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Journal of Psychoactive Drugs

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Integrated Cognitive Behavioral Therapy Versus

Twelve-Step Facilitation Therapy for Substance-
Dependent Adults with Depressive Disorders
a b e b f
Sandra A. Brown , Suzette V. Glasner-Edwards , Susan R. Tate , John R. McQuaid
b g c d
, John Chalekian & Eric Granholm
a
Veterans Affairs San Diego Healthcare System, La Jolla, CA
b
VA San Diego Healthcare System
c
Department of Decision Science, Encore Capital Group
d
VA San Diego Healthcare System, University of California, San Diego, La Jolla, CA
e
Dual Diagnosis Program, Cedars-Sinai Medical Center, La Jolla, CA
f
Department of Psychiatry, University of California, San Diego, La Jolla, CA
g
University of California, San Diego, La Jolla, CA
Version of record first published: 08 Sep 2011.

To cite this article: Sandra A. Brown , Suzette V. Glasner-Edwards , Susan R. Tate , John R. McQuaid , John Chalekian &
Eric Granholm (2006): Integrated Cognitive Behavioral Therapy Versus Twelve-Step Facilitation Therapy for Substance-
Dependent Adults with Depressive Disorders, Journal of Psychoactive Drugs, 38:4, 449-460

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 Integrated Cognitive Behavioral
Therapy Versus 1\velve-Step Facilitation
Therapy for Substance-Dependent Adults
with Depressive Disorderst
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Sandra A . B rown , Ph. D. * ; Suzette V. G lasner-Edwards, Ph. D . * * ; Susan R. Tate, Ph. D . * * * ;

John R . McQuaid , Ph . D. * * * * ; John Chalekian, M . S . * * * * * & Eric Granholm, Ph . D. * * * * * *

Abstract- In a randomized trial, this study compared the longitudinal outcome patterns of veterans (N =
66) with substance use disorders and major depressive disorder receiving standard pharmacotherapy and
either 12-Step Facilitation Therapy (fSF) or disorder-specific Integrated Cognitive Behavioral Treatment
(ICBT). Depression and substance use were assessed at intake, during and after treatment using the
Hamilton Depression Rating Scale and the Time Line Follow Back. Reductions in depression during
treatment were comparable between the two treatment groups; however, their posttreatment patterns were
distinct. While ICBT participants evidenced a steady linear decline in depression through six months
posttreatment, a quadratic trend characterized TSF participants, for whom depression declined during
treatment, but increased throughout posttreatment follow-up. During treatment, TSF participants used
substances less frequently relative to those in ICBT; however, reductions in substance use were more
stable through six months posttreatment among those in ICBT relative to TSF. While both interventions
produced improvement in depression and substance use during treatment, ICBT may yield more stable
clinical outcomes once treatment ceases.

Keywords- behavioral interventions, cognitive behavioral therapy, comorbidity, Twelve Step

facilitation

The comorbidity of alcohol and/or substance use disor­ Axis I disorder for most drugs of abuse (Grant 1 995; Grant
ders (ASUDs) and depressive disorders is highly prevalent & Harford 1 995). Unfortunately, adults with such comor­
(Regier et al. 1 990). Moreover, epidemiological studies bidity have poorer treatment outcomes whether treatment
demonstrate that depression is the most common comorbid targets the alcohoJ/drug problems or the depressive disorder

tThis research was supported by VA Medical Research Merit Review
Grant awarded to Sandra A. Brown and by VA Associate Investigator
Awards to Suzette V. Glasner and Susan R. Tate.
*ProfessorofPsychology and Psychiatty, UCSD; Chief, Psychology Service
Veterans Affairs San Diego Healthcare System, La Jolla, CA.
* * Health Science Specialist, VA San Diego Healthcare System;
Clinical Director, Dual Diagnosis Program, Cedars-Sinai Medical Center,
La Jolla, CA.
***Health Sciences Research Specialist, VA San Diego Healthcare
System; Assistant Project Scientist, Department of Psychiatry, University
of California, San Diego, La Jolla, CA.
••••Associate Chief, Psychology Service, VA San Diego Healthcare
System; Associate Professor of Clinical Psychiatry, University of California,
San Diego, La Jolla, CA.
*****Manager of Risk Analysis, Department of Decision Science,
Encore Capital Group.
******Professor of Psychiatry, VA San Diego Healthcare System,
University of California, San Diego, La Jolla, CA.
Please address correspondence and reprint requests to Sandra A.
Brown, Ph.D., Department of Psychology (01 09), University of California,
San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0 1 09; Phone: 858-
822- 1 887. Email: sanbrown@ ucsd.edu.

