dr. patricia conrod - preventure [march 7 adepis seminar]

Targeted prevention interventions and

the case of PreVenture

Patricia J. Conrod, Ph.D.

Professeure Titulaire, Université de Montréal, CHU Hôpital Ste Justine

Senior Clinical Lecturer & Consultant Clinical Psychologist, Addictions Department, Institute of Psychiatry, King’s College London

Public Health Intervention Strategies

Tx

Indicated

Selective

Universal

Limited evidence for

efficacy knowledge-

based programmes

Evidence-based

programmes: Life Skills Training

Program

Strengthening Families

Good Behaviour Game

Brief motivational

interventions for heavy

drinkers Time-limited effects

-moderate generic

treatment effects

-complicates and

complicated by

comorbid disorders

-”decade of harm”

Journal of Substance Abuse, 2001

PERSONALITY

TRAITS

CO-OCCURING

DISORDER

Impulsivity

Sensation

Seeking

Hopelessness

Anxiety

Sensitivity

Externalising

Problems Poor response inhibition and

emotional reactivity

Sensitivity to reward and the

incentive/reinforcing properties of

substances

Negative affect regulation

Anxiety

Disorders

Mood Disorders

Hyperarousal and sensitivity to

dampening effects of substances/

increased withdrawal symptoms

MOTIVATIONAL

PROFILE

DIS

INH

IBIT

ED

TR

AIT

S

INH

IBIT

ED

/ NE

UR

OT

IC T

RA

ITS

Conrod & Nikolaou, JCPP, 2016

Stimulant

--------

Drug/

Alcohol

Misuse

-------

Sedative

SUBSTANCE

USE

Substance Use Risk Profile Scale (SURPS)

(Woicik et al., 2009)

4 dimensions in 23 items:

Anxiety sensitivity, hopelessness, impulsivity and sensation seeking

Internal consistency (Woicik et al., 2009)

Concurrent validity (Woicik et al., 2009; Schlaucht et al., 2014)

Incremental validity (Woicik et al., 2009)

Predictive validity (Krank et al., 2010)

Test-retest reliability (Woicik et al., 2009)

Sensitivity/specificity (Castellanos-Ryan et al, 2013)

Generalisability, applications in different cultural and clinical contexts (Jolin-Castonguay et al., 2013; Schlaucht et al., 2014)

Translated: French, German, Spanish, Czech, Dutch, Cantonese, Japanese, Sri Lankan (Robles-García et al., 2014; Omiya et al., 2012; Malmberg, et al., 2013; Chandrika Ismail, et al., 2009; Jolin-Castonguay et al., 2013)

Hopelessness Anxiety Sensitivity Impulsivity Sensation Seeking-

R‡

Selecting HR

adolescents based

on ROC cut-offs

Selecting HR

adolescents (1SD >

mean cut-offs )†

% S, FP S, FP S, FP S, FP S, FP S, FP

Monthly binging (13%) 20, 12 27, 31 61, 32 48, 30 72, 49 70, 42

Drinking problems (17%) 49, 34 32, 31 55, 31 36, 30 84, 63 75, 53

Smoking (9%) 61, 49 33, 30 55, 33 38, 30 81, 65 72, 55

Drug use (21%) 60, 49 27, 22 54, 30 43, 28 91, 75 74, 52

BSI depression (23%) 54, 31 42, 28 51, 30 34, 30 91, 70 73, 47

Emotional problems (13%) 54, 34 59, 27 46, 34 32, 31 91, 72 80, 53

Conduct problems (41%) 26, 13 33, 29 58, 20 35, 28 77, 50 72, 46

Hyperactivity problems

(32%) 26, 15 37, 28 58, 25 38, 28 78, 55 74, 49

Table 5. Sensitivity and false positive rates (1-specificity) of the f baseline SURPS subscales in the prediction of substance use, emotional and behavioural

symptoms within the next 18 months (by T4) in the overall sample (N = 1057). (Castellanos-Ryan et al., 2011)

Personality-Targeted Interventions: Conrod et al., Psych Addictive Beh, 2000

Psychoeducational Component

Motivational Component

Motivational interviewing techniques

Goal setting exercises (for prevention trials; Conrod et al., 2010)

Cognitive-Behavioral Component

Personality-specific cognitive distortions

Anxiety sensitivity:

decatastrophizing & exposure (Barlow & Craske, 1988)

Hopeless:

negative thought challenging (Beck & Young, 1985)

Impulsive:

Response inhibition “stop”, “focus”, “choose” (Kendall & Braswell, 1985)

Negative attribution biases

Sensation seeking:

thought challenging for boredom & need for stimulation

Reward sensitivity

Personality-Targeted

Interventions: The Evidence

Phase I: Proof of concept (Conrod et al., 2000; Conrod et al., 2006).

