Psychology of Addictive Behaviors In the public domain

2008, Vol. 22, No. 1, 47–57 DOI: 10.1037/0893-164X.22.1.47

Comorbidity of Substance Dependence and Depression: Role of Life Stress

and Self-Efficacy in Sustaining Abstinence

Susan R. Tate Johnny Wu

Veterans Affairs San Diego Healthcare System and University University of California, San Diego
of California, San Diego

John R. McQuaid Kevin Cummins

Veterans Affairs San Diego Healthcare System and University University of California, San Diego
of California, San Diego

Chris Shriver and Marketa Krenek Sandra A. Brown

Veterans Affairs San Diego Healthcare System Veterans Affairs San Diego Healthcare System and University
of California, San Diego
The authors examined life stress and self-efficacy as predictors of time to relapse for 113 adults with
comorbid major depressive disorder and alcohol and/or substance dependence in a randomized clinical
trial comparing 2 psychotherapy interventions (integrated cognitive– behavioral therapy and 12-step
facilitation therapy). Life stress, self-efficacy, and substance use were assessed at treatment entry, 12
weeks (mid-treatment), and 24 weeks (end of treatment). Time to relapse was defined as the number of
days from treatment initiation until first alcohol and/or drug use. Half of the sample relapsed within the
study period of 24 weeks. There was no significant difference between treatment groups. Individuals
experiencing life stressors were more likely to relapse early than those not experiencing life stressors.
Lower self-efficacy also predicted earlier relapse. Chronic stress levels and self-efficacy were stable
across time for most individuals. In contrast, acute stress events occurred at differing times, and survival
analyses provided evidence of heightened relapse risk in the month following acute stressors. The
interaction of self-efficacy and life stress was not significant. The results highlight the significance of life
stress and self-efficacy as predictors of early relapse.

Keywords: alcohol dependence, substance dependence, life stress, self-efficacy, survival analysis

Given the high prevalence of comorbid substance use and de-
pressive disorders (Regier et al., 1990), it is important to under-
Susan R. Tate and John R. McQuaid, Veterans Affairs San Diego
Healthcare System, and Department of Psychiatry, University of Califor-
nia, San Diego; Johnny Wu, Department of Psychology, University of
California, San Diego; Kevin Cummins, Department of Psychology and
Department of Psychiatry, University of California, San Diego; Chris
Shriver and Marketa Krenek, Veterans Affairs San Diego Healthcare
System; Sandra A. Brown, Veterans Affairs San Diego Healthcare System,
and Department of Psychology and Department of Psychiatry, University
of California, San Diego.
Johnny Wu is now at the Department of Psychology, University of
Washington; Marketa Krenek is now at the Department of Psychology
Syracuse University.
This research was supported by a Veterans Affairs Medical Research
Merit Review Grant awarded to Sandra A. Brown and a Veterans Affairs
Medical Research Merit Review Entry Program Grant to Susan R. Tate.
This study was completed as an honors thesis in the psychology honors
program by Johnny Wu at University of California, San Diego, supervised
by Susan R. Tate and Sandra A. Brown.
Correspondence concerning this article should be addressed to Sandra
A. Brown, Department of Psychology (0109), University of California, San
Diego, 9500 Gilman Drive, La Jolla, CA 92093-0109. E-mail:
sanbrown@ucsd.edu
stand factors associated with treatment outcomes for individuals
with these concomitant disorders. Individuals diagnosed with both
depression and alcohol dependence have exhibited poorer drinking
outcomes than alcohol-dependent individuals without depression
(Greenfield et al., 1998). The presence of comorbid depression has
also been shown to predict earlier relapse to alcohol and drug use
among adolescents with alcohol or substance dependence (Corne-
lius et al., 2004). Higher levels of depressive symptoms have also
predicted earlier treatment attrition, greater urges to use sub-
stances, and alcohol relapse (R. A. Brown et al., 1998). These
findings highlight challenges associated with addiction treatment
in the context of depressive disorders. Findings are mixed, how-
ever, with a number of studies not detecting different addiction
outcomes for substance-dependent adults with and without depres-
sion (Carroll, Nich, & Rounsaville, 1995; Charney, Paraherakis,
Negrete, & Gill, 1998; O’Sullivan et al., 1988; Sellman & Joyce,
1996; Tate, Brown, Unrod, & Ramo, 2004).
A significant complication for dual-diagnosis treatment is the
potential for alcohol or drug use to undermine psychotherapeutic
and pharmacological intervention efforts for both disorders. Alco-
hol and drug use can cause or exacerbate depression symptoms,
either through direct effects (e.g., alcohol, sedatives) or during
withdrawal states (e.g., cocaine, amphetamines). Substance use
can also compromise the effectiveness of pharmacotherapy inter-

