Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder: a clinical trial

WITHDRAWN: Case management for persons with substance use disorders

The review has been withdrawn from publication because it is out of date and the authors are currently not available for updating it

The editorial group responsible for this previously published document have withdrawn it from publication.

Psychosocial interventions for people with both severe mental illness and substance misuse

BACKGROUND

Even low levels of substance misuse by people with a severe mental illness can have detrimental effects.

OBJECTIVES

To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care.

SEARCH METHODS

For this update (2013), the Trials Search Co-ordinator of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (July 2012), which is based on regular searches of major medical and scientific databases. The principal authors conducted two further searches (8 October 2012 and 15 January 2013) of the Cochrane Database of Systematic Reviews, MEDLINE and PsycINFO. A separate search for trials of contingency management was completed as this was an additional intervention category for this update.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness.

DATA COLLECTION AND ANALYSIS

We independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of relative risk (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. For all meta-analyses we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison.

MAIN RESULTS

We included 32 trials with a total of 3165 participants. Evaluation of long-term integrated care included four RCTs (n = 735). We found no significant differences on loss to treatment (n = 603, 3 RCTs, RR 1.09 CI 0.82 to 1.45, low quality of evidence), death by 3 years (n = 421, 2 RCTs, RR 1.18 CI 0.39 to 3.57, low quality of evidence), alcohol use (not in remission at 36 months) (n = 143, 1 RCT, RR 1.15 CI 0.84 to 1.56,low quality of evidence), substance use (n = 85, 1 RCT, RR 0.89 CI 0.63 to 1.25, low quality of evidence), global assessment of functioning (n = 171, 1 RCT, MD 0.7 CI 2.07 to 3.47, low quality of evidence), or general life satisfaction (n = 372, 2 RCTs, MD 0.02 higher CI 0.28 to 0.32, moderate quality of evidence).For evaluation of non-integrated intensive case management with usual treatment (4 RCTs, n = 163) we found no statistically significant difference for loss to treatment at 12 months (n = 134, 3 RCTs, RR 1.21 CI 0.73 to 1.99, very low quality of evidence).Motivational interviewing plus cognitive behavioural therapy compared to usual treatment (7 RCTs, total n = 878) did not reveal any advantage for retaining participants at 12 months (n = 327, 1 RCT, RR 0.99 CI 0.62 to 1.59, low quality of evidence) or for death (n = 493, 3 RCTs, RR 0.72 CI 0.22 to 2.41, low quality of evidence), and no benefit for reducing substance use (n = 119, 1 RCT, MD 0.19 CI -0.22 to 0.6, low quality of evidence), relapse (n = 36, 1 RCT, RR 0.5 CI 0.24 to 1.04, very low quality of evidence) or global functioning (n = 445, 4 RCTs, MD 1.24 CI 1.86 to 4.34, very low quality of evidence).Cognitive behavioural therapy alone compared with usual treatment (2 RCTs, n = 152) showed no significant difference for losses from treatment at 3 months (n = 152, 2 RCTs, RR 1.12 CI 0.44 to 2.86, low quality of evidence). No benefits were observed on measures of lessening cannabis use at 6 months (n = 47, 1 RCT, RR 1.30 CI 0.79 to 2.15, very low quality of evidence) or mental state (n = 105, 1 RCT, Brief Psychiatric Rating Scale MD 0.52 CI -0.78 to 1.82, low quality of evidence).We found no advantage for motivational interviewing alone compared with usual treatment (8 RCTs, n = 509) in reducing losses to treatment at 6 months (n = 62, 1 RCT, RR 1.71 CI 0.63 to 4.64, very low quality of evidence), although significantly more participants in the motivational interviewing group reported for their first aftercare appointment (n = 93, 1 RCT, RR 0.69 CI 0.53 to 0.9). Some differences, favouring treatment, were observed in abstaining from alcohol (n = 28, 1 RCT, RR 0.36 CI 0.17 to 0.75, very low quality of evidence) but not other substances (n = 89, 1 RCT, RR -0.07 CI -0.56 to 0.42, very low quality of evidence), and no differences were observed in mental state (n = 30, 1 RCT, MD 0.19 CI -0.59 to 0.21, very low quality of evidence).We found no significant differences for skills training in the numbers lost to treatment by 12 months (n = 94, 2 RCTs, RR 0.70 CI 0.44 to 1.1, very low quality of evidence).We found no differences for contingency management compared with usual treatment (2 RCTs, n = 206) in numbers lost to treatment at 3 months (n = 176, 1 RCT, RR 1.65 CI 1.18 to 2.31, low quality of evidence), number of stimulant positive urine tests at 6 months (n = 176, 1 RCT, RR 0.83 CI 0.65 to 1.06, low quality of evidence) or hospitalisations (n = 176, 1 RCT, RR 0.21 CI 0.05 to 0.93, low quality of evidence).We were unable to summarise all findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low or very low due to high or unclear risks of bias because of poor trial methods, or poorly reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals.

AUTHORS' CONCLUSIONS

We included 32 RCTs and found no compelling evidence to support any one psychosocial treatment over another for people to remain in treatment or to reduce substance use or improve mental state in people with serious mental illnesses. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high quality trials are required which address these concerns and improve the evidence in this important area.

Predictors of stimulant abuse treatment outcomes in severely mentally ill outpatients

BACKGROUND

Severe mental illness is often exclusionary criteria for studies examining factors that influence addiction treatment outcome. Therefore, little is known about predictors of treatment response of individuals receiving psychosocial treatments for addictions who suffer from co-occurring severe mental illness.

METHODS

The impact of demographic, substance abuse severity, psychiatric severity, and service utilization variables on in-treatment performance (i.e., longest duration of abstinence) in a 12-week contingency management (CM) intervention for stimulant abuse in 96 severely mentally ill adults was investigated. A 4-step linear regression was used to identify independent predictors of in-treatment abstinence.

RESULTS

This model accounted for 37.4% of variance in the longest duration of abstinence outcome. Lower levels of stimulant use (i.e., stimulant-negative urine test) and psychiatric severity (i.e., lower levels of psychiatric distress), as well as higher rates of outpatient treatment utilization at study entry were independently associated with longer duration of drug abstinence.

CONCLUSION

These data suggest that individuals with low levels of stimulant use and psychiatric severity, as well as those actively engaged in services are most likely to succeed in a typical CM intervention. For others, modifications to CM interventions, such as increasing the value of reinforcement or adding CM to evidence based psychiatric interventions may improve treatment outcomes.

