatment to treatment as usual (usually characterised by group counselling or case management) probably reduces the dropout rate and increases the longest period of abstinence. It may increase the number of people achieving continuous abstinence at the end of treatment, although this might not be maintained at longest follow-up. The most studied and the most promising psychosocial approach to be added to treatment as usual is probably contingency management. However, the other approaches were only analysed in a few small studies, so we cannot rule out the possibility that the results were not significant because of imprecision. When compared to TAU, any psychosocial treatment may improve adherence, but it may not improve abstinence at the end of treatment or the longest period of abstinence.The majority of the studies took place in the United States, and this could limit the generalisability of the findings, because the effects of psychosocial treatments could be strongly influenced by the social context and ethnicity. The results of our review do not answer the most relevant clinical question, demonstrating which is the most effective type of psychosocial approach.Further studies should directly compare contingency management with the other psychosocial approaches.
Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, Rome, Italy, 00154.
Silvia
S
Minozzi
Rosella
R
Saulle
Franco
F
De Crescenzo
Laura
L
Amato
J Consult Clin Psychol. 2007 Dec;75(6):983-91
18085914
Psychiatr Clin North Am. 1999 Jun;22(2):425-46
10385942
Behav Res Ther. 1996 Jan;34(1):41-6
8561763
Arch Gen Psychiatry. 1997 Aug;54(8):721-6
9283507
J Subst Abuse Treat. 2008 Mar;34(2):202-7
17512158
Addiction. 2009 Sep;104(9):1530-8
19686522
J Subst Abuse Treat. 2013 Jan;44(1):103-14
22657748
Drug Alcohol Depend. 2005 Feb 14;77(2):177-84
15664719
Cochrane Database Syst Rev. 2016 Sep 29;9:CD011866
27684277
J Altern Complement Med. 2013 Mar;19(3):204-10
23062020
Curr Psychiatry Rep. 2010 Oct;12(5):441-7
20697850
Drug Alcohol Depend. 2009 Feb 1;100(1-2):178-81
19041197
Exp Clin Psychopharmacol. 2006 May;14(2):148-56
16756418
J Consult Clin Psychol. 1997 Oct;65(5):803-10
9337499
J Consult Clin Psychol. 2013 Dec;81(6):1063-73
24041231
J Clin Psychopharmacol. 2013 Feb;33(1):104-8
23277248
Addiction. 1997 Dec;92(12):1717-28
9581004
J Subst Abuse Treat. 2008 Oct;35(3):285-93
18329226
J Clin Psychol. 2004 Jan;60(1):29-41
14692007
Psychiatr Serv. 2009 Apr;60(4):498-504
19339325
Behav Res Ther. 1994 Nov;32(8):857-66
7993330
Lancet. 2012 Jan 7;379(9810):55-70
22225671
Cochrane Database Syst Rev. 2011 Oct 05;(10):CD004147
21975742
Drug Alcohol Rev. 2011 Nov;30(6):606-12
21355914
J Consult Clin Psychol. 2011 Oct;79(5):686-96
21806297
J Addict Dis. 1994;13(4):143-60
7734465
Behav Res Ther. 2014 Dec;63:139-46
25461789
J Consult Clin Psychol. 2004 Dec;72(6):967-79
15612844
Drug Alcohol Depend. 2010 Feb 1;107(1):76-9