47
48 TATE ET AL.
ventions by causing serious side effects, potentiating effects of
some psychotropic medications (thereby increasing risk of over-
dose), and decreasing adherence to medication regimens (Catz,
Heckman, Kochman, & DiMarco, 2001; National Institute on
Alcohol Abuse and Alcoholism, 2005). Finally, alcohol and sub-
stance use are associated with increases in suicidal ideation and
suicide attempts, shifting intervention efforts to crisis management
rather than other therapeutic goals (e.g., Claassen et al., 2007;
Goldstein & Levitt, 2006; Shen et al., 2006).
In addition to depression symptoms, numerous studies have
demonstrated a relationship between life stress and worse post-
treatment drinking outcomes (Billings & Moos, 1983; S. A.
Brown, Vik, Patterson, Grant, & Schuckit, 1995; Canton et al.,
1988; Vuchinich & Tucker, 1996). The predictive quality of life
stressors also extends to posttreatment outcomes for cocaine (Mc-
Mahon, 2001) and opiate users (Grey, Osborn, & Reznikoff,
1986). The negative impact of life stress may be particularly
relevant for substance-dependent individuals with mood disorders,
as life stress has also been associated with recurrence of depressive
episodes, depression treatment outcomes, and attrition (e.g., Mon-
roe, Kupfer, & Frank, 1992; Monroe, Roberts, Kupfer, & Frank,
1996). Indeed, some research supports the stress-generation hy-
pothesis, which proposes that individuals with depression generate
additional stressors as a result of their symptoms, behaviors, and
social interactions (Hammen, 1991; Monroe, Slavich, Torres, &
Gotlib, 2007), thus heightening risk of substance relapse. Evalu-
ating the impact of life stress on outcomes is complex, however,
given fluctuations in stress over time. In addition, the temporal
nature of a stressor may affect risk of relapse. Stressors differ in
their temporal characteristics, with some stressors persisting for
extended periods, while other stressors occur on a specific date and
are more short lived (Shiffman, 1989). Although much evidence
has demonstrated a relationship between discrete stressful life
events and substance use, chronic stressors have received much
less attention. Our research has shown, however, that chronic
stressors also increase the risk of resuming posttreatment sub-
stance use (S. A. Brown et al., 1990; Tate, McQuaid, & Brown,
2005).
Self-efficacy is another personal characteristic that changes over
time (Finney, Noyes, Coutts, & Moos, 1998; Rychtarik, Prue,
Rapp, & King, 1992). Thus, the relationship between self-efficacy
and addiction relapse may be most appropriately evaluated in
models that consider such temporal changes. In the context of
substance abuse, self-efficacy is defined as an individual’s belief in
his or her ability to resist the urge to drink or use. Cognitive–
behavioral models of addiction relapse postulate that those with
high self-efficacy in their ability to abstain from alcohol and drugs
are more likely to use coping responses and less likely to drink or
use than those with low self-efficacy. Past research supports this
relationship between self-efficacy and treatment outcomes for al-
cohol (e.g., Greenfield et al., 2000; Rychtarik et al., 1992;
Sitharthan & Kavanagh, 1990), marijuana (e.g., Stephens, Wertz,
& Roffman, 1993), and cocaine (e.g., Avants, Margolin, & Kosten,
1996). Self-efficacy may be particularly important for substance-
dependent individuals with comorbid depression, as depression
may stem, in part, from conditions that lead individuals to believe
that they are not able to successfully execute behaviors required to
manage prospective situations (i.e., low self-efficacy; Bandura,
1982). Consistent with this conceptualization, research has linked
higher levels of depression symptoms to lower self-efficacy
(Haukkala, Uutela, Vartiainen, McAlister, & Knekt, 2000; Kanfer
& Zeiss, 1983). In a dual-diagnosis sample, individuals with
greater psychiatric distress were also more tempted to drink
(Velasquez, Carbonari, & DiClemente, 1999), which highlights the
importance of self-efficacy for those with comorbidity.
Thus far, we have discussed self-efficacy and life stress sepa-
rately. The strength of an individual’s self-efficacy conviction is
proposed to influence persistence in the face of obstacles and
aversive life experiences (Bandura, 1992). Addiction relapse mod-
els suggest that individuals experiencing life stressors may remain
abstinent in part because of their self-efficacy in being able to
resist the urge to drink or use (Witkiewitz & Marlatt, 2004). This
suggests the possibility that life stress and self-efficacy may jointly
affect the relapse process. However, we found no studies exploring
this potential interaction in comorbid samples of substance use–
disordered individuals.
Survival analysis is a technique that evaluates the time it takes
for an event to happen and has been widely used for examining
time to relapse (e.g., Brecht, von Mayrhauser, & Anglin, 2000;
Cornelius et al., 2004; Greenfield et al., 2000; Jones & McMahon,
1994; Saunders, Baily, Phillips, & Allsop, 1993). All of these
studies, however, used either unchanging predictors (e.g., gender,
ethnicity) or potentially changing variables measured at a single
time point (e.g., intake alcohol expectancies, intake self-efficacy).
Many predictors, including life stress and self-efficacy, are dy-
namic and likely alter risk of relapse over time. Survival analysis
is well suited for analyzing such time-varying predictors (Hosmer
& Lemeshow, 1999; Willett & Singer, 1993; Willett, Singer, &
Martin, 1998). For example, Hillegers et al. (2004) used survival
analyses to examine the relationship between stressful life events
as a time-varying predictor and the subsequent development of
mood disorders in adolescents. Among other applications, Willett
and Singer (1993) provided an example of survival techniques
applied to cocaine relapse (Havassy, Hall, & Wasserman, 1991)
using multiple assessments of mood as a time-varying predictor.
The survivor function depicts the proportions of the sample who
do not experience a given event—in this case, substance use—in
each time period. We employ a Cox (1972) proportional-hazards
model to determine whether time to relapse is influenced by life
stress, self-efficacy, or their interaction. Our study is unique in that
we have a comorbid sample with major depression and alcohol or
substance use disorder, and we have modeled the change in pre-
dictors over time. We hypothesize that (a) severe life stress (both
chronic stressors and discrete life events) will be associated with
shorter survival times and (b) higher self-efficacy will be associ-
ated with longer survival times. In addition to our primary hypoth-
eses, we also test whether the interaction between self-efficacy and
life stress influences time to relapse beyond the unique contribu-
tion of these factors.
Method
Participants
Participants were patients at the Veterans Affairs San Diego
Healthcare System, drawn from sequential referrals to the Sub-
stance Abuse Mental Illness Program, an abstinence-based outpa-
tient dual-diagnosis clinic. Participants were included in the study
