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

Use of smoking cessation therapies in individuals with psychiatric illness : an update for prescribers

Individuals with mental illness are particularly disadvantaged by their use of tobacco, spending as much as 40% of their income on cigarettes. They also have increased mortality from cardiovascular and respiratory disorders. The most effective interventions to help psychiatric patients stop smoking are similar to those that are effective in the general population. These include psychological treatments, nicotine replacement therapy (NRT), bupropion and nortriptyline, at least in the short term. Most studies agree that these gains can be achieved in the absence of significant adverse effects in terms of psychological morbidity. Effects diminish over time, but these findings also apply to the general population. The best long-term results have come from extended prescription and psychological interventions, and apply equally to patients with and without a history of psychiatric disorder, such as major depression. In spite of this, clinicians are not fully exploiting opportunities to help psychiatric patients stop smoking. It is not possible to plan a programme to help individuals stop smoking in mental health settings unless factors such as demographics, diagnosis and concurrent medication are taken into account.

Counselor and client characteristics in mental health versus substance abuse treatment settings providing services for co-occurring disorders

The study compares counselor and client characteristics of state-funded co-occurring disorder (COPSD) programs in mental health (MH) versus substance abuse (SA) settings. SA counselors more often had graduate degrees and MH counselors rated their knowledge and skills lower on two of nine COPSD best practice principles. MH clients were more frequently diagnosed with schizophrenia, depression, and bipolar disorder, whereas SA clients displayed evidence of greater substance use severity and had higher rates of treatment completion and abstinence at discharge. Results reveal significant implications for workforce development and potential system changes to enhance COPSD services that are unique to each setting.

Evaluation of treatment programs for dual disorder individuals: modeling longitudinal and mediation effects

This study evaluated the effectiveness of the three approaches for treating dual disorder clients who were homeless at intake: integrated assertive community treatment (IACT), assertive community treatment only (ACTO), and standard care (SC). Multilevel Random Coefficient Modeling (MRCM) was used to analyze longitudinal effects and to identify mediators of significant treatment effects. The outcome variables were consumer satisfaction, stable housing, psychiatric symptoms, and substance abuse. The eight mediators were service utilization variables: program contacts, phone contacts, substance abuse contacts, assistance with activities of daily living, transportation assistance, help finding permanent housing, help with emotional problems, and medication assistance. The 191 eligible participants were randomly assigned to one of the three conditions and followed for a period of 30 months. Both ACTO and IACT produced better outcomes than SC on consumer satisfaction and stable housing. There were no differences on any of the outcome variables between ACTO versus IACT when comparing main effects. However, there were several treatment by time interactions. In addition, there were many mediation effects.

An investigation into the aspirations and experiences of newly appointed dual diagnosis workers

This qualitative, exploratory study was designed to explore a sample of eight recently appointed dual diagnosis workers' (DDWs) perceptions of their new role and function in Northern Ireland (NI). A semi-structured interview was used and respondents were assured that their anonymity/rights would be protected. All of the narratives were shown to the respondents for their approval prior to going to press. The transcripts were analysed by using a tried and tested analytical framework. Seven key categories emerged from the findings relating to the DDWs perceptions of their: (1)understanding of the term dual diagnosis; (2) hopes; (3) fears; (4) support in their new role; (5) key clinical issues; (6) the positioning of the service; and (7) their overall role and function. This is a new and important area of work in NI. However, to date, no research has been carried out on the topic in the province. Consequently, the findings from this small study could go some way towards helping to shape the future direction of, and bring about some universality to the provision of the dual diagnosis service within different National Health Service Trusts in NI. Further research is required on this new and growing service as well as on the service users' perceptions of the care provided by DDWs. The study will be followed up on an annual basis for 3 years to provide longitudinal data. Generalization of findings requires caution because of the small sample size.

Training in dual diagnosis interventions (the COMO Study): randomised controlled trial

BACKGROUND

Despite the high prevalence of co-morbid substance use among mental health service users (dual diagnosis), very few mental health workers in the UK have had training and/or clinical experience to equip them to deliver targeted interventions to this client group.

METHOD

In a randomised controlled trial of training for dual diagnosis interventions, 79 case managers from 12 community mental health teams in South London were randomly allocated to either receive training and follow-up supervision (experimental group) or no training and supervision (control group). Baseline measures of attitude, self-efficacy and knowledge were collected prior to randomisation, and were repeated at 18 months post-training. An intention to treat analysis of follow-up data (adjusted for baseline score for that outcome and team) was performed.

RESULTS

At 18 months post-training, the AAPPQ (The Alcohol and Alcohol Problems Perception Questionnaire) total score was did not differ significantly between the two groups (adjusted difference 7.43 [95% CI -0.86 to 15.71], p = 0.08). There were significant differences in favour of the experimental group on 2 of the 6 subscales of the AAPPQ: 'adequacy of knowledge and skills in working with alcohol" (adjusted difference 3.598 [95% CI 1.03 to 6.16], p = 0.007) and "self-esteem in working with alcohol" (adjusted difference 3.00 [95% CI 0.46 to 5.54], p = 0.021). In addition there were significant improvements for the experimental group on "Knowledge About Dual Diagnosis" (adjusted difference 2.00 [95% CI 0.80 to 3.22], p = 0.002) and "Self-Efficacy Scale" (adjusted difference 13.55 [95% CI 8.00 to 26.86], p = 0.001). The effect of membership of teams was added to the analysis of covariance and this changed the results for only one variable: "self-esteem working with drinkers" was no longer significant.

CONCLUSION

A brief training course in dual diagnosis interventions had a significant effect on secondary measures of knowledge and self-efficacy that was detectable at 18 months post-training. Improvements in attitudes towards working with drinkers and drug users in mental health settings failed to reach statistical significance. Future research should explore the effects of dose of dual diagnosis training, and the successful integration of skills gained into routine care.