Journal of Psychoactive Drugs 449 Volume 38 (4), December 2006

 Brown et al.
(McKay et al. 2002; Greenfield et al. 1 998). Consequently,
developing optimal interventions to disrupt the adverse
clinical trajectories of these indiv iduals is both theoretically
and c l i nical ly important.
Several studies have shown that integrated treatment
programs addressing both psychiatric disorders and AS UDs
in the same treatment setting may improve outcomes for
dually diagnosed patients (Judd et al. 2003 ; Drake et al.
1 996); however, randomized controlled trials of the efficacy
of integrated interventions are rare. In the present investiga­
tion, the authors conducted a randomized controlled trial
to determine whether an integrated cognitive behavioral
intervention for individuals with concomitant ASUDs and
major depression would produce incremental efficacy over
a 1 2-Step intervention.
Consistent with other efficacy trials, the present inves­
ti gation examined treatment response both during the active
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treatment phase and after termination of the interventions.
Moreover, in light of previous reports in which treatment
effects either dissipated over time fol lowing the interven­
tion (Smith & Glass 1 977) or, conversely, emerged over the
course of the posttreatment eval uation period ( Rawson et al .
2002), it was assumed that treatment response could vary
across time. Hence, we exami ned cli nical trajectories of
substance use and depression outcomes both during and at
three and six months following the active treatment phase.
The combination of substance abuse and psychiatric
comorbidity has profound and well documented clinical
i mplications: such comorbidity is associated with a poorer
prognosis across many psychiatric disorders. Specifically,
ASUDs have been associated with both more severe impair­
ment and greater symptomatology for those with affective
disorders (Modesto-Lowe & Kranzler 1 999) inc l uding
suicidality (Preuss et al . 2002). Recent evidence indicates
poorer outcomes and a 60% more costly clinical course for
psychiatric patients with comorbid ASUDs as well as for
substance use disordered patients with a concomitant Axis
I disorder (Hoff & Rosenheck 1 999). Clearly there is a bi­
directional relationship in this regard: addictive substances
produce and exacerbate psychiatric symptoms (Hasin &
Grant 2002; Preuss et al . 2002) and drugs appear to be
nonrandomly used across adult psychiatric populations
(McLellan & Druley I 977).
UTILITY OF INTEGRATED INTERVENTIONS
Integrated intervention for dually diagnosed individuals,
in contrast to sequential or parallel i ntervention, has been
advocated for two decades (Drake et al. 200 I ; Zweben 2000;
Koefoed et al. I 986). This recom mendation is based on a
limited number of studies demonstrating better outcomes
when individuals with ASUDs and concomitant psychiatric
disorders are treated together in the same program with
therapists addressing both types of problems (Granholm et
al. 2003 ; Drake et al. 1 996).
Journal of Psychoactive Drugs
Integrated Intenenlion
Definitions of "i ntegrated intervention" for the dually
diagnosed have not been universally agreed upon, at times
referri ng to: patient characteristics (groups comprised of du­
ally diagnosed), temporal aspects of intervention (sequential
versus contemporaneous), therapist characteristics (attend­
ing to both types of problems rather than exclusively one or
the other), or treatment content (i nterventions i ncorporating
treatment for problems common to both disorders versus
separate interventions for each disorder). Level and type of
integration vary across studies; however, content address­
ing both disorders appears critical. For example, targeting
depression in psychosocial interventions has been shown
to be important in treatment of other addictive behaviors ,
in which depression is also a risk factor for relapse (e.g. ,
smoking cessation, and smoking cessation for indiv iduals
in treatment for alcohol dependence). In this regard, i nte­
grating depression as a focus in addiction treatment and
using behavioral strategies designed to reduce or eliminate
depressive symptoms has been shown to si gni ficantly im­
prove outcomes (Patten et al. 2002; H urt et al. 1 997). Thus,
targeting comorbidity content in the intervention appears to
be i mportant in optimizing treatment for ASUDs and depres­
sion and is therefore the focus of the integrated intervention
employed in the present study.
EFFICACY TRIALS OF PHARMACOLOGICAL AND
BEHAVIORAL INTERVENTIONS FOR COMORBID
DEPRESSION AND SUBSTANCE USE DISORDERS
A number of pharmacologic interventions have
been eval uated for efficacy in the treatment of depressive
disorders or symptoms among alcohol and drug abusers
(Pettinat 200 I ; Cornelius et al. 1 997a, b). Most of these
trials have shown significant i mprovements in depression,
but not substance use outcomes (Roy-Byrne et al. 2000;
Kranzler, Mason & Modesto-Lowe 1 998 ; Roy 1 998). Nev­
ertheless, slight to modest improvement in both depression
and substance use outcomes have been shown with the use of
several types of antidepressants (Moak et al. 2003; McGrath
et al. 1 996) administered in conj unction with behavioral
psychosocial i nterventions.
By contrast, few c l inical trials of behavioral inter­
ventions have been conducted for those with SUDs and
concomitant Axis I depressive disorders. Using a quasi­
experimental design, Kell y, McKel lar and Moos (2003)
demonstrated that severely mental ly ill i ndividuals with
comorbid SUDs and major depression continued to suffer
significant levels of depression following inpatient substance
use treatment and derived less benefit from 1 2-Step self-help
i nvolvement compared to noncomorbid individuals with
A SUDs. Moreover, the Drug Abuse Treatment Outcome
Study found that longer treatment (three to six months) and
retention in treatment were associated with better outcomes
including for those with these comorbid disorders (Hub­
bard et al. 1 997). Taken together, these fi ndings suggest
450 Volume 38 (4). December 2006
 Brown et al.
