Review of integrated mental health and substance abuse treatment for patients with dual disorders

Co-Occurrence of Substance use Disorders with other Psychiatric Disorders: Implications for Treatment Services

Introduction

This paper critically evaluates the literature on the co-occurrence of substance-use disorders (SUDs) with other psychiatric conditions. Our review considers the variety of different associations between the two, and suggests the implications of the literature for the design of treatment services that address both types of disorders. Methods: A narrative review of research and theory was conducted, covering epidemiology of co-occurring psychiatric disorders worldwide, mechanisms underlying co-occurrence, and treatment models. Results: Epidemiological research has documented a high prevalence of co-occurring disorders in both clinical samples and the general population, although the literature is based primarily on studies in high-income countries and some of the overlap might be due to the co-occurrence of milder forms of both types of disorders. Consistent with what has been reported in other reviews, we conclude that clients with co-occurring disorders tend to have a more severe course of illness, more severe health and social consequences, more difficulties in treatment, and worse treatment outcomes than clients with a single disorder; we address the implications of these findings for the design of treatment services. Conclusions: Much of the evidence shows that separately, treatments for both SUD and other psychiatric disorders are effective in reducing substance use and in improving behavioral, familial, and psychosocial outcomes. The evidence further suggests that these outcomes might be improved when treatment modalities are offered in combination within an integrated treatment plan that simultaneously addresses substance abuse and psychiatric problems. It is concluded that there is potentially more to be gained from taking a public health perspective and working on efforts to implement existing evidence-based practices at the systems level, than from the current tendency to look for ever more powerful individual-level interventions at the clinical level.

Integrating Addiction and Mental Health Treatment within a National Addiction Treatment System: Using Multiple Statistical Methods to Analyze Client and Interviewer Assessment of Co-Occurring Mental Health Problems

Aims

For a Swedish national sample of 12,833 individuals assessed for a substance use disorder (SUD) (2002-2008) in the Swedish welfare system, client self-report and clinical staff Addiction Severity Index (ASI) assessment data were used to assess mental health problem severity and needs.

Methods

Analysis of client self-report data using regression methods identified demographic characteristics associated with reporting significant mental health problems. Clinical staff assessment data from the ASI Interviewer Severity Rating (ISR) score were used to develop a K-means cluster analysis with three client cluster profiles: Narcotics (n=4795); Alcohol (n=4380); and Alcohol and Psychiatric Problems (n=3658). Chi-square and one-way ANOVA analyses identified self-reported mental health problems for these clusters.

Results

44% of clients had a history of using outpatient mental health treatment, 45% reported current mental health symptoms, and 19% reported significant mental health problems. Women were 1.6 times more likely to report significant mental health problems than men. Staff assessed that 74.8% of clients had current mental health problems and that 13.9% had significant mental health problems. Client and staff results were congruent in identifying that clients in the Alcohol profile were less likely (5%) to report having significant mental health problems compared to the other two profiles (30% each).

Conclusions

About 19% of clients with SUDs reported significant mental health problems, need integrated addiction and mental health treatment, and these clients are clustered in two population groups. An additional 25% of the addiction treatment population report current mental health symptoms and have at some point used mental health treatment. This national level assessment of the extent and severity of co-occurring disorders can inform decisions made regarding policy shifts towards an integrated system and the needs of clients with co-occurring disorders.

Integrated Dual Disorder Treatment Implementation in a Large State Sample

Individuals with co-occurring illnesses are at risk for poor outcomes related to criminal justice, hospitalization, housing, and employment. High fidelity evidence-based models, including integrated dual disorder treatment (IDDT), are associated with significant outcome improvements. A descriptive analysis of secondary datasets including the full sample of IDDT fidelity reviews completed from 2006 to 2012 in one state was completed. Total IDDT fidelity significantly improved from baseline fidelity review (68) to second review (40) [t(38) = 35.00, p < .001], and from second review to third review (13) [t(12) = 22.60, p < .001], with adequate inner-rater reliability by the second review. Individual items that were lower across reviews included practice penetration and family interventions, and higher individual items included multi-disciplinary team, integrated treatment specialist, and time-unlimited services, and treatment measures are higher than organizational measures in baseline and subsequent reviews. In this large state-wide sample, IDDT took time to implement, and improved fidelity occurred from baseline to third review, and variance between components of the practice was significant.

Predictors of outpatient mental health clinic follow-up after hospitalization among Medicaid-enrolled young adults

AIM

To assess demographic and clinical predictors of outpatient mental health clinic follow-up after inpatient psychiatric hospitalization among Medicaid-enrolled young adults.

METHODS

Using logistic regression and administrative claims data from the Maryland public mental health system and Maryland Medicaid for young adults ages 18-26 who were enrolled in Medicaid (N = 1127), the likelihood of outpatient mental health follow-up within 30 days after inpatient psychiatric hospitalization was estimated .

RESULTS

Only 51% of the young adults had any outpatient mental health follow-up visits within 30 days of discharge. Being black and having a co-occurring substance use disorder diagnosis were associated with a lower probability of having a follow-up visit (OR = 0.60, P < 0.01 and OR = 0.36, P < 0.01, respectively). In addition, those who utilized any outpatient public mental health services during the 180 days prior to their index hospitalization (N = 625, 55.4%) were more likely to have a follow-up visit than those without prior outpatient use (OR = 2.45, P < 0.01). Prior Medicaid-reimbursed primary care visits were not significantly associated with follow-up.

CONCLUSIONS

In this predominantly urban, low-income statewide sample of young adults hospitalized for serious psychiatric conditions, half did not connect with an outpatient mental healthcare provider following their discharge. Outpatient transition supports may be especially needed for young adults who were not receiving outpatient services prior to being admitted for psychiatric inpatient care, as well as for young adults with substance use disorders and African Americans.

Occupational Therapy and Evidence-Based Practice in Mental Health

Evidence-based practice (EBP) represents a paradigm shift in health care. This review has two aims. The first is to consider the merits of EBP, especially in respect of its use in mental health settings. The second is both to identify psychosocial interventions that have an established evidence base for effectiveness and to provide an analysis of the quality of this evidence and its implications for occupational therapy. Supported employment, family psychoeducation, assertive case management and integrated substance use treatment are examined in detail.