TRIAL REGISTRATION

ISRCTN98891022 14th March 2007.

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 substance reduction in people with a serious mental illness.

SEARCH STRATEGY

For this update (2007) we searched the Cochrane Schizophrenia Group Trials Register (May 2006) which is based on regular searches of major databases.

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 extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a random effects model. We calculated numbers needed to treat/harm (NNT/NNH) where data were homogeneous. For continuous data, we calculated weighted mean differences (WMD) again based on a random effects model.

MAIN RESULTS

Evaluation of long-term integrated care included 4 RCTs (total n=735). We found no significant difference on measures of substance use (n=85, 1 RCT, RR 0.89 CI 0.6 to 1.3) or loss to treatment (n=603, 3 RCTs, RR 1.09 CI 0.8 to 1.5). For the non-integrated intensive case management trials (4 RCTs, total n=151) we also found no significant difference for loss (n=134, 3 RCTs, RR 1.35 CI 0.8 to 2.2). Motivational interviewing plus cognitive behavioural therapy (3 RCTs, total n=276) did not reveal any advantage for retaining participants (n=36, 1 RCT, RR lost to treatment 0.50 CI 0.1 to 5.0) or for relapse (n=36, 1 RCT, RR 0.58 CI 0.3 to 1.1), and no benefit for reducing substance use (n=119, 1 RCT, RR 0.19 CI -0.2 to 0.6). Cognitive behavioural therapy alone (4 trials, total n=260) showed fewer participants lost from treatment (n=260, 4 RCTs, p=0.02, RR 0.61 CI 0.4 to 0.9). No benefits were observed on measures of lessening cannabis use (n=47, 1 RCT, RR 1.30 CI 0.8 to 2.2) or on the number of participants using substances (alcohol; n=46, 1 RCT, RR 5.88 CI 0.8 to 44.0, drugs; n=46, 1 RCT, RR 2.02 CI 0.9 to 4.8) and no differences were observed on measures of mental state (n=105, 1 RCT, RR 0.52 CI -0.8 to 1.8). We found no advantage for motivational interviewing alone (5 trials, total n=338) in reducing 'lost to evaluation' (n=338, 5 RCTs, RR 0.96 CI 0.6 to 1.5) compared with treatment as usual, although significantly more participants in the motivational interviewing group reported for their first aftercare appointment (n=93, 1 RCT, RR 0.69 CI 0.5 to 0.9, NNT 4 CI 3 to 12). Some differences were observed in abstaining from alcohol favouring treatment (n=28, 1 RCT, RR 0.36 CI 0.2 to 0.8, NNT 2 CI 2 to 5), but not other substances (n=89, 1 RCT, RR -0.07 CI -0.6 to 0.4) and no differences were observed in mental state (n=30, 1 RCT, WMD -4.20 CI -18.7 to 10.3). Finally, 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 0.4 to 1.1).

AUTHORS' CONCLUSIONS

We included 25 RCTs and found no compelling evidence to support any one psychosocial treatment over another to reduce substance use (or improve mental state) by people with serious mental illnesses. Furthermore, methodological difficulties exist which hinder pooling and interpreting results; high drop out rates, varying fidelity of interventions, varying outcome measures, settings and samples and comparison groups may have received higher levels of treatment than standard care. Further studies are required which address these concerns and improve the evidence in this important area.

Doppeldiagnose Psychose und Sucht - Grundlagen und Therapie

Zusammenfassung: Patienten mit der Doppeldiagnose Psychose und Sucht (DD-Patienten) sind keine Randgruppe, sondern eine große und schwer behandelbare Kerngruppe unter den Patienten mit Schizophrenie. Vor allem unter Patienten im jugendlichen und jungen Erwachsenenalter steht der Missbrauch von Cannabis an erster Stelle. Unter den verschiedenen Erklärungsmodellen für die hohe Prävalenz der Komorbidität werden derzeit das Modell einer Induktion der Psychose durch den Cannabiskonsum bei primär erhöhter Vulnerabilität für Psychosen sowie das Modell gemeinsamer Vulnerabilitätsfaktoren für beide Störungen favorisiert. Die DD-Patienten haben überwiegend eine schlechte Compliance und einen ungünstigen langfristigen Verlauf ihrer Psychose mit häufigeren Rezidiven und stationären Aufenthalten. Im Sinne einer effizienteren Behandlung dieser Patientengruppe ist es erforderlich Ansätze aus der psychiatrischen Krankenversorgung und der Suchttherapie zu integrieren und aufeinander anzupassen. Die erfolgreichsten Therapiemodelle bieten die Behandlung beider Störungen zeitlich parallel und integriert in einem Setting. Sie haben in der Regel ihren Schwerpunkt im ambulanten Sektor, bieten Pharmakotherapie, Motivationsstärkung, Psychoedukation, kognitiv-verhaltenstherapeutische Ansätze und Familieninterventionen an, und sie können alltagsrelevante Besserungen der sozialen Anpassung und Reduktionen des Konsums erzielen.

Performance of the CJDATS Co-Occurring Disorders Screening Instruments (CODSIs) among minority offenders

Previous research has shown the performance of the CJDATS Co-Occurring Disorders Screening Instruments (CODSI-MD and SMD)--six- and three-item instruments to screen for any mental disorder (CODSI-MD) and for severe mental disorders (CODSI-SMD), respectively--to be comparable or superior to other, longer instruments. This study tested the stability of the performance of the CODSI-MD and SMD across three racial/ethnic groups of offenders entering prison substance abuse treatment programs (n = 353), consisting of 96 African American, 120 Latino, and 137 White admissions. The Structured Clinical Interview (SCID) was used to obtain DSM-IV Axis I and II diagnoses; a lifetime SCID diagnosis of a mental disorder or a severe mental disorder was the criterion against which the CODSI-MD and SMD were validated. Results showed no statistical differences in sensitivity or specificity for either the CODSI-MD or SMD across the African American, Latino, and White prisoner groups. The value of the CODSI-MD and SMD as brief screens for mental disorders among offenders with diverse racial/ethnic backgrounds is discussed.