Implementing Residential Integrated Treatment for Co-occurring Disorders

Objective: Much is now known about effective treatment for co-occurring substance abuse and psychiatric difficulties and many evidence-based practice recommendations have been disseminated. Implementation of these recommended interventions in daily clinical practice has been more of a struggle. This article describes successful implementation of integrated treatment for co-occurring disorders in a small residential program. Methods: A traditional 28-day addiction service was transformed into a 3-month integrated treatment program and 155 individuals with co-occurring disorders agreed to participate in its evaluation. The transformation entailed a completely new manualized service, training in a number of clinical interventions for all program clinicians, ongoing clinical supervision, and formal measurement of clients' backgrounds, substance abuse, quality of life, mental health symptoms, self-esteem, and satisfaction with the program. We also obtained collateral informants' reports on participants' symptoms, substance use, and quality of life. Fidelity to the treatment model was continuously assessed, as were participants' knowledge and skill acquisition. In addition, impact of the implementation on the program clinicians' morale and attitudes toward evidence-based practices was assessed, as was staff turnover and per diem costs. Results: Despite very problematic clinical and sociodemographic histories, the 86 participants who completed the program showed clinically significant mental health symptom improvement, acquisition of knowledge and skill, and high self-esteem and satisfaction with the program. Program fidelity, clinician morale, commitment to the program, and attitudes toward evidence-based practice were uniformly high. These successes were achieved while maintaining the lowest per-inpatient day cost of all hospital inpatient units. Conclusions: The findings support the contention that evidence-based integrated treatment can be implemented with fidelity in regular clinical practice to the benefit of participants, staff, and the hospital. Our experience was that having a scientist-practitioner working as a staff member on the program to lead the implementation was a key element. Future reports will focus on longer-term follow-up of substance use and quality of life outcomes.

Facilitating factors in implementing four evidence-based practices: reports from addiction treatment staff

In this Robert Wood Johnson Foundation-funded study (2009-2011), treatment staff (n = 178) from 330 federally funded U.S. addiction treatment programs provided data through semistructured telephone interviews about factors that facilitated their implementation of four evidence-based practices (EBPs). Such studies can assist the addiction field in improving EBP implementation and ultimately, client care.

RESEARCH QUESTIONS

What factors were identified as facilitating implementation of the four EBPs? And, Do facilitating factors vary by EBP? Coders classified facilitating factors (n = 518) using a six-category schema. Results showed that although facilitating factors varied by EBP, organization-related factors dominated. Study implications and limitations are described.

A randomized controlled trial of family intervention for co-occurring substance use and severe psychiatric disorders

Substance use disorders have a profound impact on the course of severe mental illnesses and on the family, but little research has evaluated the impact of family intervention for this population. To address this question, a randomized controlled trial was conducted comparing a brief (2-3 mo) Family Education (ED) program with a longer-term (9-18 mo) program that combined education with teaching communication and problem-solving skills, Family Intervention for Dual Disorders (FIDD). A total of 108 clients (77% schizophrenia-spectrum) and a key relative were randomized to either ED or FIDD and assessed at baseline and every 6 months for 3 years. Rates of retention of families in both programs were moderate. Intent-to-treat analyses indicated that clients in both programs improved in psychiatric, substance abuse, and functional outcomes, as did key relatives in knowledge of co-occurring disorders, burden, and mental health functioning. Clients in FIDD had significantly less severe overall psychiatric symptoms and psychotic symptoms and tended to improve more in functioning. Relatives in FIDD improved more in mental health functioning and knowledge of co-occurring disorders. There were no consistent differences between the programs in substance abuse severity or family burden. The findings support the utility of family intervention for co-occurring disorders, and the added benefits of communication and problem-solving training, but also suggest the need to modify these programs to retain more families in treatment in order to provide them with the information and skills they need to overcome the effects of these disorders.

Comparing statistical methods for analyzing skewed longitudinal count data with many zeros: an example of smoking cessation

Count data with skewness and many zeros are common in substance abuse and addiction research. Zero-adjusting models, especially zero-inflated models, have become increasingly popular in analyzing this type of data. This paper reviews and compares five mixed-effects Poisson family models commonly used to analyze count data with a high proportion of zeros by analyzing a longitudinal outcome: number of smoking quit attempts from the New Hampshire Dual Disorders Study. The findings of our study indicated that count data with many zeros do not necessarily require zero-inflated or other zero-adjusting models. For rare event counts or count data with small means, a simpler model such as the negative binomial model may provide a better fit.

Psychosocial treatments for schizophrenia

The current state of the literature regarding psychosocial treatments for schizophrenia is reviewed within the frameworks of the recovery model of mental health and the expanded stress-vulnerability model. Interventions targeting specific domains of functioning, age groups, stages of illness, and human service system gaps are classified as evidence-based practices or promising practices according to the extent to which their efficacy is currently supported by meta-analyses and individual randomized controlled trials (RCTs). Evidence-based practices include assertive community treatment (ACT), cognitive behavior therapy (CBT) for psychosis, cognitive remediation, family psychoeducation, illness self-management training, social skills training, and supported employment. Promising practices include cognitive adaptive therapy, CBT for posttraumatic stress disorder, first-episode psychosis intervention, healthy lifestyle interventions, integrated treatment for co-occurring disorders, interventions targeting older individuals, peer support services, physical disease management, prodromal stage intervention, social cognition training, supported education, and supported housing. Implications and future directions are discussed.

Evaluation of the alcohol use disorders identification test and the drug use disorders identification test among patients at a Norwegian psychiatric emergency ward

High rates of substance use disorders (SUD) among psychiatric patients are well documented. This study explores the usefulness of the Alcohol Use Disorders Identification Test (AUDIT) and the Drug Use Disorders Identification Test (DUDIT) in identifying SUD in emergency psychiatric patients. Of 287 patients admitted consecutively, 256 participants (89%) were included, and 61-64% completed the questionnaires and the Mini-International Neuropsychiatric Interview (MINI), used as the reference standard. Both AUDIT and DUDIT were valid (area under the curve above 0.92) and reliable (Cronbach's alpha above 0.89) in psychotic and nonpsychotic men and women. The suitable cutoff scores for AUDIT were higher among the psychotic than nonpsychotic patients, with 12 versus 10 in men and 8 versus 5 in women. The suitable cutoff scores for DUDIT were 1 in both psychotic and nonpsychotic women, and 5 versus 1 in psychotic and nonpsychotic men, respectively. This study shows that AUDIT and DUDIT may provide precise information about emergency psychiatric patients' problematic alcohol and drug use.