It is proposed that occupational therapists working in mental health give priority to psychosocial interventions that are based on evidence and incorporate these into their practice. It is further proposed that, in implementing EBP, practitioners take an active evaluating position in relation to published evidence, paying particular attention to the evidence of effectiveness in equivalent clinical environments.

Barriers to accessing methamphetamine treatment: A systematic review and meta-analysis

BACKGROUND

Methamphetamine use is associated with a range of poor health, social and justice outcomes. In many parts of the world increased methamphetamine use has been identified as a major public health concern. Methamphetamine treatment programmes have been effective in reducing and ceasing use, however a range of barriers have prevented these programmes being widely adopted by methamphetamine users. This review examines the barriers to accessing meth/amphetamine treatment identified in the literature.

METHODS

Databases were systematically searched using relevant terms for peer-reviewed articles describing original research exploring the barriers to accessing treatment for meth/amphetamine use. Reviews and grey literature were excluded. Eleven studies conducted in 5 countries were included in data synthesis; this involved a systematic review of all 11 studies, and meta-analysis of the prevalence of barriers reported in 6 studies that published sufficient quantitative data.

RESULTS

Psychosocial/internal barriers to accessing methamphetamine treatment were most prevalent across studies (10/11 studies). Meta-analysis confirmed the four most commonly endorsed barriers to treatment access across studies all psychosocial barriers were embarrassment or stigma (60%, 95% CI: 54-67%); belief that treatment was unnecessary (59%, 95% CI:54-65%); preferring to withdraw alone without assistance (55%, 95% CI:45-65); and privacy concerns (51%, 95% CI:44-59%).

CONCLUSIONS

The primary barriers to accessing methamphetamine treatment are psychosocial/internal. Services and treatment models that address these barriers are urgently required. There is a growing need for methamphetamine-appropriate treatment services. Further research evaluating treatment engagement and effectiveness for methamphetamine and polysubstance use, including the development of effective pharmacotherapies is warranted.

Psychotic relapse and associated factors among patients attending health services in Southwest Ethiopia: a cross-sectional study

BACKGROUND

Psychotic relapse leads to repeated hospitalization and negatively affects the clinical prognosis of the patients. Information on prevalence of relapse among patients with psychotic disorders in Ethiopian setting is scarce. This study aimed to assess the prevalence of relapse among patients with psychotic disorders attending services in Jimma University Specialized Hospital (JUSH).

METHODS

Data were collected using interviewer administered questionnaire. We used medication adherence rating scale (MARS) to assess compliance to medication and abnormal involuntary movement scale (AIMS) to detect medication side effects. Logistic regression analysis was used to identify independent predictors of psychotic relapse. All variables with P-value <0.25 in the bivariate analyses were entered into multivariate logistic regression and variables with P-value < 0.05 in the final model were declared to be significantly associated with the outcome variable.

RESULTS

The prevalence of relapse among patients with psychotic disorder was 24.6 % (n = 95). Of this, 25.4 and 22.4 % were males and females respectively. The odds of developing psychotic relapse among patients living with family was 72 % lower than that of patients living alone (aOR = 0.28, 95 % CI = 0.08, 0.93). The odds of developing psychotic relapse among patients compliant to medication was 69 % lower than that of patients who were not compliant to medications (aOR = 0.31, 95 % CI = 0.12, 0.80). The odds of developing psychotic relapse among patients having high score on social support score was 48 % lower than that of patients who were compliant to medications (aOR = 0.52, 95 % CI = 0.28, 0.95). The odds of developing psychotic relapse among patients reporting to have sought religious support was 45 % lower than that of patients who have not sought religious support (aOR = 0.55, 95 % CI = 0.31, 0.96). On the other hand, the odds of developing psychotic relapse among participants who have experienced medication side effects was 1.83 times higher when compared to those who have never experienced medication side effects (aOR = 1.83, 95 % CI = 1.01, 3.31).

CONCLUSIONS

The high prevalence of relapse among patients with psychotic disorder needs special attention. Clinicians need to pay attention to medication side effects the patient faces. Intervening noncompliance to medication and appropriately managing medication side effects may help in preventing psychotic relapse that may result because of non-compliance. The provision of counseling, psycho education, psycho social support may help patients in improving compliance to medication and reducing psychotic relapse. Developing and strengthening community based rehabilitation services should be emphasized as part of mental healthcare services.

Acceptance and Commitment Therapy in the Treatment of Comorbid Substance Abuse and Post-Traumatic Stress Disorder

Although post-traumatic stress disorder (PTSD) and substance abuse are commonly co-occuring conditions, it is generally recommended that an individual must first receive successful substance abuse treatment before posttraumatic symptoms can be addressed. Given the high comorbidity of these conditions, however, it would be helpful if more broadly focused therapies were available that simultaneously targeted common functional processes underlying the multiple problems of the dually diagnosed. Both PTSD and substance abuse can be conceptualized as disorders with significant experiential avoidance components. One treatment that has been specifically developed for the treatment of experiential avoidance is Acceptance and Commitment Therapy (ACT). In this case study, application of ACT for an individual with comorbid PTSD and substance abuse is described, and its effects are examined.

Effect of dehydroepiandrosterone add-on therapy on mood, decision making and subsequent relapse of polydrug users

A major problem in the treatment of addiction is predicting and preventing relapse following a rehabilitation program. Recently, in preclinical rodent studies dehydroepiandrosterone (DHEA) was found to markedly improve the resistance to drug reuse. In a double-blind, placebo-controlled study, we examined the effect of DHEA on relapse rates in adult polydrug users taking part in a detoxification program enriched with intensive psychosocial interventions and aftercare. During treatment, participants (79 percent males, mean age 28) consumed DHEA (100 mg/day) or placebo daily for at least 30 days. Of the 121 initial volunteers, 64 participated for at least 1 month. While in treatment, DHEA reduced negative affect on the Positive and Negative Affect Scale (F = 4.25, P = 0.04). Furthermore, in a 16-month follow-up, we found that reuse rates in the DHEA condition were about a third compared with placebo (12 versus 38 percent; χ(2)  = 5.03, P = 0.02). DHEA treatment also resulted in an increase in DHEA sulfate (DHEA-S) 1 month following treatment, and the level of DHEA-S predicted relapse in the follow-up assessment.