COD services in community correctional settings: an examination of organizational factors that affect service delivery

Little is known about service delivery for those in the correctional system with co-occurring mental health and substance abuse disorders (COD). Using data from the National Criminal Justice Treatment Practices survey (NCJTP) on community corrections and jail agencies, this study found that correctional organizations that offer COD services differ from agencies that do not. Organizations that respond to the needs of COD offenders tend to be more "service friendly," rank higher on measures of various dimensions of organizational climate that embrace learning and goal achievement, and tend to adopt more innovations, particularly those classified as evidence-based practices. These survey findings indicate that correctional agencies who serve COD offenders are in a better position to be responsive to the changing service needs of the populations, and are more likely to be able to balance public safety and treatment goals. Future steps to develop support environments for COD assessment and treatment services are discussed in light of these findings.

A systematic review of psychosocial research on psychosocial interventions for people with co-occurring severe mental and substance use disorders

This report reviews studies of psychosocial interventions for people with co-occurring substance use disorder and severe mental illness. We identified 45 controlled studies (22 experimental and 23 quasi-experimental) of psychosocial dual diagnosis interventions through several search strategies. Three types of interventions (group counseling, contingency management, and residential dual diagnosis treatment) show consistent positive effects on substance use disorder, whereas other interventions have significant impacts on other areas of adjustment (e.g., case management enhances community tenure and legal interventions increase treatment participation). Current studies are limited by heterogeneity of interventions, participants, methods, outcomes, and measures. Treatment of co-occurring severe mental illness and substance use disorder now has a large but heterogeneous evidence base that nevertheless supports several types of interventions. Future research will need to address methodological standardization, longitudinal perspectives, interventions for subgroups and stages, sequenced interventions, and the changing realities of treatment systems.

Stop Using Stuff: trial of a drug and alcohol intervention for young people with comorbid mental illness and drug and alcohol problems

OBJECTIVE

Substance abuse is a significant problem in the treatment of young people with their first psychosis. This study reports a randomized trial of a brief manualized cognitive behavioural therapy for substance abuse in young people with psychosis.

METHOD

Subjects were randomized between the study treatment and a group treated as usual. Treatment was a four to six session brief cognitive behavioural therapy (CBT) intervention developed specifically for this patient group - Stop Using Stuff (SUS).

RESULTS

Both groups improved across the trial. However, those exposed to the active treatment improved significantly on measures of the frequency of cannabis and alcohol abuse.

CONCLUSIONS

Brief interventions in substance abuse in young people with psychosis can help moderate substance use in this difficult to treat group.

Case Management and Client Access to Health and Social Services in Outpatient Substance Abuse Treatment

A primary goal of case management is to coordinate services across treatment settings and to integrate substance abuse services with other types of services offered in the community, including housing, mental health, medical, and social services. However, case management is a global construct that consists of several key dimensions, which include extent of case management coverage, the degree of management of the referral process, and the location of case management activity (on-site, off-site, or both). This study examines the relationship between specific dimensions of case management and the utilization of health and ancillary social services in outpatient substance abuse treatment. In general, results suggest that more active case management during the referral process and providing case management both on-site and off-site are most consistent with our predictions of greater use of health and ancillary social services by substance abuse clients. However, these effects are specific to general health care and mental health services. Case management appears to have little effect on use of social services or aftercare plans.

Challenges faced by general practitioners and allied mental health services in providing mental health services in rural Queensland

OBJECTIVE

To examine the views of rural practitioners concerning issues and challenges in mental health service delivery and possible solutions.

DESIGN

A qualitative study using individual semi-structured interviews.

SETTING

Eight general practices from eight rural Queensland towns, three rural mental health services and two non-government organisations, with interviews being conducted before recent changes in government-subsidised access to allied health practitioners.

PARTICIPANTS

A sample of 37 GPs, 19 Queensland Health mental health staff and 18 participants from community organisations.

MAIN OUTCOME MEASURES

Analysis of qualitative themes from questions about the key mental health issues facing the town, how they might be addressed and what challenges would be faced in addressing them.

RESULTS

There was substantial consensus that there are significant problems with inter-service communication and liaison, and that improved collaboration and shared care will form a critical part of any effective solution. Differences between groups reflected differing organisational contexts and priorities, and limitations to the understanding each had of the challenges that other groups were facing.

CONCLUSIONS

Improvements to mental health staffing and to access to allied health might increase the ability of GPs to meet the needs of less complex patients, but specific strategies to promote better integrated services are required to address the needs of rural and regional patients with complex mental health problems. The current study provides a baseline against which effects of recent initiatives to improve mental health care can be assessed.

Group intervention for coexisting psychosis and substance use disorders in rural Australia: outcomes over 3 years

OBJECTIVE

Outpatient group interventions have been shown to be efficacious in reducing substance use among people with psychosis. This is the first Australian study to report on the effectiveness of such interventions provided in a rural area by mental health and drug and alcohol clinicians, with follow up over 3 years. The primary aim was to investigate whether an open-ended weekly outpatient group intervention, consisting of motivational interviewing (MI) and cognitive behaviour therapy (CBT), was effective in reducing substance use and improving symptomatology and general functioning among people with psychosis.

METHOD

This was a service evaluation project, with clinician-administered ratings made for four retrospective 3 monthly baseline observations and up to 12 3 monthly post-recruitment observations.