 SELF-EFFICACY, STRESS, AND TIME TO RELAPSE
if they met current criteria for Diagnostic and Statistical Manual of
Mental Disorders (4th ed.; DSM–IV; American Psychiatric Asso-
ciation, 1994) major depressive disorder and alcohol, cannabis, or
stimulant dependence with recent substance use (within 3 months
prior to intake) and accepted the program goal of abstinence from
alcohol and drug use. Participants were excluded if they (a) met
criteria for DSM–IV bipolar disorder or any psychotic disorder, (b)
met current criteria for DSM–IV opiate dependence through intra-
venous administration, (c) could not accurately recall events be-
cause of memory deficits, or (d) lived too far away to attend
psychotherapy appointments twice a week. Participants agreed to
(a) randomization to one of two psychotherapy groups; (b) face-
to-face research assessments at intake, mid-treatment (12 weeks),
and end of treatment (24 weeks); and (c) random toxicology
screens. Additionally, all participants received pharmacotherapy
via a standardized Veterans Affairs protocol for major depression
and agreed not to participate in any other formal treatment for
substance dependence or depression during the 24 weeks of treat-
ment, with the exceptions of community 12-step meetings and
residential treatment program required meetings. Ninety percent of
consecutive referrals who met study criteria consented to partici-
pate in the study. Of those who refused consent, 1 person felt the
assessments were overwhelming, 1 person expressed a preference
to receive treatment focused on his comorbid anxiety disorder, and
the remainder refused randomization to treatment condition.
A total of 168 veterans gave informed consent to participate and
were randomized to one of the two interventions. Thirty-two
participants (19.0%) who did not complete their intake assessment
were not included in the analyses: Six did not attend any therapy
sessions (1 moved out of the area, and the others were not able to
be contacted), and 26 participants attended at least one session but
were not responsive to outreach efforts by either therapists or
research staff. The remaining 136 participants were evaluated
throughout treatment. One participant gave informed consent but
refused further study participation at the time of the first research
assessment, and 1 participant was deceased prior to completing
treatment. Twenty-one additional participants (15.0%) were ex-
cluded from analysis because of missing mid-treatment data. The
final sample included 113 individuals, with an average age of 48.9
years (SD ⫽ 7.4). The majority were male (94.7%) and Caucasian
(72.6%) and had completed high school or the equivalent (96.5%).
Most participants met lifetime DSM–IV criteria for alcohol depen-
dence (90.3%), slightly more than half met criteria for stimulant
dependence (54.8%), and 29.2% met criteria for marijuana depen-
dence. Included and excluded cases did not significantly differ on
demographic or dependence characteristics.
Design and Procedure
Participants in this study were enrolled in a randomized clinical
trial comparing integrated cognitive– behavioral therapy (ICBT)
and 12-step facilitation therapy (TSF) for comorbid substance
dependence and depression (S. A. Brown et al., 2006). Both
interventions were delivered in a group format and consisted of
two consecutive 12-week phases. Phase 1 consisted of 1-hr group
sessions that met twice weekly for a total of 24 sessions from
Weeks 1 through 12, and Phase 2 consisted of 1-hr group sessions
that met once a week for a total of 12 sessions from Weeks 13
through 24. ICBT combined the interventions and structure of
49
cognitive– behavioral depression treatment (Muñoz, Ying, Perez-
Stable, & Miranda, 1993) and the cognitive– behavioral coping
skills training of Project MATCH (Kadden et al., 1994). ICBT
focused on altering dysfunctional cognitions, practicing positive
activities, and developing interpersonal communication skills. TSF
consisted of the National Institute on Alcohol Abuse and Alcohol-
ism Project MATCH TSF intervention (Nowinski, Baker, & Car-
roll, 1994), modified to be delivered in a group format rather than
individual sessions. In addition to the study treatment groups,
participants in both interventions also received monthly medica-
tion management appointments with the dual-diagnosis program
psychiatrist, who used standardized Veterans Affairs protocol for
major depressive disorder (e.g., selective serotonin reuptake inhib-
itors and atypical antidepressants).
Within 1 week of obtaining informed consent for study partic-
ipation, a trained research assistant completed a diagnostic assess-
ment using the Composite International Diagnostic Interview
(Robins et al., 1988) to confirm inclusion criteria. Current analyses
are focused on assessments of self-efficacy, life stress, and sub-
stance use conducted at three interview time points: (a) intake, (b)
mid-treatment (Week 12, end of Phase 1), and (c) end of treatment
(Week 24, end of Phase 2).
Measures
Self-efficacy. The 50-item self-report Drug-Taking Confi-
dence Questionnaire (DTCQ; Annis & Martin, 1985) assesses
coping self-efficacy for both alcohol and drug use and is a reliable
and valid indicator of self-efficacy (alcohol sample, ␣ ⫽ .98;
cocaine sample, ␣ ⫽ .98; Sklar, Annis, & Turner, 1997). Reliabil-
ity coefficients were comparable in our sample (intake, ␣ ⫽ .98;
mid-treatment, ␣ ⫽ .98). Participants rated their confidence in
their ability to resist the urge to drink alcohol or use substances on
a 0 –5 scale (0 ⫽ not at all confident to 5 ⫽ very confident) in 50
high-risk relapse situations.
Depression symptoms. The Hamilton Depression Rating Scale
(HDRS; Hamilton, 1960) is a widely used structured clinical
interview that assesses depression symptoms experienced over the
prior week. The HDRS consists of 21 items scored on a 0 – 4 scale,
with demonstrated sensitivity and specificity in alcohol-dependent
populations (Willenbring, 1986). Standards vary, but scores higher
than 20 are considered indicative of clinically depressed patients
(S. A. Brown et al., 1994). We report both mean scores and
percentages above and below the cutoff at mid-treatment.
Life stress. A trained interviewer administered the Psychiatric
Epidemiology Research Interview—Modified (Hirschfield et al.,
1977) at each assessment. This measure is a 133-item stressor
checklist followed by a semistructured interview. For each stressor
reported, the interviewer probed for a detailed description of the
experience, including date of occurrence, context, duration, con-
sequences, and proximity to substance use. The interviewer then
presented this information to a panel of at least two raters who had
achieved adequate reliability. The panel rated stressors according
to the objective rating criteria of the Bedford College Life Events
and Difficulties Schedule (G. W. Brown, Bifulco, Harris, &
Bridge, 1986). Two coinvestigators on the study who had exten-
sive prior experience with this rating system rated stressors and
trained new raters.
50 TATE ET AL.
Following the training, new raters first observed and later par-
ticipated in rating sessions with at least two previously trained