that i nterventions for severely mental ly ill patients with
comorbid depression and ASUDs may be optimized by
providing ( I ) psychosocial i nterventions combi ned with
pharmacotherapy; (2) i ntegrated content in psychosocial
treatment addressing both disorders; and (3) longer treatment
ex posure.
In light of these considerations, we conducted a ran­
domi zed cli nical trial comparing incremental efficacy and
outcomes of an integrated, disorder-specific psychosocial in­
tervention (Integrated Cognitive Behavioral Therapy, ICBT)
plus standard pharmacotherapy to the most commonly
administered form of therapy for ASUDs and depression:
12-Step Facilitation (TSF) plus pharmacotherapy. In this
initial investi gation we predicted that, among veterans with
substance dependence and concomitant major depression:
( I ) ICBT would result in greater improvement in clinical
depression outcomes during treatment relative to TSF,
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whereas, given its exclusive abstinence focus, TSF would
have greater short-term efficacy in improving substance use
outcomes relative to ICBT during active treatment; and (2)
clinical trajectories (active treatment through post-treatment)
for both depression and substance use would be better among
ICBT participants, relative to TSF participants.
METHOD
Subjects
Si xty-six outpatient veterans at the Veterans Ad­
ministration San Diego Healthcare System (VASDHS)
were included i n this study. The study. was approved by
the VASDHS and the UCSD Institutional Revue Board.
Participants were drawn from sequential referrals to the
Substance Abuse Mental Illness Program (SAM!), a dual
diagnosis clinic. Medical charts of referred patients were
reviewed by research staff to determine whether they met
the following study inclusion criteria: ( I ) presence of DSM­
IV alcohol, cannabinol, and/or stimulant dependence and
recent substance use and depressive symptoms, and (2)
Axis I diagnosis of a major depressive disorder. A research
assistant screened referrals to the study for eligibility using
a brief, semistructured interview. Veterans were excluded
if they (a) met criteria for bipolar disorder or a psychotic
disorder; (b) met criteria for current opiate dependence
through intravenous administration; (c) l ived too far from
the medical center to reasonably attend therapy groups (i.e.,
50 miles away or more); (d) were homeless (unless arrange­
ments were made for residing in a recovery home); or (e)
had memory deficits i mpairing accurate recall of events.
I ndividuals who met study criteria were provided a com­
plete description of the study and written i nformed consent
was obtained. Participants agreed to: (a) randomization to
24 weeks of ICBT or TSF therapy group; (b) in person as­
sessment i nterviews at intake and quarterly thereafter with
$30 compensation for post-treatment quarterly follow-up
assessments; (c) random toxicology screens at group sessions
Journal of Psychoactive Drugs
Integrated Intervention
and fol l ow-up i nterv iews; (d) psychopharmacological
evaluation and management by the dual diagnosis program
psychiatrist; and (e) not participate in any other formal
treatment for depression or substance dependence with the
exception of the above noted pharmacotherapy and com­
munity 12-Step addiction meetings. With the exception of
psychotic disorders and bipolar disorder, participants with
other co-occurring Axis I disorders were not excluded ( i .e . .
posttraumatic stress di sorder, anxiety disorders) nor were
individuals with Axis II disorders.
A total of 90 veterans met study inclusion criteria (73 '11
of those referred), completed informed consent, and were
randomized to condition. Of these, 24 (26.7%) were dropped
from study analyses and were not followed for subsequent
data collection. Dropped partici pants were individuals who
(a) gave i nformed consent but did not attend any group
session and were not responsive to outreach efforts (n =
5, 5.6% ); or (b) attended at least one, but less than eight
of a possible 36 sessions (M = 1 .2), the minimum consid­
ered as adequate exposure to the therapy (n = 1 5, 1 6.7%).
Additionally, one veteran gave i nformed consent but later
refused/withdrew consent and three (3.3%) participants were
excluded from analyses due to being incarcerated for more
than one-third of the study timeframe of 1 2 months.
The final sample i ncluded 6 1 males and five females.
The participants ranged in age from 3 1 to 68 years (M =
48.8; SD = 7.9), were predominantly divorced, separated,
or widowed (60%) and Caucasian (74%), with an average
of 1 3.4 years of education (SD = 1 .6) (see Table I ). The
majority of the sample met criteria for l ifetime alcohol de­
pendence, and more than half of the participants met criteria
for stimulant dependence. Participants reported, on average,
that the proportion of days abstinent from alcohol and drugs
in the three months prior to treatment was .72 (SD = .30)
with average alcohol consumption at 10 drinks per drinking
day (SD = 1 0.4) in the three months preceding treatment.
Thirty-seven percent reported drug use during the three
months pretreatment, and of those study participants, the
average proportion of days of drug use reported within the
three months pretreatment was 25% (SD = .28). The average
Hamilton Depression Rating Scale (HDRS) score at intake
was 30.2 (SD = 1 5 . 1 ) , indicating a cli nically significant level
of depression in the overall sample. While al l participants
had histories of exposure to community 1 2-Step meetings
and formal outpatient mental health or alcohol/drug treat­
ment, 68% of participants had a history of inpatient mental
health treatment.
Design
This study employed a randomized, two group design
with repeated assessments at i ntake, at mid ( 1 2 weeks) and
end (24 weeks) of treatment, and follow-up assessments at
three and six months posttreatment. Consecutive admis­
sions to the SAMI program meeti ng study criteria were
sequentially randomized by cohorts i nto either TSF group
45 1 Volume 38 (4). December 2006
 Brown et al.
intervention, or ICBT for depression and ASUDs as well as