RESULTS

Thirty-nine participants entered the group intervention, with an average attendance of 28.51 sessions (SD=24.61). Compared to a baseline period of 1 year, the group intervention was associated with significant improvements in substance use, symptomatology, treatment non-compliance, overall functioning and unscheduled service use. A median split according to treatment group attendance indicated that there was no difference in improvement profiles on a factor reflecting overall severity among those who attended fewer (mean=10.63) versus more sessions (mean=45.50), but there was a sharper reduction in the use of acute mental health services among those who attended more sessions.

CONCLUSIONS

Significant change in functioning (including substance use and symptomatology) can occur within the context of a regular but relatively short outpatient group intervention, delivered in addition to usual treatment. However, extended group attendance over a 1 year period may be further associated with prevention of relapse and less unscheduled service use.

Co-occurring disorders: policy and practice in Germany

The occurrence of substance use disorders (SUD) with other mental disorders-what is often referred to as co-occurring disorders (COD)-is a common phenomenon, but for a long time, little attention has been paid to this problem in Germany. During the last 25 years, however, COD awareness has increased due to a shift toward community-based services. Scientific research has also demonstrated the significance and clinical relevance of COD. High prevalence rates and evidence of poor clinical outcomes were found in German studies. Many practitioners as well as policymakers acknowledge that changes in systems of care are necessary to meet the requirements of COD patients. The traditional German system is currently divided into addiction services and mental health services (predominantly in inpatient settings), often resulting in ineffective sequential treatment for COD patients. Research demonstrates that integrative treatment models are more appropriate, and the division of services should be reorganized to help COD patients appropriately. Efforts have already been made to restructure healthcare systems toward a more flexible approach with improved networking between in- and outpatient services. A further issue is the general attitude toward SUD patients. Many practitioners continue to hold negative opinions (eg, "SUD patients are only weak-minded") or feel insecure when confronted with SUD. This results in SUD problems being frequently ignored or depreciated. Educational programs have been intensive over recent years to address this problem (eg, Fachkunde Sucht, an advanced training program on SUD). In general, treatment conditions for COD patients are improving, but further efforts are necessary. Guidelines and treatment strategies for COD patients have been recently published in Germany.

Intensive case management as a jail diversion program for people with a serious mental illness: a review of the literature

This article reviews the research on intensive case management (ICM) programs as a jail diversion intervention for people with a serious mental illness (SMI). The review includes two types of ICM programs: (a) general ICM programs that included an assessment of arrests and incarceration rates for people with an SMI and (b) ICM programs specifically implemented as a component of a jail diversion intervention for people with an SMI. Results indicate that general ICM programs (19) rarely led to reductions in jail or arrest rates over time, and these rates were similar to those found in standard mental health services. General ICM programs that included an integrated addiction treatment component (8) had mixed results but a trend toward reductions in rates of arrests and incarceration over time for individuals with an SMI and a co-occurring substance use disorder. Results were mixed for jail diversion interventions with an ICM program, but most ICM programs (8) led to significant reductions in arrests and incarcerations over time. Specific elements of effective ICM jail diversion programs are discussed.

The concept of recovery as an organizing principle for integrating mental health and addiction services

Despite a range of long-standing historical, political, ideological, professional, structural, and practical barriers, there has been, and continues to be, a clear consensus that integration between mental health and addiction services is sorely needed and long overdue. This paper focuses on one dimension of the challenge of integration from among the several - the conceptual - and proposes the construct of recovery as an organizing principle for bridging the divide between the two domains. After reviewing briefly the parallel history of the two traditions and their shared need for transformation to a recovery orientation, the authors offer an integrated model of recovery for persons with co-occurring disorders. They then derive from this model the underlying values, guiding principles, key strategies, and essential ingredients of recovery-oriented systems of care that comprise a common approach across both addictions and mental illness, offering a strengths-based solution to achieving integration where pathology-focused approaches have failed.

Integrating tobacco cessation treatment into mental health care for patients with posttraumatic stress disorder

The integration of tobacco cessation treatment into mental health care for posttraumatic stress disorder (PTSD), known as Integrated Care (IC), was evaluated in an uncontrolled feasibility and effectiveness study. Veterans (N = 107) in PTSD treatment at two outpatient clinics received IC delivered by mental health practitioners. Outcomes were seven-day point prevalence abstinence measured at two, four, six, and nine months post-enrollment and repeated seven-day point prevalence abstinence (RPPA) obtained across three consecutive assessment intervals (four, six, and nine months). Abstinence rates at the four assessment intervals were 28%, 23%, 25%, and 18%, respectively, and RPPA was 15%. The number of IC sessions and a previous quit history greater than six months predicted RPPA. Stopping smoking was not associated with worsening PTSD or depression.

Services to patients with dual diagnoses: findings from Washington's mental health service system

This study examined how Washington State's (WA) mental health treatment system provided services to patients with substance use disorders or dual diagnoses at several stages of care: crisis commitment, hospitalization, and outpatient treatment. A total of 30 key informants from urban and rural areas were surveyed between February and July 2004 using semi-structured interviews. Key informants represented direct service providers to chief operating officers. Themes, consensus, and disagreements were summarized. Results indicated that best practices are not consistently implemented and administrative and provider barriers hinder provision of more effective care. Findings highlight that work on how to best implement evidence-based practices is critical to improving care of dual diagnosis patients. Limitations of the study are noted as well as future research directions.

Impact of program services on treatment outcomes of patients with comorbid mental and substance use disorders

OBJECTIVE

This study examined the outcomes of individuals with co-occurring disorders who received drug treatment in programs that varied in their integration of mental health services. Patients treated in programs that provided more on-site mental health services and had staff with specialized training were expected to report less substance use and better psychological outcomes at follow-up.

METHODS

Participants with co-occurring disorders were sampled from 11 residential drug abuse treatment programs for adults in Los Angeles County. In-depth assessments of 351 patients were conducted at treatment entry and at follow-up six months later. Surveys conducted with program administrators provided information on program characteristics. Latent variable structural equation models revealed relationships of patient characteristics and program services with drug use and psychological functioning at follow-up.