Integrating smoking cessation into mental health care for post-traumatic stress disorder

Background Post-traumatic stress disorder (PTSD) is associated with a high prevalence of smoking, heavy cigarette consumption and low cessation rates.

Purpose This manuscript describes the design of a randomized, multisite effectiveness trial to test whether integrating smoking cessation treatment into mental health care (integrated care) improves prolonged abstinence rates among veterans with PTSD, compared with referral to specialized smoking cessation clinics (usual standard of care). Secondary objectives are to assess the cost-effectiveness of integrated care relative to usual standard of care, identify treatment variables that mediate differences between conditions in outcome and determine whether smoking cessation is associated with worsening PTSD and/or depression.

Methods Following randomization, subjects (projected n = 1400) from 10 Veterans Health Administration (VHA) medical centers complete follow-up assessments every three or six months for up to four years. Endpoints include 1-year prolonged abstinence at 18 months postrandomization, 7- and 30-day point-prevalence abstinence and measures of depression, PTSD and economic outcomes.

Results This study is unique in providing the largest scale test of the feasibility and effectiveness of having mental health clinicians implement evidence-based smoking cessation treatment in psychiatric care settings for veterans with PTSD. It incorporates methodological features that are desirable for cessation treatment trials, including: a) assessment of clinically meaningful long-term smoking outcomes; b) a manual guiding delivery of the experimental intervention; c) independent ratings of clinician competence and treatment adherence and d) methods for training clinicians that would enhance implementation of tobacco cessation treatment in large health care systems.

Limitations Use of an exclusively VHA sample with few females limits generalizability. Conclusions The process for meeting challenges in designing this study may provide planning of other large-scale clinical effectiveness trials in tobacco control.

Findings have potential to initiate system-wide change in clinical practice patterns for tobacco cessation treatment involving patients with mental disorders. Clinical Trials 2007; 4: 178—189. http://ctj.sagepub.com

Implementation and Outcomes of Forensic Housing First Programs

This mixed-method study used administrative data from 68 supportive housing programs and evaluative and qualitative site visit data from a subset of four forensic programs to (a) compare fidelity to the Housing First model and residential client outcomes between forensic and nonforensic programs and (b) investigate whether and how providers working in forensic programs can navigate competing Housing First principles and criminal justice mandates. Quantitative findings suggested that forensic programs were less likely to follow a harm reduction approach to substance use and clients in those programs were more likely to live in congregate settings. Qualitative findings suggested that an interplay of court involvement, limited resources, and risk environments influenced staff decisions regarding housing and treatment. Existing mental health and criminal justice collaborations necessitate adaptation to the Housing First model to accommodate client needs.

Trans-Sector Integrated Treatment in Psychosis and Addiction

BACKGROUND

Patients with psychosis often develop comorbid addiction, with a lifetime prevalence of ca. 50%. Dual diagnoses are considered hard to treat. Long-term integrated treatment programs might improve such patients' outcomes, at least to a moderate extent, but they have not yet been adequately studied or implemented in Germany to date.

METHODS

100 dual diagnosis patients participated in a single-center, randomized, controlled trial under standard hospital treatment conditions. They were randomly allotted to two groups. Patients in the intervention group were admitted to a specialized open hospital ward, where they were given integrated treatment, including disorder-specific group therapy. Their treatment was continued with further disorder-specific group therapy in the outpatient setting. Patients in the control group were admitted to an open general psychiatric ward and received treatment as usual, but no disorder-specific treatment either during their hospitalization or in the subsequent outpatient phase. Follow-up examinations were performed three, six, and twelve months after inclusion. The primary outcome was defined as the changes in substance use and abstinence motivation. The secondary outcome consisted of the patients' satisfaction with treatment and with life in general, retention rate, psychopathology, rehospitalizations, and global level of functioning.

RESULTS

The patients in the intervention group developed higher abstinence motivation than those in the control group (p = 0.009) and transiently reduced their substance use to a greater extent (p = 0.039 at three months). They were also more satisfied with their treatment (group effect: p = 0.011). Their global level of functioning and their retention rate were also higher, but these differences did not reach statistical significance.

CONCLUSION

Low-threshold, motivational, integrated treatment programs with psycho-educative and behavioral therapeutic elements may be helpful in the treatment of dual diagnosis patients and should be more extensively implemented as part of standard hospital treatment. Larger-scale, methodologically more complex studies will be needed to identify subgroups of patients that respond to such treatments in different ways.

Offense Characteristics of Incompetent to Stand Trial Defendants Charged With Violent Offenses

The current study compared offender and offense characteristics of pretrial defendants found incompetent to stand trial (IST) against those described as general offenders by victims in the 2008 Bureau of Justice Statistics (BJS) survey and evaluated factors that differentiated IST defendants who allegedly used weapons from those who did not during the course of a violent offense. IST defendants were older and used "weapons" more frequently than those reported in the BJS survey; however, other characteristics, including use of firearms, did not differ. No demographic, clinical, or legal factors differentiated pretrial defendants who used weapons from those who did not. Overall, pretrial defendants were frequently diagnosed with a comorbid substance use disorder, and were homeless, unemployed, and had an extensive history of psychiatric hospitalizations and prior arrests at the time of their alleged offenses. Such results indicate that models for comprehensive discharge planning may have utility in addressing the unique needs of this subgroup of mentally disordered offenders. The findings also raise questions about the federal and state prohibition of gun rights to all IST defendants.

Delivery of a mainstreaming treatment model towards co-existing difficulties: a brief exploration of practitioners’ understanding, views and reported experiences

Purpose

– The purpose of this paper is to describe the delivery of a mainstreaming model within a public sector, mental health (National Health Service (NHS)) organisation. The model promotes the inclusivity of a spectrum of presentations from co-existing moderate anxiety and depression to severe mental disorder (psychosis) and problematic substance and alcohol use.

