This Treatment Improvement Protocol (TIP) is designed to assist substance abuse counselors in working with adult clients who are experiencing depressive symptoms (see discussion in Part 1, Chapter 1) and administrators in supporting the work of substance abuse counselors. Depressive symptoms are common among clients in substance abuse treatment. Research indicates that substance abuse counselors will encounter significant numbers of individuals with co-occurring depressive symptoms.
When they occur, depressive symptoms can make working with clients more difficult. They can also interfere with clients' recovery and ability to participate in treatment. Table 1.1 in Part 1, Chapter 1 of this TIP lists symptoms of depression. These symptoms are found in clients with mood disorders defined in the Diagnostic and Statistical Manual of Mental Disorders (4th edition, Text Revision (DSM IV-TR; American Psychiatric Association [APA] 2000) as well in clients who present with depressive symptoms but without psychiatric illness. These clients are often referred to as experiencing “subclinical” or “mild” depression. Subclinical depression is differentiated from mood disorders by the number of symptoms present, the impact (or severity) of symptoms on the individual, and by the length of time the symptoms have been present.
The methods and techniques presented in this TIP are appropriate for clients in all stages of recovery. However, the focus of this TIP is on the first few months of early recovery, when depressive symptoms are particularly common.
This TIP is not intended to instruct or encourage substance abuse counselors in treating any mood disorder as defined in the DSM IV-TR (APA 2000a). Clients with diagnosed mood disorders (e.g., major depression, dysthymia, cyclothymia, bipolar disorder, substance-induced mood disorder, etc.) need specialized treatment from a trained and licensed mental health professional.
This TIP is divided into three parts that are bound or produced separately:
This part, Part 3 , is a literature review on the topic of depressive symptoms, and is available for use by clinical supervisors, interested substance abuse counselors, and administrators. It includes literature that addresses both clinical and administrative concerns. To facilitate ongoing updates (which will be performed every 6 months for up to 5 years from first publication), the literature review will only be available online at http://www.kap.samhsa.gov.
The following topics are addressed in Part 3 :
- Review of the literature pertaining to clinical issues discussed in Part 1 of this TIP.
- Review of the literature pertaining to administrative issues discussed in Part 2 of this TIP.
- Information about the methodology used to perform the literature search (see appendix A).
- An annotated bibliography of 82 core sources and a general bibliography.
Printed copies of Parts 1 and 2 can be obtained from SAMHSA's National Clearinghouse for Alcohol and Drug Information (www.ncadi.samhsa.gov). Electronic copies can be downloaded from www.kap.samhsa.gov.
More information on substance abuse treatment for people with depressive disorder diagnoses can be found in TIP 42, Substance Abuse Treatment for Persons with Co-Occurring Disorders (Center for Substance Abuse Treatment, 2005).
There is a small but useful body of literature that focuses specifically on the relationship of depressive symptoms that do not reach the diagnostic criteria for clinical depression to substance use disorders and their treatment. This section of the review addresses:
- What is meant by depressive symptoms.
- Epidemiology and nosology.
- Depressive symptoms, substance abuse/dependence, and substance abuse treatment.
- Treatment modalities for depressive symptoms.
Defining Depressive Symptoms
The introduction of specific inclusion, exclusion, and duration criteria for depressive disorders in the 1970s resulted in a high degree of reliability in diagnosis. However, as Klein, Shankman, and McFarland (2006) note, there is growing recognition that these classification systems, including the DSM-IV-TR (APA, 2000) and the International Statistical Classification of Diseases and Health Related Problems (ICD-10; World Health Organization 2004) do not adequately capture the distinction between normality and pathology. On the one hand, some major depressive symptoms are considered a “normal” response to bereavement, but not to other losses such as divorce or abandonment. On the other hand, depressive symptoms that do not meet a diagnostic threshold may cause considerable suffering and impairment (Angst & Merikangas, 1997), and research has consistently shown that dysfunction and impairment (both occupational and social) are associated with subdiagnostic levels of depressive symptoms (Solomon, 2001). At least one major longitudinal study (Angst, Sellaro, & Merikangas, 2000) suggests that individuals followed for 15 years showed little stability in regard to depression diagnoses.
Among the various recommendations for revisions to the classification of depressive disorders have been several efforts to define depressive disorders that are milder in symptomatology or duration than major depressive disorder (MD), dysthymic disorder, bipolar disorders, substance-induced mood disorders, or other depressive illnesses. Most evidence suggests that subthreshold depressive symptoms exist on a continuum with unipolar clinical depression, but further research is needed to rule out the possibility of a latent qualitative difference between subthreshold and diagnosable depression (Solomon, 2001). These disorders have been variously referred to “subclinical depression,” “minor depression,” and “mild depression.” Objections may be raised that terms such as “mild” and “minor” minimize the suffering associated with these disorders. Accordingly, we will refer to “depressive symptoms” with the understanding that this term implies a level of disorder (i.e., clinically significant impairment or dysfunction) that does not qualify for diagnosis as a mood disorder. Where investigators use a specific term in their writing, we simply use the term they have chosen.
As early as 1978, Research Diagnostic Criteria (RDC; Spitzer, Endicott, & Robins, 1978, p. 773) defined a non-major depressive disorder as, “Nonpsychotic episodes of illness in which the most prominent disturbance is a relatively sustained mood of depression without the full depressive syndrome, although some associated features must be present. It may be chronic or episodic.”
The RDC classification excludes symptoms due to bereavement and requires depressed mood, two depressive symptoms, and impairment or help-seeking. The duration of symptoms must be 1 week for a probable diagnosis and 2 weeks for a definite diagnosis.