Randomized controlled trial of contingency management for stimulant use in community mental health patients with serious mental illness

OBJECTIVE

The primary objective of this study was to determine whether contingency management was associated with increased abstinence from stimulant drug use in stimulant-dependent patients with serious mental illness treated in a community mental health center. Secondary objectives were to determine whether contingency management was associated with reductions in use of other substances, psychiatric symptoms, HIV risk behavior, and inpatient service utilization.

METHOD

A randomized controlled design was used to compare outcomes of 176 outpatients with serious mental illness and stimulant dependence. Participants were randomly assigned to receive 3 months of contingency management for stimulant abstinence plus treatment as usual or treatment as usual with reinforcement for study participation only. Urine drug tests and self report, clinician-report, and service utilization outcomes were assessed during the 3-month treatment period and the 3-month follow-up period.

RESULTS

Although participants in the contingency management condition were significantly less likely to complete the treatment period than those assigned to the control condition (42% compared with 65%), they were 2.4 times (95% CI=1.9–3.0)more likely to submit a stimulant-negative urine test during treatment. Compared with participants in the control condition,they had significantly lower levels of alcohol use, injection drug use, and psychiatric symptoms and were one-fifth as likely as those assigned to the control condition to be admitted for psychiatric hospitalization during treatment. They also reported significantly fewer days of stimulant drug use during the 3-month follow-up.

CONCLUSIONS

When added to treatment as usual, contingency management is associated with large reductions in stimulant,injection drug, and alcohol use.Reductions in psychiatric symptoms and hospitalizations are important secondary benefits.

Accuracy of self-report, biological tests, collateral reports and clinician ratings in identifying substance use disorders among adults with schizophrenia

Identifying substance use disorders among adults with schizophrenia presents unique challenges but is critical to research and practice. This study examined: (a) the accuracy of assessments completed using various approaches in identifying substance use disorders, (b) their ability to discriminate between disorders of abuse and dependence, and (c) the benefits of using multiple indicators to identify substance use disorders. Data are from the Clinical Antipsychotic Trials of Intervention Effectiveness study. The sample comprised 1,460 community-based adults with schizophrenia, 15.8% (n = 230) of whom were positive for a current (past month) drug or alcohol use disorder using the Structured Clinical Interview for DSM-IV Disorders (SCID). Clinician ratings, self-report, collateral reports, and results of hair and urine tests were compared to SCID diagnoses. Congruence with SCID diagnoses was good across approaches and evidence for superiority of one approach over another was limited. No approach discriminated between abuse and dependence. There was limited benefit of using multiple indicators. Findings suggest that the decision regarding the "best" approach for identifying substance use disorders among adults with schizophrenia may be made through consideration of practical issues and assessment purpose, rather than selection of the approach that yields the most accurate diagnostic assessment.

Housing First for severely mentally ill homeless methadone patients

The Housing First approach used by Pathways to Housing, Inc., was used to enhance residential independence and treatment retention of homeless, seriously mentally ill methadone patients. The Keeping Home project first secured scattered-site apartments and assertive community treatment services and then addressed patients' service needs. Three years post-implementation, methadone treatment retention for 31 Keeping Home patients versus 30 comparison participants (drawn from an administrative database) was 51.6% vs. 20% (p < .02); apartment/independent housing retention was 67.7% vs. 3% or 13% (both p's < .01). Although results firmly support Keeping Home, future research needs to address study's possible database limitations.

Advances in fidelity measurement for mental health services research: four measures

Mental health intervention research requires clear and accurate specification of treatment conditions in intervention studies. Measures are increasingly available for community-based interventions for persons with serious mental illnesses. Measures must go beyond structural features to assess critical processes in interventions. They must also balance effectiveness, or adequate coverage of active treatment elements, with efficiency, or the degree to which measures may be used cost-effectively. The context of their use is changing with the emergence of new frameworks for implementation research and quality improvement. To illustrate a range of approaches, this article describes four recently developed fidelity measures: Cognitive Therapy for Psychosis Adherence Scale, Strengths Model Fidelity Scale, Illness Management and Recovery Program Fidelity Scale, and Tool for Measurement of ACT. The fidelity measures assess interventions in a range of treatment contexts from dyads to teams. Each measure focuses assessment resources on critical elements. Each has demonstrated coverage of its target intervention and satisfactory psychometric properties and is related to outcomes. Measures have been used for training, quality improvement, or certification. They assess domains and have uses beyond their nominal position in implementation and quality frameworks. This review of recent fidelity measures indicates that process components in community-based interventions can be effectively assessed. Omission of elements assessing potentially critical active treatment components poses risk to both research and practice until there is evidence to demonstrate that they are nonessential. Further development of fidelity measurement theory and approaches should proceed in conjunction with development of theory and methods in implementation science.

A 10-year study of steady employment and non-vocational outcomes among people with serious mental illness and co-occurring substance use disorders

OBJECTIVE

Employment promotes recovery for persons with serious mental illness by providing extra income and a valued social role, but the impact of employment on other psychosocial and clinical outcomes remains unclear. This study examined non-vocational outcomes in relation to steady employment over 10 years among people with serious mental illness and co-occurring substance use disorders.

METHODS

Researchers interviewed people with co-occurring disorders at baseline and yearly for 10 years and tracked employment in relation to five non-vocational outcomes: independent living, psychiatric symptoms, substance use disorder, healthy (non-substance-abusing) relationships, and life satisfaction. Latent class trajectory analysis identified steady workers, and mixed-effects regression models compared steady workers with non-workers.

RESULTS

Both steady workers (n=51) and non-workers (n=79) improved substantially; for example, a majority of each group achieved independent housing and stable remission of substance use disorders. Steady workers achieved independent housing and higher quality of life during the first 5 years of follow-up, but the two groups achieved similar outcomes by 10 years.

CONCLUSIONS

People with co-occurring disorders can improve markedly. Those with steady employment may improve faster, but those without employment may achieve similar long-term outcomes at a slower pace.

Evaluating the effectiveness of an integrated community continuum of care program for individuals with serious mental illness

OBJECTIVE

To evaluate effectiveness of an "Continuum of Care Program" (CCCP) for persons with serious mental health conditions in reducing inpatient use, and building a continuum of integrated care that enhanced employment and residential stability. The program combined components of Assertive Community Treatment with a comprehensive wrap-around program.

METHODS

A cohort of 1154 individuals admitted to four outpatient CCCPs between December 2003 and May 31 2004 was identified and followed for 1 year. Outcome measures included clinical functioning level, drug/alcohol use, employment, residential arrangement and inpatient use. Regression was employed to explain changes in outcomes between baseline and follow-up as a function of services.