Design/methodology/approach

– This paper introduces the delivery of three collective approaches, termed the “three essential elements” to support a mainstreaming treatment model, facilitated by a “Dual Diagnosis Lead”. The model encompasses; a “direct access” referral pathway, joint collaboration with practitioners and the delivery of a “Dual Diagnosis” training programme. An independent evaluation was commissioned to explore eight mental health and substance misuse practitioners’ views and experiences in relation to the impact of the mainstreaming model. This paper also considers feedback from 230 course participants attending a one day “Dual Diagnosis” training programme.

Findings

– This paper suggests that practitioners may benefit from the implementation of the mainstreaming approach and the delivery of this approach could be moving “Dual Diagnosis” interventions closer to mainstream practice.

Research limitations/implications

– The limitations of the mainstreaming model are acknowledged in relation to the generalisation of practitioners’ views and reported experiences.

Originality/value

– This paper offers a description of the delivery of a mainstreaming model involving the “three essential elements”. The model provides a useful insight and demonstrates the possibilities which may be achieved when attempting to implement a mainstreaming treatment approach within mainstream mental health and drug and alcohol services.

Probability and predictors of treatment-seeking for substance use disorders in the U.S

BACKGROUND

Little is known about to what extent treatment-seeking behavior varies across individuals with alcohol abuse, alcohol dependence, drug abuse, and drug dependence.

METHODS

The sample included respondents from the Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) who reported a lifetime diagnosis alcohol abuse, alcohol dependence, drug abuse, or drug dependence. Unadjusted and adjusted hazard ratios are presented for time to first treatment contact by sociodemographic characteristics and comorbid psychiatric disorders. Individuals were censored from the analyses if their condition remitted prior to seeking treatment.

RESULTS

In the first year after disorder onset, rates of treatment-seeking were 13% for drug dependence, 5% for alcohol dependence, 2% for drug abuse, and 1% for alcohol abuse. The lifetime probability of seeking treatment among individuals who did not remit was also highest for drug dependence (90%), followed by drug abuse (60%), alcohol dependence (54%), and alcohol abuse (16%). Having had previous treatment contact for a substance use disorder (SUD) increased the probability of seeking treatment for another SUD. By contrast, an early age of SUD onset, belonging to an older cohort, and a higher level of education decreased the lifetime probability of treatment contact for SUD. The role of comorbid mental disorders was more complex, with some disorders increasing and other decreasing the probability of seeking treatment.

CONCLUSIONS

Given high rates of SUD and their substantial health and economic burden, these patterns suggest the need for innovative approaches to increase treatment access for individuals with SUD.

Developing a dual diagnosis service in Cork, Ireland by way of participatory action research (PAR)

Purpose

– Developing a dual diagnosis service in Cork, Ireland by way of participatory action research (PAR) background: internationally there is a growing consensus regarding the ideal of integrated treatment. In Ireland, recommendations identified the need for multi-disciplinary team integration and client participation being central to service development. Such recommendations collectively fit most appropriately with PAR, the methodological and theoretical framework best suited to achieve the objectives of the inquiry. PAR's inclusive philosophy creates processes of negotiation, self-reflexivity and exploration of power issues with the lived experience of communities. Key elements of this approach facilitate the development of emancipatory and participatory democracy whilst highlighting identified social issues through research, learning and action. The paper aims to discuss these issues.

Design/methodology/approach

– Cyclical processes of planning, action, observation and reflection in cycle one have facilitated the introduction of PAR's methodological framework into the existing public health (Health Service Executive) system of primary care addiction and mental health services. Developing stakeholder relationships in decision making processes has been pivotal in cycle 1 as the process of collective engagement evolves. Stakeholders begin to experience their collective participation in the methods adopted and a collective sense of ownership and commitment to the iterative process begins to take shape. Stakeholders in cycle 1 have participated in multiple data generation methods including: informal interviews, planned discussion and focus groups, multidisciplinary team meetings, testimonials, observations and reflections.

Findings

– Cycle 1 of this PAR inquiry has engaged stakeholders (service users and their families, practitioners including; academic/practitioners, a consultant psychiatrist, psychologist, mental health nurses, an occupational therapist, psychotherapists, an acupuncturist, an addiction counsellor, an art therapist) in an integrated process of inquiry. PAR methods adopted in this cycle have facilitated particular dual diagnosis service developments and emerging initiatives (previously unidentified). Actions collaboratively planned for and illustrated in this paper include: the implementation of a psychotherapy group and implementing direct access to an acupuncture clinic.

Originality/value

– Stakeholders collaboratively experience PAR's methodological and theoretical approach which has facilitated service developments in cycle 1 of the inquiry. This sets the stage for the completion of actions already in motion and for further initiatives to continue to evolve as cycle 2 processes emerge.

A multi-agency evaluation of the Leeds Dual Diagnosis care co-ordination protocol

Purpose

– The purpose of this paper is to demonstrate the learning from the multi-agency evaluation of the Leeds Dual Diagnosis Care co-ordination protocol undertaken by the Leeds Dual Diagnosis (DD) Project in 2013. The evaluation aimed to identify the prevalence of people with DD accessing network member services, and to identify the standard of care network members provided for people with DD in relation to the Leeds Care Co-ordination Protocol.

Design/methodology/approach

– The evaluation adopted a service evaluation methodology and included features of real world research. Two standardised self-completion questionnaires were administered using Survey Monkey™ software.

Findings

– The majority of service could provide prevalence data however the quality of data provided was significantly impacted by the limitations of client management systems. Completion of specific DD training beyond basic awareness was generally low and many participants were confused about the different levels of training available. Standards of care varied, a substantial amount of joint working was taking place via informal pathways which relied on established relationships and trust between practitioners and services. Jointing working was often informal when people were not under the Care Programme Approach.