standard pharmacotherapy of monthly medication appoint­
ments with selective serotonin reuptake inhi bitors (SSRis)
or atypical antidepressants. Both conditions comprised
two consecutive 1 2-week phases of intervention. Phase I
consisted of twice weekly one-hour group sessions plus
monthly medication management, and subsequently, Phase
II consisted of once weekly one-hour group sessions plus
monthly medication management.
Procedure
Diagnoses. Within one week of obtai ning informed
consent for study participation, a trained research assistant
completed a diagnostic assessment using the Composite
International Diagnostic Interview (CIDI), developed by
the World Health Organization (Robins et al . 1 988). The
CIDI employs a structured format for assessing psychiatric
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symptoms that occur in the context of medical conditions or
substance use and/or withdrawal separately from psychiatric
symptoms that occur i ndependent of medical conditions
or substance use and/or withdrawal. The CIDI is thus well
suited for assessment of true SUD-psychiatric comorbidity.
Only partici pants who met criteria for substance-indepen­
dent major depressive disorder were incl uded in the study.
In addition, all research diagnostic data and medical chart
information were reviewed by a supervising l icensed clinical
psychologist for consensus to confirm DSM-IV diagnoses.
El igibl e participants were randomized to treatment condi­
tion, and within one week, completed additional assessment
of alcohol and/or drug i nvolvement and current depressive
symptoms. As described below, repeated assessments of
alcohol and/or drug i nvolvement and depressive symptoms
were completed during and after treatment, and the CIDI
was readministered six months posttreatment.
Measures
S ubstance use. The Time Line Follow Back (TLFB),
a calendar-assisted structured i nterview (Sobell & Sobell
1 992) with demonstrated rel iability and validity in substance
treatment samples (Fals-Stewart et al. 2000; Maisto, Sobell
& Sobell 1 979) was used at all follow-up study v isits to as­
sess alcohol and/or drug use in the preceding three months
at treatment entry, during treatment (i.e., 1 2 and 24 weeks
after treatment initiation), and three and six months post­
treatment. The TLFB was adapted to i nclude other drugs
used and days using drugs in addition to the quantity and
frequency of alcohol use (Fals-Stewart et al. 2000 ; Ehrman
& Robbins 1 994). Additionally, items comprising the drug,
alcohol , and psychiatric severity composites of the Addiction
Severity Index (AS I) (McLellan et al. 1 985) were adm i nis­
tered at i ntake to serve as baseline descriptive measures of
the study sample.
Depression symptoms. The Hamilton Depression Rat­
ing Scale ( H DRS; Ham i l ton 1 960), a 2 1 -item structured
c l i nical i ntervi ew w i th good sensitivity and speci ficity
Journal of Psychoactive Drugs
Integrated I ntervention
among alcohol dependent populations (Wil lenbring 1 986)
was used to assess depressive symptoms in the prior week.
The HDRS was administered at intake, during treatment,
and at each fol low-up assessment. Because HDRS is a state
(versus trait) measure, it was admini stered within two weeks
of each planned fol low-up time point. HDRS was not col­
lected for participants who failed to present for follow-up
within this ti meframe.
Treatments and Therapists
Treatments were matched in terms of therapist contact:
24 60-minute, twice weekly group therapy sessions during
Phase I , and 12 60-minute weekly group therapy sessions
during the Phase II relapse prevention stage. All group
therapy sessions were facilitated by two therapy colead­
ers. For all interventions, one of the group therapists was
a senior cli nician (cl i nical psychologist) and the second
cotherapist was either a predoctoral psychology intern or
cli nical psychology graduate student. To provide therapist
continuity, the senior clinician in each respective therapy
condition was the pri mary therapist in both Phase I and
Phase I I . To avoid therapist effects, trainee rotations were
shifted every six months so that at least one cotherapist per
group was changed. Therapists were coded and recorded for
every group run throughout the investigation so that therapist
effects could be evaluated.
All therapists completed clinical trai ning in the manual­
ized i nterventions delivered. For ICBT, therapists completed
structured training i n the manualized treatment with a senior
i nvestigator with expertise in ICBT, observed professionals
conduct a minimum of six sessions over a three-week period
and recei ved weekly supervision by the senior investi ga­
tor. For TSF, over a three-week period, therapists attended
1 2-Step community meeti ngs, read 1 2-Step literature and
the TSF manual, and received direct trai ning from a senior
i nvestigator with expertise in 1 2-Step interventions as well
as several senior 1 2-Step counselors at the VASDHS.
To ensure treatment i ntegrity, all sessions were videotaped
w ith consent from study participants. A random sample
of videotapes (25%) of both manual ized treatments was
reviewed by their respective superv isors to ensure i ntegrity
of implementation, adherence to protocol and avoid con­
tamination of other content or techniques. Additionally, a
random sample of the therapy sessions were reviewed by the
project's principal i nvesti gator. Weekly 60-mi nute therapy
supervision with videotapes was ongoing throughout the
duration of the study.
Integrated Cognitive Behavioral Therapy (ICBT).
Phase I (i.e., acute treatment) of ICBT i ncluded three mod­
ules (thoughts, activities, and people) of eight sessions each.
Phase II (i.e., relapse prevention) consisted of 1 2 structured
sessions that reviewed and highli ghted the core skills learned
i n Phase I.
Each session followed a simi lar structure: (a) review
of the weekly agenda and group topics ; ( b) review of
452 Volume 38 (4), December 2006
 Brown et al.
homework; (c) presentation of didactic information and
in-group ski l l s practice; and (d) homework assignment.