The descriptive portion of the RDC criteria (i.e., “relatively sustained mood of depression without the full depressive syndrome”) captures the essence of almost all phenomenological discussion of “depressive symptoms” (e.g., Angst & Merikangas, 1997; Beck & Koenig, 1996; Kessler, Zhao, Blazer, & Swartz, 1997; Rapaport et al., 2002), in which the sufferer feels depressed and is dysfunctional but does not meet the criteria for clinical depression.
Not surprisingly then, many attempts to operationalize definitions of “depressive symptoms” rely on the DSM or ICD criteria for MD, but choose some lesser number of criteria as the cutoff. This is the strategy adopted by DSM-IV-TR in establishing research criteria for minor depression: two to four of the nine criteria for MD (one of the symptoms must be depressed mood) accompanied by distress of impairment of functioning.
Beck and Koenig's (1996) review suggests that the “not MD” operational definition is also widely used. These definitions differ in the number of MD criteria that must be met (which can be as few as one), the requirement that one of the symptoms is depressed mood (not universally required), whether a previous episode of mood disorder is an exclusion criterion, and whether MD and dysthymia must be specifically ruled out.
Within the research context (e.g., Peck, Reback, Yang, Rotheram-Fuller, & Shoptaw, 2005; Rapaport et al., 2002), some investigators have relied on questionnaires and rating scales (e.g., Beck Depression Inventory, the National Institute of Mental Health Diagnostic Interview Schedule) to classify subjects as having “depressive symptoms.” However, these strategies are conceptually similar to those that rely on DSM or ICD criteria in that a lower cutoff than that associated with MD is chosen as the inclusion criterion.
Despite a rather wide range of possible definitions, there appears to be a general consensus that the phenomenon variously called mild depression, minor depression, or depressive symptoms is a real condition and that it causes significant disruptions in functioning for those it affects (e.g., Martin, Blum, Beach, & Roman, 1996; Solomon, 2001).
Epidemiology and Nosology
Because the major work in this area has been conducted by Kessler and his colleagues, we will use here his term, “mild depression.” Studies of mild depression are relatively recent and, as already noted, definitions and inclusion criteria differ. However, some epidemiologic findings are available.
Kessler and colleagues (1997) analyzed data from the National Comorbidity Survey (NCS) to study the lifetime prevalence, correlates, course, and impairments associated with mild depression and to compare these with lifetime prevalence, correlates, course, and impairments associated with two levels of MD: 5–6 symptoms (MD 5–6) and 7–9 symptoms (MD 7–9). The estimated lifetime prevalence for mild depression was 10 percent in the general population as compared to 8.3 percent for MD 5–6, and 7.5 percent for MD 7–9. All three disorders were elevated among women, non-Hispanic whites, and the unemployed. However, unlike the case with MD and dysthymic disorder, rates of mild depression showed significant regional differences, with rates highest in the West and lowest in the South.
Almost 75 percent of persons with mild depression report more than one depressive episode. Symptom severity was correlated with the number of episodes and their duration. Over their lifetimes, people with mild depression showed fewer episodes of shorter duration than those with MD 5–6 or MD 7–9. Impairment associated with a given episode also increased as a function of the number of symptoms. However, the number of people with mild depression who reported impairment (42%) was not much lower than the number of persons with MD 5–6 who reported impairment (49.7%).
A replication study has been conducted for the NCS, but to date no publications are available detailing findings from that study relative to mild depression.
Kessler's data are in substantial agreement with a Zurich study of 600 young adults that found 11 percent had experienced mild depression at some time before the age of 30 (Angst et al., 2000). In a review of multiple studies, Beck and Koenig (1996) report lifetime rates of mild depression ranging from 8 to 74 percent using a wide range of inclusion criteria. A recent review of mild depression studies places the point prevalence of mild depression between 2 and 5 percent (Rapaport et al., 2002).
The temporal relationship between mild depression and MD has received some research attention. Kessler and colleagues (1997) found that most people who made a transition to MD did so after a large number of mild depression episodes. Rapaport and colleagues (2002) conclude that mild depression can occur independently of a lifetime history of MD, or can be a stage of MD in the course of recurrent unipolar depression. However, they note an odds ratio of 4.4 of developing MD within a year for persons with depressive symptoms compared with people with no symptoms. Based on their own work and a review of the literature, Rapaport and colleagues (2002, p. 637) sum up the evidence on the relationship between MD and mild depression, stating that “individuals with a history of major depressive disorder freely traverse between major depressive disorder, minor depression, and subsyndromal depressive symptoms.”
It is as yet unclear whether mild depression represents a separate disorder or reflects the lower end of a spectrum of depressive disorders (Angst et al., 2000; Solomon, 2001) that differ in intensity and duration, but not necessarily in kind. However, data raise questions as to the validity of viewing mild depression as a separate category. Kessler and colleagues (1997) note that almost all observed differences between mild depression and MD categories 5–6 and 7–9 are monotonic functions that are well described by the number of symptoms. Moreover, the magnitude of differences between mild depression and MD 5–6 are similar to the magnitude of differences between MD 5–6 and MD 7–9. In other words, the data suggest a single disorder varying in severity rather than any real difference between mild depression and MD. Rapaport and colleagues (2002) also note that data on familial transmission of MD and mild depression and the fluidity of MD and mild depression with relatively short timeframes argue against treating these as separate disorders.
Elsewhere, Kessler and colleagues (2005) note that almost half the respondents in the NCS who received treatment did not meet DSM-IV-TR criteria for a disorder.