RESULTS

Individuals treated in programs that provided specific dual diagnosis services subsequently had higher rates of utilizing mental health services over six months and, in turn, showed significantly greater improvements in psychological functioning (as measured by the Brief Symptom Inventory and the RAND Health Survey 36-item short form) at follow-up. More use of psychological services was also associated with less heroin use at follow-up. African Americans reported poorer levels of psychological functioning than others at both time points and were less likely to be treated in programs that provided mental health services.

CONCLUSIONS

Study findings support continued efforts to provide specialized services for individuals with co-occurring disorders within substance abuse treatment programs as well as the need to address additional barriers to obtaining these services among African Americans.

Using the Addiction Severity Index to Predict Mental and Medical Health Service Utilization

This study assessed the utility of adding the Addiction Severity Index (ASI) to demographic and clinical diagnostic information for the purpose of predicting subsequent substance use disorder service use, and use of other healthcare services by 260 veterans admitted for outpatient substance use disorder treatment. Data collected included demographics, clinical diagnoses, assessment data from the ASI, as well as measures of six-month health service utilization (e.g., substance use disorder services, other mental health services, outpatient medical visits, urgent care visits, inpatient psychiatric and medical). Multivariate analysis using Tobit regression models showed six out of seven ASI scales were significant predictors, and that combining ASI data with demographics and clinical data significantly improved prediction of health care services. It also was found that certain psychiatric and medical diagnoses were related to service use measures, and that a diagnosis of depression was related to overall healthcare utilization.

Smoking cessation and depression: current knowledge and future directions

This paper reviews the literature on comorbid smoking and depression. Current models used to explain this co-occurrence are examined, as are treatment options (both psychological and pharmacological). This paper surmises that treatment planning should consider factors that potentially confound treatment efficacy, including the nature of the depressive illness and the patient's smoking profile. Although there is limited research examining the benefits of a stepped-care framework, a tiered treatment format appears to work well, assisting those who require minimal treatment, as well as those who prolonged difficulties. Further research examining a stepped-care framework for smokers at risk of depression is required, as is appropriate training for health practitioners using this model. Further directions for research and practice are also discussed.

Screening for serious mental illness in populations with co-occurring substance use disorders: Performance of the K6 scale

Serious mental illnesses (SMIs) such as schizophrenia, bipolar disorder, and major depression are prevalent among individuals with substance use disorders, particularly those in drug treatment programs. No screening tool has yet become the gold standard for identifying SMI among individuals with substance use disorders. One candidate instrument, the K6 screening scale, is brief, easy to administer and score, and has performed well, detecting SMI in studies using general population samples. We used data from the National Survey on Drug Use and Health to examine the K6's psychometric properties in a subsample of persons with substance use disorders and found that the K6 accurately screened for severe psychological distress associated with SMI among individuals with substance use disorders and across different psychiatric disorders.

Utilization and outcomes of mental health services among patients in drug treatment

This study examined utilization of mental health services and treatment outcomes among 1,091 patients with mental health problems recruited from 39 treatment programs in 13 California counties. We compared three groups: one that received dual treatment from drug and mental health programs (N=294), one that received mental health services only within drug treatment programs (N=578), and one that received no mental health services (N=219). Individuals who received dual treatment had more severe substance use and mental health problems, followed in severity by those who received mental health services within drug treatment, and those who received no services. All groups significantly reduced their psychiatric severity at the follow-up, although there were no group differences in treatment retention and drug use outcomes. These findings suggest that individuals with mental health problems can be successfully treated within drug treatment programs and/or in conjunction with mental health providers.

Treating homeless clients with severe mental illness and substance use disorders: costs and outcomes

This study compared the costs and outcomes associated with three treatment programs that served 149 individuals with dual disorders (i.e., individuals with co-occurring severe mental illness and substance use disorders) who were homeless at baseline. The three treatment programs were: Integrated Assertive Community Treatment (IACT), Assertive Community Treatment only (ACTO), and standard care (Control). Participants were randomly assigned to treatment and followed for a period of 24 months. Clients in the IACT and ACTO programs were more satisfied with their treatment program and reported more days in stable housing than clients in the Control condition. There were no significant differences between treatment groups on psychiatric symptoms and substance use. The average total costs associated with the IACT and Control conditions were significantly less than the average total costs for the ACTO condition.

Putting community risk in perspective: a look at correlations, causes and controls

Much research, but not all, appears to show that persons with severe mental illness are more dangerous and violent than others; but it is misleading and feeds the stigma cannon. This paper critically reviews reported correlations between severe mental illness and violence, examines their statistical confounds, highlights studies which seek causal mechanisms explaining the associations, points to what those causal mechanisms tell us about controlling risk in the community, and reviews legal attempts to control community risk in light of those causal mechanisms.

Using participatory action research in a community-based initiative addressing complex mental health needs

OBJECTIVE

This paper describes the first phase of a larger project that utilizes participatory action research to examine complex mental health needs across an extensive group of stakeholders in the community.

METHOD

Within an objective qualitative analysis of focus group discussions the social ecological model is utilized to explore how integrative activities can be informed, planned and implemented across multiple elements and levels of a system. Seventy-one primary care workers, managers, policy-makers, consumers and carers from across the southern metropolitan and Gippsland regions of Victoria, Australia took part in seven focus groups. All groups responded to an identical set of focusing questions.

RESULTS

Participants produced an explanatory model describing the service system, as it relates to people with complex needs, across the levels of social ecological analysis. Qualitative themes analysis identified four priority areas to be addressed in order to improve the system's capacity for working with complexity. These included: (i) system fragmentation; (ii) integrative case management practices; (iii) community attitudes; and (iv) money and resources.

CONCLUSIONS

The emergent themes provide clues as to how complexity is constructed and interpreted across the system of involved agencies and interest groups. The implications these findings have for the development and evaluation of this community capacity-building project were examined from the perspective of constructing interventions that address both top-down and bottom-up processes.

