Integrated cognitive behavioral treatment for substance use and depressive symptoms: A homeless case series and feasibility study

doi:10.21203/rs.3.rs-1560793/v1

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Integrated cognitive behavioral treatment for substance use and depressive symptoms: A homeless case series and feasibility study

https://doi.org/10.21203/rs.3.rs-1560793/v1

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Background

Homelessness is associated with high prevalence of psychiatric disorders such as substance use disorders, including alcohol use disorder, and depression.

Methods

This case series and feasibility trial evaluated a novel integrated cognitive behavioral treatment (ICBT), which was adapted specifically for homeless individuals and developed to treat substance use and depressive symptoms simultaneously. The ICBT was delivered among four homeless individuals enrolled in the Treatment First program (a social services program where treatment is offered in conjunction with temporary transitional housing), who had access to stable and sober housing milieus.

Results

The ICBT was rated high in expectancy of improvement, credibility, and satisfaction, with few treatment-related adverse events, and fairly high treatment retention. At twelve months follow up, three of four participants were not homeless anymore. All treatment participants experienced short term reductions in substance use and/or depressive symptoms.

Conclusions

The study provided preliminary support that the ICBT is a feasible and potentially effective treatment for homeless individuals with substance use and/or depressive symptoms. However, the delivery format within the Treatment First program was not feasible due to treatment workload. The ICBT could be offered within the social services Housing First program instead (where permanent housing is offered before treatment), or to non-homeless individuals.

Trial registration

The study was registered retrospectively at Clinical trials.gov (NCT05329181).

Integrated cognitive behavioral treatment

alcohol use disorder

substance use disorder

depressive symptoms

homeless

treatment first

feasibility study

This case series and feasibility trial evaluated a novel integrated cognitive behavioral treatment (ICBT), which was adapted specifically for homeless individuals and developed to treat substance use and depressive symptoms simultaneously.
The ICBT indicated good feasibility on most measures, i.e., expectancy of improvement, credibility and satisfaction, treatment retention, treatment-related adverse events, improved housing status, as well as potential reductions in substance use (including alcohol use) and symptoms of depression and anxiety.
The delivery format, within the social services Treatment First program, was not optimal from a perspective of treatment workload. Offering ICBT within the social services Housing First program, or to comorbid non-homeless participants with SUD and depression, might be considered.

More than 400,000 and 600,000 individuals are homeless in the European Union and the United States, respectively. Homelessness is seen as a complex interaction between individual and structural factors and is associated with poor mental and physical health (Beijer et al., 2012; Beijer & Andréasson, 2009, 2010; Fazel et al., 2014) and increased mortality (Beijer et al., 2011), as well as large costs for society. Definitions of homelessness vary across countries (Fazel et al., 2014). Sun et al. (2012) proposed that the degree of homelessness could be measured and categorized into four groups with different living conditions: (1) Rough sleepers, i.e. homeless individuals who spends the night outdoors, for example in parks, under bridges, in cars or in stair-wells; (2) sheltered homeless, who spend the night in shelters, lodging houses, or so called low threshold hostels where the guests are allowed to be intoxicated by some drug (including alcohol); (3) homeless in temporary residential institutions, including treatment institutions, where it is usually not allowed to be intoxicated; and (4) homeless close to housing, e.g. persons with a short-time sublease, or a long-term contract with a foundation for those with obstacles on the regular housing market, or someone living in a trial apartment, often arranged by social services, with an option of taking over the rental tenure. According to a similar definition as Sun et al. (2012), 32,398 individuals in Sweden were homeless 2011; and the number of individuals in long-term living arrangements offered by the social services had increased, which constituted almost half of the Swedish homeless population (The Swedish National Board of Health and Welfare, 2011).

