Clinical insight level predicts successful quit or control attempts during the first three months of outpatient addiction treatment
Introduction
Addiction is a dynamic process characterized by an impaired control over use of reinforcing substances or behaviors, its persistence despite negative consequences and repeated relapses after attempts to reduce or stop (American Psychiatric Association, 2013, Auriacombe et al., 2018, Hasin et al., 2013, Maisto et al., 2016, Witkiewitz and Marlatt, 2007). Recent reviews and meta-analysis highlight that abstinence is not the only efficient approach in the treatment of addiction and “controlled” / “low risk” use is also a viable option with comparable improvement in social functioning and use reduction (Aubin and Daeppen, 2013, Henssler et al., 2021).
In the perspective that addiction is a chronic disease, its treatment is a process over several years (Auriacombe et al., 2016, Fatseas and Auriacombe, 2009, O'Brien, 2008). One of the most important predictive factors for good outcome is patient retention in treatment (Carruzzo et al., 2009). The onset of treatment is a critical period during which the risk of discontinuation is frequent. Relapse rate is very high over the first three months after quit attempts (e.g., (Nalpas and Boulze-Launay, 2018; Piñeiro et al., 2017; Snelleman et al., 2015)). Some factors at treatment initiation are known to increase relapse risk such as craving, addiction severity or psychiatric comorbidities (e.g., (Cavicchioli et al., 2020; Serre et al., 2015; Sinha et al., 2006; Sliedrecht et al., 2019; Tiet et al., 2007)). In addition, individual lack of perception of one’s own addiction, that refers to an individual’s insight level, may compromise treatment efficiency and increase relapse risk.
Insight is a multidimensional mental state defined as “the capability of psychiatric patients to recognize and accept that they are suffering from a mental illness” (Thirioux et al., 2020). Clinical insight, one sub-dimension of insight, is the capability to recognize one’s mental illness, its symptoms and consequences, and to consent to related medical care (Amador et al., 1991, David, 1990, Jaafari and Marková, 2011, Marková and Berrios, 1995, Thirioux et al., 2020).
Individuals with low insight into addiction are known to overestimate their capacity to quit by themselves or control their use (Rinn et al., 2002). Several studies showed that people with lower insight self-reported less use severity and consequences (Kim et al., 2007, Lyu et al., 2017, Maremmani et al., 2012, Schuckit et al., 2020). Interestingly, impaired clinical insight may also contribute to a lack of willingness and/or attempt to quit, and the main barrier to seeking treatment (Probst et al., 2015).
Lack of clinical insight was identified by clinical staff as an important risk factor for re-hospitalization of patients with substance use disorders (Kent and Yellowlees, 1994), probably due to higher rates of relapse. To our knowledge, only four prospective studies have examined the role of clinical insight in relapse, abstinence or recovery, all concerning alcohol addiction. In one study, lower clinical insight (before and after hospitalization) predicted less probability to be “recovered" or "improved" at 2 years (Willems et al., 1973). In another study, patients with lower clinical insight (Hanil Alcohol Insight Scale (HAIS)) upon discharge remained abstinent for less time and had fewer cumulative months of abstinence over the first year than those with higher clinical insight (Kim et al., 2007). In the third study, subjects with low clinical insight (HAIS) and high-level of implicit association for alcohol were more likely to relapse within the first month after hospitalization compared to those with good insight (Dandaba et al., 2020b). In the last study, lower clinical insight (HAIS) at baseline was associated with relapse (Shen et al., 2021). These studies suggest that the level of clinical insight may be involved in relapse, abstinence and prognosis of individuals with alcohol addiction. More studies are needed to confirm these results and to know if they are generalizable to other addictions. Moreover, the mechanisms underlying this association remain to be explored. Potential hypothesis could be that subjects with lower clinical insight may have more difficulties to cope with craving, due to lower cognitive and metacognitive abilities, or more automatic behaviors, which may prevent them to successfully control their use (Ceceli et al., 2022, David et al., 2012, Flaudias et al., 2019).