raters, using the actual data from the study, until reliability was
achieved (r ⬎.90). On the basis of the detailed presentation by the
interviewer of each stressor, raters determined whether an occur-
rence qualified as a difficulty (ongoing chronic stressor lasting at
least 4 weeks) or a stressful event (acute stressor with a discrete
onset; G. W. Brown & Harris, 1978). All chronic difficulties and
acute events were rated on the likelihood that the stressor would
seriously threaten an individual’s personal or social well-being
(Dohrenwend & Dohrenwend, 1974). Raters classified reported
stressors (both chronic difficulties and acute events) as severe,
nonsevere, or not posing adequate objective threat to warrant
rating as a stressor on the basis of the standardized Bedford
College Life Events and Difficulties Schedule manual (covering
516 pages of stressor examples and ratings). Because life stress can
be the result of recent substance use (rather than preceding sub-
stance use), raters also coded whether each stressor was a result of
recent substance use. Substance-induced stressors were excluded
from analyses. In addition, we excluded health stressors, because
prior research has conceptualized health problems as motivating
abstinence rather than relapse, as is the case for other stressors
(Monti et al., 1999; Smith, Hodgson, Bridgeman, & Shepherd,
2003), and we have demonstrated that health stressors are associ-
ated with reduced likelihood and severity of substance relapse
(e.g., Tate et al., 2005).
Substance use. The Timeline Follow-Back (TLFB; Sobell &
Sobell, 1992) was used to measure all substance use during the 3
months prior to each assessment, including the date of first use
following treatment initiation. We selected the date of first use for our
outcome because of the importance of abstinence in dually diagnosed
samples, noted previously, and because the goals and interventions of
our dual-diagnosis program are abstinence based. The TLFB mea-
sures the type of substance the participant used and the number of
days he or she used drugs as well as the quantity and frequency of
alcohol use (Ehrman & Robbins, 1994; Fals-Stewart, O’Farrell, Frei-
tas, McFarlin, & Rutigliano, 2000). The TLFB has demonstrated
reliability and validity in alcohol- and substance-dependent (Fals-
Stewart et al., 2000; Maisto, Sobell, & Sobell, 1979) and comorbid
(Carey, 1997; Carey, Carey, Maisto, & Henson, 2004) treatment
samples. Additionally, random toxicology screens were used to en-
hance reliability for participants’ self-reports of substance use. Sixty-
six percent of participants had a urine toxicology screen at some time
in Phase 1 or 2, and toxicology results matched TLFB daily self-
reports 82.2% of the time (excluding one toxicology note of an
inadequate sample). Two participants reported alcohol use that was
not detected by the toxicology screen. Five participants denied alcohol
or drug use at any time on the TLFB, but the toxicology screen
indicated use (2 used marijuana, 3 used stimulants). An additional 12
participants reported use and had toxicology results indicating use, but
the dates of use differed for self-report and toxicology results. If either
source (self-report or toxicology) indicated use, use was coded for
analyses. If both sources indicated use, the earlier of the two dates was
used.
Statistical Analysis
Time to relapse was analyzed with a Cox proportional-hazards
model performed with treatment type, self-efficacy, chronic diffi-
culties, and acute events as predictor variables. As previously
noted, survival analysis is widely used to analyze time-to-event
data (e.g., Singer & Willett, 1993), and this methodology has been
extended to handle time-varying covariates (Hosmer & Leme-
show, 1999). All analyses were conducted with STATA statistical
software (Version 9.1; StataCorp., College Station, TX).
The study period was predetermined to last until the end of
treatment for each participant (range ⫽ 24 –27 weeks). Participants
who did not relapse during the study period were fixed-right
censored (Singer & Willett, 1993). A relapse was defined as the
day an individual first used any amount of alcohol or drugs (Jones
& McMahon, 1994). Survival time was measured as the number of
days until initial substance use, beginning from each participant’s
date of treatment initiation. An individual’s substance use status
was coded for each day in our sample (abstinence vs. substance
use). Although we did not anticipate treatment group differences in
outcomes on the basis of our previous analyses (S. A. Brown et al.,
2006), we included treatment groups (ICBT and TSF) in the model
to control for possible differential treatment effects on time to
relapse. We examined self-efficacy as a time-variant covariate
because it was assumed to change over time as a result of treat-
ment. We calculated the item mean self-efficacy score (average
score across DTCQ items) using the intake assessment to predict
survival time in Phase 1 and the mid-treatment scores to predict
survival time in Phase 2.
Two qualitatively distinct stress measures were included in our
model. Chronic difficulties in each stressor domain (e.g., financial,
work, relationship) were scored as none ⫽ 0, nonsevere ⫽ 1, and
severe ⫽ 2. For each phase, difficulty scores in each domain were
summed to provide an index of overall chronic stress. The statis-
tical distribution of the summed indexes was highly skewed, with
the majority of participants scoring 1–2. The limited research
examining difficulties has commonly dichotomized the presence
or absence of a difficulty in samples with lower levels of chronic
difficulties (e.g., Monroe et al., 2007). Given the high levels of
chronic difficulties in our sample, we trichotomized each partici-
pant’s index such that 0 indicated having no difficulties
(summed index ⫽ 0; 13.3% of the sample at intake), 1 indicated
low chronic difficulty levels (summed indexes ⫽ 1–2; 58.4% at
intake), and 2 indicated high chronic difficulty levels (summed
indexes 3–7; 28.3% at intake). Like self-efficacy, chronic dif-
ficulties varied by phase of treatment (i.e., having a score for
both Phase 1 and Phase 2).
The second stress measure included in our model represented
acute events. The acute event measure was dichotomously coded
for absence or presence of an acute event. As our prior research has
documented that substance relapse is related to acute events rated
as severe (S. A. Brown, Vik, Patterson, Grant, & Schuckit, 1995),
we excluded nonsevere events from our analysis. We assumed that
if a relapse was related to an acute event, the relapse would likely
occur within 30 days following the event (Tate, 2000). Thus, a
participant was coded as having exposure to an acute event for a
30-day window following onset of each acute event. Acute events,
like substance use, were not constrained to changing at the mid-
treatment assessment but could change on any day in the time
period.
In summary, survival analysis involves computing the pro-
portion of a group that experiences the event of interest in a
given period—in our study, on a daily basis. The survivor
 SELF-EFFICACY, STRESS, AND TIME TO RELAPSE 51

