Depression Treatment for Urban Low Income Minority Substance Users

大约22%的药物使用者患有重度抑郁症，这与更高的药物滥用治疗辍学率、药物使用复发率和艾滋病毒风险行为有关。此外，在像华盛顿这样的市中心地区，药物使用率和抑郁症对少数民族以及贫困人口的影响不成比例。尽管存在这种联系，但针对抑郁症的干预措施很少被开发出来，以满足抑郁症药物使用者的具体需求。在这方面，一种可能特别合适的方法是行为激活（BA），其目的是增加个人对愉快事件的参与，从而增加与积极强化的接触，减少厌恶事件的频率。BA已被证明在治疗抑郁症方面是有效的，这种简单直接的方法可能特别适合于市中心低收入药物滥用样本的特定需求。此外，BA在几个关键的实践和理论方面补充了标准药物滥用治疗，因为它更容易被这些环境中的工作人员采用，更节省时间（例如，更少和更短的会议，小组形式），更容易被由于低教育水平和长期吸毒而遭受认知限制的患者理解，并且可以将清醒方面纳入其治疗内容。在最初的第一阶段发展项目中，制定了一个版本的药物使用改善生活治疗方案，并专门针对市中心低收入的少数民族药物使用者，他们的抑郁症状加重。发表在《临床精神病学杂志》上的Daughters等人（2008年）证明，与TAU对照组相比，LETS ACT显著减少了自我报告的抑郁症状，显著增加了活动的享受和奖励价值。虽然初步发现证明是有希望的，但仍有许多问题没有得到解答，这项工作的一些扩展是必要的，包括对治疗后药物使用和艾滋病毒风险行为的评估，接触者匹配的控制，以及更大的样本量，以便对这些结果背后的机制进行更复杂的分析。因此，本提案的目的是在我们之前的1期治疗开发工作和小规模随机对照试验（RCT）的基础上进行后续研究，并在华盛顿特区市中心243名低收入抑郁药物使用者中进行了一项全动力2期随机对照试验，比较LETS ACT和非指向性治疗（NDT）。

Approximately 22% of substance users suffer from major depression, which is associated with higher rates of substance abuse treatment dropout, relapse to substance use, and HIV risk behavior. Further, in inner-city areas such as DC, rates of substance use and depression disproportionately affect ethnic minorities, as well as those living in poverty. Despite this link, few interventions targeting depression have been developed to meet the specific needs of depressed substance users. One approach that may be especially appropriate in this regard is behavioral activation (BA), which aims to increase individuals¿ engagement in pleasant events, thereby increasing contact with positive reinforcement and decreasing the frequency of aversive events. BA has been shown to be efficacious in the treatment of depression, and this uncomplicated and straightforward approach may be especially appropriate for the specific needs of an inner city low income substance abusing sample. Further, BA compliments standard substance abuse treatment in several key practical and theoretical ways as it is more easily adopted by staff in these settings, more time efficient (e.g., fewer and shorter sessions, group format), more easily understood by patients who suffer from cognitive limitations due to low education level and chronic drug use, and can incorporate aspects of sobriety into its treatment components. In an initial Stage 1 development project, a version of BA, the Life Enhancement Treatment for Substance Use (LETS ACT), was developed and specifically tailored for inner-city low income minority substance users with elevated depressive symptoms. Published in the Journal of Clinical Psychiatry, Daughters et al. (2008) demonstrated that LETS ACT led to a significantly greater reduction in self-reported depressive symptoms and a significant increase in enjoyment and reward value of activities as compared to the TAU control group. While preliminary findings prove promising, many questions remain unanswered and several extensions of this work are necessary, including an assessment of post treatment substance use and HIV risk behavior, a contact-matched control, and a larger sample size to allow for more complex analyses of the mechanisms underlying these outcomes. Thus, the objective of the present proposal is to follow-up on our previous Stage 1 treatment development efforts and small scale randomized control trial (RCT) with a fully-powered Stage 2 RCT comparing LETS ACT to nondirective therapy (NDT) among a sample of 243 low income depressed substance users currently receiving residential substance abuse treatment in inner-city Washington, DC.