Purpose of reviewIn recent years, deficits in emotion regulation have been studied as a putative maintaining factor and promising treatment target in a broad range of mental disorders. This article aims to provide an integrative review of the latest theoretical and empirical developments in this rap

Emotion regulation and mental health: recent findings, current challenges, and future directions.

The Timeline Followback (TLFB), a retrospective calendar-based measure of daily substance use, was initially developed to obtain self-reports of alcohol use. Since its inception it has undergone extensive evaluation across diverse populations and is considered the most psychometrically sound self-report measure of drinking. Although the TLFB has been extended to other behaviors, its psychometric evaluation with other addictive behaviors has not been as extensive as for alcohol use. The present study evaluated the test-retest reliability of the TLFB for cocaine, cannabis, and cigarette use for participants recruited from outpatient alcohol and drug treatment programs and the general community across intervals ranging from 30 to 360 days prior to the interview. The dependent measure for cigarette smokers and cannabis users was daily use of cigarettes and joints, respectively, and for cocaine users it was a "Yes" or "No" regarding cocaine use for each day. The TLFB was administered in different formats for different drug types. Different interviewers conducted the two interviews. The TLFB collected highly reliable information about participants' daily use of cocaine, cannabis, and cigarettes from 30, 90, to 360 days prior to the interview. Findings from this study not only suggest that shorter time intervals (e.g., 90 days) can be used with little loss of accuracy, but also add to the growing literature that the TLFB can be used with confidence to collect psychometrically sound information about substance use (i.e., cocaine, cannabis, cigarettes) other than alcohol in treatment- and nontreatment-seeking populations for intervals from ranging up to 12 months prior to the interview.

Reliability of the Timeline Followback for cocaine, cannabis, and cigarette use.

ContextDepression and substance abuse are common and costly disorders that
frequently co-occur, but controversy about effective treatment for patients
with both disorders persists.ObjectiveTo conduct a systematic review and meta-analysis to quantify the efficacy
of antidepressant medications for treatment of combined depression and substance
use disorders.Data SourcesPubMed, MEDLINE, and Cochrane database search (1970-2003), using the
keywords antidepressant treatment or treatment depressed in conjunction with each of the following alcohol dependence, benzodiazepine dependence, opiate dependence, cocaine
dependence, marijuana dependence, and methadone; a search of bibliographies; and consultation
with experts in the field.Study SelectionAmong inclusion criteria used for study selection were prospective,
parallel group, double-blind, controlled clinical trials with random assignment
to an antidepressant medication or placebo for which trial patients met standard
diagnostic criteria for current alcohol or other drug use and a current unipolar
depressive disorder. Of the more than 300 citations extracted, 44 were placebo-controlled
clinical trials, 14 of which were selected for this analysis and included
848 patients: 5 studies of tricyclic antidepressants, 7 of selective serotonin
re-uptake inhibitors, and 2 from other classesData ExtractionWe independently screened the titles and abstracts of each citation,
identified placebo-controlled trials of patients with both substance dependence
and depression, applied the inclusion criteria, and reached consensus. Data
on study methods, sample characteristics, and depression and substance use
outcomes were extracted. The principal measure of effect size was the standardized
difference between means on the Hamilton Depression Scale (HDS).Data SynthesisFor the HDS score, the pooled effect size from the random-effects model
was 0.38 (95% confidence interval, 0.18-0.58). Heterogeneity of effect on
HDS across studies was significant (P <.02), and
studies with low placebo response showed larger effects. Moderator analysis
suggested that diagnostic methods and concurrent psychosocial interventions
influenced outcome. Studies with larger depression effect sizes (>0.5) demonstrated
favorable effects of medication on measures of quantity of substance use,
but rates of sustained abstinence were low.ConclusionsAntidepressant medication exerts a modest beneficial effect for patients
with combined depressive- and substance-use disorders. It is not a stand-alone
treatment, and concurrent therapy directly targeting the addiction is also
indicated. More research is needed to understand variations in the strength
of the effect, but the data suggest that care be exercised in the diagnosis
of depression–either by observing depression to persist during at least
a brief period of abstinence or through efforts by clinical history to screen
out substance-related depressive symptoms.

Treatment of depression in patients with alcohol or other drug dependence: a meta-analysis.