The homeless population is a vulnerable group, specifically due to an increased risk of adverse health related outcomes (Strehlow & Amos-Jones, 1999), including psychiatric disorders (Fazel et al., 2014). Swedish studies have estimated the prevalence of alcohol use disorder and/or substance use disorders (henceforth the term SUD will be used, also including alcohol use disorder) in the homeless population to 40–80%, with co-occurring psychiatric disorders between 42%-50% (Halldin, 2001; The Swedish National Board of Health and Welfare, 2011). Although psychiatric disorders have been proposed both as a potential cause and a consequence of homelessness (Fazel et al., 2014; Sun et al., 2012), little is known regarding the etiology of co-occurring depression and SUD in the homeless population (Belcher & DiBlasio, 1990). In general, it is difficult to draw reliable etiological conclusions due to the chaotic and unstable environments that many homeless individuals are exposed to (Belcher & DiBlasio, 1990). However, SUD have been found to be highly correlated with both initiation and persistence of homelessness (Patterson et al., 2012). Studies have also shown that homeless individuals are specifically vulnerable to depression (Belcher & DiBlasio, 1990). Social isolation, food deprivation, health- or relationship problems, SUD, low personal resources, self-esteem, or goal orientation; are factors that have been discussed as possible explanations to the high prevalence of depression in homeless populations. Increased depressive symptoms, i.e. negative affect, has in general been associated with increased alcohol use (Witkiewitz & Villarroel, 2009), and with risk of drop out from SUD treatment among homeless individuals (Ibabe et al., 2014).

Swedish social services are typically operating according to two housing models. In the Treatment First model, temporary transitional housing is offered using a continuous approach (e.g., non-drug free emergency shelters or low threshold hostels, or sober residential institutions, trial or train apartments) alongside with psychiatric treatment, mainly for SUD. Access to permanent housing is conditional on “housing readiness” and adherence to treatment. Conversely, the Housing First model offers permanent housing as a first step. Continuous support is also offered, but housing is not contingent on adherence to psychiatric treatment or substance abstinence. Treatment First is the mainstream model (Baxter et al., 2019; Patterson et al., 2012). At the time of this study, only a minority of the Swedish homeless population were in Housing First programs.

Standard mental health treatments are usually considered ineffective for homeless individuals with psychiatric comorbidity, due to insufficient outreach, lack of decent housing, and failure to address pending SUD (Drake et al., 1997). Housing plays a key role for homeless individuals to respond to treatment. Access to stable, safe and sober housing milieus is often seen as a prerequisite for starting treatment. Previous treatment studies for SUD have demonstrated effectiveness when homeless individuals have received simultaneous access to stable, safe and sober housing milieus (Smith et al., 1998), and the treatments have been shown to be less effective when such housing milieus have not been offered (Slesnick et al., 2007). According to international recommendations, treatment for homeless individuals should have an integrative approach for co-occurring mental illness and SUD, be tailored to the specific needs of the population, and coordinated in collaboration with other services, such as social workers (Belcher & DiBlasio, 1990; Hwang & Burns, 2014; Velasquez et al., 2000). According to our knowledge, no such cognitive behavioral treatment protocol exist today.

The aim of this study was to evaluate feasibility of a novel integrated cognitive behavioral treatment (ICBT), which was adapted specifically for homeless individuals and developed to treat substance use and depressive symptoms simultaneously (see Development of the intervention, below). Feasibility was evaluated in a small sample of homeless individuals in the Treatment First program within the social services (where treatment is offered in conjunction with temporary transitional housing), who had access to “stable housing” (safe and sober housing milieus) during the treatment period. In this study, stable housing was operationalized as situation 3 and 4 according to the definition by Sun et al. (2012; i.e., temporary residential institutions, e.g., treatment institutions where it is usually not allowed to be intoxicated, or close to housing, e.g., train or trial apartments arranged by the social services), because we did not want to exclude homeless participants in sober residential institutions. Treatment feasibility was investigated in terms of (1) expectancy of treatment improvement, credibility and satisfaction; (2) number of completed treatment sessions and cancelled sessions; (3) occurrence of adverse events; (4) improved housing status; (5) reduction in substance use (including alcohol); (6) reduction in symptoms of depression and anxiety; and (7) treatment workload.

