Testing an empiricallysupported family based therapy MDFT: USA vs' The Netherlands

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Testing an empirically-supported family based
therapy (MDFT) USA vs. The Netherlands

• H. Liddle, C. Rowe
• Center for Treatment Research on Adolescent Drug
  Abuse
• University of Miami Miller School of Medicine
• H. Rigter
• Erasmus MC, Rotterdam
• V. Hendriks
• Parnassia Research Centre, The Hague

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NIDA parent grantTraining clinicians
in empirically based family therapyPI Dr.
Howard LiddleNIDA grant number IRD1 DA016969
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Topics to be covered in our presentation

• Our collaboration is not fake
• Our proposal does not come out of the blue. It
  has strong support.
• Our proposal fits priorities from the Call for
  Proposals
• Major comments by the reviewers
• The parent grant
• Supplement study Some methodological issues
• Added value of U.S. Dutch collaboration

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Our collaboration Some history

• In 2000, five European countries (B, F, G, N, S)
  joined forces to end ideological conflict about
  cannabis by doing research
• On February 2002, joint meeting in Brussels with
  scientists from all over the world
• April 2003, joint Cannabis Research Action Plan
  of the five countries

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Priorities Cannabis Research Action Plan

• Assess the importance of age of onset of cannabis
  use
• Cannabis dependence assessment and course
• Relationship with mental health
• Treatment trial (emphasis on youth)

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Chosen from literature review MDFT

• 5 Completed RCTs (generally 1 year follow-up)
• MDFT more effective than (a) group counselling,
  (b) group family sessions, and individual CBT
• MDFT more effective than residential treatment
• Effective in white, black and Latino adolescents
• Effective in adolescents referred by Justice,
  schools, or self-referred
• Effective on multiple outcomes drug use,
  externalizing and internalizing symptoms,
  delinquency, school performance

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Conclusions drawn in the Cannabis Research
Action Plan

• MDFT is the best established treatment
• Pilot study (INCANT) September 2004 May 2005
  European therapists trained in MDFT, one per
  country (supervisors)
• If MDFT is feasible, a main study (RCT) will be
  considered (2005 2008)

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And thats where our collaboration began

• In past 1.5 years, many visits to and from Miami
• Intensive contacts between CTRADA, Erasmus MC,
  and treatment centers
• E-mails almost daily. Calls weekly. Listserve
• Cannabis Questionnaire Addiction Treatment
  Inventory Treatment Contact Logs 8 Video and
  Audio Taped translated treatment sessions

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How about the INCANT main study?

• We now know that MDFT is feasible in the
  Netherlands

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The RCT proposed to NIDA and ZonMw is the INCANT
main study in the Netherlands.

• No such in-depth study is foreseen in the other
  four countries in the immediate future, because
  of
• 1. Treatment conditions being too different
  from U.S.-based settings
• 2. Insufficient support from treatment centers
• 3. Supervisors scoring below standard on
  measures of MDFT compliance, adherence, and
  competence
• (Scores of Dutch supervisor were excellent.)

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Conclusions so far

• Our collaboration has real substance. Much
  preliminary work has been done.
• Dutch conditions for the proposed supplement
  study are good (excellent supervisor, eager
  therapists in favor of MDFT, managerial and
  political support)

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Overall judgment of reviewers Positive Very
Positive

• Major comments
• Is there really a need for adolescent treatment
  in the Netherlands for cannabis use disorder plus
  associated problems?
• What is the focus of MDFT treatment? What is the
  outcome? Just cannabis use outcomes or more?
• Enough power to assess expected outcomes? Long
  enough follow-up?

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Treatments for adolescents Some notes

• Cannabis is not a (lasting) problem for most
  users
• However, for some users it is. Especially when
  they
• Start using the drug at a young age (true in the
  Netherlands)
• Have other problems as well (true in the
  Netherlands)
• Additional complication may be increasing
  potency of cannabis

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Comment 1 Adolescents

• Our proposal targets 3 key issues in the Call for
  Proposals Youth, Cannabis, Treatment
• The Netherlands lacks facilities for
  evidence-based treatment of adolescents with
  cannabis use disorder (among other behavioral
  problems high co-morbidity)
• Adolescents are especially sensitive to the
  development of resilient cannabis use disorder

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CANNABIS How many stop their use entirely on
their own in 5 years time?
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Associations of mental disorders with substance
use disorders
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Comment 1 Adolescents (Continued)

• Age of first use of cannabis has gone down
• Treatment demand has increased
• Unmet treatment need worrying to Government and
  treatment centers
• Concentration of THC has increased

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Comment 2What is the focus of MDFT treatment?
What is the outcome?

• Primary outcome cannabis and other substance use
• Secondary outcomes less externalizing and
  internalizing symptoms, better family and school
  functioning, less delinquency

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Pieces of MDFT approach

• MDFT intervenes into multiple systems of
  development and influence (family, peers, school,
  etc.). Four domains of attention/intervention
• Adolescent
• Parent(s)
• Family
• Extra-familial

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Pieces of MDFT approach

• Problems are multidimensional
• Multidimensional problems require
  multi-component, multi-focus interventions
• All those domains/systems may help the adolescent
  to overcome his or her problems

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Howard, I would include here some slides
re. Comment 3 by reviewers power, length of
follow-upAnd also some slides on the parent
study, showing proficiency in implementation
research
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Wrapping up

• Our collaboration is real
• Much preliminary work has been done
• Proposal fits priorities of the Call
• The Netherlands excellent site for testing MDFT
  outside the USA
• We have addressed the comments by the reviewers
  (who were positive very positive)
• Added value (see last slide)

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Conditions favoring a collaborative
implementation trial of MDFT in the Netherlands

• Strong commitment from the two centers in The
  Hague management, trained supervisor, team of
  dedicated therapists eagerly waiting to be
  trained
• Strong collaboration between the two centers
• Treatment philosophy similar to that of CTRADA.
  Treatment As Usual can be standardized.

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Conditions favoring a collaborative
implementation trial of MDFT in the Netherlands

• Regular flow of adolescents and parents/families
  demanding treatment (from all over the country
  present waiting list will be made undone shortly)
• Parents willing to join treatment
• Training materials ready (no translation needed)
• National Government in favor (might donate
  additional funds)

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FINALLY Added value of a NIDA ZonMw trial

• Opportunity to establish the effectiveness of
  MDFT outside the USA
• Broader experience with practical applicability
  (implementation) of MDFT, across more settings
  and in more ethnic groups (in the Netherlands
  including Mediterranean and Caribbean youth 30
  of clients)
• In the Netherlands, badly needed addition to
  treatment repertoire
• Emphasis on multidimensionality of problem
  behaviors in youth
• Much appreciated collaboration between research
  groups from different settings