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Ramchand R., Griffin B.A., Suttorp M. et al.
Journal of Studies on Alcohol and Drugs: 2011, 72, p. 380–389.
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It worked as well as somewhat longer and more elaborate experimental therapies, but how would a basic US programme for cannabis using youngsters fare when compared to much more extensive real-world therapies? On average at least as well if not better was the answer.
Summary Would a relatively brief, research-based treatment for youth cannabis use problems do well compared to more extensive programmes developed by treatment services, was the issue addressed by this US study. The programme being tested was the basic treatment in the multi-site US Cannabis Youth Treatment (CYT) Study. It consisted of two one-on-one motivational enhancement sessions followed by three cognitive-behavioural therapy sessions conducted in small groups of five or six children. Running over six weeks, it was intended to be a brief, low-cost initial treatment which could be widely adopted even in non-clinical settings such as school welfare services. The motivational sessions incorporated assessment feedback and comparison of cannabis use against national norms, followed by completion of what was called a 'personal goal worksheet'. Subsequent group sessions were geared to acquiring the skills (such as refusing drug offers) and resources (non-drug using friends and alternative activities) to become and remain drug-free.
All four clinics in the trial provided this basic treatment plus two others lasting 12 weeks, twice as long. None of these more extensive or more elaborate alternatives significantly improved on the basic approach. Over the next 30 months, all were followed by worthwhile but limited improvements in substance use and related problems, and many of the adolescents continued to use drugs and generate high costs for society. This at best partly encouraging picture should be seen in the light of the treatments and the populations being served. Some treatments were longer and more expensive than others but all were relatively brief, cheap and non-intensive.
It remained possible that though the brief CYT option was as effective as the longer ones tried in the trial, its limitations would be revealed relative to real-world and more extensive comparison programmes developed by treatment services for a similar population. The three comparison programmes had been among those in a US government-funded study which did not impose any changes in the therapies, but simply followed up patients to assess their progress relative to baseline assessments. Rather than the six weeks of the basic CYT option, comparison programmes lasted two to five months, and their patients spent significantly more time in therapy than CYT patients.
In two stages, the featured study honed down the 431 youngsters at the comparison services who were followed up 12 months later In both the CYT study and at comparison services over 9 in 10 were followed up. so that they were as similar as possible to the 174 followed up at the same point in the CYT study. First the same inclusion and exclusion filters were applied: all the patients had to be aged 12 to 18 and to meet criteria for cannabis use problems but not to be very heavy drinkers or users of other drugs or severely disturbed or ill. Then from the remaining 323 youngsters were selected the (effectively) 115 who most closely matched the CYT sample on 108 variables, many previously found related to drug and alcohol treatment outcomes, such as substance use severity, emotional wellbeing, and criminality. The few remaining differences between the CYT and comparison sample were adjusted for in the analyses. Over 8 in 10 of the samples were currently involved with the criminal justice system.
Among these comparable samples, at the one-year follow-up youngsters offered the basic six-week CYT programme has made significantly greater reductions in the frequency of their substance use over the past month, and over the past three months had experienced significantly greater reductions in related problems and self-reported less and/or less severe criminality. On the more stringent criterion of no use of illegal drugs when free to use (ie, not in custody or some other controlled environment), the CYT youngsters also fared better, but the difference was not statistically significant, and neither were differences in the proportion who had been in a controlled environment in the past three months or in the severity of emotional problems over that period. However, across both the CYT sample and comparison services, improvements fell far short of ideal; for example, only a thirds of youngsters had avoided illegal drug use when free to use.
Youth allocated to the CYT's basic motivational and cognitive-behavioural therapy had better substance use/problem and crime outcomes than those who received care at the three 'real world' comparison services, though the proportion who totally avoided illegal drug use and being institutionalised did not significantly differ and neither did their emotional health. The relatively greater effectiveness of the CYT programme is particularly noteworthy because it is a brief and comparatively inexpensive intervention. However, the study could not rule out the possibility that remaining unmeasured differences between the samples and/or differences in the treatment settings and staff could have accounted for the differences in outcomes. In particular, the CYT programme benefited from the resources of a research study, such as relatively intensive training and supervision of therapists. Though whatever the treatment the 12-month outcomes remained far from ideal, the relatively low cost and at least equivalent effectiveness of the basic CYT programme makes it an attractive option for the kind of youngsters with cannabis use problems typically admitted to publicly funded outpatient programmes.
commentary These findings that a relatively brief research-constructed therapy produced roughly equivalent outcomes to longer 'real-world' programmes have been confirmed in an earlier study which compared outcomes from all the CYT programmes (ie, not just the basic one) treated at two of the study's sites with those among youngsters treated in the normal way at the same services. The latter were subject to an eclectic and individualised programme occupying typically three times the number of treatment hours. Despite this, over the following year the frequency of substance use fell more among the CYT patients, though those treated in the usual programmes improved more in their emotional wellbeing and in the propensity of their general life situations to generate further problematic substance use. A later study at the same treatment organisation tested the basic CYT programme plus two family therapy sessions against the much more extensive usual programme offered by the service. During the following year the increase in days abstinent was slightly but significantly greater after the usual programme. On all other measures including substance-related problems there were no statistically significant differences. Given its relative brevity, the CYT programme cost much less per day abstinent and also per patient free to use substances but who did not at the end of the follow-up period.
It is important to reiterate the caution that these studies did not randomly allocate patients to CYT versus usual programmes and neither would the resources available to each in terms of training and supervision of therapists have necessarily been equalised. Outside the context of a research study, the briefer CYT options might have revealed their weaknesses relative a longer and more individualised programme. But the failure of any of the treatments to make major differences to most of the youngsters, and the minor differences between their outcomes, suggest that for these sometimes deeply troubled and in trouble youngsters, treatment for their cannabis and other substance use was a relatively minor influence on their lives.
For an account of the parent Cannabis Youth Treatment trial and a discussion of its findings see study 7 in these Finding background notes. For an assessment of the (generally modest) impacts of treatment for youth cannabis use in general see this Findings analysis.
Last revised 13 September 2011
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STUDY 2011 Treatment of adolescents with a cannabis use disorder: Main findings of a randomized controlled trial comparing multidimensional family therapy and cognitive behavioral therapy in The Netherlands