Substance Use Comorbidity Care: Evidence-Based Stepped Strategies for Depression

抑郁症是物质使用障碍（SUD）患者中最常见的并发精神疾病。抑郁症与成瘾的严重程度和不良的治疗结果有关。先前在患有SUD的个体中治疗重性抑郁症（MDD）的尝试受到以下三个限制中的至少一个的阻碍：1）未能将MDD和SUD的治疗整合在一个干预中，导致未经治疗的情绪症状导致物质使用，而物质使用有助于维持情绪症状; 2）使用单一治疗方式（例如，单独药物治疗），也导致大多数患者的微小改善;以及，3）使用复杂的认知干预，需要训练有素的人员，这增加了干预的成本并限制了其未来的适用性。本申请的目标是开始解决这个问题。 本阶段Ia提案的重点是开发和初步测试阶梯式护理模式，为SUD和MDD提供综合治疗。我们初步称之为物质使用合并症护理：基于证据的抑郁症分步策略（SUCCESS-D）的干预措施将通过以下方式克服先前的局限性：1）提供SUD和MDD的综合治疗; 2）使用行为和药理干预;以及，3）创建一个由顾问驱动的干预措施，以增加可行性。提供综合治疗和使用补充治疗方法相结合，应导致更好的情绪和物质使用的结果，从而解决了一个主要的未解决的需要，在治疗SUD。 由辅导员提供的第一级SUCCESS-D将整合动机访谈（MI）和行为激活技术，以减少药物使用，促进治疗保留，并减少抑郁症状。在第二个层面，将实施一种药理学算法，即德克萨斯抑郁症药物治疗算法（TMA-D），以治疗未能通过SUCCESS-D第一步实现缓解的个人的抑郁症状，而认知行为治疗将提供给那些继续使用药物的人。希望这种综合干预措施将构成一种比现有方法更全面和可能更有效的治疗模式。 这项研究的数据将在一个大型美沙酮维持诊所和一个大型无毒品项目中进行，将有助于规划未来的干预研究，这些研究将使用阶梯式护理模式为患有其他共病的药物滥用患者或更多样化的社区治疗环境提供适当的治疗策略。

Depression is the most common co-occurring psychiatric disorder in individuals with substance use disorders (SUD). Depression has been associated with both severity of addiction and poor treatment outcome. Previous attempts at treating major depressive disorder (MDD) in individuals with SUD have been hampered by at least one of three limitations: 1) Failure to integrate the treatment of MDD and SUD in one intervention, causing untreated mood symptoms to lead to substance use, while the substance use contributed to the maintenance of mood symptoms; 2) Use of single treatment modalities (e.g., medication alone), also leading to small improvement in most patients; and, 3) Use of complex cognitive interventions requiring highly trained personnel that increase the cost of the interventions and limit their future applicability. The goal of the present application is to start to address this problem. The focus of this Stage Ia proposal is the development and initial testing of a stepped-care model to provide integrated treatment for SUD and MDD. The intervention, which we preliminarily call Substance Use Comorbidity Care: Evidence-Based Stepped Strategies for Depression (SUCCESS-D) will overcome prior limitations by: 1) Providing integrated treatment of SUD and MDD; 2) Using behavioral and pharmacological interventions; and, 3) Creating an intervention that is counselor-driven to increase feasibility. The combination of provision of integrated treatment and use of complementary treatment approaches should lead to better mood and substance use outcomes, thus addressing a major unsolved need in the treatment of SUD. The first level of SUCCESS-D, delivered by counselors, will integrate motivational interviewing (MI) and behavioral activation techniques to decrease drug use, promote treatment retention, and reduce depressive symptoms. At the second level, a pharmacological algorithm, the Texas Medication Algorithm for Depression (TMA-D) will be implemented to treat the depressive symptoms of individuals who fail to achieve remission with the first step of SUCCESS-D, while cognitive-behavioral treatment will be offered to those who continue to use substances. It is hoped that this integrated intervention will constitute a more comprehensive and potentially more effective treatment model than currently existing approaches. Data from this study, which will be conducted in a large methadone maintenance clinic and a large drug-free program, will help plan future intervention studies that will use stepped-care models to provide appropriate treatment strategies for substance abuse patients with other co-occurring disorders or in more diverse community-based treatment settings.