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Cited by 55Substance Abuse Treatment and OutcomesCannabis and Cannabinoid ResearchAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

Integrated cognitive behavioral therapy for comorbid cannabis use and anxiety disorders: A pilot randomized controlled trial

Open access
Buckner, Julia D., Zvolensky, Michael J., Ecker, Anthony H., Schmidt, Norman B., Lewis, Elizabeth M., Paulus, Daniel J., Lopez-Gamundi, Paula, Crapanzano, Kathleen A. +1 more·2019·Behaviour Research and Therapy
DOI 10.1016/j.brat.2018.10.014PMC PMC6409106
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Abstract

Cannabis use disorder (CUD) is the most common illicit substance use disorder and individuals with CUD have high rates of comorbid anxiety disorders. Comorbidity between CUD and anxiety disorders is of public health relevance given that although motivation enhancement therapy (MET) combined with cognitive-behavioral therapy (CBT) is an efficacious intervention for CUD, outcomes are worse for patients with elevated anxiety. The current study tested the acceptability and efficacy of the integration of a transdiagnostic anxiety CBT (i.e., treatment of patients with any anxiety disorder) with MET-CBT (integrated cannabis and anxiety reduction treatment, or ICART) for CUD compared to MET-CBT alone. Treatment-seeking cannabis users (56.4% male, Mage = 23.2, 63.3% non-Hispanic White) with CUD and at least one comorbid anxiety disorder were randomly assigned to ICART (n = 27) or MET-CBT (n = 28). Patients in the ICART condition attended significantly more treatment sessions than those in the MET-CBT condition. Patients in the ICART condition were more likely to be abstinent post-treatment than those in MET-CBT. Further, treatment produced decreases in cannabis use and related problems. Notably, therapy type did not moderate the impact of treatment on frequency of use and related problems. Together, these data suggest that ICART may be at least as efficacious as a gold-standard psychosocial CUD treatment, MET-CBT, for a difficult-to-treat subpopulation of cannabis users. © 2018 Elsevier Ltd

Integrity signals

Registry

Crossref · 10.1016/j.brat.2018.10.014

Cites

54 of 54 references verified0 citation errors · 0 not checkable

Statistics

5 tests recomputed · 0 with the reported and recomputed p on opposite sides of .05

Claims the paper makes

5 of 26 cited sources checked · 2 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Patients with elevated anxiety have poorer cannabis outcomes after MET-CBT, including more cannabis use and related problems.

    “patients with elevated anxiety report more cannabis use and related problems following treatment (Buckner & Carroll, 2010).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Buckner & Carroll, 2010 source

      The Results (§3.2; page unavailable) link higher pretreatment anxiety to more cannabis-related problems at follow-up among women, but not men. Results (§3.4) link changes in anxiety to later cannabis use and problems, including in the CBT-MET condition. The claim overstates these findings by treating elevated anxiety as a general predictor of both greater use and more problems after CBT-MET. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Premisecitation

    Several anxiety disorders are associated with cannabis use and cannabis use disorder.

    “a variety of anxiety disorders (e.g., social anxiety, generalized anxiety, panic) are related to cannabis use and CUD (e.g., Buckner, Heimberg, Ecker, & Vinci, 2013; Marmorstein, White, Loeber, & Stouthamer-Loeber, 2010; Zvolensky et al., 2006)”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites Buckner, Heimberg, Ecker, & Vinci, 2013 source

      The Relations Between Social Anxiety and Substance-Related Problems section reports an association between social anxiety disorder (SAD) and cannabis dependence and cannabis-related problems. The Uniqueness/Nonspuriousness section notes that panic disorder and generalized anxiety disorder occur among people with cannabis dependence, but says neither remained related to dependence in multivariate analysis. The paper therefore does not support the claim as broadly for the other named disorders, particularly for cannabis use. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • cites Marmorstein, White, Loeber, & Stouthamer-Loeber, 2010 source

      The Results (Risk for Substance-related Problems; page unavailable) link generalized and social anxiety to marijuana-related problems among boys who had used marijuana, although only the social-anxiety association remained significant after adjustment for delinquency. The paper studies anxiety levels and first marijuana-related problems, not diagnosed anxiety disorders or cannabis use disorder; it does not examine panic disorder. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites Zvolensky et al., 2006 source
  • Premisecitation

    Reductions in anxiety during cannabis use disorder treatment are associated with better outcomes.