Participants and study site

All study participants were clients at the social welfare office for the homeless, a specialized unit within the social services in Stockholm, Sweden. The participants were referred to outpatient ICBT at Pelarbacken, a specialized primary care center for homeless patients. Participants were included in the study if they (a) fulfilled the DSM-5 (American Psychiatric Association, 2013) criteria for AUD or SUD, (b) fulfilled the Swedish criteria for homelessness (The Swedish National Board of Health and Welfare, 2011) and had access to ”steady housing” (defined as situation 3 or 4 according to Sun et al. [2012]), (c) were between 16-65 years old, (d), were able to read and write Swedish and were able to carry out treatment, 5-15 sessions together with homework assignments, and (e) had regular contact with a social worker at the social welfare office for the homeless. Exclusion criteria were (f) another primary psychiatric condition (e.g., bipolar disorder, psychosis, suicidal ideation), (g) failure to attend first two treatment sessions, (h) other aggravating circumstances, for example violence in close relationships. Recruitment began in June 2016 and ended in January 2017. The last follow-up measure was administrated in July 2018.

In total, six homeless individuals were invited to participate in the study, of which five completed informed consent and were included. One participant started treatment but moved to another city. This participant was removed from the study, as the ethical permit did not cover other cities (or social services) than Stockholm. See Table 1 for baseline demographic characteristics of the four remaining participants.

[INSERT TABLE 1 ABOUT HERE]

Measures

Acceptability

Perceived credibility and satisfaction of treatment, were measured with the Credibility/Expectancy Questionnaire (CEQ; Devilly & Borkovec, 2000) and the Client Satisfaction Questionnaire (CSQ-8; Attkisson & Greenfield, 1994), respectively. Higher scores indicate higher treatment credibility and satisfaction. The participants also reported adverse events using a self-report measure adapted for psychological treatment (Ljótsson et al., 2014). For each adverse event reported participant also rated the discomfort caused by the event when it occurred, as well as residual discomfort (level of discomfort at the time of assessment). Ratings were made between 0 (“did not affect me at all”) and 3 (“affected me very negatively”).

The CEQ was administered after treatment session 2, and the CSQ-8 after treatment. The adverse event measure was administered after treatment, and at 3-, 6- and 12-month following treatment cessation.

Housing status

Demographic questions were administered pre, and post treatment, as well as during follow up. The degree of homelessness was assessed with the questions “When was the last time that you had a housing of your own?” and ”Where did you sleep last night?”, with response alternatives based upon the Swedish national definition of homelessness: ”Outside”; ”At a shelter”; ”In a temporary (sober) residential institution”, ”In a reference-based training or trial apartment”, or ”In my own apartment (own lease)”. In addition, information of the participants’ housing status was collected from the registers of the social welfare office for the homeless at baseline and follow up.

Substance use and psychiatric symptoms

The TimeLine Follow Back (TLFB; Sobell et al., 1979), a retrospective calendar instrument to assess days and quantity of alcohol and drug use, was used as primary measure for substance use. The TLFB have been found to have good psychometric properties in a homeless population (Sacks et al., 2003). In this study, alcohol and substance use, was assessed using a retrospective 90-day calendar interview at baseline, and a retrospective 7 days measure was assessed weekly during treatment sessions. Number of units (alcohol or drug use) per week were reported as means per week, during baseline and treatment. The TLFB was not administered at follow up.

The Patient Health Questionnaire (PHQ-9; Kroenke et al., 2001) is a 9-item self-report measure (score range 0-27) that assesses depression severity with the following cut-off categories: None-minimal (0-4), mild (5-9), moderate (10-14), moderately-severe (15-19), severe (20-27). The PHQ-9 has shown high internal consistency (α =.81; Titov et al., 2011).

The Generalized Anxiety Questionnaire (GAD-7; Spitzer et al., 2006) is a 7 item self-report measure (score range 0-21) to assess anxiety, with the following cut-off categories: Mild (5-9), moderate (10-14), severe (15-21).

The Alcohol Use Disorders Identification Test (AUDIT; Saunders et al., 1993) is a 10 item self-report measure (score range 0-40) that assesses alcohol consumption. A cut-off of 8 and 6, indicates a hazardous and harmful pattern of alcohol consumption for men and women, respectively.