Research limitations/implications

– Due of the methodological choices the evaluation cannot be considered impartial. The prevalence data gathered lacks robustness and does not reflect the number of people who meet clinical threshold for DD as valid screening tools were not used by all services. The standards of care identified only reflect practitioner's personal views and do not provide a definitive answer to the standard of care being delivered. The response rate in relation to standards of care was low with large amounts of missing data negatively impacting the external validity of data gathered.

Practical implications

– The completion of this evaluation demonstrates that it is extremely challenging to undertake a multi-agency evaluation with limited resources. It has highlighted key challenges and areas for future development locally in relation to DD. The themes explored are likely to be of interest to commissioners, service managers, DD consultant nurses and anyone involved in the strategic development of DD.

Originality/value

– The evaluation has generated information which is of practical significance to local commissioners and Leeds DD Network Members. The knowledge and learning from this evaluation has subsequently been used by the Leeds DD Strategy Group to inform the new action plan for the DD Project, the re-commissioning of substance misuse services and the new mental health framework being developed for Leeds.

Differences between patients with schizophrenia with and without co-occurring methamphetamine use disorders in a Taiwanese public psychiatric hospital

This study aimed to examine the factors related to and the outcomes of schizophrenic patients with co-occurring methamphetamine use disorders (MUDs). All schizophrenic patients discharged from a psychiatric hospital between January 1, 2006, and December 31, 2006, were monitored. This study compared the important demographic and clinical variables between patients with co-occurring MUDs and those without, and postdischarge measured time to rehospitalization during a 1-year period. Seven hundred fifty-six patients were included in this study. Of these patients, 88 (11.6%) reported the use of methamphetamine. Univariate analyses indicated that male sex, low educational level, discharge against medical advice, missed first appointment after discharge, co-occurring other illicit substance use disorder, age (younger), diazepam equivalents prescribed at discharge (higher), number of previous admissions within the past 5 years (higher), and length of hospital stay (longer) were predictive of patients with co-occurring MUDs. There were also significant differences in time to rehospitalization between these two groups during the follow-up periods. Many factors can be identified in schizophrenic patients with co-occurring MUDs. Furthermore, schizophrenic patients with co-occurring MUDs were more likely to be rehospitalized. Future studies in many different mental health systems are needed before these findings can be generalized.

Psychosocial rehabilitation and chronic mental illness: international trends and South African issues

Psychosocial rehabilitation of persons with chronic mental illness has received increasing research attention over the past three decades. It is now widely accepted that pharmacotherapy alone is insufficient to treat persons with chronic mental illness. Additionally, there has been a paradigm shift towards the integration of evidence-based rehabilitation models and recovery models, which focus on collaborative approaches to care. This article reviews research findings relating to psychosocial rehabilitation interventions and models, and considers the implementation of psychosocial rehabilitation policies and practices in the South African healthcare context. Challenges to implementation and recommendations are presented.

Facilitators and barriers in dual recovery: a literature review of first-person perspectives

Purpose

– The co-occurrence of mental health and substance use problems is prevalent, and has been problematic both in terms of its complexity for the person and of the challenges it poses to health care practitioners. Recovery in co-occurring mental health and substance use problems is viewed as with multiple challenges embedded in it. As most of the existing literature on recovery tends to treat recovery in mental health and substance use problems separately, it is critical to assess the nature of our current understanding of what has been described as “complex” or “dual” recovery. The purpose of this paper is to identify and discuss what persons with co-occurring mental health and substance use problems describe as facilitators and barriers in their recovery process as revealed in the literature.

Design/methodology/approach

– The method used for this study was a small-scale review of the literature gleaned from a wider general view. Searches were conducted in CINAHL, Psych info, Medline, Embase, SweMed+, and NORART.

Findings

– Three overarching themes were identified as facilitators of dual recovery: first, meaningful everyday life; second, focus on strengths and future orientation; and third, re-establishing a social life and supportive relationships. Two overarching themes were identified as barriers to dual recovery: first, lack of tailored help and second, complex systems and uncoordinated services.

Originality/value

– The recovery literature mostly focuses on recovery in mental health and substance use problems separately, with less attention being paid in the first-person literature to what helps and what hinders dual recovery.

Mortality and psychiatric disorders among public mental health care clients in Utrecht: a register-based cohort study

BACKGROUND

Different studies have shown similar or even lower mortality among homeless persons with compared to homeless persons without a severe mental disorder.

AIMS

To clarify the association between presence of a psychiatric diagnosis and mortality among the socially marginalized.

METHODS

The Public Mental health care (PMHc) is a legal task of the municipal authority aiming at prevention and intervention in case of (imminent) homelessness among persons with a serious shortage of self-sufficiency. The data of PMHc clients (N=6,724) and personally matched controls (N=66,247) were linked to the registries of Statistics Netherlands and analysed in a Cox model.

RESULTS

The increased mortality among PMHc clients, compared to the general population (HR=2.99, 95%-CI: 2.63-3.41), was associated with a broad range of death causes. Clients with a record linkage to the Psychiatric Case Registry Middle Netherlands ('PMHc+') had an increased risk of suicide (HR=2.63, 0.99-7.02, P=0.052), but a lower risk of natural death causes (HR=0.71, 0.54-0.92, P=0.011), compared to clients without this record linkage ('PMHc-'). Compared to controls, however, 'PMHc-' clients experienced substantially increased risks of suicide (HR=3.63, 1.42-9.26, P=0.007) and death associated with mental and behavioural disorders (ICD-10 Ch.V) (HR=7.85, 3.54-17.43, P<0.001).

CONCLUSION

Psychiatric services may deliver an important contribution to the prevention of premature natural death among the socially marginalized.

KEYPHRASES

The earlier observed lower mortality among vulnerably housed and homeless persons with a psychiatric diagnosis compared to vulnerably housed and homeless persons without a psychiatric diagnosis appears to be due to a significantly lower risk of natural causes of death. Compared to controls from the general population, vulnerably housed and homeless persons without registered diagnosis at a local psychiatric service have a significantly increased mortality associated both with natural death causes and with suicide and death due to mental and behavioural disorders. Services for mental health care may deliver an important contribution to the prevention of premature death due to somatic disorders among the socially marginalized.