    “decreases in anxiety during CUD treatment are related to better outcomes (Buckner & Carroll, 2010)”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Buckner & Carroll, 2010 source
  • Findingown data

    Participants in ICART attended significantly more treatment sessions on average than participants in MET-CBT.

    “On average, participants in the ICART condition (M = 8.26, SD = 4.01) attended significantly more treatment sessions than those in the MET-CBT condition (M = 6.00, SD = 3.04), F (1, 534) = 5.57, p = .022, d = .65.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Treatment acceptability, defined as attending more than one therapy session, did not differ significantly between ICART and MET-CBT.

    “Using this metric, acceptability did not significantly differ between conditions: ICART = 88.9%, MET-CBT = 92.9%, χ2 (1, N = 55) = 0.26, p = .609.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 16
  • Classified as probably not a substantial claim. 7

  • May combine two claims.

    Interpretationcitation

    ICART's greater number of attended sessions and higher likelihood of cannabis abstinence indicate greater clinically significant improvement.

    “Thus, our finding that ICART was associated with more treatment sessions attended and greater likelihood of cannabis abstinence is indicative of greater clinically significant improvement in regard to CUD treatment outcome research (Carroll et al., 2006).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Carroll et al., 2006 source

  • May combine two claims.

    Findingown data

    At Week 12, 12% of ICART patients and 0% of MET-CBT patients tested negative for cannabis via urinalysis, a difference that was not statistically significant.

    “Regarding abstinence rates at Week 12 specifically, 12% of patients in the ICART condition tested negative for cannabis use via urinalysis at Week 12, compared to 0% of patients in the MET-CBT condition, χ2 = 3.56, p = .059, Cramer’s V = .26.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    During treatment, 11.1% of ICART patients and 3.6% of MET-CBT patients tested negative for cannabis via urinalysis, a non-significant difference.

    “although 11.1% of patients in the ICART condition tested negative for cannabis use via urinalysis during treatment compared to 3.6% of patients in MET-CBT, this difference was not statistically significant, χ2 = 1.16, p = .282, Cramer’s V = .15.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The treatment conditions did not differ on baseline outcome variables except that ICART reported greater baseline anxiety.

    “Conditions did not differ on baseline levels of outcome variables except that the ICART condition reported greater baseline anxiety, F (1, 54) = 7.36, p = .009, d = .75.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Self-reported cannabis use decreased reliably over time in both MET-CBT and ICART, with no reliable treatment-by-time interaction.

    “there was not a reliable interaction (probability of an interaction = 73.7%) between treatment condition and time (β = −0.55, 95% CI = [−2.33, 1.24]).”
    • Also stated in: § Impact of Treatment · plain
      “Self-reported cannabis use reliably decreased over time in the MET-CBT condition (probability of a non-zero slope = 99.6%; β= −2.19, 95% CBI = [−4.08, −0.52).”
    • Also stated in: § Impact of Treatment · plain
      “cannabis use reliably decreased over time in the ICART condition (probability of a non-zero slope > 99.9%; β= −2.41, 95% CBI = [−3.56, −1.33]).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Cannabis-related problems decreased reliably over time in both MET-CBT and ICART, with no reliable treatment-by-time interaction.

    “There was not a reliable interaction (probability of an interaction = 28.2%) between treatment condition and time (β = 0.10, 95% CI = [−0.24, 0.42]) on cannabis problems.”
    • Also stated in: § Impact of Treatment · plain
      “Cannabis problems reliably decreased over time in the MET-CBT condition (probability of a non-zero slope > 99.9%; β = −0.48, 95% CBI = [−0.72, −0.24]).”
    • Also stated in: § Impact of Treatment · plain
      “cannabis problems reliably decreased over time in the ICART condition (probability of a non-zero slope > 99.9%; β = −0.43, 95% CBI = [−0.73, −0.16]).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Anxiety scores decreased reliably over time in both conditions, and there was a reliable treatment-by-time interaction such that ICART reduced anxiety more than MET-CBT.

    “There was a reliable interaction (probability of an interaction = 97.0%) between treatment condition and time (β = −0.34, 95% CI = [−0.67, −0.01]) on anxiety scores.”
    • Also stated in: § Impact of Treatment · plain
      “although both treatments reduced anxiety reliably, the active condition reduced to a greater degree relative to control.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Anxiety severity is associated with greater use of non-cannabis false safety behaviors, and such use is associated with more cannabis problems among anxious users.