Treatment for dual diagnosis patients in the psychiatric and substance abuse systems

The purpose of this study was to describe and compare the extent to which psychiatric and substance abuse programs treating dual diagnosis patients in the residential and outpatient modalities offered the components recommended for this client group. Surveys were completed by managers of 753 programs in the Department of Veterans Affairs that had a treatment regimen oriented to dual diagnosis patients. Programs within both the psychiatric and substance abuse systems had some of the key services of integrated treatment (e.g., assessment and diagnosis, crisis intervention, counseling targeted at psychiatric and at substance use problems, medications, patient education, HIV screening and counseling, family counseling and education). However, compared to psychiatric programs, substance abuse programs were more likely to offer some of these services and other critical components (e.g., a cognitive-behavioral treatment orientation, assignment of a single case manager to each patient). Outpatient psychiatric programs were particularly lacking on key management practices (e.g., use of clinical practice guidelines, performance monitoring of providers) and services (e.g., detoxification, 12-step meetings) of integrated treatment. Generally, differences between psychiatric and substance abuse programs appeared to involve difficulties in developing treatment that is fully oriented toward the co-occurring diagnosis. To improve the provision of high-quality dual-focused care, we recommend planners' use of cross-system teams and applications of recently produced tools designed to increase programs' ability to deliver integrated care to dually disordered individuals.

Temporal trends in rates of dual diagnoses at a Canadian addictions hospital over a five-year period

OBJECTIVES

Dual diagnosis refers to co-occurring substance use and psychiatric disorders. The principal aims of this investigation were two-fold: 1) to identify aspects of patients' drug use and prior treatment histories associated with their receiving a dual diagnosis upon admission to the Donwood Institute, a residential drug treatment facility located in Toronto, Canada; 2) to track temporal trends in the rates of diagnosed comorbidities over a five-year period at this same institution.

METHODS

We conducted an analysis of the intake assessment forms and hospital records of 159 patients who had been admitted to a drug treatment facility during the month of September for each of the years between 1998 and 2002 inclusive. Comparisons were made between patients who had received a psychiatric diagnosis on admission and patients who had received no such diagnosis. We then employed logistic regression analyses to explore the relationship of the variable psychiatric diagnosis on admission to other patient variables.

RESULTS

Among the patients studied in our sample, those receiving psychotherapy or taking prescription psychotropic medication at the time of their admission as well as patients whose primary problem substance was cannabis or who had been previously admitted to the treatment facility were significantly more likely to have received a psychiatric diagnosis on admission, in spite of our finding that several patients receiving psychotherapy or taking at least one psychotropic medication did not receive a psychiatric diagnosis on admission.

CONCLUSIONS

Whilst our data indicate that psychiatric comorbidity is common among individuals in treatment for substance use disorders at the Donwood Institute, it is possible that some individuals with psychiatric illness in our sample were not diagnosed as such when presenting for treatment of their substance use difficulties. Moreover, temporal tracking of rates of dual diagnoses did not reveal a consistent increase during the period studied.

Hepatitis C Treatment for People With Severe Mental Illness

Over 4 million people in the United States are chronically infected with hepatitis C virus (HCV), and, if untreated, over 20% of these will progress to more serious disease. Persons with severe mental illness (SMI) have markedly elevated rates of HCV infection, but treatment of persons with SMI and HCV has been controversial. Effective antiviral treatment is available, but side effects include depression and other neuropsychiatric symptoms. This article reviews the available data on neuropsychiatric side effects of interferon (IFN) treatment, discusses the limitations of the current research, and makes recommendations regarding HCV treatment in persons with SMI.

Managed Care, Inter-agency Linkages, and Outpatient Substance Abuse Treatment

: Although treatment of co-occurring behavioral and physical health problems could be facilitated by the linkages between health care providers, it is uncertain how such inter-agency linkages are affected by managed care. We used a sample of 167 service linkages to examine the effects of managed care arrangements on inter-agency communication, coordination, and perceived effectiveness. These linkages were identified based on interviews with 62 outpatient substance abuse treatment units in 2000. Results indicate that frequency of communication and inter-agency coordination are positively related to several managed care arrangements and may moderate the relationships between managed care arrangements and perceived effectiveness.

Integrated versus parallel treatment of co-occurring psychiatric and substance use disorders

The study examines 1-year treatment outcomes of 216 individuals with co-occurring severe and persistent mental illness and substance use disorders who were assigned to an integrated or parallel treatment condition. Comparisons indicated that the integrated group achieved greater reductions in the incidence of psychiatric hospitalization and arrest. The results of this study support the enhanced effectiveness of integrated treatment in decreasing the use of higher cost crisis-oriented services in clients with severe mental illness and substance use disorders.

Substance abuse and recovery in a Psychiatric Intensive Care Unit

OBJECTIVES

The purpose of this study is to compare the development in symptoms, behaviors, function and treatment between patients with or without a substance use (SU) diagnose in a Psychiatric Intensive Care Unit (PICU).

METHODS

A total of 118 admitted patients were assessed at admittance, day 3 and discharge from the PICU. Symptoms of psychopathology, therapeutic steps taken, violent episodes and length of patient stay were recorded.

RESULTS

More males than females received an SU diagnosis. Substance use patients had less psychiatric symptoms at admittance and showed a faster symptom reduction, more favorable and faster improvement of function and a shorter length of stay. Except for symptom reduction and shorter length of stay, these differences were largely due to differences in sex and diagnoses in the two groups.

CONCLUSION

In a naturalistic group of patients in a PICU, SU is associated with favorable outcomes compared to patients not using substances.