The Drug Use Disorders Identification Test (DUDIT; Berman et al., 2005) is a 11 item self-report measure (score range 0-44) to identify and assess non-alcohol drug use patterns. A cut-off score of 6 and 2 indicates problematic drug use for men and women, respectively; and a score of ≥25 indicates heavily dependence on drugs (Berman et al., 2005; Hildebrand, 2015).

Primary and secondary measures were administered before and after treatment, as well as at 3-, 6- and 12-month following treatment cessation. In addition, TLFB and PHQ-9 (one week interval) were administered weekly during treatment.

Procedure

Prior to inclusion participants signed an informed consent, including consent for collaboration with the social welfare office for the homeless, and was assessed for psychiatric comorbidity with the Mini International Neuropsychiatric Interview 7.0 (MINI-7; Sheehan et al., 1998). The individual treatment sessions lasted between 30-60 minutes and were conducted at a location preferred by the participants. Two participants choose to receive the treatment at Pelarbacken, and two participants at another health care clinic and in their homes. In parallel to the treatment, participants received regular health care and social services interventions, such as housing supporters. The first author, a clinical psychologist, assessed and delivered the treatment as face-to face sessions for all participants except one. This participant was assessed with MINI-7 by a psychiatrist at Pelarbacken and had the first 9 treatment sessions delivered by a nurse at Pelarbacken who was trained by the first author, and the last 6 sessions delivered by the first author.

Ethical considerations and safety procedures

This study was conducted in accordance with the Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects and was approved by the Regional Ethics Board of Stockholm, Sweden (ref. no. ref. no. 2015/2355-31/5). The following steps were taken to ensure participants safety and minimize drop out: (1) The ICBT was delivered at Pelarbacken, a specialized primary care center for homeless patients, with access to a team of health care providers such, physicians, nurses and psychiatrists; (2) participants had an option to complete the ICBT sessions outside of Pelarbacken, for example as home visits, to reduce contact with alcohol and drug intensive milieus; (3) each ICBT session started with an “emergency list” targeting possible short term issues that needed to be resolved to continue treatment for example lapses/relapses, medication, economical/housing complications; (4) participants had an option to have between session contact via phone or text messages, as well as weekly text message reminders of sessions; (5) participants that did not improve were offered referral to other treatment, e.g., specialized psychiatric treatment for anxiety; (6) participant’ names, stories and age were modified to ensure confidentiality, and lastly (7) the ICBT was conducted in collaboration with the participants social worker at the social welfare office for the homeless, optional parallel meetings were scheduled together with the participant and their social secretaires to ensure treatment confidentiality and secrecy. This last safety procedure was especially important as homeless individuals within the Treatment First model might risking losing their housing milieu, due to reported substance use.

Analysis and missing data

Six-month follow-up assessment was missing for participant Baako, who was abroad at the occasion for measurement. Twelve-month follow-up was missing for Annelie, due to a relapse of drug use. In addition, assessment of GAD-7 was missing for Annelie at six-month follow-up, due to a measurement error. These data were presented as not assessed. Three CSQ-8 items were missing for Annelie and were replaced with the respective mean CSQ-8 item score of the other participants. Alcohol, substance use, and depressive symptoms were assessed weekly during treatment sessions. Not assessed weeks were reported and replaced with last observation carried forward (see Figure 3). TLFB units (alcohol or drug use) were presented in means per week. All adverse events that were reported were reviewed and categorized as treatment-, or non-treatment related, by the first author. Quantitative analyses were done using R Studio version 1.1.456 (R Core Team, 2018).