Consumer perceptions of trauma assessment and intervention in substance abuse treatment

Substance abuse treatment programs are increasing their use of integrated interventions for trauma and substance abuse. While positive behavioral outcomes have been associated with this model, the purpose of this study was to determine consumers' satisfaction with it. Participants were 51 men and 102 women who received trauma assessments and interventions through a drug treatment court. Satisfaction with treatment was measured through the Consumer Perception of Care (CPC). Participants were generally satisfied with the trauma assessments and interventions they received. Number of traumatic experiences, measured by the Adverse Childhood Experiences (ACE) scale, and level of distress, as assessed on the Trauma Symptom Inventory (TSI), were significantly associated with assessment and treatment satisfaction. Gender differences were noted, with men reporting fewer traumatic experiences and trauma-symptoms and less satisfaction with trauma assessment. Implications for the integration of trauma and substance abuse interventions in drug treatment courts and other programs are discussed.

An outcomes study of eTherapy for dual diagnosis using Breaking Free Online

Purpose

– In recent years there has been a proliferation of computer-based psychotherapeutic interventions for common mental health difficulties. Building on this, a small number of such interventions have now been developed to address substance dependence, one of which is Breaking Free Online (BFO). A new “eTherapy” self-help service, which was set up by the UK mental health charity Self-Help Services, has provided access to BFO to service users presenting with comorbid mental health and substance misuse difficulties. The purpose of this paper is to evaluate a range of clinical outcomes in the first cohort of service users accessing this dual diagnosis service.

Design/methodology/approach

– A number of standardised psychometric assessments were conducted with service users at baseline and post-treatment at discharge from the service. Outcome data were available for 47 service users out of an original cohort of 74.

Findings

– Statistically significant improvements were found in terms of measures of social functioning, depression, anxiety, alcohol and drug use and social anxiety. Clinically relevant gains were also identified, with fewer service users reaching threshold scores for depression and anxiety at post-treatment compared to baseline. Effect sizes also indicated that the identified improvements across the psychometric measures were robust and significant.

Research limitations/implications

– These findings provide further support for the clinical effectiveness of BFO, and also provide evidence that an eTherapy self-help service may be appropriate for some individuals presenting with dual diagnosis. Further research is underway with larger and alternative clinical populations to examine the effectiveness of BFO and also this novel eTherapy self-help approach.

Originality/value

– This paper has provided initial data to support effectiveness of a novel eTherapy service for dual diagnosis.

Six-month outcomes of an integrated assertive community treatment team serving adults with complex behavioral health and housing needs

Assertive community treatment (ACT) and integrated dual disorders treatment (IDDT) have individually proven effective for treatment of adults with complex behavioral health and housing needs. This study evaluated the effectiveness of an ACT team that delivered integrated care consistent with IDDT principles. Participants included 60 adults with a history of chronic homelessness and co-occurring mental health and substance use disorders. Measures assessing mental health, substance use, and residential stability were completed at intake to the program and then 6 months later. Participants reported statistically significant improvements in mental health symptomatology and residential stability over time, although there were no changes in substance use. Findings support the effectiveness of the intervention for improving mental health and housing stability among adults with complex behavioral health and housing needs. Fidelity data support the notion that multiple evidence-based interventions can be integrated while still maintaining adequate fidelity to individual components.

Organizational factors influencing implementation of evidence-based practices for integrated treatment in behavioral health agencies

Objective. In recent years, New Mexico has prioritized integrated treatment for cooccurring mental health and substance use disorders within its public behavioral health system. This report describes factors likely to be important when implementing evidence-based practices (EBPs) in community agencies. Methods. Our mixed-method research design consisted of observations, semistructured interviews, and surveys undertaken with employees at 14 agencies at baseline and after 18 months. We developed four-agency typologies based on iterative coding and analysis of observations and interviews. We then examined survey data from employees at the four exemplar agencies to validate qualitative findings. Results. Financial resources and strong leadership impacted agency capacity to train providers and implement EBPs. Quantitative analysis of service provider survey responses from these agencies (N = 38) supported qualitative findings and demonstrated significant mean score differences in leadership, organizational climate, and attitudes toward EBPs in anticipated directions. Conclusion. The availability of strong leadership and financial resources were key components to initial implementation success in this study of community agencies in New Mexico. Reliance only on external funding poses risks for sustainment when demoralizing work climates precipitate employee turnover. Strong agency leadership does not always compensate for deficient financial resources in vulnerable communities.

Stigma, agency and recovery amongst people with severe mental illness

Evidence suggests that people with a severe mental illness still suffer high levels of stigma and discrimination. However little is known about how people with a severe mental illness manage such stigma. As such, the overall aim of this study is to document and analyze behavioral and psychological strategies of stigma management and control in a sample of people in recovery from a severe mental illness. To meet this aim, we conducted a five-year (2008-2012) qualitative longitudinal study in Washington D.C. Participants were recruited from small-scale congregate housing units ('recovery communities') for people in recovery, provided by a public mental health agency. We conducted regular focus groups at these communities, augmented by in-depth participant observation. Analysis was propelled by the grounded theory approach. A key finding of this study is that stigma and discrimination were not perceived as commonly experienced problems by participants. Instead, stigma and discrimination were perceived as omnipresent potential problems to which participants remained eternally vigilant, taking various preventive measures. Most notable among these measures was a concerted and self-conscious effort to behave and look 'normal'; through dress, appearance, conduct and demeanor. In this endeavor, participants possessed and deployed a considered degree of agency to prevent, avoid or preempt stigma and discrimination. These efforts appeared to have a strong semiotic dimension, as participants reported their developing 'normality' (and increased agentic power) was tangible proof of their ongoing recovery. Participants also routinely discussed severe mental illness in normative terms, noting its similarity to physical illnesses such as diabetes, or to generic mental health problems experienced by all. These behavioral and psychological strategies of normalization appeared to be consolidated within the recovery communities, which provided physical shelter and highly-valued peer support. This fostered participants' ability to face and embrace the outside world with confidence, pride and dignity.