    “anxiety severity is also related to greater use of non-cannabis FSB (e.g., avoiding anxiety provoking situations) and use of such FSB is related to more cannabis problems among anxious users (Buckner et al., 2017).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Buckner et al., 2017

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Participants were randomly assigned to ICART or MET-CBT using urn randomization that controlled for age, sex, cannabis use frequency, primary anxiety diagnosis, and cannabis use disorder severity.

    “participants were randomly assigned to receive either Integrated Cannabis and Anxiety Reduction Treatment (ICART) or motivational enhancement/cognitive behavior therapy (MET-CBT) for CUD via urn randomization to control for age, sex, cannabis use frequency, primary anxiety diagnosis, and CUD severity.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    False Safety behavior Elimination Treatment is a transdiagnostic cognitive-behavioral therapy that targets false safety behaviors across multiple anxiety disorders.

    “False Safety behavior Elimination Treatment (FSET; Schmidt, Buckner, Pusser, Woolaway-Bickel, & Preston, 2012) is one such transdiagnostic CBT that addresses several anxiety disorders simultaneously by addressing False Safety Behaviors (FSB)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Schmidt, Buckner, Pusser, Woolaway-Bickel, & Preston, 2012 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The Timeline Follow Back is a reliable and valid self-report measure of cannabis use.

    “The TLFB is a reliable and valid self-report measure of cannabis use (O'Farrell, Fals-Stewart, & Murphy, 2003; Robinson, Sobell, Sobell, & Leo, 2014).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites O'Farrell, Fals-Stewart, & Murphy, 2003 source
    • cites Robinson, Sobell, Sobell, & Leo, 2014 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Treatment fidelity was monitored by video-recording all sessions and reviewing them in weekly supervision with a licensed clinical psychologist.

    “All treatment sessions were video-recorded for review during weekly supervision with the first author, a licensed clinical psychologist, for fidelity to the treatment manual.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The ADIS-IV has been shown to be a reliable and valid measure of DSM-IV anxiety and mood disorders.

    “The ADIS-IV has been shown to be a reliable and valid measure of DSM-IV (American Psychiatric Association, 2000) anxiety and mood disorders (Brown, DiNardo, Lehman, & Campbell, 2001).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Brown, DiNardo, Lehman, & Campbell, 2001 source

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    FSET has been found to reduce anxiety and depression and improve quality of life.

    “FSET involves the identification and elimination of FSBs and has been found to decrease anxiety and depression and improve quality of life (Schmidt et al., 2012).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Schmidt et al., 2012 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The SIGH-A showed good internal consistency at baseline and excellent inter-rater reliability in this study.

    “The scale also demonstrated good internal consistency in the current study at baseline (α = .842).”
    • Also stated in: § Measures · plain
      “intraclass Correlation Coefficient was excellent (ICC = .82, 95% CI: .67-.90).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The Marijuana Problems Scale had good internal consistency in the current sample, with alpha of .87.

    “The measure achieved good internal consistency in prior work (e.g,. Ecker & Buckner, 2014; Lozano, Stephens, & Roffman, 2006) and in the current sample (α = .87).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    ICART appeared acceptable because ICART participants were not more likely to drop out after the first session despite learning that treatment involved reducing false safety behaviors and avoidance.

    “ICART seemed to be an acceptable treatment given that participants in the ICART condition were not more likely to drop out after session one, despite learning that treatment would entail reducing their reliance on FSB and other avoidance strategies.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Abstinence, when achieved, is rarely maintained after cannabis use disorder treatment, and reductions in use and related problems are more appropriate measures of treatment success.

    “abstinence, if achieved, is rarely maintained following CUD treatment, whereas reductions in use and use-related problems tend to be more appropriate indices of treatment success (c.f., Marijuana Treatment Project Research Group, 2004).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Marijuana Treatment Project Research Group, 2004 source

  • May combine two claims.

    Interpretationreasoning

    The longer ICART course may be needed for patients to learn and use anxiety-management skills, which led to greater anxiety reductions in ICART.