DEPRESSION AND SUBSTANCE dependencies are among the most prevalent and costly disorders confronting the health care system, and they tend to cooccur, leading to greater overall severity and worse health-related outcomes, including increased risk of suicide. A wide range of initiatives have been developed to improve screening and diagnosis of depressive and drugor alcohol-use disorders in primary medical care settings where they commonly present, as well as in mental health or addiction treatment programs. However, controversy about how to treat patients with the concurrent disorders persists. One of the most basic questions is whether to treat depression in the setting of ongoing substance abuse. Recent recommendations suggest concurrent substance abuse should not be a barrier to treating depression. However, clinicians working with substance-dependent patients are often reluctant, for a variety of reasons, to initiate specific antidepressant treatment, including concerns about confusing substanceinduced depressive symptoms with true depressive disorders. Evidence is needed to help guide treatment. We therefore undertook a metaanalysis of placebo-controlled trials to

Treatment of Depression in Patients With Alcohol or Other Drug Dependence

Alcohol dependence (AD) is the most serious form of alcohol-use disorder. AD is associated with intense mental, physical, and functional impairment; high societal costs; and long-term suffering by both the dependent individual and the individual’s family members (e.g., Caetano, Nelson, & Cunradi, 2001). However, AD is also fairly widespread, with a 12-month prevalence rate of nearly 4% in the general population (Hasin, Stinson, Ogburn, & Grant, 2007). Despite the development and implementation of several empirically supported treatments, only about 25% of clients have been found to remain abstinent during the first year following treatment termination (Miller, Walters, & Bennett, 2001). Thus, there is a strong and pressing need to improve the efficacy of treatment for AD.

According to the relapse prevention model proposed by Marlatt and colleagues (Marlatt & Witkiewitz, 2005), relapse is likely to occur when at-risk individuals are confronted with high-risk situations and lack the coping skills necessary to deal with such situations effectively. Consistent with this model, a number of studies have focused on identifying specific high-risk situations. Extensive evidence from these studies has shown that negative affect is one of the most prominent factors associated with relapse to maladaptive drinking. First, AD is highly associated with affect-related disorders, such as anxiety, depression, and borderline personality disorder (Gregory et al., 2008; Hasin et al., 2007), and individuals with co-occurring symptoms of these disorders display significantly higher rates of relapse after treatment (Bradizza, Stasiewicz, & Paas, 2006). Second, the majority of clients retrospectively attribute relapse to negative affective states (Lowman, Allen, & Stout, 1996; Zywiak, Connors, Maisto, & Westerberg, 1996). Third, negative affect -- such as stress/nervousness, anxiety, anger, dysphoric/depressed mood, feelings of loneliness/uselessness/boredom -- predicts subsequent desire to drink/drinking-level in epidemiological studies and relapse in treatment-outcome studies (Falk, Yi & Hilton, 2008; Gamble et al., 2010; Hodgins, el-Guebaly, & Armstrong, 1995; Swendsen et al., 2000; Willinger et al., 2002). Fourth, in laboratory paradigms, the induction of negative affect was shown to predict increased urges to drink and increased expectancies of relief after drinking (Cooney, Litt, Morse, Bauer & Gaupp, 1997; Birch et al., 2004; Sinha et al., 2009). Fifth, interventions focusing on the reduction of depressed mood or anxiety symptoms have been shown to decrease relapse and severity of alcohol use disorders (Brown, Evans, Miller, Burgess, & Mueller, 1997; Watt, Stewart, Birch, & Bernier, 2006), and interventions with a strong focus on emotion-regulation skills, such as dialectical behavioral therapy (Linehan, 1993a) have been shown to reduce substance use (including alcohol) in clients suffering from borderline personality disorder (Harned et al., 2008; Linehan et al., 2002). Finally, evidence suggests that although alcohol may initially reduce negative affect to some extent (Armeli et al., 2003; Kushner et al., 1996; Swendsen et al., 2000), maladaptive use eventually leads to the continuation and potential increase of such affect, thereby generating a vicious cycle contributing to the chronic and escalating nature of AD (Heinz et al., 1998; Koob & Le Moal, 2001; Witkiewitz & Villarroel, 2009).

In line with these findings, a number of theories contend that affect regulation is a primary motive for alcohol use; such models include the affective processing model (Baker, Piper, McCarthy, Majeskie, & Fiore, 2004), the motivational model of alcohol use (Cox & Klinger, 1988; Cooper, Frone, Russel, & Mudar, 1995), the stress and negative affect model (Colder & Chassin, 1993), the self-medication model (Khantzian, 1997), the stress response dampening theory (Levenson, Sher, Grossman, Newman, & Newlin, 1980), and the tension reduction hypothesis (Conger, 1956). The implication of these models is that emotion-regulation skills (i.e., skills relevant for “monitoring, evaluating, and modifying emotional reactions, especially their intensive and temporal features, to accomplish one’s goals”; Thompson, 1994, pp. 27-28), should be important -- if not essential -- for preventing relapse in AD. This hypothesis received preliminary support from studies demonstrating that trait emotional intelligence (defined as the ability to be aware of emotions, identify emotions correctly and modify emotions effectively) was negatively associated with alcohol-related problems (Riley & Schutte, 2003) and that emotional intelligence moderated the association between negative emotions and craving for alcohol in AD patients (Cordovil de Sousa Uva et al., 2010). Additional research has shown that abstinent alcoholics report more difficulty effectively regulating their emotions than do social drinkers (Fox, Hong, & Sinha, 2008). However, research has yet to investigate the predictive effects of emotion-regulation skills on alcohol use during and after treatment.