ICBT combined two empirically validated interventions:
Cognitive-Behavioral Depression Treatment with a manual
developed by Munoz and colleagues ( 1 993) and the Cogni­
tive-Behavioral Coping Skills Training of Project MATCH.
(Kadden et al . 1 992). The thoughts module incl uded material
focused on identifying dysfunctional cognitions, generating
alternative cognitions, and practicing thought challenging
techniques in situations that lead to depressi ve symptoms
and/or high-risk relapse situations. The activities module
focused on identifying, scheduli ng, and assessing effective­
ness of positive activities for improving mood and managing
pressures to drink or use and other risk situations. The people
module focused on assertiveness and communication train­
ing designed to increase positi ve interactions and facilitate
patient efficacy when refusing offers of alcohol or drugs.
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Twelve-Step Facilitlltion (TSF) Therapy. TSF, a formal
therapist-guided group intervention, consisted of the NIAAA
Project MATCH TSF intervention (Nowinski, Baker & Car­
roll 1 994) modified i n two ways: ( I ) hour-long group rather
than individual sessions (more consistent with the 1 2-Step
model), and (2) i ncl usion of an aftercare phase. Phase I of
TSF used the well standardized procedures and content from
Project MATCH covering four core topics (e.g., acceptance,
surrender) and six electives (e.g., enabling, and persons,
places, or things) to support the goal of abstinence. Each
session included a review of readings, new didactic material,
and discussion of recovery tasks including encouragement to
regularly attend community 1 2-Step meetings. Participants
were asked to complete standard readings (AA Big Book,
1 2 Traditions, and Living Sober). Depression issues were
managed in this context, as were other personal issues, in
relation to TSF themes of spirituality and practical ity while
maintai ning the 1 2-Step focus. Phase I I (aftercare) consisted
of simi lar group sessions held once per week with a review
of Phase I topics.
Community 12-Step involvement. As part of the
informed consent process, participants agreed not to partici­
pate in any other treatment for depression or substance abuse
with the exception of pharmacotherapy and attending com­
munity addiction self-help groups such as AA, NA, or CA.
In the TSF intervention group, participants were explicitly
asked about their community 1 2-Step meeting attendance
between sessions and actively encouraged to attend on a
regular basis. By contrast, in the ICBT group, community
1 2-Step meeting attendance was not a focus of the manualized
intervention a00 !EliciJElls were not queried a00ut community 12-
Step involvement All !EiiciJElls in l:x:lth groups reiXXted some prior
invol vernent in community self-help groups (Xior to treatment entry.
Enrollment. To facil itate patient enroll ment and de­
crease wai t-time to the start of treatment, rol l i ng group
admissions were used. Following the procedures developed
by Munoz and colleagues ( 1993), participants were allowed
to start at the beginning of any module in Phase I. Both treat-
Joumul of P�ychouctive Drugs
I ntegrated Intervention
ment conditions were running at all times with staggered
start times (every two weeks) to allow ongoing entry and
to enhance ecological validi ty.
Stamhlrd pharmacotherapy. All participants received
an ini tial medication eval uation and monthly 30-mi nute
medication cli nic appointments with the treating psychiatrist
at the SAM! program . Medications were prescribed in an
open-label format using standard VA pharmacology protocol
for treatment of major depression. SSRls and atypical an­
tidepressants comprised 90% of the pharmacologic agents.
Clinic visits and prescribed medications were recorded to
eval uate the distri bution across treatment groups.
Data Analytic Plan
Two dependent variables were selected a priori for
primary statistical analyses: percent days abstinent (PDA)
provided a measure of the frequency of substance use
(Project MATCH 1 998). The HDRS total score constituted
a global measure of depression symptoms.
Participants were excl uded from analyses if they were
missing two or more values on any outcome trajectory
measure. To address our hypothesis regarding improvement
in depression and substance use during treatment, repeated
measures ANOYAs were conducted on changes in depres­
sion and substance use from pretreatment to the end of Phase
I treatment ( 1 2 weeks after treatment initiation). Next, we
eval uated our hypothesis regarding clinical trajectories (i.e.,
changes in depression and substance use from the end of
Phase I through six months post-treatment) controll ing for
intake values. In this latter set of analyses, repeated measures
A NOVAs were modeled using the PROC MIXED procedure
of SAS (Littell et al. 1 996). This analytic strategy was used
to assess ( I ) whether substance use and depression values
changed significantly through time or if there was an effect of
treatment (e.g., main effects); (2) if the rate change through
time differed by treatment type (e.g. i nteraction of main
effects); and most importantly (3) if a particular functional
form (e.g. linear vs. quadratic) could be fit to the trajectories
and if these trajectories differed between treatment types.
PROC MIXED was used (instead of PROC GLM/REPEAT­
ED or repeated measures GLM i n SPSS) si nce it affords ( I )
the opportunity to i nclude observations with data missing
at random i n the time series (e.g. , no l ist-wise deletion) and
(2) can treat time as a continuous covariate in the repeated
design making trajectory parameters estimable. Using this
procedure, l inear and quadratic parameters were estimated
for each treatment type simultaneously, and interaction terms
were estimated to assess whether the trajectories between
treatments differed significantly over time.
RESULTS
Completers versus Early Drop-Outs
Following informed consent, 48 subjects were randomly
assigned to ICBT, and 42 to TSF. Of those, a total of 26.7%
453 Volume 38 (4). December 2006
 Brown et al. lntegrdted lnterwntion

