Jaime Delgadillo, PhD Leeds Community Healthcare NHS Trust and University of York

1. Feasibility RCT of brief interventions for depression and co-occurring substance use disorders Jaime Delgadillo, PhDLeeds Community Healthcare NHS Trustand University of York

2. Co-morbidity: Prevalence and impact Depression commonly co-exists with substance use disorders (Kessler et al, 1997; Merikangas et al, 1998; Farrell et al, 2001; Schifano et al, 2002) Point prevalence of MDD = 2.6%, MDD+MDA = 11.4% in the UK (National Institute of Health and Clinical Excellence, 2010) Point prevalence of depression in UK substance misuse services is around 50% (Strathdee et al, 2002; Weaver et al, 2003) Pharmacological treatments for depression in alcohol and drug users have mixed evidence, with some reviews that indicate a modest beneficial effect (Iovieno et al., 2011; Nunes & Levin, 2004) and other reviews that question its efficacy (Lingford-Hughes, Welch & Nutt, 2012; Pedrelli et al., 2011; Torrens et al., 2005). In view of such evidence, exploring the potential of psychological treatments may be a fruitful avenue for research and practice.

3. Methods Design Feasibility RCT comparing: (A) 12-session behavioural activation delivered by IAPT therapist vs. (B) 1 session CBT Guided Self-Help delivered by drugs worker Eligibility criteria Include: patients accessing community OST, screen positive for Major Depression Exclude: primary anxiety disorder is presenting problem, psychotic or bipolar disorder, severe dependency (SDS>10) Measures Primary outcome: PHQ-9 (Kroenke et al, 2001) Secondary: Percentage of days abstinent derived from TOP (Marsden et al, 2008) Follow-up was at end, 6, 12 and 24 weeks follow-up Randomisation Individual randomisation to BA or GSH BA condition was delivered in parallel and co-located modalities

4. Step-wise screening and recruitment strategy Routine case-finding If: TOP <= 12 Then: PHQ-9 + GAD-7 If: PHQ-9 >= 12 Suitability screening interview & informed consent Random allocation BA in primary care Usual drugs treatment + guided self-help References: (Delgadillo et al, 2011, 2012)

5. Results: feasibility Screening and randomization • Approached 207 potential participants; of whom 186 (90%) were screened • Screened was refused or inappropriate in about 10% of cases • Consented and randomized 50 participants who met criteria • Ratio of screened and recruited patients was 4 : 1 Engagement in brief interventions • Only 42% actually attended at least 1 therapy appointment (engaged) • Engagement was not associated with demographics, abstinence, or baseline severity of depression • Non-engagement was associated with poly-substance use • Patients offered therapy appointments co-located in addiction clinics (vs. general primary care clinics) were more likely to engage with treatment (Odds ratio = 7.14, p = .04).

6. Results: predicting engagement

7. Results: preliminary treatment effects Within-group effect sizes were: d = .49 for BA d = .63 for GSH Overall NNT for all participants = 5.83

8. Concluding summary • It was feasible to apply a high volume, step-wise screening method in routine addiction treatment • Patients offered therapy appointments co-located in addiction clinics (vs. general primary care clinics) were more likely to engage with treatment • Poly-substance users were less likely to engage with treatment • No significant differences were found between brief behavioral activation and CBT workbook based guided self-help in terms of depression symptom reductions or percent days abstinence • Participants in both groups appeared to generally improve over time; the within-group effect sizes were moderate • These findings could inform the development of a fully-powered efficacy trial, ideally only applying co-located care, delivered by non-specialists, combining brief CBT plus contingency management

9. Acknowledgements RESEARCH TEAM Chief investigator: Jaime Delgadillo1 Study Co-ordinator: Stuart Gore2 Academic collaborators: Liz Hughes3, Dean McMillan3, Shehzad Ali3, Simon Gilbody3, Dave Ekers4, Gail Gilchrist5 Randomisation facilitator: Rebecca Forster1 CLINICAL TEAMS BA therapists: Geraldine Greenwood1, Omar Moreea1, Helen Stocks1, Susan Watson1, Jodi Clark1 GSH therapists: Julio Mendoza2, Iain Cullum6, Jo Craven7, Tony Hargreaves8, Zoe Patterson9, Melanie Senior9 ORGANISATIONS INVOLVED 1. Leeds Community Healthcare NHS 6. BARCA Leeds 2. St. Anne’s Community Services 7. DISC 3. University of York 8. ADS 4. Durham University 9. Multiple Choice 5. Institute of Psychiatry, KCL