The currently available literature has mainly focused on the association of insight with the ability to remain abstinent from alcohol among subjects that are already abstinent. According to the fact that lower clinical insight is a known barrier to initiate treatment, we may also question whether insight might play a role in the success of individuals to initiate abstinence or regain control in use.
We hypothesized that people with lower clinical insight had a lower probability to succeed in becoming abstinent during treatment. Our main objective was to examine, based on prospective analyses, the correlation between baseline clinical insight and successful attempts to quit during the first 3 months of outpatient addiction treatment.
Section snippets
Procedure of the ADDICTAQUI cohort
Data were extracted from the Addiction Aquitaine Cohort (ADDICTAQUI) (Auriacombe, 2019). ADDICTAQUI is a longitudinal naturalistic cohort which included participants in outpatient addiction treatment centers over the age of 18 that met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5) (American Psychiatric Association, 2013) criteria for at least one substance use disorder or behavioral addiction. Non-inclusion criteria were severe cognitive impairment or
Sample description
During the inclusion period, 115 subjects completed a baseline (T0) HAIS-m, of which 58 completed the follow-up T1 interview, 4 were excluded due to missing data at HAIS-m. This latter group of 54 subjects is our study sample and was included in the analyses. As described in Table 1, the participants were primarily male (57.4%), with an average age of 40.9 (SD = 13.4) years old. Average study level was 13.4 years (SD = 3.1). Large majority of participants (90.7%, n = 49) received treatment
Discussion
Our main objective was to examine the correlation between baseline clinical insight level and successful attempts to quit or regain control in use during the first 3 months of outpatient addiction treatment. Adjusting for sociodemographic, addiction type and severity, our results show, for the first time, that lower clinical insight at treatment initiation was associated with a higher risk to not succeed in attempts to quit/control use in the first 3 months of outpatient addiction treatment.
The
Conclusion
This study explored the prospective association between baseline clinical insight at treatment initiation and self-report of success in quit /control attempts after three months of treatment in a sample of individuals with various addictions. Interestingly, individuals with lower clinical insight were less likely to self-report a success, even after adjustment for addiction severity, sociodemographic and comorbidities. This was not the case in individuals with a similar baseline severity but a
Funding source
Nouvelle-Aquitaine region [funding no. 2017-1R30114-00013238].
CRediT authorship contribution statement
Lambert L.: Conceptualization, Data collection, Analyses, Writing – original draft, Manuscript reviewing. Serre F.: Conceptualization, Data collection, Funding acquisition, Supervision, Manuscript reviewing. Auriacombe M.: Conceptualization, Funding acquisition, Manuscript reviewing, Supervision. Thirioux B.: Manuscript reviewing, Funding acquisition. Jaafari N.: Manuscript reviewing, Funding acquisition. All authors have approved the current version of the manuscript.
Declarations of interest
None.
Acknowledgements
The authors are grateful to medical staff of the Bordeaux recruitment site of ADDICTAQUI cohort for facilitating recruitment of participants (Drs., Saman Sarram, Jacques Dubernet, Bérengère Gelot, Victor Harly, Louise Jakubiec, Raphaëlle Cardon, Matthieu Boudard). A very special thanks to all the interviewers of the ADDICTAQUI Bordeaux site team 2019-2021 (Jean-Marc Alexandre, Charlotte Kervran, Sarah Moriceau, Lucie Fournet, Marion Desset, Thibaut Gellé, Kelly Hyves, Emmanuelle Baillet, Léa
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2022, Transplantation ReviewsCitation Excerpt :Impaired insight, an underdeveloped grasp of a problem, its risks, and treatment need [25,48], associates with ALD outcomes [49]. Low receptivity to psychiatric matters is often central to liver disease pathophysiology (i.e., AUD denial and treatment refusal leading to heavy drinking and liver injury) and can impacts LT candidates' completion of SUD treatment [50]. Patients may complain to medicine and surgery about psychiatric and SUD referrals.