Using a different measure (i.e., whether individuals endorsed specific screening questions for low mood and anhedonia), the National Institute on Alcohol Abuse and Alcoholism's National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) determined that 33.8 percent of the population had some form of “mild” or “minor” depression (Compton, Conway, Stinson, & Grant, 2006). However, the NCS measure of mild depression is a more clinically significant measure of depressive symptoms than this measure from the NESARC.
The DSM-IV-TR also recognizes that there are specific features of depressive-spectrum disorders related to gender and cultural background, with certain symptoms being more common depending on age, gender, and culture. It should be expected that there can be differences in the incidence and presentation of subclinical depressive symptoms related to these factors as well.
Depressive Symptoms, Substance Abuse, and Substance Abuse Treatment
The recent emergence of concern with subclinical depressive symptoms and difficulties agreeing on definitions of the phenomenon limit the availability of data on the relationship between depressive symptoms and substance use disorders. However, a few studies that directly address the relationship do exist. In addition, useful information may be inferred from studies of clinical depression and substance abuse to the extent that subclinical and clinical depression represent points on a continuum rather than discrete disorders. Pending further research on this hypothesis, however, the most conservative approach is to stay within the bounds of studies that specifically address mild depression as defined by Kessler and colleagues (1997).
Kessler and colleagues (1997) report that prior substance use disorder raises the odds of mild depression insignificantly, but that all substance use disorders taken together are a significant predictor of mild depression. There is a small but significant relationship between a client's prior history of a substance use disorder and later mild depression.
Karno and Longabaugh (2003) studied depressive symptoms as measured by the Beck Depression Inventory (BDI) in 141 substance abuse admissions to the Providence Clinical Research Unit of Project MATCH. Of these, nearly 30 percent had BDI scores of 10 to 18 (indicative of elevated depressive symptoms) while an additional 18 percent had scores greater than 19 (indicative of clinical depression). By contrast, a study of a nontreatment population of 75 individuals with alcohol use disorders (84% of whom met DSM-IV criteria for dependence) found only about 20 percent of participants had elevated BDI scores (Blume, Schmaling, & Marlatt, 2001).
Another study administered the BDI to 162 gay and bisexual methamphetamine abusers admitted for treatment (Peck et al., 2005). Results indicated somewhat higher levels of depression than those reported by Karno and Longabaugh: 44.8 percent were in the mild to moderate range on the BDI and an additional 28 percent were in the moderate to severe range.
Based on these very limited data, it would appear that the rates of mild depression are perhaps two to three times higher among individuals with substance use disorders than in the general population.
Treatment Outcomes Among Individuals With Substance Use Disorders and Depressive Symptoms
A number of nonexperimental studies have examined the relationship between depressive symptoms and substance abuse treatment outcomes. In general, these studies find that depressive symptoms are an impediment to recovery.
For example, an analysis of 1,450 subjects from Project MATCH (Conner, Sorensen, & Leonard, 2005) examined the association of BDI score and drinking at treatment entry and in months 2 and 3 of treatment. Elevated BDI scores predicted greater quantity and frequency of drinking during the first month of treatment, but showed little association with drinking in months 2 and 3. The authors suggest that this effect reflects drinking as a coping response, but also the interference of depressive symptoms with engagement in or attendance at treatment. Paradoxically, the effects of treatment-entry levels of drinking did not predict drinking levels during month 1. Thus, the authors conclude that depressive symptoms can provide a unique marker of those clients needing specialized interventions to increase engagement and reduce the risk of dropout.
In a study of individuals with polysubstance use disorders, Dodge, Sindelar, and Sinha (2005) found that higher depressive symptom scores at intake predicted decreased likelihood of abstinence at discharge even when demographic and treatment-related variables (e.g., length of stay) were controlled. Doumas, Blasey, and Thacker (2005) found that higher levels of depressive symptoms at treatment entry were also associated with increased dropout rates from treatment. Another study found that current major depression at admission to a hospital inpatient alcoholism program was predictive of poorer treatment outcomes at 1 year (Greenfield et al., 1998), and Strowig (2000) found that depressed mood was the most commonly cited reason for relapse after alcohol treatment.
A study of 298 male veterans (Curran et al., 2000) measured depressive symptoms during and 3 months after participation in an inpatient alcohol treatment program. Clients with mild to moderate depressive symptoms at the 3-month followup were 2.9 times more likely than nondepressed subjects to experience relapse. Severely depressed clients were 4.9 times more likely to relapse. Depressive symptoms both during treatment and at followup were no more likely to be associated with relapse than were depressive symptoms at followup only. A second study by Curran, Kirchner, Worley, Rookey, and Booth (2002) found that severe depression at intake to an intensive outpatient Department of Veterans Affairs program predicted early attrition.
Another study suggests that associating alcohol-related consequences with depression can increase clients' motivation to change their drinking behavior (Blume et al., 2001). The authors hypothesized that elevated BDI scores would be related to greater motivation to change within the stages of the transtheoretical stages of change model (Prochaska & DiClemente, 1992). Seventy-five clients with alcohol use disorders participated in the study. Of these, about 15 percent had elevated BDI scores. As predicted, BDI scores were positively correlated with precontemplation and contemplation scores as measured by the Readiness to Change questionnaire.
A limited number of studies have looked specifically at the effects of treating elevated depressive symptoms on substance abuse outcomes. Karno and Longabaugh (2003) examined whether patient depressive symptoms interacted with therapist focus on painful emotional material in predicting the outcome of alcohol treatment. For clients with clinically diagnosable depression, a low therapist focus on painful emotional material was associated with better drinking outcomes. However, this relationship did not hold for clients with mild depression. These results were confirmed by a more recent reanalysis of the data from Project MATCH (Karno & Longabaugh, 2007).