function is a plot of these daily proportions accumulated across
time. One can compute daily risks to examine whether risk (or
hazard) differs systematically for different groups within a
sample. As described by Willett and Singer (1993), survival
analyses resemble logistic regression models with daily absti-
nence or relapse as the outcome variable and model variables as
predictors accumulated over time. As separate proportions are
calculated for each day, both static predictors (ICBT vs. TSF
treatment group) and time-varying predictors (self-efficacy,
chronic difficulties, acute events) can be included, coded on a
day-to-day basis. Finally, the interaction of life stress and
self-efficacy was evaluated in an extended model. Two inter-
action terms were added to the initial Cox proportional-hazards
model: Self-Efficacy ⫻ Chronic Difficulties and Self-
Efficacy ⫻ Acute Events. Thus, we evaluated the ongoing risk
of relapse given an individual’s treatment (ICBT vs. TSF),
current self-efficacy, acute events, and chronic difficulties and
the interaction of self-efficacy and life stress.
Results
Substance Use Outcomes
Fifty-six (50%) individuals relapsed within the study period, 38
(34%) reported no alcohol or drug use, and 19 (17%) reported no
alcohol and drug use in Phase 1 and were censored because of
missing Phase 2 outcome or predictor variables (i.e., 17 were
missing mid-treatment DTCQs, and 2 were missing Phase 2
TLFBs). There were no significant differences between the 19
censored and 94 remaining cases on any demographic or model
variables. Most individuals who relapsed did so in the first 60 days
(39% in the 1st month, and 30% in the 2nd month). The remaining
31% of the relapses were spread across the remainder of the study
period. Of the 56 relapses, 31 individuals (55%) drank alcohol, 8
(14%) used stimulants (i.e., cocaine or methamphetamine), 8
(14%) used marijuana, and 9 (17%) reported multiple substances
used. All participants who relapsed used a substance for which
they had met diagnostic criteria.
Depression Symptoms and Substance Use
Sample characteristics by relapse status are depicted in Table
1. Although it is not a focus of this study and was not included
in the model, depression was examined as a predictor of relapse
in each phase via logistic regressions. Depression symptoms
were not related to likelihood of relapse in either phase; intake
HDRS predicting relapse in Phase 1, ␹2(1, N ⫽ 113) ⫽ 0.14,
p ⫽ .71, odds ratio ⫽ 1.01; mid-treatment HDRS predicting
relapse in Phase 2, ␹2(1, N ⫽ 49) ⫽ 0.21, p ⫽ .66, odds ratio ⫽
0.99. Depression scores for 45% of the participants were below
the HDRS clinically depressed cutoff of 20 at the mid-treatment
assessment. Remission of depression symptoms at mid-
treatment was not related to relapse in Phase 2, ␹2(1, N ⫽ 49) ⫽
0.002, p ⫽ .97 (22.7% of participants below the cutoff relapsed,
and 22.2% of participants above the cutoff relapsed).
Model Predicting Time to Relapse
The Cox proportional-hazards model was used to predict time to
relapse via treatment type, self-efficacy, chronic difficulties, and
acute events. Covariates were first examined for both proportion-

