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PROBEM STATEMENT: SUD in vulnerable patient populations is undertreated

Substance use disorder (SUD) is a common mental health problem associated with physical, mental health and social issues. Though well-treatable - for instance by cognitive behavioural therapy (CBT), there are subgroups that do not benefit equally from these interventions. Patients with low cognitive and/or adaptive functioning have - compared to the general population - a higher risk for addiction and worse treatment outcomes. However, current SUD treatment, such as CBT, is reflective and language-based and relies on cognitive and adaptive skills, such as attention span, memory and ability to apply new knowledge to daily life. Because CBT does not fit the needs of these vulnerable patients, these persons are less likely to receive or complete treatment. Furthermore, even though they are a large group within mental healthcare, they are underrepresented in scientific research on SUD. Within this project we aim to provide evidence for adapted SUD treatment that better fits the needs of this underserved and under-researched group.

 

SOLUTION: Adapted CBT enhanced with technology

We build on from our experience in treating vulnerable populations with adapted CBT protocols (such as CBT+) and applying innovative technology in mental healthcare. CBT protocols tailored to SUD include adapted CBT-exercises, increased repetition, visualization, and use of simple language. Technologies such as interactive virtual reality (VR) can be added to these protocols to offer a focus on doing and experiencing in realistic contexts as opposed to talking and reflecting in a therapy room. In addition to VR, experience sampling (ES) apps can be used to self-monitor craving and accompanying triggers throughout daily live and thus gain more insight into triggers when they actually occur. This approach better fits the characteristics of vulnerable patients and does justice to the contextual nature of addiction.

 

GOALS: Effective integration of CBT+ TECH

We study how and when we can effectively integrate VR and ES in CBT+, together the CBT+TECH intervention. We combine CBT+ with the existing Triggers & Helpers VR intervention to create highly personalized, interactive scenarios in which patient and therapist can explore individual triggers and practice with coping skills. We use an ES app to collect input on craving and triggers throughout the day, for use in therapy. The main goal of this project is to determine to what extent self-efficacy, craving, substance use, interoceptive awareness, self-control and readiness to change improve in patients who receive CBT+TECH compared to those who receive treatment as usual. In addition, we aim to create the most optimal, effective and efficient version of CBT+TECH, resulting in a treatment protocol ready for implementation.

 

STUDY DESIGN: Human-centred design & realist evaluation

While CBT+TECH can potentially benefit a broader group of patients with SUD, we focus on patients with low cognitive and/or adaptive skills who receive treatment in either addiction care (Tactus), forensic psychiatry (Transfore) or ID care (Trajectum). To coordinate the study, we set up an interdisciplinary project team, including researchers on SUD, eHealth, human-centred design and ID, patient representatives and therapists. We use the MOST framework to create the most efficient and effective version of CBT+TECH by means of multiple evaluation studies. Principles from the CeHRes Roadmap are used to ensure that the intervention closely fits the needs and skills of patients and therapists, and that attention is paid to implementation from the start. This results in five work packages (WPs):

WP1: Integrating TECH in CBT+ via a co-creation approach;

WP2: Multiple evaluation studies on working mechanisms of TECH in CBT+ via a single-case experimental designs on VR, cross-over trial of ES and pilot study of the entire CBT+TECH protocol;

WP3: Optimization of CBT+TECH plus treatment protocol by the interdisciplinary project team;

WP4: Mixed-methods realist evaluation of CBT+TECH compared to treatment as usual;

WP5: Implementation planning of CBT+TECH.

 

IMPLEMENTATION & DISSEMINATION facilitated by development, approach and support

Uptake of CBT+TECH and knowledge from this project by treatment providers outside our project group is facilitated by

(1) our user centred development and evaluation approach, that ensures optimal usability in clinical care,

(2) the fit with current SUD treatment guidelines, as well as health insurance reimbursement regulations,

(3) our strong scientific and clinical network to disseminate our findings, and

(4) the CBT+TECH protocol that will be developed within this project, along with

(5) online information packages targeted to both patients and practitioners, and

(6) an implementation plan with accompanying activities developed in WP5.

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