RESULTS

Statistically significant changes were seen over a 1-year period in all outcomes. Housing, employment and mental health improved, whereas inpatient utilization and level of care need increased. Older individuals receiving higher levels of care at baseline and those with higher case management and medical service utilization reported higher inpatient use. Outcomes also varied by provider suggesting the contribution of workforce differences to outcomes.

CONCLUSIONS

Although significant, changes in outcomes were small. Outcome effectiveness was mixed and generally unrelated to services. These findings imply that significant changes in outcomes may require several years to obtain.

Interventions for improving outcomes in patients with multimorbidity in primary care and community settings

BACKGROUND

Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions for multimorbidity.

OBJECTIVES

To determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual.

SEARCH METHODS

We searched MEDLINE, EMBASE, CINAHL, CAB Health, AMED, HealthStar, The Cochrane Central Register of Controlled Trials (CENTRAL), the EPOC Register and the Database of Abstracts of Reviews of Effectiveness (DARE), and the EPOC Register in April 2011.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs), and interrupted time series analyses (ITS) reporting on interventions to improve outcomes for people with multimorbidity in primary care and community settings. The outcomes included any validated measure of physical or mental health, psychosocial status including quality of life outcomes, well-being, and measures of disability or functional status. We also included measures of patient and provider behaviour including measures of medication adherence, utilisation of health services, and acceptability of services and costs.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for eligibility, extracted data, and assessed study quality. Meta-analysis of results was not possible so we carried out a narrative synthesis of the results from the included studies.

MAIN RESULTS

Ten studies examining a range of complex interventions for patients with multimorbidity were identified. All were RCTs and there was low risk of bias. Two of the nine studies focused on specific co-morbidities. The remaining studies focused on multimorbidity, generally in older patients. All studies involved complex interventions with multiple elements. In six of the ten studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In the remaining four studies, the interventions were predominantly patient oriented. Overall the results were mixed with a trend towards improved prescribing and medication adherence. The results indicate that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors or functional difficulties in patients with co-morbid conditions or multimorbidity may be more effective. Cost data were limited with no economic analyses included, though the improvements in prescribing and risk factor management in some studies provided potentially significant cost savings.

AUTHORS' CONCLUSIONS

This review highlights the paucity of research into interventions to improve outcomes for multimorbidity with the focus to date being on co-morbid conditions or multimorbidity in older patients. The limited results suggest that interventions to date have had mixed effects but have shown a tendency to improve prescribing and medication adherence, particularly if interventions can be targeted at risk factors or specific functional difficulties in people with co-morbid conditions or multimorbidity. There is a need for clear definitions of participants, consideration of appropriate outcomes, and further pragmatic studies based in primary care settings.

A brief treatment engagement intervention for individuals with co-occurring mental illness and substance use disorders: results of a randomized clinical trial

Study objectives were to evaluate a brief intervention designed to facilitate outpatient engagement following an inpatient psychiatric stay for individuals with mental illness and substance use. A total of 102 veterans were randomly assigned to one of two conditions: (1) Time Limited Care-Coordination (TLC), an eight-week co-occurring disorders intervention or (2) a matched attention (MA) control condition in the form of health education sessions. Both groups also received treatment as usual in inpatient and outpatient settings. Sixty-nine percent of TLC participants attended an outpatient appointment within 14 days of discharge, compared to only 33% of MA participants (P < 0.01). TLC participants were also more likely to be engaged in outpatient services at the end of the intervention period (44 vs. 22%, P < 0.01). This study provided evidence that an eight-week intervention could improve treatment engagement. Research is currently underway to examine impact of TLC intervention beyond the 8 week study period.

Home visits during pregnancy and after birth for women with an alcohol or drug problem

BACKGROUND

One potential method of improving outcome for pregnant or postpartum women with a drug or alcohol problem is with home visits.

OBJECTIVES

To determine the effects of home visits during pregnancy and/or after birth for women with a drug or alcohol problem.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011), CENTRAL (The Cochrane Library 2011, Issue 4 of 4), MEDLINE (1966 to 30 November 2011), EMBASE (1980 to 30 November 2011), CINAHL (1982 to 30 November 2011) and PsycINFO (1974 to 30 November 2011) supplemented by searches of citations from previous reviews and trials and contact with experts.

SELECTION CRITERIA

Studies using random or quasi-random allocation of pregnant or postpartum women with a drug or alcohol problem to home visits. Trials enrolling high-risk women of whom more than 50% were reported to use drugs or alcohol were also eligible.

DATA COLLECTION AND ANALYSIS

Review authors performed assessments of trials independently. We performed statistical analyses using fixed-effect and random-effects models where appropriate.

MAIN RESULTS

Seven studies (reporting 803 mother-infant pairs) compared home visits mostly after birth with no home visits. Visitors included community health nurses, paediatric nurses, trained counsellors, paraprofessional advocates, midwives and lay African-American women. Several studies had significant methodological limitations. There was no significant difference in continued illicit drug use (three studies, 384 women; risk ratio (RR) 1.05, 95% confidence interval (CI) 0.89 to 1.24), continued alcohol use (three studies, 379 women; RR 1.18, 95% CI 0.96 to 1.46), failure to enrol in a drug treatment program (two studies, 211 women; RR 0.45, 95% CI 0.10 to 1.94), not breastfeeding at six months (two studies, 260 infants; RR 0.95, 95% CI 0.83 to 1.10), incomplete six-month infant vaccination schedule (two studies, 260 infants; RR 1.09, 95% CI 0.91 to 1.32), the Bayley Mental Development Index (three studies, 199 infants; mean difference 2.89, 95% CI -1.17 to 6.95) or Psychomotor Index (MD 3.14, 95% CI -0.03 to 6.32), child behavioural problems (RR 0.46, 95% CI 0.21 to 1.01), infants not in care of biological mother (two studies, 254 infants; RR 0.83, 95% CI 0.50 to 1.39), non-accidental injury and non-voluntary foster care (two studies, 254 infants; RR 0.16, 95% CI 0.02 to 1.23) or infant death (three studies, 288 infants; RR 0.70, 95% CI 0.12 to 4.16). Individual studies reported a significant reduction in involvement with child protective services (RR 0.38, 95% CI 0.20 to 0.74) and failure to use postpartum contraception (RR 0.41, 95% CI 0.20 to 0.82).

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend the routine use of home visits for pregnant or postpartum women with a drug or alcohol problem. Further large, high-quality trials are needed.