Table 1
Sample Characteristics by Relapse Status in Phases 1 and 2

Survivors Phase 1 Phase 2 Censoreda

(abstainers) relapse relapse (missing data)
Characteristic (n ⫽ 38) (n ⫽ 45) (n ⫽ 11) (n ⫽ 19)

Treatment (% TSF / % ICBT) 45/55 44/56 46/55 63/37

Mean (SD) depression
Intake 28.6 (12.0) 29.1 (12.4) 25.3 (10.9) 29.3 (12.4)
Mid-treatment 23.2 (13.5) 27.3 (13.3) 21.2 (11.8) 27.5 (10.6)
Depression (% in remission)b
Mid-treatment 45 26 46 20
Mean (SD) self-efficacy
Intake 3.5 (1.0) 3.0 (1.2) 3.6 (1.1) 3.5 (1.2)
Mid-treatment 4.0 (1.0) 3.2 (1.1) 4.0 (0.8) 3.8 (1.5)
Self efficacy (% low/middle/high)
Intake 0/42/58 13/40/47 9/18/73 5/37/58
Mid-treatment 0/24/76 3/47/50 0/18/82 0/50/50
Chronic difficulties (% none/low/high)
Phase 1 16/60/24 13/47/40 0/73/27 16/74/10
Phase 2 21/55/24 16/51/33 0/80/20 6/76/18
Acute events (%)
Phase 1c 24 21 9 11
Phase 2 5 18 36 26

Note. TSF ⫽ twelve-step facilitation therapy; ICBT ⫽ integrated cognitive-behavioral therapy.