Investigators at Brown University School of Medicine (Brown, Evans, Miller, Burgess, & Mueller, 1997; Ramsey, Brown, Stuart, Burgess, & Miller, 2002) provided 8 sessions of cognitive-behavioral therapy for depression (CBT-D) or a relaxation control to 35 patients undergoing alcohol abuse treatment at a day treatment program. Subjects had Dynamic Personality Inventory scores greater than 10 and were referred to by the authors as “alcoholics with elevated depressive symptoms” to distinguish them from “depressed alcoholics” meeting diagnostic criteria for a depressive disorder. During the first 3 months of followup, the CBT-D group had more abstinent days than the control subjects, but not lower overall abstinence. However, in the 3- to 6-month followup period, the CBT-D group showed significantly greater total abstinence (47% versus 13%) as well as more days abstinent and fewer drinks per day. The authors report that subjects in the CBT-D group found the depression coping skills useful and relevant to their recovery.
Peck and colleagues (2005) monitored the course of depressive symptoms as treatment for methamphetamine dependence progressed. Participants reported a significant decrease in depressive symptoms regardless of specific treatment modality or other key variables such as HIV/AIDS status. A study by Janiri and colleagues (2005) found similar results among alcohol, opioid, and polysubstance users in three different clinical settings. In this study, depressive symptoms were correlated with craving and protracted withdrawal.
A recent meta-analysis (Nunes & Levin, 2004) examined controlled trials of antidepressant medication for the treatment of combined substance use and depressive disorders. Fourteen trials met the analysis inclusion criteria: five trials of tricyclics, seven of serotonin-specific reuptake inhibitors, and two of other classes of antidepressants. The authors conclude that antidepressant medication exerts a modest beneficial effect for patients with combined depressive and substance use disorders. However, medication should not be considered a stand-alone treatment, and concurrent therapy directly targeting the addiction is also indicated.
Subclinical levels of depressive symptoms have been associated with poorer outcomes for other health problems such as heart disease (Kubzansky, Davidson, & Rozanski, 2005).
In summary, limited available evidence suggests that elevated depressive symptoms are an impediment to recovery and that treatment outcomes improve when these symptoms are specifically addressed.
Treatment Modalities for Depressive Symptoms
The literature on the treatment of depressive disorders is vast (see, for example, Reinecke & Davison, 2002; Stein, Kupfer, & Schatzberg, 2006), but the relationship between specific treatments and improvements remains evasive (Lambert & Davis, 2002). However, in summarizing the literature on treatment of depression, Lambert and Davis (2002) conclude that the sum total of naturalistic studies and randomized controlled trials presents a comprehensive picture that demonstrates the effectiveness of psychotherapy for individuals with depression. These same authors conclude that pharmacotherapies are also effective but no more effective than psychotherapy. Additionally, current treatment guidelines for depression indicate that psychotherapy is effective, particularly with mild and moderate depression (APA, 2000b) and that a combination of psychotherapy and pharmacotherapy is more effective than pharmacotherapy alone (Fochtmann & Gelenberg, 2005).
Overall, the major impediment to successful treatment of depression appears not to be a lack of effective treatments but a lack of effective implementation of these treatments.
By comparison, research is sparse on specific treatments for depressive symptoms that do not rise to the level of diagnosable depression. As is the case for treatment of depressive symptoms in substance abuse settings, the pool of available research can be substantially increased by accepting the hypothesis that depressive symptoms and diagnosable depression constitute a continuum of severity rather than kind. Again, however, pending validation of this hypothesis, a focus specifically on populations with depressive symptoms is the most conservative approach.
Ackermann and Williams (2002) report on an extensive analysis of controlled studies of treatment for depressive symptoms. Studies were collected using the keywords “depressive disorder,” and “depression” crossed with “minor,” “subsyndromal,” “subthreshold,” and “nonmajor.” They found only five studies that compared a psychological or pharmacological treatment for depressive symptoms to a placebo or control. Their table summarizing these five controlled trials is reprinted below (see Figure 1) in its entirety.
Ackermann and Williams conclude that, collectively, these studies provide mixed support for a small to moderate benefit of the pharmacological and psychological treatments tested. The authors also report on studies of alternative treatments including aerobic exercise. They conclude that the evidence supports a positive effect of supervised exercise three times per week on mild to moderate MD. Some weak evidence exists for various botanicals and vitamins, but there is too little research upon which to base a conclusion about these treatments. The authors conclude that the currently available clinical trial data provide little guidance in the treatment of depressive symptoms that do not rise to the level of diagnosable depression.
Adapted from: Ackermann & Williams 2002, p. 296. [Permission pending]
One widely studied intervention for subclinical depressive symptoms is the Coping with Depression (CWD) course, originally developed as a treatment for MD (Lewinsohn & Clarke, 1984). The course content is based on the social learning theory premise that depression is a learned response that can be unlearned. It uses a cognitive-behavioral intervention that teaches participants techniques to influence their moods and to enhance coping skills. CWD has been implemented on a national scale for the treatment of adults with subclinical depressive symptoms in the Netherlands (Allart-van Dam, Hosman, Hoogduin, & Schaap, 2003). In the Dutch version, the course consists of 12 weekly 2-hour sessions consisting of lectures, skills training, and review of homework assignments. A booster session is offered 6 weeks after course completion. Allart-van Dam and colleagues (2003) conducted a randomly-controlled clinical trial of CWD with 110 adults with subclinical depressive symptoms. Short-term outcome data indicated that the course was successful in reducing depressive symptoms as well as affecting mediating variables such as frequency of depressive thoughts, participation in pleasant activities, and social support. Long-term outcomes are currently under investigation.