Overview of special sub-section on money management articles: cross-disciplinary perspectives on money management by addicts

BACKGROUND

How addicts manage their funds can be understood from the studies of impulsive spending, contingency management, self-reported expenditures, behavioral economics, and anthropology.

OBJECTIVE

To show how these differing perspectives can provide theoretical explanations for substance abuse, they were applied to the question of when extra "windfall" funds are spent on substances of abuse. Treatment implications of these perspectives were examined.

METHODS

Relevant literature was reviewed.

RESULTS

Behavioral economics and related approaches provide the basis for money-management-based interventions targeting substance abuse, informed configuration of reinforcers to compete with substances, and therapeutically framing the choice between abstinence and substance use.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

A cross-discipline consideration of how addicts manage their funds has the potential to inform and improve substance abuse treatment.

Helping homeless individuals with co-occurring disorders: the four components

Homeless individuals with co-occurring disorders (CODs) of severe mental illness and substance use disorder are one of the most vulnerable populations. This article provides practitioners with a framework and strategies for helping this client population. Four components emerged from a literature review: (1) ensuring an effective transition for individuals with CODs from an institution (such as a hospital, foster care, prison, or residential program) into the community, a particularly important component for clients who were previously homeless, impoverished, or at risk of homelessness; (2) increasing the resources of homeless individuals with CODs by helping them apply for government entitlements or supported employment (3) linking homeless individuals to supportive housing, including housing first options as opposed to only treatment first options, and being flexible in meeting their housing needs; and (4) engaging homeless individuals in COD treatment, incorporating modified assertive community treatment, motivational interviewing, cognitive-behavioral therapy, contingency management, and COD specialized self-help groups.

Modified therapeutic community aftercare for clients triply diagnosed with HIV/AIDS and co-occurring mental and substance use disorders

This clinical trial evaluated a modified therapeutic community aftercare (MTC-A) program for a population triply diagnosed with HIV/AIDS, a substance use disorder, and a mental disorder. After six months of MTC residential treatment (MTC-R), subjects were randomly assigned to MTC-A (n=42) or to standard aftercare (C; n=34). Follow-up interviews at six and 12 months assessed eight outcome domains and adherence to prescribed HIV medication. A propensity model was used to re-balance the retrieved sample. At the six-month follow-up, High stratum MTC-A clients (those with greater psychological functioning and stable physical health at baseline) had greater improvement overall and for substance use and mental health than C clients in the same stratum. In contrast, C clients in the Low/Medium stratum (those with poorer psychological functioning and improved physical health) had more favorable outcomes overall and for substance use than their MTC-A counterparts; however, this stratum was not re-balanced effectively. Differences in HIV medication adherence were not detected. Clients with greater psychological functioning and stable health at treatment entry benefit more from the MTC-A program. In view of the potentially progressive nature of HIV, measuring physical and mental health during treatment and controlling for changes could be important in future research.

Barriers to implementing evidence-based practices in addiction treatment programs: comparing staff reports on Motivational Interviewing, Adolescent Community Reinforcement Approach, Assertive Community Treatment, and Cognitive-behavioral Therapy

PURPOSE

This qualitative study explored barriers to implementing evidence-based practices (EBPs) in community-based addiction treatment organizations (CBOs) by comparing staff descriptions of barriers for four EBPs: Motivational Interviewing (MI), Adolescent Community Reinforcement Approach (A-CRA), Assertive Community Treatment (ACT), and Cognitive-behavioral Therapy (CBT).

METHODS

The CBOs received CSAT/SAMHSA funding from 2003 to 2008 to deliver services using EBPs. Phone interview responses from 172 CBO staff directly involved in EBP implementation were analyzed using content analysis, a method for making inferences and developing themes from the systematic review of participant narratives (Berelson, 1952).

RESULTS

Staff described different types of barriers to implementing each EBP. For MI, the majority of barriers involved staff resistance or organizational setting. For A-CRA, the majority of barriers involved specific characteristics of the EBP or client resistance. For CBT, the majority of barriers were associated with client resistance, and for ACT, the majority of barriers were associated with resources.

DISCUSSION

EBP designers, policy makers who support EBP dissemination and funders should include explicit strategies to address such barriers. Addiction programs proposing to use specific EBPs must consider whether their programs have the organizational capacity and community capacity to meet the demands of the EBP selected.

Integrated Residential Treatment for Persons with Severe and Persistent Mental Illness: Lessons in Recovery

This retrospective study examines 24-month outcomes for 38 participants with histories of chronic homelessness and hospitalizations in an urban, residential integrated treatment (IT) program and compares characteristics of those who stayed in the program 24 months with those who left within their first year of residence. Informed by an Assertive Community Treatment approach, characterized by outreach (or what might better be referred to as inreach), low staff to consumer ratio, and meeting of basic needs, the residential program emphasized harm reduction and motivational interventions. The longitudinal study design was supplemented with a comparative analysis of treatment completers and noncompleters. There were significant differences between the two groups at baseline in terms of engagement with treatment, alcohol use severity, and mental health diagnosis. Additionally, those who stayed with the program showed significant reductions in alcohol and drug use, significant reduction in hospitalizations, and advances in treatment engagement.

Case management and assertive community treatment. What is the difference?

There has been a long-running controversy about the relative benefits of Assertive Community Treatment (ACT) compared to Case Management (CM). Several health care systems have initiated major service overhauls on the basis of published evidence. Yet this evidence has been ambiguous and supports differing interpretations. Research is examined which explores the differences in outcomes reported. It uses a range of approaches, most prominently meta-regression, to test a small range of hypotheses to explain the heterogeneity in outcomes. The main determinant of differences between ACT and CM studies is the local bed management procedures and occupancy practice. Those organizational aspects of ACT which are generally shared by CM teams are associated with reduced hospital care but the stringent staffing proposed for ACT does not affect it. ACT is a specialized form of CM, not a categorically different approach. The benefits of introducing it will depend on the nature of current local practice. Important lessons about the need to focus on treatments rather than structures seem not to have been learnt. Psychiatry's recent excessive focus on service structures may have had unintended consequences for our professional identity.