Quality of life in veterans with alcohol dependence and co-occurring mental illness

Quality of life is negatively impacted by diagnosis of mental illness. Those with mental illness report problems in physical, psychological, cognitive, social, and occupational functioning. This study was designed to examine changes in quality of life in veterans with dual diagnoses. All veterans participated in a treatment study designed to treat alcohol dependence with naltrexone, disulfiram, and the combination of naltrexone/disulfiram or placebo for 12 weeks. Quality of life was assessed before treatment and at the end of treatment. Quality of life improved for all veterans and the improvement was more significant for those who abstained from alcohol throughout treatment. Severity of psychiatric symptom was associated with worse quality of life. This study demonstrates the importance of addressing social functioning in veterans with dual diagnosis.

Remote "hovering" with individuals with psychotic disorders and substance use: feasibility, engagement, and therapeutic alliance with a text-messaging mobile interventionist

OBJECTIVE

People with serious mental illnesses and substance abuse problems (i.e., dual diagnosis) constitute a particularly challenging and costly clinical group. This study evaluated the feasibility and acceptability of a novel model of care in which a mobile interventionist used mobile phone text messaging to remotely monitor and provide daily support to individuals with psychotic disorders and substance use.

METHODS

Seventeen participants with dual diagnosis were enrolled in a 12-week single-arm trial. A clinical social worker served as the mobile interventionist and sent daily text messages to participants' privately owned mobile phones to assess their medication adherence and clinical status. The mobile interventionist provided text-message feedback and support and suggested various coping strategies flexibly, in response to participants' replies to prompts. At the end of the trial, participants completed a usability and satisfaction measure and two self-rated measures of therapeutic alliance with their clinicians. In one version, participants rated their relationship with their mobile interventionist; in the second version, they rated their relationship with their community-based treatment team.

RESULTS

Participants received an average of 139 text messages (SD = 37.5) each from the mobile interventionist over the 12-week trial. On average, participants responded to 87% of the mobile interventionist's messages that required a reply. More than 90% of participants thought the intervention was useful and rewarding and that it helped them be more effective and productive in their lives. Participants' assessments of their relationship with the mobile interventionist were positive. Paired-sample t-test found that the therapeutic alliance ratings participants provided for their mobile interventionist were significantly higher than those provided for their community-based treatment team clinicians, who they met with regularly.

CONCLUSIONS

Our findings suggest that text-message "hovering" can be conducted successfully with individuals with psychotic disorders and substance abuse. Developing a cadre of mobile interventionists who are specifically trained on how to engage patients via mobile devices while adhering to ethical guidelines and regulatory standards may be an effective way to strengthen service delivery models, improve patient outcomes, and reduce costs.

Stress, substance abuse, and addiction

Experiencing stressful life events is reciprocally associated with substance use and abuse. The nature of these relationships varies based on the age of stress exposure and stage of substance use involvement. This chapter reviews the developmental and biological processes involved in the relationship of stress exposure and substance use initiation, substance use maintenance and relapse, and response to substance abuse treatment. Special emphasis is given to describing the various stress-related mechanisms involved in substance use and abuse, highlighting the differences between each of these phases of drug use and drawing upon current research to make suggestions for treatments of substance use disorder (SUD) patients. Stress is inherent to the experience of life and, in many situations, unavoidable. Through ongoing research and treatment development, there is the potential to modify the relationship of stress with ongoing substance use and abuse.

Strategies to predict, measure, and improve psychosocial treatment adherence

Nonadherence to psychosocial and behavioral treatment is a significant public health problem that presents a barrier to recovery and effective treatment. An estimated 20% to 70% of individuals who initiate psychosocial mental health services discontinue treatment prior to clinicians' recommendations. Empirically supported, evidence-based, stand-alone or adjunctive psychosocial interventions treat an increasingly wide range of mental health conditions. A core assumption of most, if not all, interventions is that clients will fully and actively engage in the treatment protocol. Adherence to psychosocial treatment has received much less scientific attention, however, than adherence to medical treatment. Drawing extensively from existing research, this comprehensive review conceptualizes several types of psychosocial and behavioral treatment adherence, examines predictors of adherence to psychosocial treatment, summarizes measures of adherence, and describes existing interventions to enhance psychosocial treatment adherence.

12-step facilitation for the dually diagnosed: a randomized clinical trial

There are few clinical trials of 12-step treatments for individuals with serious mental illness and alcohol or drug dependence. This randomized trial assessed the effects of adding a 12-session 12-step facilitation therapy (TSF), adapted from that used in Project MATCH, to treatment as usual in an outpatient dual diagnosis program. Participants were 121 individuals dually diagnosed with alcohol dependence and a serious mental disorder, followed during 12 weeks of treatment and 36 weeks post-treatment. Participants receiving TSF had greater participation in 12-step programs, but did not demonstrate greater improvement in alcohol and drug use. However, considered dimensionally, greater participation in TSF was associated with greater improvement in substance use, and greater 12-step participation predicted decreases in frequency and intensity of drinking. Findings suggest that future work with TSF in this population should focus on maximizing exposure to TSF, and maximizing the effect of TSF on 12-step participation.

Predictors of persistent psychotic symptoms in persons with methamphetamine abuse receiving psychiatric treatment

The objective of this study was to identify predictors of sustained psychotic symptoms after methamphetamine (MA) abuse during the course of 6 months from patterns of MA and other substance use, depressive symptoms, family history of psychosis, antisocial personality disorder, and trauma history. A total of 295 individuals with MA abuse and psychotic symptoms seeking psychiatric services were assessed at baseline and then monthly on symptoms and substance use for 6 months. Trajectory analyses revealed two trajectories of the individuals with positive symptoms, with one group presenting with persistent psychotic symptoms (30% of the sample). Those with persistent psychosis were significantly older, had more severe psychotic symptoms, misused MA for more years, had more antisocial personality traits, and had more sustained depressive symptoms. The strongest predictors of belonging to the persistent psychosis group, via logistic regressions, were more severe psychotic symptoms, longer use of MA, and sustained depressive symptoms. Our results highlight the important comorbidities, especially regarding depressive symptoms and persistent psychosis, in individuals seeking psychiatric help after MA abuse. This study also highlights the importance of identifying people with persistent psychosis within MA users to facilitate rapid and effective treatment of co-occurring psychotic disorder.