Phase II: Efficacy (Conrod et al., 2008; 2010; 2011)

Phase III: Effectiveness (Conrod et al., 2013; O’Leary-Barrett et al., 2013)

Phase IV: Process, secondary outcomes, pathways, delivery models (www.Co-venture.ca; Conrod et al., in progress)

Phase V: Special populations, contexts, generalisability, optimisation (www.capstudy.org.au; Newton et al., 2012; Mushquash, et al., 2008;2013; Dutch Preventure -

Lemmens et al., 2011), TRUANCY Trial, PRIMEVenture, Distance-Delivered Interventions (Olthuis,

et al., 2013;2014); UNIVenture

Preventure Trial – UK (Conrod, 2003; funded by Action on Addiction)

Phase II: Efficacy trial Primary aims: Efficacy when tested under more rigorous design?

Secondary aims: Adapted for UK context? Prevention? Illicit drugs?

Participants: secondary school students across London

Age range: 13 – 15 (median 14)

68% female

Ethnicity: 39% white (British and other), 10% South Asian, 30% African or Caribbean, 21% Other or mixed.

Consent: Parent consent required for both baseline survey (passive) and

intervention (active).

Active student consent required for both survey and intervention.

Interventions: Random assignment – Personality targeted interventions (NT, SS, IMP, AS)

No intervention control

Preventure Trial 2-year outcomes:

Survival as a non-cannabis user

OR = 0.7, CI = 0.5-1.0

Conrod, P.J., Castellanos-Ryan, N. & Strang, J. (2010). Archives Gen

Psychiatry.

OR=0.2; 95% CI= 0.1 -0.5

Conrod, P.J., Castellanos-Ryan, N. & Strang, J. (2010). Archives Gen Psychiatry.

Preventure Trial 2-year outcomes:

Survival as a non-cocaine user

UK Adventure Trial: Effectiveness when delivered by teachers

Phase III trial funded by Action on Addiction, 2006-2010

Hypotheses Primary: Effectiveness when delivered by schools and teachers 3-day training workshop for teachers, supervised practice and

fidelity assessment.

Secondary:

Mental health benefits? ‘Herd effects’?: secondary effects on general population?

Teacher Training Protocol 3-day Workshop

Theory

Generic counselling skills (emphathy!)

Targeting personality in treatment and prevention

Practical Supervision

Session 1 + Feedback

Session 2 + Feedback

UK

Adventure

Trial

1268 (54.6%)

Low personality risk

1025 (52.4%)

Low personality risk

Followed 6, 12, 18 & 24

months

Followed 6, 12, 18 & 24

months

ADVENTURE TRIAL: Two-Year Drinking Outcomes

and Herd Effects Conrod et al., JAMA-Psychiatry, 2013

0.3

0.35

0.4

0.45

0.5

0.55

0.6

0.65

0.7

0.75

0.8

�T2 �T3 �T4 �T5

P(Drink = yes) * log(Freq)

Control Low Risk Control High Risk Intervention Low Risk Intervention High Risk

Une chose que j'ai aimé en ce qui concerne les

séances

Process Research: Student Feedback (Adventure)

What I liked Helped with controlling anger and thinking first” (IMP)

“Helped me understand more about other people” (IMP)

“It was easy to express feelings as everyone was encouraging and thoughtful” (AS)

“Learning ways to avoid problems” (AS)

“It also don’t make you feel alone, that it’s only you” (sic)

“I had fun and it helped me with my choices” (SS)

“Teaches us how to push aside the bad thoughts in certain situations” (SS)

“You can say how you feel without being embarrassed” (NT)