Drinking motives as mediators between PTSD symptom severity and alcohol consumption in persons with severe mental illnesses

Research has consistently shown that drinking to alleviate negative emotional states predicts alcohol use and relapse among clients with co-occurring disorders including depressive and posttraumatic stress disorders. However, studies examining the mediating role of drinking motives in persons with severe mental illness (SMI) are few. The current survey of 116 community mental health clients (51.7% men; 47.4% women) diagnosed with either a schizophrenia spectrum disorder (41, 35.3%) or major mood disorder (75, 64.7%) tested the hypothesis that convivial drinking and drinking to cope with negative emotions would mediate posttraumatic stress symptoms (PSS-I) and alcohol consumption (QF). A series of path models revealed that convivial drinking fully mediated hyper-arousal symptoms and alcohol consumption, and negative coping fully mediated total posttraumatic stress symptoms, avoidance and hyper-arousal symptoms and alcohol consumption. The results support an emotional distress reduction model of alcohol use in people with severe mental illness, and highlight the need to assess specific drinking motives and target them in cognitive-behavioral treatment approaches. The cross sectional design employed limits cause-effect inferences regarding mediation, and highlights the need for longitudinal designs to sort out causal pathways among symptoms, drinking motives and alcohol consumption in clients with SMI.

Dual diagnosis clients' treatment satisfaction - a systematic review

BACKGROUND

The aim of this systematic review is to synthesize existing evidence about treatment satisfaction among clients with substance misuse and mental health co-morbidity (dual diagnoses, DD).

METHODS

We examined satisfaction with treatment received, variations in satisfaction levels by type of treatment intervention and by diagnosis (i.e. DD clients vs. single diagnosis clients), and the influence of factors other than treatment type on satisfaction. Peer-reviewed studies published in English since 1970 were identified by searching electronic databases using pre-defined search strings.

RESULTS

Across the 27 studies that met inclusion criteria, high average satisfaction scores were found. In most studies, integrated DD treatment yielded greater client satisfaction than standard treatment without explicit DD focus. In standard treatment without DD focus, DD clients tended to be less satisfied than single diagnosis clients. Whilst the evidence base on client and treatment variables related to satisfaction is small, it suggested client demographics and symptom severity to be unrelated to treatment satisfaction. However, satisfaction tended to be linked to other treatment process and outcome variables. Findings are limited in that many studies had very small sample sizes, did not use validated satisfaction instruments and may not have controlled for potential confounders. A framework for further research in this important area is discussed.

CONCLUSIONS

High satisfaction levels with current treatment provision, especially among those in integrated treatment, should enhance therapeutic optimism among practitioners dealing with DD clients.

Fidelity and outcomes in six integrated dual disorders treatment programs

Fidelity scores and outcomes were measured in six outpatient programs in California which implemented Integrated Dual Disorders Treatment (IDDT). Outcomes were measured for 1 year in four sites and 2 years in two sites; fidelity was assessed at 6 month intervals. Three of the six sites achieved high fidelity (at least a 4 on a 5 point fidelity scale) and three moderate fidelity (at least a 3). Retention in treatment, mental health functioning, stage of substance abuse treatment, abstinence, and psychiatric hospitalization were measured. Outcomes for individual programs were generally positive but not consistent within programs or across programs. Using pooled data in a longitudinal regression model with random effects at person level and adjustment of standard errors for clustering by site, change over time was not statistically significant for the primary outcomes. Fidelity scores had limited association with positive outcomes.

Assessing the STIRR model of best practices for blood-borne infections of clients with severe mental illness

OBJECTIVES

People with co-occurring severe mental illness and a substance use disorder are at markedly elevated risk of infection from HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV), but they generally do not receive basic recommended screening or preventive and treatment services. Barriers to services include lack of programs offered by mental health providers and client refusal of available services. Clients from racial-ethnic minority groups are even less likely to accept recommended services. The intervention tested was designed to facilitate integrated infectious disease programming in mental health settings and to increase acceptance of such services among clients.

METHODS

A randomized controlled trial (N=236) compared enhanced treatment as usual (control) with a brief intervention to deliver best-practice services for blood-borne diseases in an urban sample of clients with co-occurring disorders who were largely from racial-ethnic minority groups. The "STIRR" intervention included Screening for HIV and HCV risk factors, Testing for HIV and hepatitis, Immunization against hepatitis A and B, Risk reduction counseling, and medical treatment Referral and support at the site of mental health care.

RESULTS

Clients randomly assigned to the STIRR intervention had high levels (over 80%) of participation and acceptance of core services. They were more likely to be tested for HBV and HCV, to be immunized against hepatitis A virus and HBV, and to increase their knowledge about hepatitis and reduce their substance abuse. However, they showed no reduction in risk behavior, were no more likely to be referred to care, and showed no increase in HIV knowledge. Intervention costs were $541 per client (including $234 for blood tests).

CONCLUSIONS

STIRR appears to be efficacious in providing a basic, best-practice package of interventions for clients with co-occurring disorders.

The efficacy of assertive community treatment to treat substance use

BACKGROUND

Assertive Community Treatment (ACT) has been studied extensively in people with severe mental illness, but there have only been a few clinical trials in which substance use was one of the measured outcomes.

OBJECTIVE

The goal of this article was to describe the efficacy of ACT in treating co-occurring substance use disorders and suggest approaches to make it more efficacious.

DESIGN

A literature review was conducted and randomized clinical trials describing ACT's impact on substance use were reviewed.

RESULTS

Four randomized clinical trials of ACT that measured substance abuse adequately were identified, all of which showed small to no effect on substance abuse compared with control conditions. Methodological issues might account for the small effects. ACT might further reduce substance use by being paired with evidenced-based substance abuse treatment, helping clients become housed or helping them manage their money better.

CONCLUSION

Integrated ACT, in which the ACT team provides substance abuse counseling, has the potential to reduce substance use by several mechanisms, but this has been difficult to demonstrate in clinical trials when participants in control groups receive similar interventions.

The TMACT: a new tool for measuring fidelity to assertive community treatment

BACKGROUND

Fidelity assessment is important for implementation of evidence-based practices (EBPs), including assertive community treatment (ACT).

OBJECTIVES

The TMACT, an enhanced fidelity tool, was developed and pilot-tested to better assess critical ACT structures and processes.

DESIGN

Ten ACT teams were administered the TMACT and the long-standing ACT fidelity measure, the Dartmouth Assertive Community Treatment Scale (DACTS), at baseline, 6, 12, and 18 months.

RESULTS

Overall, fidelity scores for all 10 teams were relatively high. Six teams showed improvement, concluding with high TMACT scores at 18 months. Four teams with significantly lower total scores had experienced turnover and organizational barriers. TMACT ratings were higher in core ACT practices than in recovery practices and EBPs. TMACT scores rose steadily but were significantly lower than DACTS scores, which remained unchanged.

CONCLUSIONS

The TMACT sets higher performance standards through enhanced assessment of recovery-orientation, EBPs, and teamwork and is more sensitive to change than the DACTS.