An effectiveness trial of CWD in the Netherlands was also conducted using participants in 20 CWD groups organized by 10 different providers of outpatient services (Cuijpers, Smit, Voordouw, & Kramer, 2005). Improvements in the treated groups mirrored those in the clinical trial reported by Allart-Van Dam and colleagues (2003). However, the investigators note that their treated clients were still “considerably more depressed than the general population.” They conclude that CDW alone may not be a sufficient intervention for some individuals with subclinical depressive symptoms.
In summary, there are some promising treatments for persons with subclinical depressive symptoms and substance use disorders, but few proven strategies.
The successful implementation of strategies to address depressive symptoms in substance abuse treatment depends heavily on the leadership and support provided by treatment organizations and their administrators. This section provides a conceptualization of the implementation of clinical innovations and directs the reader to sources that elaborate the empirical basis for recommendations made in the Administrator's Guide that accompanies this TIP.
What Is Known About the Adoption of Clinical Innovations
Numerous recent reports, including the President's New Freedom Commission on Mental Health (2003), have noted a significant gap between what is known about effective treatments and what is actually delivered in practice. Substantial progress has been made in the treatment of substance abuse and co-occurring disorders including depression (see TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders [CSAT 2005]); however, the challenge remains of ensuring that this progress is reflected in the care that is offered to clients.
Although the literature on implementation of clinical innovations is vast (see Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005), there is no more dramatic illustration of the challenges involved than the case of the United States Preventive Services Task Force's (USPSTF) Guide to Clinical Preventive Services. This collection of science-based recommendations for health screening was developed by a prestigious panel of experts, well publicized in the professional and public press, accessible online through the National Library of Medicine, and reprinted by private publishers who have sold more than 64,000 copies. Woolf, DiGuiseppi, Atkins, & Kamerow (1996) reviewed studies of the use of this Guide and found that 55 percent of family practitioners had not looked at it, and that 25 percent of family practitioners and 80 percent of internists had not heard of it. Accordingly, the chances of the average patient benefiting from this carefully constructed and heavily publicized clinical resource were quite low. This case study clearly illustrates the point made by Peterslia (1990) that innovative programs such as this “are not self-executing.”
A lack of specific and informed attention to implementation leads to frustration (for both administrators and clinicians), wasted resources (both on research and ineffective implementation), and most important, services to clients that are less effective than they could be. As noted by Haynes (1993, p. 221), “it is troubling to spend billions on health care research while neglecting the fact that most of the evidence generated from such studies is going to waste.”
However, there is now considerable practical knowledge on how to foster successful implementation of strategies such as those presented in this TIP. The remainder of this review surveys this knowledge and directs the reader to useful resources.
The Centrality of Organizational Change and Administrative Support in Successful Implementation
Two common assumptions must be challenged at the outset: (1) that innovations will be embraced simply because they are superior to current practice, and (2) that the responsibility for adopting clinical innovations rests with clinicians.
Regarding the first point, Emerson assured us that “if you build a better mousetrap, the world will beat a path to your door,” but half a century of research on the adoption of innovation suggests that Emerson was wrong about both mousetraps and new clinical practices (Rogers, 2003). Although superiority to current practice is a factor in adoption, it is by no means the only or even the most important factor (Davis & Taylor-Vaisey, 1997).
The second assumption could be an overgeneralization from our experience as consumers (we can freely switch from brand X to brand Y). By contrast, the individual clinician is highly constrained by context, and the factors that facilitate or impede adoption and implementation are almost all associated with the organization (e.g., the program, clinic, or hospital) and with the larger systems in which the organization operates (e.g., local, State) (Fixsen et al., 2005).
Providers may want to be members of what Kamerow (1997) calls, “the good provider club.” However, as Kamerow further notes, good intentions are not enough. Without organizational change and organizational support, most efforts by well-intentioned clinicians to adopt new practices will fail. The responsibility for adoption and implementation of new practices falls squarely on organizations and their administrators.
Implementation and the Factors Affecting It
A primary source used in the preparation of this subsection of the review was Implementation Research: A Synthesis of the Literature (Fixsen et al., 2005). This landmark document is recommended reading for all administrators who wish to improve the implementation of clinical innovations in their programs and organizations.
Implementation is a purposeful and planned process of organizational change, not an outcome, as such. Administrators should be able to describe their implementation activities. These activities should be measurable, and the implementation activities should be visible to those both inside and outside the organization. Implementation has three goals (Fixsen et al., 2005):
Changes in professional behavior (i.e., the knowledge and skills of practitioners and other key staff members within an organization or system.
Changes in organizational structures and cultures, both formal and informal (values, philosophies, ethics, policies, procedures, decisionmaking), to routinely bring about and support changes in professional behavior.
Changes in relationships to consumers, systems partners, and stakeholders (regarding location and nature of engagement, inclusion, and satisfaction).
It is important to understand the difference between something that looks like implementation and something that actually is implementation. As described by Fixsen and colleagues (2005), three types of implementation can be identified:
Paper Implementation in which new policies and procedures are developed, written down, and placed in filing cabinets. Here, actual changes in clinical practice (which do not occur) are uncoupled from the paper trail. However, when necessary, the paper policies and procedures can be produced to demonstrate that change has taken place.
Process Implementation in which largely irrelevant training is conducted, new vocabulary (usually devoid of operational meaning) is adopted, a new “culture” is promulgated, motivational posters are hung, and so on. In other words, the trappings of change are visible, but no substantive changes are actually made—this can also be described as a process of “cargo cult implementation” (see box on next page).