19828264
Annu Rev Public Health. 1996;17:259-73
8724227
Addict Behav. 1997 May-Jun;22(3):405-18
9183510
Int J Addict. 1995;30(12):1603-45
8557410
Am J Drug Alcohol Abuse. 2009;35(1):48-53
19152207
J Subst Abuse Treat. 2002 Dec;23(4):343-50
12495796
J Natl Med Assoc. 1989 Jan;81(1):27-38
2657079
BMJ. 2008 Apr 26;336(7650):924-6
18436948
Subst Abuse Treat Prev Policy. 2007 Mar 29;2:10
17394653
Drug Alcohol Rev. 2004 Dec;23(4):391-8
15763743
Arch Gen Psychiatry. 1999 Jun;56(6):493-502
10359461
Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007024
20091613
Lancet. 2008 Nov 15;372(9651):1733-45
18817968
Arch Gen Psychiatry. 2006 Feb;63(2):201-8
16461864
J Consult Clin Psychol. 1989 Aug;57(4):559-63
2671072
J Subst Abuse Treat. 2013 Mar;44(3):349-54
22999380
J Subst Abuse Treat. 2002 Oct;23(3):191-7
12392805
Behav Ther. 2009 Dec;40(4):325-36
19892078
Am Psychol. 2010 Feb-Mar;65(2):98-109
20141265
Am J Psychiatry. 1991 May;148(5):630-5
1850208
Arch Gen Psychiatry. 1994 Mar;51(3):177-87
8122955
Curr Drug Abuse Rev. 2010 Mar;3(1):49-62
20088819
BMC Public Health. 2006 Aug 18;6:214
16919170
J Nerv Ment Dis. 1994 Oct;182(10):570-5
7931205
Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003023
17636713
Am J Addict. 2008 May-Jun;17(3):209-17
18463998
Am J Psychiatry. 1992 Mar;149(3):371-5
1536277
Addiction. 1996 Aug;91(8):1197-209
8828247
PLoS One. 2012;7(3):e33594
22448255
Exp Clin Psychopharmacol. 2008 Dec;16(6):547-54
19086775
Drug Alcohol Depend. 2013 Nov 1;133(1):30-6
23866988
Drug Alcohol Depend. 2006 Jun 9;83(1):65-72
16310974
Psychiatr Serv. 1998 Jun;49(6):782-7
9634157
Addiction. 2000 Apr;95(4):601-12
10829335
Arch Gen Psychiatry. 2006 Feb;63(2):219-28
16461866
J Stud Alcohol. 1998 Mar;59(2):152-62
9500302
Biol Psychiatry. 1996 Oct 1;40(7):617-28
8886295
Eur Addict Res. 2007;13(1):6-10
17172773
Drug Alcohol Depend. 2011 Apr 1;114(2-3):225-8
21041041
Arch Gen Psychiatry. 2003 Oct;60(10):1043-52
14557150
Eur Addict Res. 2011;17(3):139-45
21447950
Neuropsychopharmacology. 2010 Jan;35(1):217-38
19710631
J Psychoactive Drugs. 2013 Nov-Dec;45(5):434-42
24592670
J Consult Clin Psychol. 2010 Feb;78(1):89-97
20099954
J Consult Clin Psychol. 2003 Aug;71(4):754-63
12924680
Psychopharmacology (Berl). 1983;80(3):199-205
6412263
Am J Psychiatry. 2013 Jan;170(1):94-101
23138961
Drug Alcohol Depend. 2014 Aug 1;141:79-84
24913200
J Subst Abuse Treat. 2009 Jan;36(1):118-25
18657938
Am J Psychiatry. 1993 May;150(5):763-9
8480823
J Subst Abuse Treat. 1996 Jan-Feb;13(1):3-11
8699540
Psicothema. 2007 Feb;19(1):134-9
17295995
J Appl Behav Anal. 2008 Winter;41(4):539-49
19192858
Addiction. 2000 Sep;95(9):1335-49
11048353
Drug Alcohol Depend. 1998 Feb 1;49(3):249-60
9571389
Am J Psychiatry. 2014 Jun;171(6):683-90
24700332
J Addict Dis. 1994;13(4):115-28
7734463
Am J Drug Alcohol Abuse. 2009;35(2):103-8
19322731
Behav Ther. 2014 Nov;45(6):745-59