Development of the intervention

The integrated ICBT was developed as part of a collaborate treatment program between the social welfare office for the homeless and Pelarbacken. Initially during the program, homeless individuals were offered relapse prevention for substance use in a group format. Relapse prevention is a cognitive behavioral approach that aims to teach a variety of specific coping skills and decrease individual high-risk situations associated with relapse for substance use (Marlatt & George, 1984). However, relapse prevention was not considered optimal as the participants stated that they used alcohol and drugs in “all situations”, as a natural part of the homeless life. Furthermore, post treatment interviews and individual behavioral analyses of prior patients showed that the far most common reason for alcohol or drug use, was coping with negative affect (46% reported this reason). A novel ICBT was developed emanating from the following analysis (1) being homeless often implicates having lost contact with several important life areas, substance use might be the only reinforcing activity left; (2) common reactions are stress and depressive symptoms, and avoidance based strategies such as passivity, isolation, avoidance of social contact, or substance use; (3) when decreasing substance use, a transient approximate 3 month period of increased “depression-like” symptoms occurs, which might lead to lapses or relapses (this period is also called post-acute abstinence, or protracted abstinence [see for example Heilig et al., 2010]). The ICBT (5-15 sessions) was developed to extend over this time period, with the overall aim of participants to (1) access a stable, sober housing milieu, and decrease substance use; (2) learn strategies to cope with negative affect; and (3) learn strategies to cope with life changes, increase activities such as work, social contact, exercise or leisure activities (see Table 2 for treatment components, Figure 1 for an example of the treatment content, and Figure 2 for participants).

[INSERT TABLE 2 ABOUT HERE]

[INSERT FIGURE 1 ABOUT HERE]

[INSERT FIGURE 2 ABOUT HERE]

Acceptability, treatment sessions and adverse events

Mean CEQ ratings of treatment credibility (M = 8.38, Sd = 0.89, range 1-9) and expectancy (M = 75%, Sd = 16.90, range 0-100%), after session two were high. Satisfaction with treatment was rated in the higher range of CSQ-8, with a mean of 29 (Sd = 3.83) out of 32. Participants received in total 42 treatment sessions (M = 10.5, range 5 to 15). In total 16 scheduled sessions (28%) were cancelled by the participants (range 0 to 6). In total five adverse events were reported, of which two were categorized as treatment related (see Table 3).

[INSERT TABLE 3 ABOUT HERE]

Housing status, substance use and psychiatric symptoms

No participant lost their housing during the study, due to e.g., reported alcohol or drug use. Three participants had taken over the lease for their trial apartment and were thus not homeless anymore at twelve months follow up. One participant, Jennifer, had moved from a training to a trial apartment. Overall, Annelie showed no improvements in psychiatric symptoms. She experienced a relapse for heavy drug use at the time for the twelve months follow up and did not complete any of the measures, but if she had, all measures would probably had been elevated compared to baseline. All other participants seemed to show some reduction in anxiety from baseline to twelve-months follow up. Drug use patterns, assessed with the DUDIT seemed similar at baseline compared to twelve-months follow up, or showed some reduction as with participant Baako. Depressive symptoms seemed to reduce continuously for Jennifer and Baako. Adam experienced a lapse or relapse of alcohol use at twelve months follow up, as well as elevated depressive symptoms (see Table 4).

[INSERT TABLE 4 ABOUT HERE]

[INSERT FIGURE 3 ABOUT HERE]

This study evaluated the feasibility of a novel integrated cognitive behavioral treatment (ICBT), adapted for homeless individuals, developed to treat substance use (including alcohol use) and depressive symptoms simultaneously. The ICBT was evaluated among four homeless individuals in the social services Treatment First program. In the Treatment First program homeless clients are offered a temporary accommodation, in conjunction with treatment. Further access to permanent housing within the Treatment First program is conditional on “housing readiness” and adherence to treatment (e.g., being sober), while substance use might lead to losing a temporary housing milieu, such as trial or train apartments. In this study, all participants had access to stable, sober housing milieus, before starting the ICBT. Access to stable, sober housing milieus have been described as a condition for homeless individuals to be able to engage in treatment (Källmén et al., 2014). Previous substance use treatment studies among homeless individuals have shown good results when housing have been offered simultaneously (Smith et al., 1998), and been less effective when only treatment have been offered (Slesnick et al., 2007).