TABLE 1
Participant Characteristics at Intake by Study Condition

Overall 12-Step ICBT

Characteristic (N = 66) (n = 29) (n = 37)
Gender
Male 61 26 35
Female 5 3 2
Age, mean, yrs (SD) 48.8 (7.9) 48.9 (7.6) 49. 1 (6.8)
Marital status (%)
Married I I. I 1 8.5 5.6
Divorced/Widowed/Separated 60.3 48. 1 69.4
Never married 28.6 33.3 25.0
Education, mean, yrs (SD) 1 3.4 ( 1 .6) 1 3.8 ( 1 .8) 1 3.2 ( 1 .8)
Ethnicity (%)
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Caucasian 74.6 70.4 77.8

Hispanic 1 2.7 14.8 I I. I
African-American II.I 1 1. 1 I I. I
American Indian 1 .6 3.7 0.0
Depression
HDRS Total Score, mean (SD) 30.2 ( 1 5. 1 ) 30.7 ( 1 4.3) 29.8 ( 1 5.7)
Substance Use Measures
ASI Alcohol Composite, mean (SD) 0.25 (0.2) 0.28 (0.2) 0.24 (0.2)
ASI Drug Composite, mean (SD) 0.07 (0. 1 ) 0.09 (0. 1 ) 0.06 (0. 1 )
TLFB Proportion Days Abstinent, mean (SD) 0.72 (0.3) 0.69 (0.3) 0.75 (0.3)
CIDI Measures (%)
Alcohol Dependence (life) 9 1 .2 86.4 94. 3
Marijuana Dependence (life) 1 3. 1 1 6.0 1 1.1
Stimulant Dependence (life) 54. 1 52.0 55.6
Other Drug Dependence (life) 6.6 8.0 5.6
Post Traumatic Stress Disorder 43. 3 4 1 .7 44.4
Note: ICBT = Integrated Cognitive Behavioral Therapy; HDRS = Hamilton Depression Rating Scale; AS I= Addiction Severity Index;
TLFB = Timeline Follow Back; CIDI = Composite International Diagnostic Interview. There were no significant differences observed
between groups on any measures.

dropped after attending an average of 1 .2 sessions: 1 2.2 %
(n = I I ) of those assigned to ICBT compared to 1 4.5 % (n =
1 3) of those assigned to TSF with no significant difference
between groups. Dropped participants did not differ from
participants retained in the study analyses on any demo­
graphic characteristics (e.g., age, marital status, ethnicity)
or on drug or psychiatric severity composites of the Addic­
tion Severity Index (ASI). Dropped participants had higher
= 37) and TSF (N = 29) completers were compared on
demographic characteristics and depression and substance
use measures (HDRS and PDA, respectively) at intake us­
ing chi-squared tests and independent t-tests. The groups
did not differ on any measure indicating the absence of a
differential bias as a function of treatment assignment. The
average number of treatment sessions attended was 1 7.9 (SD
= 1 1 .4) for ICBT participants and 22. 1 (SD = 8.9) for TSF

alcohol ASI scores than retained participants (0.43 versus
0.27, respectively), t (76) = 2.86; p < .05.
Intake Characteristics
Means and standard deviations of demographic, sub­
stance use, and depression measures at intake separated
by treatment assignment are shown in Table I . ICBT (N
participants (t (64) = 1 .62; p = . I I ). Thirty-eight percent of
participants in the overall sample attended a minimum of
24 of a possible 36 group therapy sessions.
Therapist Effects
A nested ANOVA was performed to assess if primary
therapists and therapists within treatments had any impact

Journal of PJychoactive Drugs 4.54 Volume 38 (4), December 2006

 Brown et al. Integrated Inten·ention

TABLE 2
Depression and Substance Use Outcomes Across Time

Study Condition Depression (HDRS) Substance Use (PDA)

Mean (SEM) Mean (SEM)
Pretreatment
1 2-Step 32.2 (3.5) 68 (6.0)
ICBT 32.2 (2.8) 74 (4.4)
Mid-Treatment
1 2-Step 30.4 (3.4) 95 (6. 1 )
ICBT 26.3 (2.8) 90 (4.5)
End-of-Treatment
1 2-Step 23.2 (3.4) 93 (6. 1 )
ICBT 27.7 (2.8) 84 (4.6)
Three Months Post-Treatment
1 2 S tep
- 26.3 (3.5) 87 (6. 1 )
ICBT 22.2 (2.8) 80 (4.5)
Six Months Post-Treatment
Downloaded by [Laurentian University] at 04:44 19 April 2013

1 2-Step 27.9 (3.9) 72 (8.3)

ICBT 25.9 (2.9) 87 (5.6)
Note: HDRS = Hamilton Depression Rating Scale; PDA = Proportion Days Abstinent; 1 2-Step = Twelve Step
Facilitation Therapy ; ICBT = Integrated Cognitive Behavioral Therapy. Pairwise contrasts revealed no signi ficant
differences between groups.