25311285
Addict Behav. 1996 May-Jun;21(3):363-76
8883486
J Nerv Ment Dis. 1995 Apr;183(4):251-9
7714514
Arch Gen Psychiatry. 1989 Feb;46(2):117-21
2492422
Drug Alcohol Depend. 2006 Dec 1;85(3):198-204
16723192
Addiction. 2006 Jul;101(7):1014-26
16771893
Cochrane Database Syst Rev. 2015 Apr 17;(4):CD006754
25882271
J Consult Clin Psychol. 1998 Oct;66(5):761-7
9803694
Addiction. 2011 May;106(5):960-7
21226886
Alcohol Clin Exp Res. 2011 Apr;35(4):643-51
21223301
J Consult Clin Psychol. 2012 Apr;80(2):276-85
22229758
Drug Alcohol Depend. 2005 Aug 1;79(2):119-28
16002021
Exp Clin Psychopharmacol. 2007 Jun;15(3):301-7
17563217
Prev Med. 2015 Nov;80:82-8
26164071
J Consult Clin Psychol. 1998 Oct;66(5):811-24
9803700
Exp Clin Psychopharmacol. 2008 Apr;16(2):132-43
18489017
J Subst Abuse Treat. 2014 Aug;47(2):168-74
24746956
J Fam Psychol. 2011 Aug;25(4):610-4
21639636
Drug Alcohol Depend. 2005 Oct 1;80(1):91-103
16157232
J Urban Health. 2004 Sep;81(3):505-15
15273272
Drug Alcohol Depend. 2013 Jun 1;130(1-3):234-7
23182410
Addiction. 2005 Mar;100(3):367-78
15733250
Drug Alcohol Depend. 2005 May 9;78(2):125-34
15845315
BMC Psychiatry. 2015 Jul 10;15:156
26159624
BMC Public Health. 2010 Dec 20;10:774
21172026
Arch Gen Psychiatry. 2004 Mar;61(3):264-72
14993114
Drug Alcohol Depend. 2007 Nov 2;91(1):97-101
17573205
Drug Alcohol Depend. 2014 Apr 1;137:36-47
24559607
Am J Addict. 2011 Sep-Oct;20(5):456-61
21838845
Arch Gen Psychiatry. 2002 Sep;59(9):817-24
12215081
Drug Alcohol Depend. 2012 Nov 1;126(1-2):224-31
22695473
Am J Drug Alcohol Abuse. 1991 Sep;17(3):229-47
1928019
Addiction. 1998 May;93(5):713-27
9692270
Drug Alcohol Depend. 2011 Oct 1;118(1):48-55
21454024
Clin Neuropharmacol. 1996 Feb;19(1):52-8
8867517
J Consult Clin Psychol. 2010 Feb;78(1):111-20
20099956
Drug Alcohol Depend. 2008 Nov 1;98(1-2):13-23
18585871
Drug Alcohol Depend. 2014 Dec 1;145:94-100
25456571
Addict Behav. 2006 Jul;31(7):1245-51
16137832
Arch Gen Psychiatry. 1994 Jul;51(7):568-76
8031230
Drug Alcohol Depend. 2004 Apr 9;74(1):1-13
15072802
Open Forum Infect Dis. 2015 Jan 01;2(1):ofu114
25884003
Am J Drug Alcohol Abuse. 1994 Nov;20(4):517-27
7832183
Addict Behav. 2014 Mar;39(3):660-8
24355401
Am J Public Health. 2010 May;100(5):913-8
19833998
J Consult Clin Psychol. 2007 Oct;75(5):765-74
17907858
Cochrane Database Syst Rev. 2011 Sep 07;(9):CD005031
21901695
J Stud Alcohol Drugs. 2007 May;68(3):353-61
17446974
Arch Gen Psychiatry. 1996 May;53(5):409-15
8624184
BMJ. 2004 Jun 19;328(7454):1490
15205295
Psychol Addict Behav. 2008 Dec;22(4):544-50
19071979
Lancet. 2013 Nov 9;382(9904):1564-74
23993281
Addiction. 2010 Dec;105(12):2120-7
20854334
Drug Alcohol Depend. 2011 Jul 1;116(1-3):177-87
21306837
Emerg Med Australas. 2008 Oct;20(5):391-402
18973636
Behav Res Ther. 1977;15(5):438-41
612346
J Consult Clin Psychol. 2000 Feb;68(1):64-72
10710841
J Addict Dis. 1997;16(2):41-56