“Finding a way to deal with negative thinking” (NT)

Process Research: Student Feedback (Adventure)

What I didn’t like

“More sessions please!” (IMP)

“Maybe put it in a way so you can act out the scenes”

(IMP)

“It ended” (SS)

“A little bit long” (SS)

Make the sessions a bit longer” (AS)

“Nothing- 5/5” (AS)

“The pictures are a bit weird” (NT)

“Nothing was boring but some situations didn’t apply to

me” (NT)

Une chose que je n'ai pas aimé

Trials in progress New adaptations: Dutch (BMC Public Health, 2011), Australian (Newton et al., JCPP, 2016) French Canadian (www.Co-Venture.ca) Czech on going in Mexico

Implementation Models: Phase IV: CAP-STUDY, NMHR-Australia (Teesson,

Conrod, et al., 2011-2016). Climate vs. Teacher-delivered Preventure vs. Climate and

Preventure (CAP) vs. Control Cluster randomised trial in Australian high schools Examining potential role for stepped-care strategy

PREVENTURE outcomes in Australia (Newton et al., JCPP, 2016

Mediators of alcohol and drug

prevention

Delay onset of substance misuse (O’Leary-Barrett, submitted;

Spoth et al., 2009; Spoth et al., 2014)

Drinking onset

binge drinking

Smoking ? (Whelan et al., 2014)

Impulsivity and prosocial peer networks (Castellanos-Ryan et

al., 2013).

Early onset alcohol misuse and adolescent brain

development (e.g., Nagel, 2005)

Mediators of 2-year intervention

effects Mediation Analysis:

MacKinnon’s products of coefficients method

referring to the impact of each mediator

individually when controlling for gender,

ethnicity and baseline symptoms

O’Leary-Barrett, et al., 2015, JCCP

1854 (84%) of control sample completed 24-month FU

1854 (84%) of control sample completed 36-month FU

1854 (84%) of control sample completed 48-month FU

1854 (84%) of control sample completed 24-month FU

1854 (84%) of control sample completed 36-month FU

1854 (84%) of control sample completed 48-month FU

1004 invited to take part in

interventions

251 (25%) score high in NT

251 (25%) score high in AS

251 (25%) score high in IMP

251 (25%) score high in SS

1004 Not invited to take part in

interventions:

251 (25%) score high in NT

251 (25%) score high in AS

251 (25%) score high in IMP

251 (25%) score high in SS

32 public and private schools, each with approximately 150 Year 7 students, recruited from Greater Montreal Area, randomly assigned to treatment condition.

2208 (92%) students complete screening survey and consent to trial

1004 (45.5%) high risk

1854 (84%) of control sample completed12-month FU

1004 (45.5%) high risk 1204 (54.5%) low risk

1204 (54.5%) low risk

Baseline

24mo

36mo

48mo

12mo

16 schools (50%) Control Condition

2208 (92%) students complete screening survey and consent to trial

16 schools (50%) Intervention Condition

1854 (84%) of control sample completed12-month FU

Preventure

training of

school staff

Early Use

Cognitive dev

Em / Behav

Problems

Academic

Failure

ADDICTION

OUTCOMES NEURO-

Venture Brain structure-

function

NEURO-

Venture Brain structure-

function

NEURO-

Venture Brain structure-

function

Conclusions Evidence supporting the efficacy and effectiveness of targeted interventions

for the prevention of substance use and mental health problems is mounting.

We have demonstrated that it is feasible to implement CBT interventions in schools across a number of different political and educational contexts.

Results inform models of substance misuse etiology Provides a strong mental health and neurodevelopmental perspective on

youth drug and alcohol prevention Evidence of disease and communicable components of substance abuse

vulnerability

Are communities promoting evidence-based programmes in schools? Greater Montreal Area currently implementing programme, with plans to train Laval and Lac

St-Jean.

Two-part models with growth functions

(Conrod et al., JAMA Psychiatry, 2013)

Teacher Training Protocol 3-day Workshop

Theory

Generic counselling skills (emphathy!)

Targeting personality in treatment and prevention

Practical Supervision

Session 1 + Feedback

Session 2 + Feedback

Merci

Patricia Conrod

Patricia.conrod@umontreal.ca