on depression and substance use outcomes. This analysis
revealed no significant effect of Therapist (F( I ,39) = .26, p
= .84) nor any effect of Therapist nested within Treatment
(F(5,35) = .5 1 , p = .78).
Pharmacological Treatments
Groups did not differ in proportion receiving antide­
pressant medication or number of medication management
appointments attended during the six-month active phase of
the i ntervention (M = 3.7 appointments, SD = 2. 1 ; F( l ,64)
= .48, p = .49). All veterans attended at least one medica­
tion management appointment in Phase I and 97% were
prescribed an antidepressant medication (i.e., SSRis).
Community 1 2-Step Involvement
Consistent with the focus of treatment, those in TSF
were more likely to report 1 2-Step attendance in the commu­
nity than partici pants in the ICBT condition at mid-treatment
(94.7% vs. 60.9% respectively), end of treatment (84.2% vs.
44.0%), and three months posttreatment (78.9% vs. 46.7%).
By six months post-treatment, the percentage attending
1 2-Step community meetings did not statistically differ for
the two groups, X2 (N = 45) = 3.4, p = .065, although there
was a continued trend for higher attendance among TSF
participants (TSF = 73.7%, ICBT = 46.2%).
-0.07, p = .95). As can be seen in Table 2, changes in de­
pression during the active treatment phase were comparable
between the two treatment groups, with both groups showing
a decl ine in HDRS scores. Consistent with this descri ption,
a repeated measures AN OVA revealed a significant effect of
time (F(2,83) = 4. 1 1 , p = .02) but neither an effect of treat­
ment assignment (ICBT vs. TSF) (F< I ) nor an interaction
among these factors (F(2,83) = 2.9, p = .06). Despite the
similar changes in depression observed between groups
during active treatment, the two groups ev idenced disti nct
post-treatment clinical outcome trajectories (see Figure I ).
As is clear from this figure, depressive symptoms i ncreased
in a nonlinear manner across time for TSF participants, but
remained stable through six months post-treatment among
ICBT partici pants. Consistent with this description, for
those i n TSF, both the linear (F( I , I 1 6) = 4.06, p = .03) and
quadratic (F( I , 1 1 6) = 4.04, p = .04) terms were significant,
while both parameters were nonsignificant for ICBT par­
ticipants (F( l , l l 6) = . 3 1 , p = .58, F( l , 1 1 6) = .24, p = .63),
respectively. As is clear in Figure I , depression levels among
TSF participants steadily increased to approach intake values
by six months post-treatment, although a pairwise contrast
of HDRS scores between groups at six months revealed that
the difference between TSF and ICBT scores fai led to reach
significance (t( l l4) = .4 1 , p = .68).

Changes in Depression During and After Treatment
Twenty participants had two or more missing values
on the HDRS, and thus, analyses of depression outcomes
i ncl uded 46 participants (ICBT = 28, TSF = 1 8). Participants
who were excluded from these analyses did not differ from
i ncluded participants on HDRS scores at i ntake (t(44) =
Changes in Substance Involvement During
and After Treatment
Twelve participants had two or more missing values
on the TLFB-Percentage Days Abstinent (PDA) index, and
thus, analyses of PDA outcomes included 54 participants
(ICBT = 35, TSF = 1 9). Participants who were excl uded

Journal of Psychoactive Drugs 455 Volume 38 (4). December 2006

 Brown et al. Integrated Intervention

FIGURE 1
Modeled Hamilton Depression Total Scores as a Function of Time, Separated by Group

Q)
'- 35
0 Treatment Post-Treatment
()
en
co
-
0
I- 30
c
0
·c;;
en
�
a.
Downloaded by [Laurentian University] at 04:44 19 April 2013

Q) 25
0
c
ICBT
0 - - - ·

:::
12 Step
E
m
:I: 20
Mid End 3M 6M

Assessment Periods

Mid = mid-treatment (i.e., end of Phase I); End = end-of-treatment; 3M = three months post-treatment; 6M = six months post-treatment.

from these analyses did not differ from i ncl uded participants
on PDA scores at i ntake (t(52) = -0.68, p = .50). A repeated
measures ANOVA revealed a highly significant effect of
time (F(2, 1 00) = 1 4.96, p < .000 1 ), but neither an effect of
treatment assignment (F < I ) nor a significant treatment x
time i nteraction (F(2, 1 00) = l .23, p = . 30). Again, however,
trajectory analyses revealed that reductions in substance use
were more stable through six months post-treatment among
those who received I CBT, whereas those in TSF evidenced
a decline in the proportion of days abstinent at three and
six months post-treatment (see Figure 2). Specifically, there
was a significant linear decrease (F( 1 , 1 3 1 ) = 5.32, p = .02)
for 1 2 Step participants while the trend was non-signifi­
cant for ICBT (F( l , l 3 1 ) = 1 .08, p = . 30), suggesting ICBT
participants were better able to sustain abstinence by the
end of treatment, and after treatment (87% at six months)
compared to 1 2-Step (72%). However, a pairwise contrast
of PDA scores between groups at six months post-treatment
revealed that this difference failed to reach significance
(t( 1 27) = - 1 .56, p = . 1 2).
DISCUSSION
The results of this study indicate that both ICBT and
TSF for veterans with comorbid depressive disorders and
ASUDs produce reductions i n depressi ve symptoms and
substance use during active treatment. By contrast, partici­
pants i n the ICBT condition appear to be able to maintain
both depression and substance use i mprovements six months
following treatment, whereas TSF participants demonstrated
a gradual i ncrease i n depressive symptoms and substance
use following formal treatment, despite continued 1 2-Step
involvement in the community. These trajectory differences
suggest a differential impact of the i nterventions on the clini­
cal course of depression and substance use i n this comorbid
population.
Contrary to our predictions, duri ng the active treat­
ment phase, the efficacy of 1 2-Step facil itation therapy was
equivalent to that of the i ntegrated i ntervention in terms of
depressive symptoms. Although the present study i s the first
randomized, controlled trial to compare 1 2-Step facilitation
therapy to integrated CBT in a comorbid depressed, sub­
stance disordered population, extant studies of the effects
of 1 2-Step self-help i nvolvement in depressed patients with
comorbid alcohol and/or S UDs are i nconsistent with this
fi nding. I n a recent study, Kelly, McKellar and Moos (2003)
found that patients with comorbid depression and SUDs
fai led to show an i m provement in depressive symptoms
despite 1 2-Step self-help i nvolvement. However, there are
notable differences between the present study and studies

Journal of Psychoactive Drugs 456 Volume 38 (4), December 2006

 Brown et al. Integrated Intervention

FIGURE 2
Modeled Percentage Days Abstinent as a Function of Time, Separated by Group

