SECTION 3 Preventive medicine and public health in assessing patient smoking status and encouraging them to the risk of traumatic stress disorder symptoms). Conversely, quit. The five"Amodel, based on research on persuasion cognitive restructuring and exposure therapies effectively and the health belief model, involves these five steps reduce symptoms of PTSD and prevent relapse. l. Ask all patients about their current smoking status. he same 2. Advise smoking patients to quit. Provide feedbac principles as CISD and involve providing survivors with the role of smoking in causing or exacerbatir m information about resources and with opportunities to share current health concerns, as well as personalized tion about the benefits of however, such approaches either have no beneficial effects or 3. Assess their smoking and related health status may be harmful because the suicidal act is glorified, inspiring 4. Assist patients in their quit attempts. Refer them for psy- suicidal thoughts in participants and copycat behavior. 4 hosocial treatment, or discuss pharmacologic treatment Effective treatments for substance dependence include contingency management and social network and family 5. Arrange a follow-up appointment in the next 3 months models. Contingency management( CM)models operate on the premise that drug use is highly reinforcing and that moti The five A"program has been shown to be effective for vation for abstinence can be increased when abstinence and motivating patients to quit smoking"(see Box 15-2 articipation in non-drug-related activities are reinforced CM interventions use a variety of reinforcements, including vouchers with monetary value that can be exchanged for 2. Longer-Term Interventions goods and services, retail items/gift certificates, and for heroin users,take-home methadone doses. Although CM is most Consistent with the finding that insecure attachment is asso- effective for promoting drug abstinence when reinforcement ed is present(with high rates of relapse once the reinforcement interventions that help to facilitate maternal responsiveness is removed), it does seem to be an effective approach for and expression of positive affect, as well as teach effective improving compliance(counseling session attendance; taking renting skills to reduce child abuse and neglect, are likel medication as prescribed) during treatment, which may o enhance resilience of at-risk children(e. g, impoverished translate into longer-term posttreatment benefits parents, teenage mother). School-based and community Social network and family models are rooted in research based programs that encourage prosocial behavior, foster showing that social support is critical for increasing the like expression of positive affect, and teach empathy and cogni lihood of treatment entry and engagement, abstinence, and tive skills for effectively regulating negative emotions as well sustained recovery. In addition to interventions that focus or as problem-solving skills have been useful for improving involving drug-free family members and significant others eneral mental health and substance use. Programs that in treatment, self-help groups(e.g, Alcoholics Anonymous, address substance use and other risky behaviors teach skills Narcotics Anony mous, Rational Recovery) are also effective that are also effective for increasing resilience and preventing for improving substance use outcomes mental health disorders. 2 F. Medical/Pharmacologic Interventions disorders. CBT focuses on restructuring maladaptive cogni tion and teaching effective strategies for coping with stress. Pharmacotherapies, particularly selective serotonin reuptake In addition, it also identifies thoughts, feelings, and behav- inhibitors(SSRIs)and serotonin-norepinephrine reuptake iors(triggers) that maintain substance use and teaches strate- inhibitors (SNRIs), are often used for the treatment of gies for coping with triggers(people, places, things, thoughts, anxiety and depression with the goal of reducing symptoms feelings). Exposure may be used as part of CBr to foster and improving overall quality of life. However, research sug- extinction of the learned association between environmental gests that the effectiveness of SSRis and benzodiazepines for ues and fear as well as between triggers and drug craving. treating anxiety are limited to the period of medication are effec: suggests that cognitive and behavioral approaches administration, with patients experiencing a relapse of e for preventing a first depressive episode, for symptoms on cessation. Similarly, pharmacotherapy is less ncouraging drug abstinence during treatment, and for pro- effective than cognitive therapy for preventing relapse after moting sustained abstinence. Also, patients show continued medication discontinuation, although relapse appears to be reductions in substance use for as long as I year after CBt reduced if(1)the patient experiences full remission of symp ends. For anxiety, CBT is more effective than pharmaco- toms(partial remission of symptoms increases the risk of therapy for producing symptom reduction and preventing relapse after discontinuing medication) and(2)medication relapse. Research on the relative effectiveness of psychos- is continued for at least 4 to 6 months after remission of for ubstance use shows that both are equally effective when However, research does suggest that the increased risk of Ised as monotherapy and that their combination offers no suicide associated with pharmacologic treatment can be advantage mitigated by the addition of CBT After exposure to trauma, intervening with individuals Pharmacologic interventions for substance use(Table exhibiting symptoms of acute stress disorder(ASD)might 21-4)either encourage abstinence initiation or prevent help to forestall the development of posttraumatic stress relapse through the following: disorder (PTSD). However, research on critical incidents stress debriefing( CISD), a popular brief intervention for Blocking the effects of drugs and thereby reducing their individuals exposed to trauma, has been mixed; some studies euphoric effects; such drugs will also instigate the onset find it helpful, and others find it is iatrogenic (i.e, increasing of withdrawal symptoms (i.e, antagonists