Performance Implementation means achieving the three implementation objectives described earlier in ways that result in tangible benefits to clients and other stakeholders.
The effects of real (performance) versus paper or process implementation on client outcomes can be profound. Figure 2 shows the difference in client outcomes over time for a high-fidelity and low-fidelity implementation of Assertive Community Treatment (ACT). By the third year, remission rates in the low-fidelity implementation were almost four times the rates in the high-fidelity implementation.
Cargo Cult Implementation
In the South Seas, there is a cargo cult of people. During the war they saw airplanes with lots of good materials, and they want the same thing to happen now. So they've arranged to make things like runways, to put fires along the sides of the runways, to make a wooden hut for a man to sit in, with two wooden pieces on his head for headphones and bars of bamboo sticking out like antennas—he's the controller—and they wait for the airplanes to land. They're doing everything right. The form is perfect. It looks exactly the way it looked before. But it doesn't work. No airplanes land.
Dr. Richard Feynman in a 1974 Cal Tech commencement address
Working With Factors That Affect Implementation
Before discussing the factors affecting implementation, it is necessary to distinguish between what we are calling an “innovation” and evidence-based practices (EBPs). By innovation, we mean a new approach to agency or organization services or some component of these services. So, for example, offering onsite health care at a homeless shelter, providing child care to mothers in an outpatient treatment program, or addressing depressive symptoms in a substance abuse treatment program (the topic of this TIP) fit the definition of an innovation. Innovations often involve considerable experimentation and formative evaluation by administrators and staff (Tharp & Gallimore, 1979).
An EBP is a practice that, based on expert or consensus opinion about available evidence, is expected to produce a specific clinical outcome (measurable change in client status). EBPs are well-specified, and are clearly defined as to what they are and are not, how to implement them, and so on. Examples of EBPs include ACT (Drake et al., 1998) and motivational interviewing (Miller & Rollnick, 2002). EBPs generally must be implemented with fidelity to the original model in order to have the expected impact, and many types of changes to the EBP will be undesirable and threaten outcomes (Adams, 1994; Mowbray, Holter, Teague, & Bybee, 2003; Yeaton & Sechrest, 1981). Such undesirable changes are called “drift.”
An innovation may or may not consist of or include one or more EBPs. So, for example, a health screening program in a homeless shelter might draw a number of EBPs for health screening from the USPSTF Guide to Clinical Preventive Services that need to be implemented with fidelity. However, the manner in which the screening program is structured, outreach is conducted, and health counseling is provided might better fit the definition of an innovation. Here, approaches used by similar programs might be copied, modified, and/or refined based on actual implementation experience.
The factors that affect implementation of an innovation are described in detail by Fixsen and colleagues (2005) and summarized in Figure 3. These factors can be conceptualized as a set of matches or mismatches between an innovation and the context into which it is introduced. When such mismatches occur, administrators must find ways to reconcile them. So, for example, changes in training and supervision are needed to respond to a mismatch between staff skills and the requirements of the innovation. One way to respond to a mismatch between current interagency networks and those that the innovation requires might be the establishment of referral agreements. Both of these accomodations operate by changing the context and “matching” it to the innovation.
Accomodations can also be made by altering the innovation. When dealing with an “innovation” as defined above, such accomodations are part of the development process and their effects can be tested with formative evaluations. However, when dealing with an EBP or an EBP that is a component of an innovation, alterations risk drift (noting that local alterations to an EBP can lead to desirable refinements as well as problems with fidelity). In a practical sense, this means that the administrator must make every attempt to alter the context to accommodate the EBP.
Organizational Factors Affecting Implementation
A key organizational factor that affects implementation is receptivity to innovation. Rogers (2003) discusses how organizations differ in their receptivity and how key factors such as the degree of centralization, how formalized rules are, and the level of staff knowledge/expertise affect the implementation of new innovations. Some of these factors play different roles in the early and later stages of innovation. Low centralization, high complexity, and low formalization appear to facilitate initiation of the innovation process. However, these same organizational characteristics can present challenges to long-term implementation.
References for Part 3, Section 1
- Adams P. Marketing social change: The case of family preservation. Children and Youth Services Review. 1994;16:417–443.
- Allart-van Dam E, Hosman CMH, Hoogduin CAL, Schaap CPDR. The Coping With Depression Course: Short-term outcomes and mediating effects of a randomized controlled trial in the treatment of subclinical depression. Behavior Therapy. 2003;34:381–396.
- American Psychiatric Association. (2000a). Diagnostic and Statistical Manual of Mental Disorders (4th Text Revision ed.). Washington, DC: American Psychiatric Association.
- American Psychiatric Association. (2000b). Practice guideline for the treatment of patients with major depressive disorder (Revision). American Journal of Psychiatry, 157, 1–45. [PubMed: 10767867]
- Angst J, Merikangas K. The depressive spectrum: Diagnostic classification and course. Journal of Affective Disorders. 1997;45:31–39. [PubMed: 9268773]
- Angst J, Sellaro R, Merikangas KR. Depressive spectrum diagnoses. Comprehensive Psychiatry. 2000;41(2 Suppl. 1):39–47. [PubMed: 10746903]
- Beck DA, Koenig HG. Minor depression: A review of the literature. Journal of Addictions and Offender Counseling. 1996;26:177–209. [PubMed: 8877487]
- Blume AW, Schmaling KB, Marlatt GA. Motivating drinking behavior change: Depressive symptoms may not be noxious. Addictive Behaviors. 2001;26:267–272. [PubMed: 11316381]
- Center for Substance Abuse Treatment. (2005). Substance Abuse Treatment for Persons With Co-Occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. Rockville, MD: Substance Abuse and Mental Health Services Administration.