Intensive case management for severe mental illness

BACKGROUND

Intensive Case Management (ICM) is a community based package of care, aiming to provide long term care for severely mentally ill people who do not require immediate admission. ICM evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (less than 20) and high intensity input.

OBJECTIVES

To assess the effects of Intensive Case Management (caseload <20) in comparison with non-Intensive Case Management (caseload > 20) and with standard community care in people with severe mental illness. To evaluate whether the effect of ICM on hospitalisation depends on its fidelity to the ACT model and on the setting.

SEARCH STRATEGY

For the current update of this review we searched the Cochrane Schizophrenia Group Trials Register (February 2009), which is compiled by systematic searches of major databases, hand searches and conference proceedings.

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community-care setting, where Intensive Case Management, non-Intensive Case Management or standard care were compared. Outcomes such as service use, adverse effects, global state, social functioning, mental state, behaviour, quality of life, satisfaction and costs were sought.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For binary outcomes we calculated relative risk (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data we estimated mean difference (MD) between groups and its 95% confidence interval (CI). We employed a random-effects model for analyses.We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect.

MAIN RESULTS

We included 38 trials (7328 participants) in this review. The trials provided data for two comparisons: 1. ICM versus standard care, 2. ICM versus non-ICM.1. ICM versus standard care Twenty-four trials provided data on length of hospitalisation, and results favoured Intensive Case Management (n=3595, 24 RCTs, MD -0.86 CI -1.37 to -0.34). There was a high level of heterogeneity, but this significance still remained when the outlier studies were excluded from the analysis (n=3143, 20 RCTs, MD -0.62 CI -1.00 to -0.23). Nine studies found participants in the ICM group were less likely to be lost to psychiatric services (n=1633, 9 RCTs, RR 0.43 CI 0.30 to 0.61, I²=49%, p=0.05).One global state scale did show an Improvement in global state for those receiving ICM, the GAF scale (n=818, 5 RCTs, MD 3.41 CI 1.66 to 5.16). Results for mental state as measured through various rating scales, however, were equivocal, with no compelling evidence that ICM was really any better than standard care in improving mental state. No differences in mortality between ICM and standard care groups occurred, either due to 'all causes' (n=1456, 9 RCTs, RR 0.84 CI 0.48 to 1.47) or to 'suicide' (n=1456, 9 RCTs, RR 0.68 CI 0.31 to 1.51).Social functioning results varied, no differences were found in terms of contact with the legal system and with employment status, whereas significant improvement in accommodation status was found, as was the incidence of not living independently, which was lower in the ICM group (n=1185, 4 RCTs, RR 0.65 CI 0.49 to 0.88).Quality of life data found no significant difference between groups, but data were weak. CSQ scores showed a greater participant satisfaction in the ICM group (n=423, 2 RCTs, MD 3.23 CI 2.31 to 4.14).2. ICM versus non-ICM The included studies failed to show a significant advantage of ICM in reducing the average length of hospitalisation (n=2220, 21 RCTs, MD -0.08 CI -0.37 to 0.21). They did find ICM to be more advantageous than non-ICM in reducing rate of lost to follow-up (n=2195, 9 RCTs, RR 0.72 CI 0.52 to 0.99), although data showed a substantial level of heterogeneity (I²=59%, p=0.01). Overall, no significant differences were found in the effects of ICM compared to non-ICM for broad outcomes such as service use, mortality, social functioning, mental state, behaviour, quality of life, satisfaction and costs.3. Fidelity to ACT Within the meta-regression we found that i. the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36 CI -0.66 to -0.07); and ii. the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20 CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but 'baseline hospital use' result is still significantly influencing time in hospital (regression coefficient -0.18 CI -0.29 to -0.07, p=0.0027).

AUTHORS' CONCLUSIONS

ICM was found effective in ameliorating many outcomes relevant to people with severe mental illnesses. Compared to standard care ICM was shown to reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. ICM is of value at least to people with severe mental illnesses who are in the sub-group of those with a high level of hospitalisation (about 4 days/month in past 2 years) and the intervention should be performed close to the original model.It is not clear, however, what gain ICM provides on top of a less formal non-ICM approach.We do not think that more trials comparing current ICM with standard care or non-ICM are justified, but currently we know of no review comparing non-ICM with standard care and this should be undertaken.

Treating comorbid substance use disorders in schizophrenia

AIM

To review the literature on pharmacological and psychosocial treatment approaches for people with schizophrenia and comorbid substance use disorder(s) (SUD).

METHOD

Selective literature review.

RESULTS

Despite the high prevalence of comorbid SUD among people with schizophrenia, there is a considerable paucity of rigorously conducted randomized controlled treatment trials. While there is some evidence for clozapine, and for the adjunctive use of agents such as naltrexone for comorbid alcohol dependence, the available literature largely comprises case studies, case series, open label studies and retrospective surveys. In terms of psychosocial approaches, there is reasonable consensus that integrated approaches are most appropriate. Regarding specific aspects of care, motivational interviewing, cognitive behavioural therapy and contingency management have an emerging supportive literature, as do family interventions. However, there is no 'one size fits all', and a flexible approach with the ability to apply specific components of care to particular individuals, is required. Group-based therapies and longer-term residential services have an important role for some patients, but further research is required to delineate more clearly which patients will benefit from these strategies.

CONCLUSIONS

While there is growing (albeit limited) evidence that integrated and well articulated interventions that encompass pharmacological and psychosocial parameters can be beneficial for people with schizophrenia and comorbid SUD, there remains a considerable gap in the literature available to inform evidence-based practice.

The rise and fall of assertive community treatment?

Assertive community treatment is one of the most researched and clinically replicated of all community mental health teams. It is clearly defined with established scales to measure its model fidelity. In the last decade its earlier claims to substantially reduce hospitalization have not been replicated in research studies. This inconsistency has generated considerable controversy. A careful systematic review and meta-regression analysis was conducted of 64 trials including 7,819 patients. The review included measures of model fidelity and hospitalization outcomes. Variation in reduced hospitalization was found to be mainly due to variation in control service practice but model fidelity to team organization principles was also associated with reduced hospitalization. Low caseloads and specified ACT staffing, however, had no effect at all on outcome. 'Ordinary CMHTs' share most of the organizational aspects of ACT and appear to deliver equal outcomes with much reduced resources. The value of investing in high fidelity ACT teams must, therefore, be in doubt.

