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Kathleen M. Carroll, PhD; Bruce J. Rounsaville, MD; Lynn T. Gordon, RN, MPA; Charla Nich, MS; Peter Jatlow, MD; Roseann M. Bisighini; Frank H. Gawin, MD

Arch Gen Psychiatry. 1994;51(3):177-187.

Abstract
Background
At present, there is no consensus regarding effective treatment for cocaine abuse or the most productive roles for the two major forms of treatment, pharmacotherapy and psychotherapy. We conducted the first randomized clinical trial evaluating psychotherapy and pharmacotherapy, alone and in combination, as treatment for ambulatory cocaine abusers.

Methods
One hundred thirty-nine subjects were assigned to one of four conditions offered over a 12-week abstinence initiation trial: relapse prevention plus desipramine hydrochloride, clinical management plus desipramine, relapse prevention plus placebo, and clinical management plus placebo. All treatments were manual-guided, delivered by experienced therapists, and monitored to promote the integrity of both forms of treatment.

Results
First, although all groups showed significant improvement, significant main effects for medication or psychotherapy, or their combination, were not found for treatment retention, reduction in cocaine use, or other outcomes at 12 weeks. Second, baseline severity of cocaine use interacted differently with psychotherapy and pharmacotherapy: higher-severity patients had significantly better outcome when treated with relapse prevention than with clinical management, while desipramine was associated with improved abstinence initiation among lower-severity subjects. Third, desipramine was significantly more effective than placebo in reducing cocaine use over 6, but not 12, weeks of treatment. Fourth, depressed subjects had greater reduction in cocaine use than nondepressed subjects and had better response to relapse prevention than to clinical management.

Conclusion
These findings underscore the significance of heterogeneity among cocaine abusers and the need to develop specialized treatments for clinically distinct subgroups of cocaine abusers.

Author Affiliations
From the Division of Substance Abuse, Departments of Psychiatry (Drs Carroll and Rounsaville and Ms Bisighini) and Laboratory Medicine (Dr Jatlow), Yale University School of Medicine, and the APT Foundation (Mss Gordon and Nich), New Haven, Conn; and Veterans Affairs Medical Center, Brentwood, Calif (Dr Gawin).

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