Training substance abuse treatment staff to care for co-occurring disorders

Although co-occurring disorders have been associated with poorer substance abuse treatment outcomes and higher costs of care, few individuals with co-occurring disorders receive appropriate mental health care. This article describes the design and implementation of an intervention to improve the quality of mental health care provided in outpatient substance abuse treatment programs without requiring new treatment staff. The intervention focuses on individuals with affective and anxiety disorders and consists of three components: training and supervising staff, educating and activating clients, and linking with community resources. We evaluated three treatment programs (one intervention and two comparison) for the first component by having program staff complete both self-administered questionnaires and semistructured interviews. Staff knowledge and attitudes about co-occurring disorders, job satisfaction, and morale all indicated an improvement at the intervention relative to the comparison sites. The evaluation is still under way; results for implementation of the other two components and for outcomes will be reported later.

Motivational interviewing and clinical psychiatry

OBJECTIVES

Our objectives were as follows: 1) to survey the literature on motivational interviewing (MI), "a client-centered yet directive method for enhancing intrinsic motivation to change by exploring and resolving client ambivalence" and a well-established method of brief intervention, especially in the field of addictions treatment; 2) to review hypothesis about its mode of action; and 3) to discuss its possible impact on clinical psychiatry, in particular, on teaching communication skills.

METHOD

Literature reviews and metaanalyses of numerous clinical trials of MI for addictions treatment have already been published and are briefly summarised. So far, no literature survey exists for MI applied to psychiatric patients. This review is limited to a synthesis of the articles relevant to psychiatry and to comments based on our team's experiences with MI.

RESULTS

There is no evidence that MI achieves better results than our other established techniques for treating addictions; it may simply work faster. The explanation for the method's rapid effectiveness remains speculative. Outcomes concerning the application of MI to psychiatric patients, although preliminary, are promising. Methods of assessing the integrity of MI treatment are more developed than in most psychotherapies, which permits the learning progress of trainees to be measured.

CONCLUSIONS

MI offers a complement to usual psychiatric procedures. It may be worthwhile to teach it, not only for addictions but also for other broad treatment issues, such as enhancing patients' medication compliance and professionals' communication skills. Questions remain concerning MI's feasibility in psychiatry settings.

Integrating care for patients with infectious, psychiatric, and substance use disorders: concepts and approaches

Patients with chronic viral infections such as HIV/AIDS or hepatitis C often have multiple co-existing problems such as psychiatric and addictive disorders, as well as social problems such as lack of housing, transportation and income that present challenging obstacles to successful management. Because services for these different problems are usually provided by different disciplines in varying locations, fragmentation of care can lead to treatment dropouts, lack of adherence, and poor outcomes. Integration strategies, ranging from simple efforts to improve communication and coordinate care to fully integrated multidisciplinary teams have been used to improve disease management. Although evidence for effectiveness is comprised primarily of observational studies of demonstration programmes, integration may be desirable on a pragmatic basis alone. Quality improvement strategies are attractive vehicles for implementing care integration and measuring its impact. Careful assessment of the problem to be solved and the development of targeted strategies will maximize chances of a successful outcome.

Motivational interviewing and clinical psychiatry

OBJECTIVES

Our objectives were as follows: (1) to survey the literature on motivational interviewing (MI), "a client-centered yet directive method for enhancing intrinsic motivation to change by exploring and resolving client ambivalence" and a well-established method of brief intervention, especially in the field of addictions treatment; (2) to review hypotheses about its mode of action; and (3) to discuss its possible impact on clinical psychiatry, in particular, on teaching communications skills.

METHOD

Literature reviews and metaanalyses of numerous clinical trials of MI for addictions treatment have already been published and are briefly summarized. So far, no literature survey exists for MI applied to psychiatric patients. This review is limited to a synthesis of the articles relevant to psychiatry and to comments based on our team's experiences with MI.

RESULTS

There is no evidence that MI achieves better results than other established techniques for treating addictions; it may simply work faster. The explanation for the method's rapid effectiveness remains speculative. Outcomes concerning the application of MI to psychiatric patients, although preliminary, are promising. Methods of assessing the integrity of MI treatment are more developed than in most psychotherapies, which permits the learning progress of trainees to be measured.

CONCLUSIONS

MI offers a complement to usual psychiatric procedures. It may be worthwhile to teach it, not only for addictions but also for other broad treatment issues, such as enhancing patients' medication compliance and professionals' communication skills. Questions remain concerning MI's feasibility in psychiatry settings.

Assessing cost-effectiveness in mental health: helping policy-makers prioritize and plan health services

OBJECTIVE

We assessed, from a health sector perspective, options for change that could improve the efficiency of Australia's current mental health services by directing available resources toward 'best practice' cost-effective services.

METHOD

We summarize cost-effectiveness results of a range of interventions for depression, schizophrenia, attention deficit hyperactivity disorder and anxiety disorders that have been presented in previous papers in this journal. Recommendations for change are formulated after taking into account 'second-filter criteria' of equity, feasibility of implementing change, acceptability to stakeholders and the strength of the evidence. In addition, we estimate the impact on total expenditure if the recommended mental health interventions for depression and schizophrenia are to be implemented in Australia.

RESULTS

There are cost-effective treatment options for mental disorders that are currently underutilized (e.g. cognitive-behavioural therapy (CBT) for depression and anxiety, bibliotherapy for depression, family interventions for schizophrenia and clozapine for the worst course of schizophrenia). There are also less cost-effective treatments in current practice (e.g. widespread use of olanzapine and risperidone in the treatment of established schizophrenia and, within those atypicals, a preference for olanzapine over risperidone). Feasibility of funding mechanisms and training of staff are the main second-filter issues for CBT and family interventions. Acceptability to various stakeholders is the main barrier to implementation of more cost-effective drug treatment regimens. More efficient drug intervention options identified for schizophrenia would cost 68 million Australian dollars less than current practice. These savings would more than cover the estimated 36M Australian dollars annual cost of delivering family interventions to the 51% of people with schizophrenia whom we estimated to be eligible and this would lead to an estimated 12% improvement in their health status. Implementing recommended strategies for depression would cost 121M Australian dollars annually for the 24% of people with depression who seek care currently, but do not receive an evidence-based treatment.