9083824
Arch Gen Psychiatry. 2005 Oct;62(10):1148-56
16203960
Addiction. 2006 Oct;101(10):1479-92
16968350
Am J Psychiatry. 2008 Jul;165(7):881-8
18450927
J Consult Clin Psychol. 1998 Oct;66(5):832-7
9803702
J Appl Behav Anal. 2008 Winter;41(4):551-63
19192859
Addict Behav. 2008 Apr;33(4):593-604
18068905
N Engl J Med. 1988 May 5;318(18):1173-82
3283549
J Consult Clin Psychol. 1997 Oct;65(5):778-88
9337497
Exp Clin Psychopharmacol. 2001 Feb;9(1):14-23
11519628
Am J Psychiatry. 2014 Apr;171(4):436-44
24577287
Arch Gen Psychiatry. 1984 Sep;41(9):903-9
6431939
J Consult Clin Psychol. 1999 Jun;67(3):420-7
10369063
J Stud Alcohol Drugs. 2013 Jul;74(4):642-51
23739030
J Subst Abuse Treat. 2008 Mar;34(2):180-91
17512156
Clin Neuropharmacol. 1995 Apr;18(2):183-95
8635177
World Psychiatry. 2005 Oct;4(3):173-6
16633544
BMC Public Health. 2005 Apr 19;5:40
15840173
Mol Psychiatry. 2004 Jun;9(6):557-69
15098002
Addiction. 2001 Sep;96(9):1279-87
11672492
Curr Opin Psychiatry. 2009 May;22(3):263-8
19307968
J Subst Abuse Treat. 2001 Oct;21(3):111-7
11728784
Exp Clin Psychopharmacol. 2006 Aug;14(3):350-60
16893278
Am J Psychiatry. 2001 Aug;158(8):1215-9
11481153
Addict Behav. 2009 Oct;34(10):859-66
19362429
Exp Clin Psychopharmacol. 2007 Jun;15(3):293-300
17563216
Am J Geriatr Psychiatry. 2006 Sep;14(9):777-86
16943174
Braz J Psychiatry. 2006 Sep;28(3):196-202
17063219
J Consult Clin Psychol. 2000 Jun;68(3):515-20
10883569
Exp Clin Psychopharmacol. 2009 Jun;17(3):131-8
19586227
Psychol Addict Behav. 2013 Jun;27(2):477-88
22775772
Subst Abus. 2009 Oct-Dec;30(4):306-17
19904666
Am Psychol. 2012 Feb-Mar;67(2):87-100
21787037
Annu Rev Clin Psychol. 2005;1:91-111
17716083
Arch Gen Psychiatry. 1994 Dec;51(12):989-97
7979888
Am J Drug Alcohol Abuse. 1991 Jun;17(2):137-52
1862788
J Subst Abuse Treat. 1997 Jan-Feb;14(1):45-54
9218236
Cochrane Database Syst Rev. 2014 Dec 03;(12):CD009269
25470303
Cochrane Database Syst Rev. 2010 Feb 17;(2):CD007380
20166094
J Addict Dis. 2014;33(3):253-65
25115166
J Subst Abuse Treat. 2013 Jul;45(1):109-17
23453480
J Clin Epidemiol. 2011 Apr;64(4):383-94
21195583
Arch Gen Psychiatry. 2006 Apr;63(4):426-32
16585472
Addict Behav. 2009 Oct;34(10):867-77
19375870
J Stud Alcohol Drugs. 2007 Sep;68(5):663-72
17690799
Cochrane Database Syst Rev. 2006 Jul 19;(3):CD005032
16856072
Am J Respir Crit Care Med. 2006 Sep 1;174(5):605-14
16931644
J Consult Clin Psychol. 2005 Apr;73(2):354-9
15796645
Cochrane Database Syst Rev. 2011 May 11;(5):CD008063
21563163
Am J Psychiatry. 2007 Jan;164(1):100-7
17202550
J Psychoactive Drugs. 2003 Oct-Dec;35(4):471-8
14986876
Addict Behav. 2013 Sep;38(9):2455-62
23708468
Am J Psychiatry. 2005 Aug;162(8):1452-60
16055766
J Consult Clin Psychol. 2012 Apr;80(2):286-98
22250852
Drug Alcohol Depend. 1998 Sep 1;52(1):1-13
9788001
Arch Gen Psychiatry. 2005 Feb;62(2):199-207
15699297
Subst Abus. 2010 Apr;31(2):98-107
20408061