- Compton WM, Conway KP, Stinson FS, Grant BF. Changes in the prevalence of major depression and comorbid substance use disorders in the United States between 1991-1992 and 2001-2002. American Journal of Psychiatry. 2006;163:2141–2147. [PubMed: 17151166]
- Conner KR, Sorensen S, Leonard KE. Initial depression and subsequent drinking during alcoholism treatment. Journal of Studies of Alcohol. 2005;66:401–406. [PubMed: 16047530]
- Cuijpers P, Smit F, Voordouw I, Kramer J. Outcome of cognitive behaviour therapy for minor depression in routine practice. Psychology and Psychotherapy: Theory, Research and Practice. 2005;78:179–188. [PubMed: 16004697]
- Curran GM, Flynn HA, Kirchner J, Booth BM. Depression after alcohol treatment as a risk factor for relapse among male veterans. Journal of Substance Abuse Treatment. 2000;19:259–265. [PubMed: 11027896]
- Curran GM, Kirchner JE, Worley M, Rookey C, Booth BM. Depressive symptomatology and early attrition from intensive outpatient substance use treatment. Journal of Behavioral Health Services and Research. 2002;29:138–143. [PubMed: 12032971]
- Davis DA, Taylor-Vaisey A. Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. Canadian Medical Association Journal. 1997;157:408–416. [PMC free article: PMC1227916] [PubMed: 9275952]
- Dodge R, Sindelar J, Sinha R. The role of depression symptoms in predicting drug abstinence in outpatient substance abuse treatment. Journal of Substance Abuse Treatment. 2005;28:189–196. [PubMed: 15780549]
- Doumas DM, Blasey CM, Thacker CL. Attrition from alcohol and drug outpatient treatment: psychological distress and interpersonal problems as indicators. Alcoholism Treatment Quarterly. 2005;23:55–67.
- Drake RE, McHugo GJ, Clark RE, Teague GB, Xie H, Miles K. et al. Assertive Community Treatment for patients with co-occurring severe mental illness and substance use disorder: A clinical trial. American Journal of Orthopsychiatry. 1998;68:201–215. [PubMed: 9589759]
- Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation Research: A Synthesis of the Literature. FMHI Publication #231. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network. Retrieved December 19, 2005, from http://nirn
.fmhi.usf .edu/resources/publications /Monograph/pdf/Monograph_full.pdf .
- Fochtmann, L. J. & Gelenberg, A. J. (2005). Guideline watch: Practice guideline for the treatment of patients with major depressive disorder (2nd ed.). Focus, 3, 34–42.
- Greenfield SF, Weiss RD, Muenz LR, Vagge LM, Kelly JF, Bello LR. et al. The effect of depression on return to drinking: A prospective study. Archives of General Psychiatry. 1998;55:259–265. [PubMed: 9510220]
- Haynes RB. Some problems in applying evidence in clinical practice. Annals of the New York Academy of Sciences. 1993;703:210–224. [PubMed: 8192298]
- Haynes RB. Some problems in applying evidence in clinical practice. Annals of the New York Academy of Sciences. 2005;703:210–224. [PubMed: 8192298]
- Janiri L, Martinotti G, Dario T, Reina D, Paparello F, Pozzi G. et al. Anhedonia and substance-related symptoms in detoxified substance-dependent subjects: A correlation study. Neuropsychobiology. 2005;52:37–44. [PubMed: 15942262]
- Kamerow DB. Before and after guidelines. Journal of Family Practice. 1997;44:344–346. [PubMed: 9108829]
- Karno MP, Longabaugh R. Patient depressive symptoms and therapist focus on emotional material: A new look at Project MATCH. Journal of Studies on Alcohol. 2003;64:607–615. [PubMed: 14572181]
- Kessler RC, Zhao S, Blazer DG, Swartz M. Prevalence, correlates, and course of minor depression and major depression in the national comorbidity survey. Journal of Affective Disorders. 1997;45:19–30. [PubMed: 9268772]
- Klein, D. N., Shankman, S. A., & McFarland, B. R. (2006). Epidemiology of mood disorders. In Stein, D. J., Kupfer, D. J., & Schatzberg, A. F. (Eds.), The American Psychiatric Publishing Textbook of Mood Disorders. Washington, DC: American Psychiatric Publishing.
- Kubzansky LD, Davidson KW, Rozanski A. The clinical impact of negative psychological states: Expanding the spectrum of risk for coronary artery disease. Psychosomatic Medicine. 2005;67:S10–S14. [PubMed: 15953792]
- Lambert, M. J., & Davis, M. J. (2002). Treatment for depression: What the research says. In M.A. Reinecke & M. R. Davison (Eds.), Comparative Treatments of Depression: Springer Series on Comparative Treatments for Psychological Disorders. NewYork: Springer Publishing Company.
- Lewinsohn PM, Clarke GN. Group treatment of depressed individuals: The “coping with depression” course. Advances in Behaviour Research Therapy. 1984;6:99–114.
- Lynch DJ, Tamburrino MB, Nagel R. Telephone counseling for patients with minor depression: Preliminary findings in a family practice setting. Journal of Family Practice. 1997;44:293–298. [PubMed: 9071250]
- Martin JK, Blum TC, Beach SRH, Roman PM. Subclinical depression and performance at work. Social Psychiatry. 1996;31:3–9. [PubMed: 8821918]
- McHugo GJ, Drake RE, Teague GB, Xie H. Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study. Psychiatric Services. 1999;50:818–824. [PubMed: 10375153]
- Miller, W. R., & Rollnick, S (2002). Motivational Interviewing: Preparing People for Change (2nd. ed.). New York: Guilford Press.
