انگیختگی ادراکی ایجاد حافظه های جدید اپیزودیک را بهبود می بخشد

The present study sought to examine the interactive effects of court-mandated (CM) treatment and antisocial personality disorder (ASPD) on treatment dropout among 236 inner-city male substance users receiving residential substance abuse treatment. Of the 236 participants, 39.4% (n = 93) met criteria for ASPD and 72.5% (n = 171) were mandated to treatment through a pretrial release-to-treatment program. Results indicated a significant interaction between ASPD and CM status, such that patients with ASPD who were voluntarily receiving treatment were significantly more likely to drop out of treatment than each of the other groups. Subsequent discrete time survival analyses to predict days until dropout, using Cox proportional hazards regression, indicated similar findings, with patients with ASPD who were voluntarily receiving treatment completing fewer days of treatment than each of the other groups. These findings suggest the effectiveness of the court system in retaining patients with ASPD, as well as the role of ASPD in predicting treatment dropout for individuals who are in treatment voluntarily. Implications, including the potential value of the early implementation of specialized interventions aimed at improving adherence for patients with ASPD who are receiving treatment voluntarily, are discussed.

Antisocial personality disorder (ASPD) is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as a pervasive pattern of disregard for and violation of the rights of others, and is characterized by chronic deviant behavior, deceitfulness, and lack of conscience ( American Psychiatric Association [APA], 1994). Although ASPD is present in only about 3–4% of the general population ( Kessler et al., 1994), it is highly pervasive among individuals with substance use disorder. Approximately 90% of individuals diagnosed with ASPD are concomitant substance abusers ( Forrest, 1991), and rates of ASPD are upward of 40–50% in drug treatment samples ( Brooner et al., 1997, Messina et al., 1999 and Satel, 1999). This dual diagnosis is especially problematic due to its association with a number of negative outcomes, such as aggressive and violent behavior ( Brooner et al., 1992 and Cottler et al., 1995), serious criminal activity (e.g., use of a weapon, felony arrests; Abrams, 1989, Brooner et al., 1992 and Cottler et al., 1995), elevated risk of contracting and transmitting HIV ( Brooner et al., 1993 and Compton et al., 1995), and illicit drug use ( Compton et al., 2003, King et al., 2001 and Nurco et al., 1991). Recent research has begun to focus on the ability of traditional substance use treatment settings to retain patients with both ASPD and substance dependence, as treatment length is one of the most consistent predictors of successful substance use outcomes (Gossop et al., 2002, Martin et al., 2003 and Simpson et al., 1997). There have been a number of studies suggesting that substance users with comorbid ASPD are at an increased risk for treatment dropout and subsequent return to drug use and criminal behavior (e.g., Alterman et al., 1998, Cacciola et al., 1996, Carroll et al., 1993, Greenberg et al., 1994, Kokkevi et al., 1998 and Leal et al., 1994). In particular, some have suggested that substance users with ASPD lack the intrinsic motivation necessary to remain in treatment long enough to achieve full benefits (e.g., Condelli & Hubbard, 1994). However, these findings have not been consistent, with a handful of other studies reporting either success in treating this population or no differences in retention rates for substance users with and without ASPD comorbidity (e.g., Gil et al., 1992, King et al., 2001 and Marlowe et al., 1997). Therefore, the extent and the circumstance in which ASPD is a risk factor for poor substance use treatment outcomes remain unclear. One variable that may affect treatment retention rates for patients with ASPD is whether the patient is receiving treatment voluntarily or the patient is receiving treatment through the court system. As one example, individuals in pretrial-release-to-treatment programs are offered the opportunity to avoid a criminal record or incarceration contingent upon the successful completion of a substance use treatment program (Young, Fluellen, & Belenko, 2004). Overall, empirical evidence suggests that these programs are effective in retaining patients in treatment, reducing substance use, and reducing rates of recidivism, compared to criminal offenders not mandated to court and those mandated to programs such as probation and drug court (Harrell, 1998, Harrell & Cavanaugh, 1995, Young, 2002, Young & Belenko, 2002 and Young et al., 2004). For instance, patients in a pretrial program in Brooklyn, NY—the Drug Treatment Alternative to Prison (DTAP) program—were compared to control offenders and patients mandated to treatment through parole, probation, and drug court programs. Findings indicated that patients on DTAP had rates of retention higher than those of the other groups at both 6-month and 12-month postadmission follow-ups (Young, 2002 and Young & Belenko, 2002). Furthermore, a follow-up study examining the effectiveness of DTAP reported that criminal recidivism among DTAP participants was substantially below that of a matched comparison group of offenders who were mandated to treatment from conventional criminal justice sources (Young et al., 2004). In considering the effects of pretrial-release-to-treatment programs on individuals with ASPD, one study examining treatment outcome in a group of court-mandated (CM) substance users found that comorbid ASPD was not associated with treatment dropout, and that this group fared equally well compared to CM/non-ASPD patients in terms of reduced drug use and recidivism rates (Messina et al., 1999), suggesting the feasibility of CM programs in retaining substance-abusing clients with ASPD in treatment. Based on suggestive yet mixed findings separately suggesting the potential relevance of ASPD status and the role of the court system in understanding substance use treatment dropout, further research considering the interaction of these variables may be useful. Specifically, given the knowledge that patients with ASPD are at an increased risk for treatment dropout and that utilizing the court system to retain substance-using patients appears effective, it is important to understand whether the court system improves retention rates specific to patients with ASPD. Evidence from the Messina et al. (1999) study suggests that patients with ASPD respond well to CM treatment. However, a voluntary treatment comparison group was not included in the study. This omission is important because it precludes comparison with ASPD drug users receiving treatment on a voluntary basis, who may be at a heightened risk for treatment dropout in the absence of treatments with clear contingencies for remaining in treatment (Brooner et al., 1998, Messina et al., 2003 and Silverman et al., 1998). Thus, this study attempts to further address this issue by examining the interactive effects of CM treatment and ASPD status on treatment dropout among 236 inner-city male substance users receiving residential substance abuse treatment.