The ICBT was rated high in expectancy, credibility and satisfaction, with few treatment-related adverse events. No participant dropped out of the treatment (not counting the participant who moved to another city, and was removed from the study due to geographical limitations in the ethical permit). In total, the number of completed treatment sessions was fairly high (n = 42, 72%), and the scheduled drop-out sessions fairly low (n = 16, 28%). Previous studies have shown that treatment retention is difficult among homeless individuals, only about 25–33% completes treatments for substance use, even though the treatment programs are tailored especially to the needs of the population (Caton et al., 2007). One possible explanation for treatment retention in this study, could be that several recommended strategies to engage homeless individuals (Zerger, 2002) were used in conjunction with treatment, such as offering a safe environment and outreach (home visits). Another possible explanation consists of the content of the treatment. Ibabe et al. (2014), found that recent emotional stress among homeless individuals predicted less participation in substance use treatment compared to substance use alone, which predicted significantly more participation in treatment. In this study, substance use and depressive symptoms were treated simultaneously using a behavioral activation approach, thus addressing recent and emerging emotional stress, continuously. Notably, three of four participants were not homeless at the end of the study, although the majority reported substance use during the ICBT, while they had access to sober trial and training apartments. During the time of the study Housing First programs (where permanent housing is offered, without demanding abstinence from substance or alcohol use) were being implemented at the social services. Consequently, it is possible that the principle of “housing readiness” in the Treatment First program were applied less rigorously at the study site. Finally, although the study design does not permit causal inference, the results also indicated that all participant experienced short term reductions in the primary measure substance use, and/or depressive symptoms. Overall, the above-mentioned results indicates that the ICBT might be a feasible and potentially effective treatment for homeless individuals with substance use and/or depressive symptoms.

However, the delivery format, within the Treatment First program, was not optimal from a perspective of treatment workload. One single clinical psychologist (the first author) conducted practically all clinical assessments, treatment sessions and scheduling, including a range of procedures designed to ensure treatment confidentiality and safety within the Treatment First program, such as home visits and cooperation with social workers and other health care clinics. These procedures might have increased participant safety, and decreased drop-out, cancelled visits and adverse events, but the workload surrounding treatment deliverance in this study, seemed beyond regular clinical praxis. A further unexpected treatment obstacle was that half of the participants expressed that it was stressful to complete the ICBT, in relation to work, other health care visits and mandatory measures within the Treatment First program, such as housing supporters. Incorporating the ICBT into support systems of Housing First programs instead, for example in an Assertive Community Treatment team (an interdisciplinary program with healthcare professionals and social workers), would probably increase feasibility from a treatment deliverance perspective. If so, it would also be possible to coordinate and plan different interventions tailored to the participants needs, reduce necessity of several safety procedures employed in this study, as well as workload for the treatment deliverer. It would also enable possibility for “on demand” treatment interventions, to address e.g. lapses and relapses, as support is continuously offered after participants get access to permanent housing.

Although the focus of the ICBT was substance use and depressive symptoms, all participants in this study also suffered from anxiety. This was necessary not a problem, as behavioral activation (the main treatment component) may also be effective for anxiety disorders (Hopko et al., 2006; Stein et al., 2020). However, three of four participants suffered from post-traumatic stress disorder, for which this treatment was not sufficient. An alternative treatment approach to adapt for homeless individuals could have been to prolonged exposure (Foa, 2011), which also have been evaluated in an integrated format for substance use (Back et al., 2019).

This study was conducted among homeless participants receiving standard social service and health care interventions, and thus had high ecological validity. Several safety procedures were employed that ensured participant safety and treatment confidentiality within the Treatment First program, which was another strength of this study. Lastly, treatment was developed based upon behavior analysis of homeless participants, and addressed an important gap identified in previous research (Belcher & DiBlasio, 1990; Hwang & Burns, 2014; Velasquez et al., 2000). Notably, comorbidity for SUD and depressive symptoms are not only common among homeless individuals. A recent meta-analysis among non-homeless community and clinical samples found that the pooled prevalence of any SUD in major depression was 25% (with AUD having the highest pooled prevalence of 21%), and that these comorbidity rates had not changed over the past three decades (Hunt et al., 2020). National treatment recommendations in Sweden (The Swedish National Board of Health and Welfare, 2017) recommends integrated treatment for AUD and depression. No such cognitive behavioral treatment protocols exists today according to our knowledge. From this perspective, treatment development for specific vulnerable groups such as homeless individuals can be beneficial also for other patient populations.