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.

Drug and alcohol trajectories among adults with schizophrenia: data from the CATIE study

OBJECTIVE

The primary aim is to describe drug and alcohol trajectories in adults with schizophrenia.

METHOD

Growth mixture models were used to examine disordered and non-disordered use and abstinence in the Clinical Antipsychotic Trials of Intervention Effectiveness study.

RESULTS

Five classes - always abstinent; fluctuating use, abuse, and occasional abstinence; occasional (ab)use; stopped (ab)use; abusing - fit best. Overlap exists between always abstinent drug and alcohol classes; less overlap exists across other classes.

CONCLUSION

There is heterogeneity in drug and alcohol use among adults with schizophrenia. The lack of overlap between classes, save always abstinent, suggests modeling drug and alcohol use separately.

Characterizing the longitudinal patterns of substance use among individuals diagnosed with serious mental illness after psychiatric hospitalization

AIM

To characterize longitudinal patterns of substance use across a large sample of psychiatric patients discharged from inpatient admission, followed for 1-year post-hospitalization.

DESIGN

Prospective cohort study.

SETTING

Kansas City, MO, USA; Pittsburgh, PA, USA; Worcester, MA, USA.

PARTICIPANTS

Eight hundred and one schizophrenia-spectrum (n = 204), bipolar (n = 137) and depressive disorder (n = 460) patients from the MacArthur Violence Risk Assessment Study.

MEASUREMENTS

Symptoms, functioning, drug/alcohol use assessed by the Brief Psychiatric Rating Scale, the Global Assessment of Functioning, and substance use interviews.

FINDINGS

Patients used alcohol (67.0%; n = 540) and cannabis (30.0%; n = 237) more frequently than other substances up to 30 days before admission, and those with depressive and schizophrenia-spectrum used heroin more than individuals with bipolar (P = 0.023). Post-hospitalization, patients using alcohol (B = -0.15, P < 0.001) and cannabis (B = -0.27, P < 0.001) decreased, but patterns varied across diagnosis and genders. Patients using cannabis decreased at greater rates in depressive and schizophrenia-spectrum compared with bipolar (all P < 0.05), and more men used alcohol (B = 0.76, P < 0.001) and cannabis (B = 1.56, P < 0.001) than women. Cannabis (B = 1.65, P < 0.001) and alcohol (B = 1.04, P = 0.002) were associated with higher symptomatology; cannabis (B = -2.33, P < 0.001) and alcohol (B = -1.45, P = 0.012) were associated with lower functioning.

CONCLUSIONS

Substance use is frequent and associated with poor recovery in patients with serious mental illness recently discharged from psychiatric hospitalization. Addiction treatments personalized by diagnosis and gender may be effective for improving outcomes in people with serious mental illness.

Predictors of substance use disorder treatment outcomes among patients with psychotic disorders

Although integrated approaches are recommended and effective for treating patients with co-occurring substance use and psychotic disorders (SUD-PSY), many patients receive standard, nonintegrated substance use disorder (SUD) treatment. Research has yet to investigate how patients with co-occurring substance use and psychotic disorders respond to standard SUD treatment, an issue we address here. In a naturalistic follow-up of 236 male SUD-PSY patients receiving 12-step facilitation or cognitive-behavioral-oriented SUD treatment, we found that patients (1) demonstrated significant improvements in proximal outcomes (e.g., approach coping) from treatment intake to discharge, and in distal outcomes (e.g., psychiatric symptoms, substance use frequency) from treatment intake to 1- and 5-year follow-ups, and (2) tended to have similar outcomes whether they received 12-step facilitation or cognitive-behavioral SUD treatment. Patients who (3) were more involved in treatment, as reflected by more positive perceptions of and more satisfaction, tended to experience better proximal outcomes and engage in more continuing care, and those who (4) experienced better proximal outcomes tended to have better psychiatric and substance use outcomes in the years following treatment. Our results suggest that SUD-PSY patients can benefit from standard SUD treatments, even though it may not directly address their psychiatric disorders.

Psychiatric and addiction consultation for patients in critical care

Practicing within the paradigm of compartmentalized specially treatment without a collaborative practice is ineffective for the chemical dependency and dual diagnosis population. Chemical dependency is not well understood as a disease, evidenced by barriers cited from the 2005 Survey on Drug Use and Health. Recovery from addiction and dual diagnosis logically demands an integrated and science-based treatment approach with unified standards for care and improved educational standards for preparation of care providers. Consultation and collaboration with addiction and psychiatric specialists is needed to establish consistency in standards for treatment and holistic care, essential for comorbidity. Continued learning and research about the complexity of the addiction process and comorbidity will provide continued accurate information about the harmful effects of alcoholism and drug abuse which in turn will empower individuals to make informed choices and result in better treatment and social policies.

Pharmacotherapy of alcohol use disorders and concurrent psychiatric disorders: a review

Alcohol use disorders (AUDs) are among the most prevalent psychiatric disorders. Epidemiologic studies have shown a high prevalence of concurrent psychiatric disorders among people with AUDs as well as a higher prevalence of AUDs in people with psychiatric disorders than in the general population. Though psychiatric patients with concurrent AUDs are at increased risk for morbidity and mortality, they are commonly undertreated for their alcohol-related disorders. The efficacy of pharmacotherapy for AUDs is well documented. Our paper reviews the common pharmacotherapies available for AUDs and focuses on the available research regarding treatment of AUDs among psychiatric populations with mood, anxiety, and psychotic disorders. Despite the high prevalence of concurrent AUDs and psychiatric disorders, very limited information has been collected using a randomized controlled trial design targeting those concurrent conditions. Several prevalent psychiatric disorders have not been studied when co-occurring with AUDs. Further research of pharmacological treatments for concurrent AUDs and psychiatric diagnoses is urgently needed.