Using the Group-Based Dual Trajectory Model to Analyze Two Related Longitudinal Outcomes

The group-based latent trajectory model allows investigators to identify distinctive trajectory groups based on relevant outcomes. Dual trajectory analysis enables examination of the interrelationship between two outcomes simultaneously. This paper describes the application of the group-based dual trajectory model in mental health and substance abuse research. We analyzed two related recovery outcomes: 1) social contact with non-substance abusing friends and 2) stage of substance abuse treatment. We identified four groups for social contact and four groups for substance abuse treatment. We then examined the interrelationship between the two outcomes across the trajectory groups over 10 years. The two outcomes are positively associated longitudinally and evolve in the same direction, although for specific groups, the two outcomes do not covary. By examining dynamic linkages across all trajectory groups between two longitudinal outcomes, the dual model provides a more comprehensive and realistic understanding of the underlying relationships between the two outcomes under investigation.

The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements

The Schizophrenia Patient Outcomes Research Team (PORT) psychosocial treatment recommendations provide a comprehensive summary of current evidence-based psychosocial treatment interventions for persons with schizophrenia. There have been 2 previous sets of psychosocial treatment recommendations (Lehman AF, Steinwachs DM. Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophr Bull. 1998;24:1-10 and Lehman AF, Kreyenbuhl J, Buchanan RW, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. Schizophr Bull. 2004;30:193-217). This article reports the third set of PORT recommendations that includes updated reviews in 7 areas as well as adding 5 new areas of review. Members of the psychosocial Evidence Review Group conducted reviews of the literature in each intervention area and drafted the recommendation or summary statement with supporting discussion. A Psychosocial Advisory Committee was consulted in all aspects of the review, and an expert panel commented on draft recommendations and summary statements. Our review process produced 8 treatment recommendations in the following areas: assertive community treatment, supported employment, cognitive behavioral therapy, family-based services, token economy, skills training, psychosocial interventions for alcohol and substance use disorders, and psychosocial interventions for weight management. Reviews of treatments focused on medication adherence, cognitive remediation, psychosocial treatments for recent onset schizophrenia, and peer support and peer-delivered services indicated that none of these treatment areas yet have enough evidence to merit a treatment recommendation, though each is an emerging area of interest. This update of PORT psychosocial treatment recommendations underscores both the expansion of knowledge regarding psychosocial treatments for persons with schizophrenia at the same time as the limitations in their implementation in clinical practice settings.

Psychotherapy for Schizophrenia in an ACT Team Context

Cognitive-behavioral therapy (CBT) and assertive community treatment (ACT) are two evidence-based approaches to the treatment of schizophrenia; nevertheless, the two approaches are rarely combined. In the present case study, we discuss the treatment of a man diagnosed with schizophrenia with severe social anxiety. CBT approaches were used and treatment was conducted within the context of ACT services. CBT and ACT were found to be complementary, and the combination of approaches was found to be effective helping to reduce the client’s social anxiety. Implications for the treatment of schizophrenia are discussed.

Use of integrated dual disorder treatment via assertive community treatment versus clinical case management for persons with co-occurring disorders and antisocial personality disorder

We conducted secondary analyses of data from a randomized trial testing the effectiveness of Assertive Community Treatment (ACT) in delivery of integrated dual disorder treatment (IDDT) to explore the impact of IDDT delivered through ACT teams compared with standard clinical case management for dually-disordered persons with and without antisocial personality disorder (ASPD). This analysis included 36 individuals with ASPD and 88 individuals without ASPD. Participants with ASPD assigned to ACT showed a significantly greater reduction in alcohol use and were less likely to go to jail than those in standard clinical case management, whereas participants without ASPD did not differ between the 2 case management approaches. There were no significant differences for other substance use or criminal justice outcomes. This study provides preliminary evidence that persons with co-occurring serious mental illness, substance use disorders, and ASPD may benefit from delivery of IDDT through ACT teams.

Measuring principal substance of abuse in comorbid patients for clinical research

Few individuals with substance use disorders limit their intake to one substance of abuse; however, many studies focus on a single substance. Unfortunately, the optimal method to determine the principal substance is unclear. In particular, this issue is problematic in patients with co-occurring psychiatric illness, who commonly use multiple substances. Hence we compared three methods for assessing the principal substance of abuse in 150 subjects with bipolar disorder and substance dependence: 1) the Addiction Severity Index interview, 2) a self-administered questionnaire, and 3) the most frequently used substance. While most subjects were concordant on the interview and the other two methods, we found substantial disagreement (9.3% between the interview and the questionnaire, and 12.7% between the interview and the most frequently used substance) and partial agreement (14.0%). These findings from a comorbid population demonstrate that different methods to assess principal substance of abuse could lead to different conclusions about treatment outcomes. Hence studies of comorbid patients may benefit from 1) using more than one method to assess principal substance and 2) reporting use of all substances as well as a targeted substance.

Reprint of "Treatment of cannabis use disorders in people with schizophrenia spectrum disorders--a systematic review"

BACKGROUND

Cannabis use disorders (CUD) are prevalent among people with schizophrenia spectrum disorders (SSD), with a range of detrimental effects, e.g. reduced compliance to medication and psychosocial interventions, and increased level of psychotic-dimension symptoms. The aim of this study was to review literature on treatments of CUD in SSD-patients.

METHODS

PubMed, PsycINFO, EMBASE, and The Cochrane Central Register of Controlled Trials were searched.

RESULTS

41 articles were selected, 11 treating cannabis as a separate outcome. Contingency management was only effective while active. Pharmacological interventions appeared effective, but lacked randomized controlled trials (RCTs). Psychosocial interventions, e.g. motivational interviewing and cognitive behavior therapy (CBT), were ineffective in most studies with cannabis as a separate outcome, but effective in studies that grouped cannabis together with other substance use disorders.

CONCLUSIONS

Insufficient evidence exists on treating this form of dual-diagnosis patients. Studies grouping several types of substances as a single outcome may overlook differential effects. Future RCTs should investigate combinations of psychosocial, pharmacological, and contingency management.

Lessening Homelessness Among Persons with Mental Illness: A Comparison of Five Randomized Treatment Trials

We evaluate the influence of housing, services, and individual characteristics on housing loss among formerly homeless mentally ill persons who participated in a five-site (4-city) study in the U.S. Housing and service availability were manipulated within randomized experimental designs and substance abuse and other covariates were measured with a common protocol. Findings indicate that housing availability was the primary predictor of subsequent ability to avoid homelessness, while enhanced services reduced the risk of homelessness if housing was also available. Substance abuse increased the risk of housing loss in some conditions in some projects, but specific findings differed between projects and with respect to time spent in shelters and on the streets. We identify implications for research on homeless persons with mental illness that spans different national and local contexts and involves diverse ethnic groups.