1 00
Treatment Post-Treatment
-
c::
Q) 90
c::
� - -
en -
_

..0
..... _ _ _

<( 80
en
>-
(\]
0 70
-
c::
Q)
Downloaded by [Laurentian University] at 04:44 19 April 2013

0
.....
Q) 60 - - - · ICBT
a.. - 1 2 Step

50
Mid End 3M 6M

Assessment Periods

Mid = mid-treatment (i.e., end of Phase I); End = end-of-treatment; 3M = three months post-treatment; 6M = six months post-treatment.

of 1 2-Step self-help i nvolvement: ( I ) the manualized TSF
group is led by a team of professional therapists, whereas
1 2-Step community self-help groups are not, and (2) the
participants in the TSF group in the present study all had
comorbid unipolar depression diagnoses. Thus, nonspecific
therapist factors as well as qualitati ve differences in group
composition and content may account for the discrepancy
between the present study and the findings of Kelly and
colleagues. Although the ICBT participants freely attended
1 2-Step self-help groups during the course of the study, it
is conceivable that the focus of the TSF i ntervention on
encouraging patients to "get active" in community 1 2-Step
groups resulted in greater consistency of 1 2-Step attendance
duri ng the acti ve treatment phase. Moreover, i ncreased
i n vol vement in community 1 2-Step groups among TSF
partici pants during the active treatment phase may have
i mpacted depression levels by facilitating behavioral activa­
tion (Hopko et al. 2003). Additionally, consistent utilization
of professional services, frequently observed at higher rates
among psychiatrically comorbid alcohol and SUD patients
rel ative to noncomorbid patients (Tomasson & Vaglum
1 998) may have partially mediated the observed reduction
in TSF participants' depression.
TSF participants evidenced an increase in depressive
symptoms during the post-treatment fol low-up period,
approaching intake levels of depression by six months post-
treatment. On the other hand, ICBT participants remained
stable in terms of depression levels throughout the follow-up
period, suggesting that they were better able to draw upon the
skills they learned in treatment to manage their depressive
symptoms (e.g., coping skills, negative mood regulation).
Consistent with this notion, recent work has demonstrated
that post-treatment improvement in depression outcomes
from CBT is strongly related to the development of self­
efficacy for managing depression and of self-management
behaviors (e.g., monitoring for early warning signs, keep­
ing track of depressive symptoms, engaging in pleasant
activities) (McQuaid, Carmona & Segal 2004; Ludman et
al. 2003). The ICBT intervention employed in the present
study focuses largely on facilitating the development of such
self-management behaviors, which may be an important
mechanism in maintaining symptomatic and behavioral
change among psychiatrically comorbid substance-depen­
dent individuals. Future investigation of the association
of treatment outcome with self-efficacy and self-manage­
ment behaviors is merited and may del ineate mediational
mechanisms in cli nical trajectories observed in comorbid
populations.
Contrary to our predictions , the TSF participants
evidenced comparable substance use outcomes relative to
the ICBT participants during the active treatment phase.
Nevertheless, s i m i l ar to the pattern of fi ndi ngs that

lou mal of P�yc/wactive Drugs 457 Volume 38 (4), December 2006

 Brown ct al.
characterized the depression symptoms, the TSF partici­
pants did not maintain reductions in substance use during
the post-treatment fol low-up phase, and in fact, markedly
and consistently increased their use of substances over the
course of the six months fol lowing treatment. Again, this
finding suggests that ICBT may facilitate the development
of coping ski lls for managing both recurrent depressive
symptoms and high risk addiction relapse si tuations. Despite
three-quarters of the TSF participants reporting attendance
to community 1 2-Step meetings, the benefit derived from
the experimental TSF therapy in this study appears to dis­
si pate when patients leave the formal treatment setting.
Moreover, the i ncreased depressi ve symptoms experienced
by TSF participants in the post-treatment phase may have
triggered relapse risk situations (e.g., negative affect, con­
flict with others) or impeded their ability to derive benefit
Downloaded by [Laurentian University] at 04:44 19 April 2013
from 1 2-Step community meetings. As noted by Kelly and
colleagues (2003) , who found that one year post-treatment,
patients with comorbid depressive disorders and alcohol
and/or SUDs were less l i kely to have a sponsor, had fewer
1 2-Step friends, and had less contact with 1 2-Step friends
than alcohol/SUD-only patients, certain features of commu­
nication and socialization among individuals with depressive
disorders (e.g., poor eye contact, slowed speech) may make
it more difficult for such patients to connect with other fel­
lowship members, and v ice versa. In li ght of evidence that
engagement in 1 2-Step self-help programs is associated with
social ability (Noordsy et al. 1 996) and that the efficacy of
1 2-Step involvement i n improvi ng substance use outcomes
is mediated, in part, by the development of social networks
in the context of the recovery program (Humphreys et al.
1 999) , the gradual decline i n abstinence rates post-treatment
may result from the interpersonal deficits that arise from their
depression and, i n turn, i m pede their ability to benefit from
1 2-Step self-help programs. Further research is needed to
confirm the role of such mediating mechanisms (e.g., social
support, 1 2-Step attendance, self-efficacy). Nevertheless,
these fi ndings hi ghlight the potential i mportance of social
skills and/or assertiveness training, such as that provided for
ICBT participants, i n the treatment of depressed substance­
dependent patients.
Several methodological l i m i tations of the study af­
fect the i n terpretation of the results. First, this study
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