CONCLUSIONS

Despite considerable methodological problems, a range of cost-effective and less cost-effective interventions for major mental disorders can be discerned. The biggest hurdle to implementation of more efficient mental health services is that this change would require reallocation of funds between interventions, between disorders and between service providers with different funding mechanisms.

Literature on integrated HIV care: a review

With a significant proportion of HIV-infected patients now presenting with co-occurring substance abuse disorders and mental disorders, interest in integrated HIV care is growing. However, no review of integrated HIV care has been conducted. Using relevant key word searches of the Medline and Psychlit databases, the authors identified about 450 publications. The few evaluations of integrated models tended to focus on measurements of engagement and retention in medical care, and their findings indicated an association between integrated HIV care and increased service utilization. No random assignment controlled studies were identified, except in the peripheral area of integrated care (without HIV primary care) for persons with co-occurring substance abuse disorders and mental disorders. The majority of reviewed articles described integrated models operating in the field and various aspects of implementation and sustainability. Overall, they supported use of a wide range of primary and ancillary services delivered by a multidisciplinary team that employs a 'biopsychosocial' approach. Despite the lack of scientific knowledge regarding the effects of integrated HIV care, those wanting to optimize treatment for patients with multiple interacting disorders can gain useful and practical knowledge from this literature.

Understanding the interface of HIV, trauma, post-traumatic stress disorder, and substance use and its implications for health outcomes

Many individuals living with HIV have been exposed to some type of traumatic event during their lives and may be living with symptoms of post-traumatic stress disorder (PTSD). A substantial number of these individuals are also likely to show evidence of a co-morbid substance use disorder (SUD). There is reason to believe that the co-occurrence of HIV and PTSD or co-morbid PTSD and SUD (PTSD/SUD) may predict poorer health outcomes. There are several pathways through which PTSD or PTSD/SUD might adversely impact the health of individuals living with HIV, including participation in negative health behaviours, low levels of adherence to antiretroviral medications, and/or a direct, deleterious effect on immune function. Psychological interventions are needed to treat PTSD and PTSD/SUD in HIV-positive individuals, and reduce the negative impact of these conditions on health outcomes. This article will explore data on the prevalence of trauma exposure, PTSD, and PTSD/SUD among individuals living with HIV, the pathways through which these conditions might affect health, possible interventions for PTSD and PTSD/SUD for individuals living with HIV, and methods for integrating care for individuals with these disorders. Future directions for research related to HIV, PTSD, and PTSD/SUD will also be discussed.

Treatment services and service delivery models for dually diagnosed clients: variations across mental health and substance abuse providers

This paper reports on a survey of administrators (n = 26) and staff (n = 248) in 10 mental health and 16 substance abuse programs in Los Angeles County providing services to individuals with co-occurring disorders. Although half or more of the administrators and staff reported that their programs had some degree of on-site service integration, there was a lack of agreement within most programs as to the extent of integration. Characteristics of services provided and interactions with other service providers are also examined. Future research is needed regarding the divergent perceptions of administrators and staff and their relationship to treatment outcomes.

Comorbidity: cannabis and complexity

Cannabis is one of the most commonly used illicit drugs, and its effects have traditionally been seen as less harmful than outcomes associated with the highly prevalent use of alcohol and other illicit substances (e.g., cocaine and amphetamines), and injecting drugs. Consequently, less attention has been focused on developing and evaluating interventions in this area. However, current research supports the idea that cannabis does pose a number of acute and chronic health risks to the individual and to society. The authors review findings concerning the physiological and neurological effects of cannabis, prevalence of use, and studies concerning its possible role as a "gateway" drug. Diagnostic criteria for cannabis dependence and abuse are discussed, with a focus on whether a cannabis withdrawal syndrome exists and if so how it can be diagnosed. There is strong support for a link between cannabis and the development and exacerbation of psychosis and other mental health conditions (e.g., anxiety, depression). Further research is needed to determine the underlying neurochemical processes and their possible contribution to etiology, as well as the social factors that contribute to the increasing use of cannabis by young people. In addition there is a need for systematic evaluation using randomized controlled trials to determine effective prevention and treatment strategies. A number of public health programs that address cannabis use are reviewed along with available evidence for their effectiveness.

The 'co-morbidity roundabout': a framework to guide assessment and intervention strategies and engineer change among people with co-morbid problems

This paper describes the nature and consequences of co-morbidity, as applied to co-occurring mental health and alcohol/other drug (AOD) use problems. The 'co-morbidity roundabout' is introduced as a useful metaphor for conceptualizing the current experiences of people with co-occurring mental health and AOD use problems. In order to successfully negotiate the 'roundabout', the 'drivers' (people with co-morbid mental health and AOD use problems) must consider a range of internal and external conditions (knowledge about services, support from family, friends, health providers, motivation to change, etc.), account for their vehicle's characteristics (other conditions and demands, including social/legal/financial issues), keep their travel itinerary in mind (plans for change including treatment) and navigate through the many detours and dead-ends that they may confront (eligibility for services, accessibility of treatments, etc.). Co-morbidity is a major contributing factor in 'drivers' failing to successfully negotiate, or even becoming 'stuck' on, the 'roundabout'. A summary of relevant treatment research is also presented, including descriptions of brief interventions and more intensive treatment approaches. Finally, the 'co-morbidity roundabout' metaphor is expanded to assist clinicians to translate the findings from this treatment research into clinical practice. Further suggestions are made for improved navigation through and exit from the 'roundabout', including recommendations for the use of a stepped-care approach to the assessment and treatment of clients with co-morbid mental health and AOD use problems.