    “this longer course of treatment may be necessary for patients to learn and use specific anxiety-management skills, which led to greater decreases in anxiety in the ICART condition.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The greater baseline anxiety in the ICART condition did not account for the greater anxiety reduction observed in ICART.
19 of 19

  • The paper relies on this without support.

    The greater baseline anxiety in the ICART condition did not account for the greater anxiety reduction observed in ICART.

    “Conditions did not differ on baseline levels of outcome variables except that the ICART condition reported greater baseline anxiety, F (1, 54) = 7.36, p = .009, d = .75.”
    “although both treatments reduced anxiety reliably, the active condition reduced to a greater degree relative to control.”
1 of 1

Statistics that don’t add up

Each reported p-value recomputed from its test statistic and degrees of freedom.

  • Inconsistent p-value: F (1, 534) = 5.57, p = .022

    Minor

    The paper reports p = .022 here; recomputing from the test statistic and its degrees of freedom gives p = .019. The check cannot tell whether the statistic or the p-value is the misprint.

    Reported p = .022 · recomputed p = .019

1 of 1

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • Doesn’t add upF(1, 534) = 5.57reported p = .022 · recomputed p = .019

    “F (1, 534) = 5.57, p = .022”

  • Consistentχ²(1) = 0.26reported p = .609 · recomputed p = .610

    “χ2 (1, N = 55) = 0.26, p = .609”

  • Consistentχ²(1) = 6.63reported p = .01 · recomputed p = .010

    “χ2 (1, N = 55) = 6.63, p = .010”

  • Consistentχ²(1) = 0.23reported p = .631 · recomputed p = .632

    “χ2 (1, N = 55) = 0.23, p = .631”

  • ConsistentF(1, 54) = 7.36reported p = .009 · recomputed p = .009

    “F (1, 54) = 7.36, p = .009”

5 of 5

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • The listed third Bayesian outcome changes between methods descriptions

    Minor

    One description identifies cannabis use as the third modeled outcome; the next identifies safety behaviors instead. The reported outcome analyses cover cannabis use, not safety behaviors.

  • Baseline-anxiety ANOVA has the wrong residual degree of freedom

    Minor

    The stated group sizes total 55. A two-group baseline ANOVA using those participants has 53 residual degrees of freedom, not 54.

    Reported 54 · recomputed 53

  • Treatment-session ANOVA has an impossible residual degree of freedom

    Minor

    With 55 participants and two treatment groups, a one-way comparison of each participant's session count has 53 residual degrees of freedom, not 534.

    Reported 534 · recomputed 53

3 of 3

Cites

Flagged first, then by citations

4 of the 58 references couldn’t be matched to a known paper.

Cited by

Sorted by citations

Related

Authors
Buckner, J. D., Zvolensky, M. J., Ecker, A. H., Schmidt, N. B., Lewis, E. M., Paulus, D. J., Lopez-Gamundi, P., Crapanzano, K. A., & Bakhshaie, J.
Affiliations
  • Louisiana State University (US)
  • The University of Texas MD Anderson Cancer Center (US)
  • Baylor College of Medicine (US)
  • Florida State University (US)
  • University of Houston (US)
  • The University of Texas Health Science Center at Houston (US)
Corresponding author
Buckner, Julia D.
ORCID
Venue
Behaviour Research and Therapy
Publisher
Elsevier BV
Published
2019-04
Volume
115
Pages
38-45
ISSN
0005-7967 (ISSN-L)
DOI
10.1016/j.brat.2018.10.014
PMC
PMC6409106
OpenAlex
W2898536234
Cited by
55
References
58
Citations by year
2026: 7 · 2025: 8 · 2024: 9 · 2023: 7 · 2022: 7 · 2021: 4 · 2020: 6 · 2019: 6 · 2018: 1
FWCI
3.31
Type
journal article
Language
en
Open access
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • Behaviour Research and Therapy (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • Civil War Book Review (submittedVersion)
Funders
National Institute on Drug Abuse (R34DA031937)
Topics
  • Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
  • Health Sciences › Medicine › Pharmacology › Cannabis and Cannabinoid Research
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
cannabis use disorder, anxiety disorders, comorbidities, cannabis abstinence, treatment acceptability
MeSH terms
Marijuana Use, Adolescent, Adult, Anxiety Disorders, Female, Humans, Male, Pilot Projects, Cognitive Behavioral Therapy, Treatment Outcome, Diagnosis, Dual (Psychiatry), Young Adult

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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

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