Stress Management, Psychosocial Therapy

by National Institute of Health

(Page 6 of 6)

SSRIs may have particular appeal for use in AOD users, because these agents are easy to take (require only one daily dose), have no abuse potential, and are relatively safe when used in excessive doses or combined with AODs. Higley and colleagues examined the efficacy of the SSRI sertraline in mitigating the effects of stress on alcohol consumption in nonhuman primates. In that study, sertraline reduced alcohol consumption and aggressiveness in animals that had been exposed to stress before being returned to their home cages, presumably by increasing serotonin activity in the central nervous system. Under conditions of extreme stress, however, sertraline became ineffective and the animals resumed high drinking levels.

Based on those observations, the investigators suggested that relapse to drinking may be most likely to occur during periods of stress and that SSRIs may not be able to prevent such a relapse. Under nonstress conditions, including following a stressful situation, however, SSRIs, such as sertraline, may be effective in reducing alcohol consumption. Thus, pharmacological treatment with SSRIs may be most effective in conjunction with other nonpharmacological therapies, such as cognitive-behavioral therapy, for improving or preventing stress. Interestingly, in a study among patients with posttraumatic stress disorder (PTSD), patients treated with the SSRI fluoxetine (Prozac®) showed improvement on a scale designed to measure stress resilience.

The opioid antagonist naltrexone also has been shown to be effective in preventing relapse in detoxified alcoholics. These effects result at least in part from the agent's effect on reward pathways. In animal models opioid antagonists also have been shown to prevent increased drinking in animals that had experienced a stressful situation, suggesting that these medications also may influence the stress-drinking correlation. However, researchers have not yet studied systematically this potential role of naltrexone.

Psychosocial Therapy

If stress, the vulnerability to stress, and the presence or absence of protective factors are important mediators in the initiation of and relapse to AOD use, then specific treatment approaches targeting these areas might play a central role in the prevention and treatment of AOD use. Indeed, most AOD treatment approaches currently used contain social skills training and problem-solving components. This treatment philosophy is based on the classic relapse prevention model proposed by Marlatt and Gordon, which features such important stress management components as cognitive restructuring, coping skills, and problem-solving skills. For example, cognitive restructuring teaches people to interpret events, attitudes, and feelings in a rational way and to respond constructively to a crisis or stressful situation. Similarly, problemsolving skills training teaches patients to analyze problem situations and act constructively rather than impulsively. Finally, most treatment programs recognize the importance of social support systems in managing stress and therefore encourage patients to attend such self-help groups as Alcoholics Anonymous and Narcotics Anonymous and/or to recruit support from friends and family.

Although such a stress management approach has intuitive appeal, researchers have not thoroughly explored and evaluated this approach experimentally. For example, whereas numerous studies have demonstrated the usefulness of relapseprevention protocols using these and other strategies in the treatment of AOD abuse, weight loss, and smoking cessation, many of those studies could not assess the specific contributions of the stress-reduction techniques to recovery.

A few studies, however, have attempted to identify the effective components of therapy. For example, in one study of 130 AOD abusers, patients who received supplemental skills training and social network development after treatment showed greater improvement in several areas (avoidance of AOD use; problem-solving; and coping with stress, relapse, and social interaction) compared with a control group. In a study of coping responses and relapse in adolescents, lower stress management abilities (fewer problem-solving and/or coping strategies and less self-assurance) were associated with a higher risk of relapse. In another study of relapse among adolescent AOD users, self-esteem, high quality of support, and social support satisfaction - all of which are likely to improve stress vulnerability - were crucial determinants of a subject's outcome at 6 months.

In summary, stress management techniques are an integral part of most AOD abuse treatment programs, although it is difficult to specifically ascertain the value of these techniques. Studies that have attempted to examine this issue, however, have demonstrated that measures both to enhance healthy coping strategies and problem-solving techniques and to maximize social support systems are important components of successful treatment.

Summary

The relationship between stress and AOD use is complex. Most likely, however, stress and the body's response to it do play a role in the vulnerability to initial AOD use, initiation of AOD abuse treatment, and relapse in recovering AOD users. This relationship probably is mediated, at least in part, by common neurochemical systems, such as the serotonin, dopamine, and opiate peptide systems, as well as the HPA axis. Further exploration of these connections should lead to important pharmacological developments in the prevention and treatment of AOD abuse, including alcohol use disorders.

Effective psychosocial approaches to AOD abuse treatment all contain elements aimed at reducing and managing stress. It is difficult, however, to separate the effects of such specific stress-reduction techniques from the effects of other effective treatment components. Nevertheless, studies indicate that treatment techniques that foster coping skills, problem-solving skills, and social support play a pivotal role in successful treatment. In the future, individualized treatment approaches that emphasize stress management strategies in those patients in whom a clear connection between stress and relapse exists will become particularly important.

About the Author

NIH is the nation's medical research agency - making important medical discoveries that improve health and save lives. The National Institutes of Health (NIH), a part of the U.S. Department of Health and Human Services, is the primary Federal agency for conducting and supporting medical research.