- Miranda J, Munoz R. Intervention for minor depression in primary care patients. Psychosomatic Medicine. 1994;56:136–141. [PubMed: 8008800]
- Mowbray CT, Holter MC, Teague GB, Bybee D. Fidelity criteria: Development, measurement, and validation. American Journal of Evaluation. 2003;24:315–340.
- New Freedom Commission on Mental Health. (2003). Achieving the Promise: Transforming Mental Health Care in America: Final Report. (Rep. No. DHHS Publication No. SMA-03-3832). Rockville, MD: Substance Abuse and Mental Health Services Administration.
- Nunes EV, Levin FR. Treatment of depression in patients with alcohol or other drug dependence: A meta-analysis. JAMA: Journal of the American Medical Association. 2004;291:1887–1896. [PubMed: 15100209]
- Parnetti L, Sommacal S, Morselli LAM, Senin U. Multicentre controlled randomised double-blind placebo study of minaprine in elderly patients suffering from prolonged depressive reaction. Drug Invest. 1993;6:181–188.
- Paykel ES, Hollyman JA, Freeling P, Sedgwick P. Predictors of therapeutic benefit from amitriptyline in mild depression: a general practice placebo-controlled trial. Journal of Affective Disorders. 1988;14:83–95. [PubMed: 2963054]
- Peck JA, Reback CJ, Yang X, Rotheram-Fuller E, Shoptaw S. Sustained reductions in drug use and depression symptoms from treatment for drug abuse in methamphetamine-dependent gay and bisexual men. Journal of Urban Health: Bulletin of the New York Academy of Medicine. 2005;82(1 Suppl.1):i100–i108. [PMC free article: PMC3456165] [PubMed: 15738315]
- Petersilia J. Conditions that permit intensive supervision. Crime and Delinquency. 1990;36:126–145.
- Prochaska, J. O., & DiClemente, C. C. (1992). Stages of change in the modification of problem behaviors. In M. Hersen, R. M. Eisler, & P. M. Miller, (Eds.), Progress in Behavior Modification (pp. 184–214). Sycamore, IL: Sycamore Publishing Company.
- Ramsey SE, Brown RA, Stuart GL, Burgess ES, Miller IW. Cognitive variables in alcohol dependent patients with elevated depressive symptoms: Changes and predictive utility as a function of treatment modality. Substance Abuse. 2002;23:171–182. [PubMed: 12444350]
- Rapaport MH, Judd LL, Schettler PJ, Yonkers KA, Thase ME, Kupfer DJ. et al. A descriptive analysis of minor depression. American Journal of Psychiatry. 2002;159:637–643. [PubMed: 11925303]
- Reinecke, M. A. & Davison, M. R. (2002). Comparative treatments of depression. New York, NY: Springer Publishing Company.
- Reinecke, M. A. & Davison, M. R. (Eds.). (2005). Comparative Treatments of Depression: Springer Series on Comparative Treatments for Psychological Disorders. New York; Springer Publishing Company.
- Rogers, E. M. (2003). Diffusion of Innovations (5th ed.). New York: Free Press.
- Solomon, A. (2001). The Noonday Demon: An Atlas of Depression. New York: Scribner.
- Spitzer RL, Endicott J, Robins E. Research diagnostic criteria: Rationale and reliability. Archives of General Psychiatry. 1978;35:773–782. [PubMed: 655775]
- Stein, D. J., Kupfer, D. J., & Schatzberg, A. F., (Eds.) (2006). American Psychiatric Publishing Textbook of Mood Disorders. Arlington, VA: American Psychiatric Publishing, Inc.
- Strowig AB. Relapse determinants reported by men treated for alcohol addiction: The prominence of depressed mood. Journal of Substance Abuse Treatment. 2000;19:469–474. [PubMed: 11166511]
- Tharp, R. G., & Gallimore, R. (1979). The ecology of program research and evaluation: A model of evaluation succession. In L. Sechrest, S. G. West, M. A. Phillips, R. Edner, R. & W. Yeaton (Eds.). Evaluation Studies Review Annual (39–60). Beverly Hills, CA: Sage.
- Williams JW Jr, Barrett J, Oxman T, Frank E, Katon W, Sullivan M. et al. Treatment of dysthymia and minor depression in primary care: A randomized controlled trial in older adults. JAMA. 2000;284:1519–1526. [PubMed: 11000645]
- Woolf SH, DiGuiseppi CG, Atkins D, Kamerow DB. Developing evidence-based clinical practice guidelines: Lessons learned by the U.S. Preventive Services Task Force. Annual Review of Public Health. 1996;17:511–538. [PubMed: 8724238]
- World Health Organization. (2004). The International Statistical Classification of Diseases and Related Health Problems (ICD-10) (2nd ed.). Geneva, Switzerland: World Health Organization.
- Yeaton WH, Sechrest L. Critical dimensions in the choice and maintenance of successful treatments: Strength, integrity, and effectiveness. Journal of Consulting and Clinical Psychology. 1981;49:56–167. [PubMed: 7217482]
This document is available online only (www
.kap.samhsa.gov) and supports TIP 48, Managing Depressive Symptoms in Substance Abuse Clients DuringEarly Recovery.
Substance Abuse and Mental Health Services Administration (US), Rockville (MD)
Center for Substance Abuse Treatment. Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2008. (Treatment Improvement Protocol (TIP) Series, No. 48.) Part 3, Managing Depressive Symptoms: A Review of the Literature, Section 1—A Review of the Literature.