To facilitate the utilization of the emotion-regulation framework for clinical purposes, Berking (2010) has synthesized and expanded upon previous theories (e.g., Gross, 1998; Larsen, 2000; Saarni, 1999; Greenberg, 2002) and proposed a skill-based model of emotion regulation. According to the Adaptive Coping with Emotions (ACE) Model (Berking, 2010), effective emotion regulation can be conceptualized as the situation-adapted interplay of the abilities to (a) be aware of emotions, (b) identify and label emotions, (c) correctly interpret emotion-related body sensations, (d) understand the prompts of emotions, (e) actively modify negative emotions to feel better, (f) accept negative emotions when necessary, (g) tolerate negative emotions when they cannot be changed, (h) confront (vs. avoid) distressing situations in order to attain important goals, and (i) compassionately support (encourage, self-soothe) oneself in emotionally distressing situations (in order to counterbalance potential short-term negative effects that engagement in the other skills may have on one’s emotions). Empirical studies have shown that all skills included in the ACE model are significantly associated with various indicators of mental health in clinical and at-risk populations (Berking et al., 2010; Berking, Meier, & Wupperman, 2010; Berking, Orth, Wupperman, Meier, & Caspar, 2008; Berking, Wupperman, et al. 2008; Berking & Znoj, 2008). However, research has not yet investigated whether these skills are associated with AD and whether they facilitate abstinence during or after treatment for AD. In addition, as deficient emotion-regulation skills are likely to be associated with other potential predictors of relapse, such as symptom severity (Langenbucher, Sulesund, Chung, & Morgenstern, 1996), degree of comorbidity (Tate, Brown, Unrod, & Ramo, 2004), cognitive abilities (Blume, Schmaling, & Marlatt, 2005), and negative mood (Hodgins et al., 1995), it is important to investigate whether emotion-regulation skills predict alcohol use beyond these additional factors.

Moreover, there is a lack of research comparing the emotion-regulation skills of populations with alcohol-use disorders with those of other clinical populations. Although some evidence exists for the transdiagnostic nature of emotion-regulation skills (Aldao, Nolen-Hoeksema, & Schweizer, 2010), deficits in these skills may be more integral to some disorders than to others. For example, in the emotional disorders (i.e. depression and anxiety) the inability to effectively regulate dysfunctional emotions can be conceptualized as the core of these disorders (Moses & Barlow, 2006); whereas in disorders such as AD, deficits in these skills might be seen as one relevant factor among many that contribute to the onset and maintenance of the disorder (Marlatt & Donovan, 2005). Finally, few studies have assessed a broad range of emotion-regulation skills in order to identify the skills most strongly associated with (changes in) psychopathological symptoms (e.g. Berking, Wupperman, et al., 2008) -- and thus the skills that should be considered important targets in treatment. At this point, no such study is available for AD.

Therefore, the major aim of the present study was to test the primary hypotheses that (1) more effective pretreatment emotion-regulation skills would negatively predict alcohol use during treatment and (2) more effective posttreatment emotion-regulation skills would negatively predict alcohol use during the three months following termination of treatment; even when controlling for other predictors potentially related to emotion regulation.

Additionally, we investigated whether, (a) more effective pretreatment emotion-regulation skills would be associated with lower pretreatment AD symptom severity, (b) AD patients would report less successful emotion-regulation than did non-clinical controls, but more successful emotion-regulation than did patients meeting criteria for major depressive disorder (MDD), and (c) specific emotion-regulation skills could be identified as particularly important in negatively predicting alcohol use during and after treatment for AD.

/pdf/deficits-in-emotion-regulation-skills-predict-alcohol-use-1nprijbilv.pdf

Deficits in emotion-regulation skills predict alcohol use during and after cognitive-behavioral therapy for alcohol dependence.

Reliability and validity of a smoking timeline follow-back interview.

Alcoholics with depressive symptoms score > or = 10 on the Beck Depression Inventory (A.T. Beck, C. H. Ward, M. Mendelson, J. Mock, & J. Erbaugh, 1961) received 8 individual sessions of cognitive-behavioral treatment for depression (CBT-D, n = 19) or a relaxation training control (RTC; n = 16) plus standard alcohol treatment. CBT-D patients had greater reductions in somatic depressive symptoms and depressed and anxious mood than RTC patients during treatment. Patients receiving CBT-D had a greater percentage of days abstinent but not greater overall abstinence or fewer drinks per day during the first 3-month follow-up. However, between the 3- and 6-month follow-ups, CBT-D patients had significantly better alcohol use outcomes on total abstinence (47% vs. 13%), percent days abstinent (90.5% vs. 68.3%), and drinks per day (0.46 vs. 5.71). Theoretical and clinical implications of using CBT-D in alcohol treatment are discussed.

D. Matthew Evans

Papers

Reliability and validity of a smoking timeline follow-back interview.

Cognitive-behavioral treatment for depression in alcoholism.