A limitation of the study was that the primary measure assessing substance use (TLFB) was not administered at follow up, which aggravated comparisons between substance use during treatment and follow up. Conversely, depressive symptoms were not assessed at baseline using the same retrospective 12-week time period as TLFB. Furthermore, retrospective baseline TLFB was only assessed at one time point. Using a multiple baseline design (Smith, 2012), would have ensured better experimental control.

Further studies could evaluate the integrated treatment in homeless samples in Housing First programs, or among comorbid non-homeless participants with SUD and depression.

AUDIT

the Alcohol Use Disorders Identification Test

CEQ

the Credibility/Expectancy Questionnaire

CSQ-8

the Client Satisfaction Questionnaire

DUDIT

the Drug Use Disorders Identification Test

GAD-7

the Generalized Anxiety Questionnaire

ICBT

Integrated Cognitive Behavioral Treatment for substance use and depressive symptoms

MINI-7

the Mini International Neuropsychiatric Interview 7.0

PHQ-9

the Patient Health Questionnaire

SUD

Substance Use Disorders

TLFB

the TimeLine Follow Back

Ethics approval and consent to participate

This study was approved by the Regional Ethics Board of Stockholm, Sweden (ref. no. 2017/1479-31). All participants signed an informed consent before enrolled in the study.

Consent for publication

Not applicable.

Availability of data and materials

Dataset sharing is not possible due to integrity reasons, as the study participants were patients in routine health care.

Competing interests

The authors declare that they have no conflict of interest.

Funding

This study was funded by internal founds of Ersta diakoni.

Authors' contributions

Author OM conceived of the study, developed the treatment, and treated the participants. Author JB, HS and BL aided in the research design and ethical application. Author UB gave theoretical input. Author OM wrote a draft version of the manuscript. All authors contributed equally to the final manuscript.

Acknowledgements

The authors would first and foremost like to thank the participants in the study. The authors would also like to thank Yanqiu Yu for contributing with statistical support. Finally, author OM would like to thank street-doctors Robert Irestig and Rolf Byström, and dentist Patricia de Palma, for showing the way.

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Table 1 Baseline demographic properties of participants

Alias	Adam	Jennifer	Baako	Annelie
Age	≈60	≈50	≈50	≈30
Gender	Male	Female	Male	Female
Civil status	Single	Married	Single	Single
Own children (in contact)	Yes (no)	Yes (yes)	No	No
Number of children (ages)	2 (26, 23)	2 (39, 33)
Employment (maintenance support)	No (yes)	No (yes)	Yes (no)	No (yes)
On sick-leave	Yes	Yes	No	No
Length of homelessness	11 years	2 years	7 years	8 years
Current housing status	Trial apartment^a	Train apartment^a	Trial apartment^a	Trial apartment^a
Presented complaints	Depression, anxiety, alcohol problems	Anxiety	Depression, isolation, social anxiety, gambling	Depression, social anxiety, anxiety, trauma, irritation, cannabis use
DSM-5 diagnoses^b	APD, AUD^c, GAD, MDD, PTSD	AUD^c, PD	AG, APD, AUD^c, MDD, PTSD, SAD, SUD^cd	GAD, MDD, OCD, PDA, PTSD, SAD, SUD^cd

^aTrain and trial apartment, homeless housing situation 3 according to the definition by Sun et al. (2012)

^bAssessed with the Mini International Neuropsychiatric Interview 7.0 (Sheehan et al., 1998)

