Dismantling the Components and Dosing of CBT for Co-Occurring Disorders

描述（由申请人提供）：这是最近完成的“家长”R01 （AA015069：“CBT治疗共病酒精焦虑症”）的竞争性续期申请。在接受酒精使用障碍（AUD）治疗的患者中，多达一半的患者同时患有焦虑症，这些患者的饮酒复发率是其他患者的两倍。为了解决这个问题，家长R01评估了一个基于cbt的项目，该项目结合了三次跨诊断焦虑减少治疗，以及三次旨在消除焦虑与饮酒之间的认知和行为联系（例如，预期、应对饮酒动机、条件联想）的疗程。在一项超过300例的随机试验中，家长R01显示，与加入减压控制治疗（53%复发）和单独接受AUD治疗的匹配非随机队列（61%复发）相比，将这种CBT加入以社区为基础的AUD治疗显著改善了四个月的酒精预后（例如，41%复发）。虽然这证实了父母R01的主要研究假设，但必须承认，效果并不大，CBT只减轻了大约一半与共发焦虑症相关的复发风险增加。幸运的是，父母R01的结果也指出了可能显著提高CBT治疗效果的修改方法。具体来说，在父母R01中的发现模式表明，解除耦合治疗，而不是减少焦虑治疗，导致了酒精治疗结果的改善。这表明进一步强调解耦治疗要素将提高CBT的整体有效性；然而，减少焦虑对改善这些患者的酒精预后的重要性仍然不明确。例如，用于减少焦虑的三次会议可能不足以影响父母的酒精结果。另外，可能需要减少焦虑治疗与去偶联治疗协同工作，以改善酒精治疗的结果。更新工作将采用拆解方法，在两个剂量水平上分离这些治疗成分的单独和相互作用，以提高已验证但仍未达到最佳效果的有效性

DESCRIPTION (provided by applicant): This is a competitive renewal application for the recently completed "parent" R01 (AA015069: "CBT Treatment for Anxiety Disorder in Comorbid Alcoholics"). Up to half of patients in treatment for an alcohol use disorder (AUD) have a co-occurring anxiety disorder and these patients relapse to drinking at twice the rate of other patients. To address this, the parent R01 evaluated a CBT-based program that combined three sessions of trans-diagnostic anxiety reduction therapy with three sessions designed to de-couple the cognitive and behavioral bonds linking anxiety to alcohol use (e.g., expectancies, coping drinking motives, conditioned associations). In a randomized trial with over 300 cases, the parent R01 showed that adding this CBT to a residential community-based AUD treatment significantly improved four-month alcohol outcomes (e.g., 41% relapsed) compared to adding a stress reduction control treatment (53% relapsed) and compared to a matched, non-randomized cohort undergoing the AUD treatment alone (61% relapsed). While this confirmed the primary study hypotheses in the parent R01, it must be acknowledged that the effects were not large and that the CBT alleviated only about half of the increased relapse risk associated with co- occurring anxiety disorders. Fortunately, the results of the parent R01 also point the way to modifications that are likely to significantly increase the therapeutic effect of the CBT. Specifically, the pattern of findings in the parent R01 indicates that the de-coupling therapy, rather than the anxiety reduction therapy, caused the improved alcohol outcomes. This suggests that further emphasizing the de-coupling therapy elements would increase the CBT's overall effectiveness; however, the importance of anxiety reduction for improving alcohol outcomes in these patients remains ambiguous. For example, the three sessions devoted to anxiety reduction may have been insufficient to affect alcohol outcomes in the parent R01. Alternatively, anxiety reduction therapy may be needed to work synergistically with de-coupling therapy to improve alcohol outcomes. The renewal work would use a dismantling approach to isolate the separate and interactive effects of these therapy components at two dose levels toward the goal of increasing the effectiveness of the validated but still sub-optimally performing parent R01 version of the CBT. 350 AUD patients with an anxiety disorder would be randomized to groups receiving either: 1) six sessions of CBT for anxiety reduction (CBT- AR); 2) six sessions of CBT for anxiety-alcohol de-coupling (CBT-DC); or, 3) the original CBT with its three anxiety reduction sessions and three de-coupling sessions (CBT-O). Based on the parent R01 findings indicating that the de-coupling components are the active ingredients of the CBT therapy, we predict that the best alcohol outcomes will be obtained in the CBT-DC group (six DC sessions) followed by the CBT-O (three DC sessions) further followed by the CBT-AR (zero DC sessions). This design would also indicate synergy effects between the AR and DC CBT components if the CBT-O out-performs the other two groups.