a
The censored group was composed of survivors (abstainers) in Phase 1 who were excluded because of missing data in Phase 2. Mid-treatment self-efficacy
scores were available for only 2 participants, and mid-treatment depression scores were available for 10 participants in this group. bHamilton Depression
Rating Scale scores less than 20 were coded as remitted. cNineteen percent of Phase 1 survivors experienced an acute event in the 12 weeks of Phase
1 (across survivor and censored groups). In contrast, 21% of the Phase 1 relapse group experienced an acute life event prior to relapse (M ⫽ 32 days, SD ⫽
24 days, Mdn ⫽ 30 days).
52
ality of hazards and multicollinearity. None of the covariates
significantly interacted with time, and there was no evidence of
multicollinearity.
Time to relapse was predicted by the model, ␹2(4, N ⫽ 113) ⫽
20.44, p ⬍ .001. Type of treatment received was not significantly
associated with risk of substance relapse during treatment in this
comorbid sample (hazard ratio ⫽ 1.13, 95% confidence interval
[CI] ⫽ 0.67–1.92, p ⫽ .65; see Figure 1a). Median survival times
were 148 days for TSF (n ⫽ 54; 48% of the sample) and 122 days
for ICBT (n ⫽ 59; 52% of the sample). Table 1 shows sample
characteristics by relapse status, and Table 2 provides the median
survival days (time to relapse) for participants by treatment, self-
efficacy level, and life stressors (chronic difficulties and acute
events).
Self-Efficacy and Time to Relapse
We assumed self-efficacy would change over time as a result of
treatment, and DTCQ scores increased significantly from the in-
take assessment to the Phase 1 assessment at mid-treatment,
t(84) ⫽ 2.98, p ⫽ .004. Self-efficacy was a significant predictor in
the model ( p ⫽ .003). Each unit increase in the DTCQ decreased
the risk of relapse by a hazard ratio of 0.71 (95% CI ⫽ 0.56 – 0.89).
Figure 1. Estimated survivorship functions following treatment initiation as related to (a) treatment type, (b)
self-efficacy, (c) chronic difficulties, and (d) acute events. TSF ⫽ 12-step facilitation therapy; ICBT ⫽ integrated
cognitive– behavioral therapy.
TATE ET AL.
Table 1 lists DTCQ scores by relapse status for each phase. In
Phase 2, little difference was seen between self-efficacy scores by
relapse status, as those with low self-efficacy relapsed early (see
Figure 1b). As continuous self-efficacy measures (either mean or
total scores) are most common in the research literature (e.g.,
Blume, Schmaling, & Marlatt, 2001; Maisto, Clifford, Long-
abaugh, & Beattie, 2002), analyses were conducted with mean
DTCQ scores. For presentation in the figure, self-efficacy was split
into three levels to simplify display and interpretation (Singer &
Willett, 1993). We produced survival functions by trichotomizing
DTCQ scores: (a) low indicates individuals who had scores of
0.00 –1.66, (b) medium indicates individuals who had scores of
1.67–3.33, and (c) high indicates individuals who had scores of
3.34 –5.00. As shown in Figure 1b, individuals with higher levels
of self-efficacy had longer survival times, and lower self-efficacy
was predictive of relapse early in treatment. Table 2 lists the
median survival days by these categories. Using the trichotomized
categories for the 49 participants who survived to the second
phase, we found that 33 participants (67.3%) did not change
self-efficacy levels (26 started and remained high, 7 started and
remained in the middle category, and no one started and remained
in the low category) and 16 individuals (32.7%) did change self-
 SELF-EFFICACY, STRESS, AND TIME TO RELAPSE 53

Table 2 Both types of stress were significant predictors in the model. For
Survival Characteristics by Treatment, Self-Efficacy, Acute chronic difficulties ( p ⫽ .02), each unit increase in the trichoto-
Events, and Chronic Difficulties mized stress score increased the risk of relapse by a hazard ratio of
1.66 (95% CI ⫽ 1.08 –2.55). Increasing levels of chronic difficul-
Variable No. participantsa Median survival days ties shortened survival time (see Figure 1c). Among the 49 par-
Treatment ticipants who did not relapse in Phase 1, the majority did not
TSFb 54 148 change chronic difficulty levels in Phase 2 (n ⫽ 43). Six individ-
ICBTc 59 122 uals had trichotomized difficulty scores that changed levels at
Self-efficacyd mid-treatment (1 increased and 4 decreased); none of these 6
Low 8 18
Medium 47 85 participants relapsed in Phase 2. In the group with no chronic
High 74 170 difficulties, fewer than half of the cases relapsed; hence, median
Chronic difficulties survival time was beyond our study period (see Table 2).
None 17 — Acute events were also significant in the model ( p ⫽ .009), such
Moderate 69 170
Severe 33 62
that having an acute event increased the risk of relapse by a hazard
Acute events ratio of 2.91 (95% CI ⫽ 1.30 – 6.51). As depicted in Figure 1d,
None 110 — individuals who were under the influence of an acute event (bot-
Any 20 41 tom function), compared to those who were not (top function), had
shorter survival times. Because events are acute experiences oc-
Note. Dashes indicate that fewer than half of the participants relapsed;
hence, median survival time was beyond the study period. TSF ⫽ twelve- curring on a discrete date and we assumed increased risk could
step facilitation therapy; ICBT ⫽ integrated cognitive-behavioral therapy. persist for 30 days (Tate, 2000), individuals fluctuated between
a
Number of participants who were in each condition at least once during functions depending on whether they had experienced an acute
b c
the study period. Twelve-step facilitation therapy. Integrated event within the prior 30 days. Thus, a participant’s risk of relapse
d
cognitive– behavioral therapy. Self-efficacy scores were categorized
into low (0.00 –1.66), medium (1.67–3.33), and high (3.34 –5.00) groups. was depicted by the “absent” curve until the day of an acute event.
As of that date, risk of relapse was depicted by the “present” curve
for the subsequent 30 days, at which time the risk returned to the
decreased risk levels depicted in the absent curve. Five individuals
efficacy levels (4 decreased from the high to the middle level, 1 reported multiple concurring acute events. The median survival
person increased from low to high, and 11 increased from middle time for individuals who did not experience an acute event was
to high). Twenty-four percent of those with unchanged self- beyond our study period (see Table 2).
efficacy relapsed in Phase 2, compared to 25% of participants with Finally, the interactions of chronic difficulties with self-efficacy
decreased self-efficacy and 17% of participants with increased and acute events with self-efficacy were added to the initial model.
self-efficacy. Of note, only 2 participants with low self-efficacy The inclusion of the interaction terms did not significantly improve
did not relapse in Phase 1: One person relapsed in Phase 2 despite the model, ⌬␹2(2, N ⫽ 113) ⫽ 2.60, p ⫽ .27. Interpretation of this
a self-reported increase from low to high self-efficacy at mid- finding is guarded given the limited range of self-efficacy ob-
treatment, and 1 person was censored because of missing Phase 2 served in our sample over the time frame, as the majority of
data. participants with low self-efficacy relapsed early.