^cIn a controlled mileu

^dCannabis use

APD = Antisocial Personality Disorder

AG = Agoraphobia

AUD = Alcohol Use Disorder

GAD = Generalized Anxiety Disorder

MDD = Major Depressive Disorder

OCD = Obsessive Compulsive Disorder

PDA = Panic Disorder with Agoraphobia

PTSD = Post Traumatic Stress Disorder

SAD = Social Anxiety Disorder

SUD = Substance Use Disorder

Table 2 Components of integrated treatment

Treatment interventions

Goal setting

Happiness scale^c, behavior analysis

Psychoeducation

Information regarding: (1) Homeless individuals health and life situation, (2) common

reactions when decreasing substance use among homeless individuals, difference

between lapses and relapses and how to cope with them^e, (3) common reactions to

depressive symptoms among homeless individuals, (4) “self-medication”

Behavior activation^ab

Activity monitoring (activity diary), activity scheduling

Sobriety sampling^c

Strategies to postpone and cope with substance use

Breathing training^d

Strategies to cope with anxiety

Rumination^b

Strategies to identify and cope with rumination and urges

^aCore treatment components

^badapted from Martell (2010)

^cadapted from Meyers & Smith (1995)

^dadapted from Foa et al. (2019)

^eadapted from Saxon & Wirbing (2004)

Table 3 Treatment sessions and adverse events

	Total	Adam	Jennifer	Baako	Annelie
Number of sessions
Completed treatment sessions, n (%)	42 (72%)	15 (100%)	15 (71%)	7 (58%)	5 (50%)
Scheduled drop-out sessions, n (%)	16 (28%)	0 (0%)	6 (29%)	5 (42%)	5 (50%)
Adverse events	5
Treatment related	2	“Lapse” (2/0)	“Panic attacks” (3/1)	-	-
Non-treatment related	3	-	“Had to take lung test for heart failure (3/2)	-	“Robbed by two guys” (2/0)
			“Anesthetized in respiration at hospital” (3/3)

Number within parenthesis represents the level of discomfort (0-3) when the event occurred, and residual discomfort (at the time of assessment). For example, Adam reported a lapse and rated the level of discomfort as 2 and the residual discomfort as 0, which was categorized as a treatment related adverse event.

Table 4 Housing status and psychiatric symptoms

	Adam					Jennifer					Baako					Annelie
	BL	P	FU3	FU6	FU12	BL	P	FU3	FU6	FU12	BL	P	FU3	FU6	FU12	BL	P	FU3	FU6	FU12
Housing status^a	Trial (3)	Trial (3)	Trial (3)	Trial (3)	Own (4)	Train (3)	Train (3)	Train (3)	Train (3)	Trial (3)	Trial (3)	Trial (3)	Trial (3)	Trial (3)	Own (4)	Trial (3)	Trial (3)	Own (4)	Own (4)	Own (4)
Measure
PHQ9	22	8	9	12	20	9	3	2	6	2	10	8	9	NA	4	22	18	24	18	NA
GAD7	10	4	4	4	7	12	0	1	5	4	6	8	7	NA	2	19	21	21	NA	NA
AUDIT	0	0	0	0	15	5	7	0	0	1	10	20	14	NA	12	3	3	4	3	NA
DUDIT	0	0	0	0	0	0	0	0	0	0	8	8	6	NA	5	11	0	8	4	NA

^aRegister data from the Social Welfare Office for the Homeless, number within parentheses represents homeless housing situation according to the definition by Sun et al. (2012)

BL = Baseline

P = Post treatment

FU3, FU6 and FU12 = follow up at three, six and twelve months, respectively

Train = Training apartment

Trial = Trial apartment

Own = Own apartment (not homeless)

NA = Measure not assessed

PHQ9 = The Patient Health Questionnaire (Kroenke et al., 2001)

GAD7 = The Generalised Anxiety Disorder 7-item scale (Spitzer et al., 2006)

AUDIT = The Alcohol Use Disorders Identification Test (Saunders et al., 1993)

DUDIT = The Drug Use Disorders Identification Test (Berman et al., 2005)

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Integrated cognitive behavioral treatment for substance use and depressive symptoms: A homeless case series and feasibility study

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Abstract

Figures

Key Messages Regarding Feasibility

Background

Methods

Results

Acceptability, treatment sessions and adverse events

Housing status, substance use and psychiatric symptoms

Discussion

List Of Abbreviations

Declarations

References

Tables

Supplementary Files

Status:

Version 1