Depression Treatment for Low Income Substance Users

Approximately 22% of substance users suffer from major depression, which is associated with
higher rates of substance abuse treatment dropout, relapse to substance use, and HIV risk
behavior. Further, in inner-city areas such as DC, rates of substance use and depression
disproportionately affect ethnic minorities, as well as those living in poverty. Despite
this link, few interventions targeting depression have been developed to meet the specific
needs of depressed substance users. One approach that may be especially appropriate in this
regard is behavioral activation (BA), which aims to increase individuals' engagement in
pleasant events, thereby increasing contact with positive reinforcement and decreasing the
frequency of aversive events. BA has been shown to be efficacious in the treatment of
depression, and this uncomplicated and straightforward approach may be especially
appropriate for the specific needs of an inner city low income substance abusing sample.
Further, BA compliments standard substance abuse treatment in several key practical and
theoretical ways as it is more easily adopted by staff in these settings, more time
efficient (e.g., fewer and shorter sessions, group format), more easily understood by
patients who suffer from cognitive limitations due to low education level and chronic drug
use, and can incorporate aspects of sobriety into its treatment components. In an initial
Stage 1 development project, a version of BA, the Life Enhancement Treatment for Substance
Use (LETS ACT), was developed and specifically tailored for inner-city low income minority
substance users with elevated depressive symptoms. Results demonstrated that LETS ACT led to
a significantly greater reduction in self-reported depressive symptoms and a significant
increase in enjoyment and reward value of activities as compared to the TAU control group
(Daughters et al., 2008). While preliminary findings prove promising, many questions remain
unanswered and several extensions of this work are necessary, including an assessment of
post treatment substance use and HIV risk behavior, a contact-matched control, and a larger
sample size to allow for more complex analyses of the mechanisms underlying these outcomes.
Thus, the objective of the present proposal is to follow-up on our previous Stage 1
treatment development efforts and small scale randomized control trial (RCT) with a
fully-powered Stage 2 RCT comparing LETS ACT to nondirective therapy (NDT) among a sample of
243 low income depressed substance users currently receiving residential substance abuse
treatment in inner-city Washington, DC.

Inclusion Criteria:

- between 18 and 65 years of age

- beginning their last month of residential treatment

- meet criteria for current Major Depressive Disorder

Exclusion Criteria:

- limited mental competency [Mini Mental State Examination score < 23]

- psychosis

- the use of psychotropic medication for < 3 months

- the inability to give informed, voluntary, written consent to participate