Stressors and Time to Relapse

A range of acute events and chronic difficulties was experienced
during the study period. Eighty percent of the total sample had a
chronic financial difficulty during the study, 20% had a chronic
legal difficulty, 20% had a chronic relationship difficulty, 19% had
a chronic housing difficulty, and a single individual had a chronic
work difficulty. Twelve percent of the sample had no chronic
difficulty during the entire study period, 46% had one chronic
difficulty, and 42% had multiple chronic difficulties. The domains
of acute events experienced were as follows: Six percent of the
total sample had a relationship event, 6% had a legal event, 4% had
a housing event, 3% had a death event, 3% had a work event, and
a single individual had a financial event. Table 1 lists the percent-
ages of participants with chronic difficulties and acute events by
relapse status. For the survivor and censored groups, the acute
events percentage reflects participants who experienced an acute
event at any time in Phase 1 (initial 12 weeks) or Phase 2 (sub-
sequent 12 weeks). For the relapse groups, the percentage reflects
participants who experienced an acute event prior to the day of
relapse (Phase 1, M ⫽ 32 days, SD ⫽ 24 days; Phase 2, M ⫽ 122
days, SD ⫽ 31 days).
Discussion
The present study demonstrates significant relationships be-
tween self-efficacy, life stress, and time to relapse during the initial
6 months in treatment for adults with comorbid major depressive
disorder and substance dependence. Consistent with prior alcohol
and drug research (Greenfield et al., 2000; Rychtarik et al., 1992;
Stephens et al., 1993), we found that individuals with higher levels
of self-efficacy maintained abstinence from alcohol and drugs
longer than those with lower levels of self-efficacy. Indeed, a
prominent feature of the survival function (Figure 1b) was the
sharp decline in abstinence seen in those with low self-efficacy in
the early weeks of treatment. The difference in survival between
those with middle and high levels of self-efficacy was much less
pronounced. Our findings vividly portray the heightened risk of
relapse for those with low self-efficacy early in treatment. Spec-
ulation regarding the impact of changes in self-efficacy during
treatment is limited by the fact that almost everyone with low
self-efficacy in our sample relapsed very early in treatment. For-
tunately, a minority of patients fell into the low self-efficacy range.
Future development and testing of intensive interventions aimed at
54 TATE ET AL.
this small portion of high-risk individuals early in treatment may
improve outcomes.
Both chronic and acute stress elevated relapse risk among the
dually diagnosed sample of this study. Those with higher levels of
chronic difficulties relapsed sooner and were at greater risk of
relapsing. High levels of chronic difficulties more than doubled the
risk of relapse compared to individuals with no chronic difficulty.
As chronic stress became increasingly severe and extended across
multiple domains (e.g., financial, legal, and housing), the risk of
relapse increased. Assessing such protracted stress identifies indi-
viduals at high risk for early return to drinking or using. Chronic
life difficulties may contribute to increased likelihood of resuming
substance use by posing more adaptational demands on the indi-
vidual, through protracted exposure to negative affective states
(e.g., depression, anxiety, and worry), or through depletion of
coping resources (e.g., social support and financial resources).
Substance abusers coping with chronic life stress may also be
susceptible to developing a sense of learned helplessness when
managing persistent problems with newly acquired coping skills
that are perceived as more effortful and less immediately effective
than substance use. Many addiction treatment programs incorpo-
rate stress management interventions focused on enhancing coping
skills in high-risk situations. Our findings suggest that the inclu-
sion of stress management interventions may be particularly useful
for comorbid populations, given that the vast majority of our
participants reported experiencing these protracted stressors. Ad-
ditionally, these chronic stressors were stable over time for most of
our sample. In contrast to discrete high-risk situations, which are
often the focus of addiction stress management interventions, the
chronicity of these difficulties highlights the need for coping skills
training specific to managing prolonged stress. In addition to stress
management skills training, interventions targeting specific types
of stressors may be beneficial. For example, the most common
type of difficulty in our study was in the financial domain, and
vocational rehabilitation programs may be helpful for substance
abusers experiencing problems in this domain. Providing other
resources (e.g., legal or relationship counseling) as an adjunct to
treatment may ameliorate or postpone the likelihood of turning to
substance use for individuals coping with these types of chronic
difficulties.
Acute stress events nearly tripled the risk of relapse, signifi-
cantly reducing survival times. This finding supports prior research
demonstrating that these types of stressors are related to poorer
substance use outcomes (S. A. Brown et al., 1995; Canton et al.,
1988; McMahon, 2001; Vuchinich & Tucker, 1996). Despite re-
cent studies using survival analysis to examine the relationship
between stressful life events and depression (Hillegers et al., 2004;
Kendler, Kuhn, & Prescott, 2004), our study is the first to examine
the time-limited relationship between the occurrence of an acute
stress event and relapse within 30 days following the event. For-
tunately, acute events designated as severe on the Bedford College
Life Events and Difficulties Schedule (Bifulco et al. 1989; G. W.
Brown et al., 1986) life stress rating criteria tend to be infrequent
occurrences (e.g., death of a loved one, divorce, eviction, and
incarceration). In contrast to the protracted nature of negative
affect associated with chronic difficulties, the intensity of emo-
tional response to acute events may overwhelm substance abusers,
which suggests distinct coping and intervention needs for comor-
bid populations during addiction treatment. The continuing decline
in the event curve over time suggests that acute events continued
to pose risk throughout the treatment phases we examined. Tem-
porary increases in the frequency of treatment provider contact
(e.g., booster sessions) or stress-specific adjunct interventions,
such as grief counseling, may be of benefit.
Our findings do not support an interaction between self-efficacy
and life stressors in predicting time to relapse. It is possible that we
lacked adequate power to detect an interaction of this magnitude,
or the complexities associated with these variables in our sample
might have limited our ability to detect such moderating effects.
For example, an individual’s self-efficacy estimates may reflect
self-confidence in the context of chronic difficulties, which would
reduce the likelihood of detecting an interaction. Additionally,
since individuals with low self-efficacy relapsed early in our study,
little variation in self-efficacy remained across later time periods,
limiting statistical power for detecting interaction effects over the
study period. Future studies with these variables are needed to
ascertain whether the distributional characteristics of our predictor
variables over time are replicated across settings.
The likelihood of early relapse was similar across the two types
of treatment in our study (ICBT vs. TSF). We had not anticipated
differences on the basis of our prior analyses of substance use
outcomes during treatment (percentage of days abstinent, average
drinks per drinking day) in this sample (S. A. Brown et al., 2006).
The addiction portions of our interventions were based on manuals
developed for Project MATCH, and few differences were detected
between the TSF and cognitive– behavioral coping skills condi-
tions in that study (Project MATCH Research Group, 1998).
Additionally, neither severity of depression symptoms nor depres-
sion remission predicted relapse within our sample of depressed
substance-dependent adults. In some prior studies comparing de-
pressed and nondepressed substance-dependent patients, depres-
sion predicted worse addiction outcomes (e.g., R. A. Brown et al.,
1998; Cornelius et al., 2004; Greenfield et al., 1998). However, our
findings suggest that variance in depression levels above clinical
thresholds is not related to substance relapse. Of note, participants
in our remitted group at mid-treatment were not asymptomatic but
continued to experience symptoms. Depression research has sug-
gested that residual depressive symptoms constitute a “subthresh-
old continuation of an active major depressive episode” (Judd,
Paulus, Zeller, 1999, p. 764; Judd et al., 2000), with heightened
risk for depression relapse. Thus, remitted participants in our
sample are not comparable to nondepressed participants in prior
studies.
Our results should be interpreted in the context of potential
sample and methodological limitations. These findings were based
on a sample of predominantly White men and may not generalize
to other groups. Our sample included substance-dependent indi-
viduals with comorbid depression, and future research is needed to
determine whether the relationships between hypothesized predic-
tors and time to relapse extend to other common types of comor-
bidity (e.g., anxiety disorders, schizophrenia, and bipolar disor-
der). Although our trichotomization of chronic difficulties
appeared to capture qualitative distinctions among stress levels,
more research is needed to validate this classification. In addition,
larger studies should examine whether various domains of stress
(e.g., relationship, financial, housing) differentially affect time to
relapse. Our prior research suggested that relapse was most likely
to occur within 30 days following a acute event, but an individual
 SELF-EFFICACY, STRESS, AND TIME TO RELAPSE
may not be free of negative impact of the event after this period.
More research is needed to examine the length of impact for acute
stress events on subsequent substance use. As mentioned previ-
ously, we selected initial substance use as our outcome variable on
the basis of the abstinence goals of our dual-diagnosis program and
the potential for substance use to negatively impact dual-diagnosis
treatment. However, addiction models posit different predictors for
initial substance use episodes versus protracted use (e.g., Marlatt &
Gordon, 1980), and our prior research has also detected differences
in predictors for initiation versus continuation of posttreatment
substance use (Tate, 2000; Tate et al., 2005). Thus, more studies
are needed to examine the relationship of life stress and self-
efficacy to other important substance outcomes. Finally, it was
beyond the scope of this study to incorporate depression symptoms
in our survival models. Future models including both depression
and addiction outcomes in dual-diagnosis studies are needed.
In summary, the present study highlights the importance of
self-efficacy, chronic difficulties, and acute events on time to
relapse for substance-dependent adults with depression. We have
demonstrated that individuals with comorbid substance depen-
dence and depression are at a heightened risk for relapse and
earlier resumption of substance use when experiencing life stres-
sors, both chronic difficulties and acute events. Consistent with
prior research and theory, self-efficacy was also related to risk of
resuming substance for comorbid adults. As previously noted,
extending abstinence may be particularly important in treatment of
individuals with substance use and other comorbid psychiatric
disorders. Alcohol and substance use can undermine pharmaco-
therapy interventions through decreased medication adherence,
missed appointments, and compromised evaluation of response to
medication. Further, substance relapse early in the course of treat-
ment will likely impair one’s ability to learn and effectively utilize
new skills needed to address either disorder. Our findings clarify
particular areas of vulnerability, aiding clinicians in identifying
individuals at greater risk. Future research is needed to evaluate
whether additional provider contact or targeted intervention efforts
would prove beneficial in ameliorating the heightened risks posed
by life stressors.
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Received September 26, 2006
Revision received May 23, 2007
Accepted May 24, 2007 䡲

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