Improving Treatment Engagement in Individuals with Co-occurring Substance Use and Psychosis: A Telemedicine Family-Based Approach

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ABSTRACT Treatment engagement is a significant concern for individuals with first episode psychosis (FEP). Having a co-occurring substance use disorder is a primary predictor of low treatment adherence and risk for treatment dropout, and over 50% of people with FEP have a lifetime history of substance use disorder. Though integrated treatments are available for individuals with substance use and FEP, they cannot be effective if clients are not engaged in treatment. Clients with co-occurring substance use and FEP have limited reductions in their substance use, as <20% successfully engage in recommended substance use treatment. These results call for novel strategies that increase substance use disorder treatment engagement for this vulnerable population. Community Reinforcement Approach and Family Training (CRAFT) is an evidence-based treatment that significantly increases treatment engagement for transdiagnostic substance use disorders. CRAFT acknowledges that people with substance use disorders may not be ready to change their substance use, and it capitalizes on the motivation of family members as agents of change. Adapting CRAFT to a co-occurring substance use disorder and FEP population has the potential to make a significant impact by increasing clients’ substance use treatment engagement and reducing their use. Since elevated family distress is associated with both substance use and psychosis, reducing family distress may be a potential mechanism by which CRAFT improves treatment engagement for this population. Many individuals with FEP have frequent contact with family, but time, transportation, finances, and childcare are barriers to family members accessing additional services. Utilizing telemedicine (video conferencing) mitigates these barriers, and such tools can achieve similar treatment outcomes to in-person psychotherapy. To expand my background in cross-sectional substance use and psychotic disorders research to psychosocial treatment research, I propose to 1) develop and refine a CRAFT protocol for FEP delivered via telemedicine (CRAFT-FT) and in-person (CRAFT-F), and 2) conduct a pilot randomized controlled trial to test preliminary efficacy of CRAFT-FT with family members of people with substance use disorders and FEP compared to treatment as usual (TAU) and CRAFT-F. Determining changes in treatment engagement, substance use, and family distress will provide effect size estimation for larger R01 studies and advanced training. My mentorship team (Drs. Dost Öngür, Roger Weiss, Kim Mueser, Robert Meyers, Janet Wozniak, and Jim Hudson) will provide comprehensive guidance to address my training gaps: 1) treatment development, 2) telemedicine, 3) clinical intervention research, 4) advanced statistical methods, and 5) professional development (scientific communication/leadership) as I become an independent investigator. By achieving my K23 research and training aims, I will gain the necessary expertise for my long-term career goal of developing and implementing novel and accessible interventions while identifying predictors of treatment outcomes for people with co-occurring substance use and psychiatric disorders and their families.