Complications of severe mental illness related to alcohol and drug use disorders

Polypharmacy in antipsychotic pharmacological treatment among patients with dual diagnosis in Denmark

INTRODUCTION

Antipsychotic polypharmacy is prevalent, however literature on antipsychotic polypharmacy during treatment among patients with dual diagnosis is largely non-existent. This study aims to investigating the extent of antipsychotic polypharmacy dual diagnosis patients during hospitalisations.

METHODS

Utilizing cohort data from an integrated dual diagnosis in-patient facility from patients hospitalized between 1 March 2012, to 31 December 2016, we compared the mean antipsychotic medication administered at admission and discharge and examined covariate associations with logistic regressions.

RESULTS

The study identified 907 hospital admissions, of which 641 were the first for each patient during the period. At admission, 74.1% received antipsychotics; polypharmacy spanned psychiatric disorders. categories. Patients with affective or personality spectrum disorders were less likely to have antipsychotic polypharmacy upon admission compared to those with psychosis spectrum disorders. 2013-2016 admissions presented less polypharmacy than 2012. Mean antipsychotic numbers remained unchanged for >30-day hospitalizations. Patients admitted without antipsychotic polypharmacy with an affective spectrum disorder or aged 41-50 or over 51 years old were less likely to be discharged with antipsychotic polypharmacy when compared to patients with psychosis spectrum disorder or aged 18-30 years old.

CONCLUSION

Approximately three-quarters of admitted patients were treated with antipsychotic medication. Antipsychotic polypharmacy was observed across all psychiatric disorder categories, indicating potential off-label use. Addressing antipsychotic polypharmacy during treatment is challenging, even for specialised facilities. Rational antipsychotic prescribing, deprescribing protocols, and further prescription pattern research are needed.

Integrated Treatment Group Curriculum for People with Serious Mental Health Conditions Who Use Substances

Without proper treatment, people with co-occurring mental health and substance use problems are at great risk for poor outcomes and high treatment costs in multiple domains. Intermediary organizations can provide support to programs implementing integrated treatment and other evidence-based practices; this includes developing practical tools for programs built to encourage fidelity to a particular practice. In this paper, we describe a group curriculum workbook designed to help practitioners provide integrated treatment with fidelity and a pilot learning collaborative to evaluate whether this workbook is a helpful tool for programs to support people with serious mental health conditions and substance use in identifying and achieving personal goals. Results of the pilot found that nearly all participants demonstrated progress with respect to their identified goals, and group facilitators reported that the workbook was easy to use, that participants enjoyed the material, and that they intended to continue offering the group as part of their regular programming.

Examining the influence of substance use on mental health rating during COVID-19: A Canadian perspective

Introduction

Substance use and mental health symptoms (e.g., depression and anxiety) have increased during the COVID-19 pandemic, partly due to implementation of physical distancing measures aimed at containing the spread of the SARS-CoV-2 virus. However, there is limited pandemic-specific research that has examined the relationship between substance use and mental health with other correlates of well-being, including life satisfaction and social confidants.

Methods

In the current study, we used ordered logistic regression analyses to examine whether a greater frequency of substance use (e.g., alcohol, cannabis, and opioids) during the pandemic predicted poorer ratings of self-reported mental health in a large sample of Canadians aged 15 to 64 years. We further considered whether life satisfaction and number of social confidants interacted with substance use to influence mental health, and stratified the models by sex and personal feelings of shame surrounding the use of substances (i.e., high and low shame).

Results

Findings indicated that frequency of substance use was significantly associated with increased odds of reporting poorer mental health for males and females exhibiting both low and high shame. In females reporting low shame, we found that as frequency of cannabis use increased, life satisfaction has a much greater positive association with mental health. Whereas, in females disclosing high shame, maintaining social relations was particularly important to benefit the mental health of current users of opioids, relative to past and non-users. No such interaction was found in males.

Discussion

Overall, the findings of the current study showed the negative mental health consequences of substance use during COVID-19 in a large Canadian sample, and most importantly revealed a critical sex difference in the way in which social determinants interact with substance use to influence mental health.

Inanspruchnehmende einer Spielsuchtambulanz mit „Doppeldiagnosen“

Zusammenfassung: Zielsetzung: Internetnutzungsstörungen werden als wichtiges gesundheitsrelevantes Phänomen akzeptiert und sind bekanntermaßen mit hohen Raten an komorbiden psychischen Erkrankungen assoziiert. Jedoch ist das Wissen über das gleichzeitige Auftreten mit einer weiteren Verhaltenssucht begrenzt. Die vorliegende Arbeit bietet eine erste klinische Charakterisierung bei gleichzeitig auftretender Internetnutzungs- und Glücksspielstörung (Doppeldiagnose). Methodik: Die Analyse beruhte auf einer konsekutiven klinischen Stichprobe von Betroffenen ( N=1813), die sich wegen einer Verhaltenssucht ambulant vorstellten. Daten wurden aus der klinischen Exploration sowie psychometrischen Verfahren zur Erfassung von Depressivität, Stress, Angstsymptomen und Funktionsniveau erhoben und mit Betroffenen, die entweder eine Computerspiel- oder Glücksspielstörung aufwiesen, verglichen. Ergebnisse: Bei n=46 Betroffenen wurde eine Doppeldiagnose gestellt. Diese Gruppe wies zudem eine höhere Anzahl weiterer psychischer Störungen auf. Die Auswertung der klinischen Inventare wies auf eine insgesamt hohe Symptombelastung hin, ohne dass sich die Gruppen signifikant voneinander unterschieden. Schlussfolgerungen: Eine kleine Gruppe Inanspruchnehmender erfüllt die Kriterien einer Internetnutzungs- und einer Glücksspielstörung. Es ergeben sich keine auffälligen Unterschiede in der Symptombelastung zu Betroffenen mit singulärer Abhängigkeit, jedoch ist zu vermuten, dass Doppeldiagnosen eine differenzierte therapeutische Herangehensweise erfordern.

Recommendations for Integrated Systems and Services for People With Co-occurring Mental Health and Substance Use Conditions

People with co-occurring mental and substance use disorders experience poor outcomes and incur high costs in multiple domains. Efforts to develop and disseminate evidence-based integrated programs for people with such co-occurring disorders began to wane in the past decade as efforts shifted toward integrating primary health care. Several recent trends underscore the need to refocus efforts on providing integrated care for people with both mental and substance use disorders. The authors summarize what is known about integrated care for people with these co-occurring disorders and recommend advancing implementation and research on integration and improving outcomes with existing resources.

Trends in Psychiatric Hospitalizations of Patients With Dual Diagnosis in Spain

OBJECTIVE

Substance use disorders are highly prevalent in people living with a mental health disorder. Co-occurring substance use disorders have been associated with a worse prognosis and poorer adherence to treatment. The aim of this study was to analyze the temporal trends in the prevalence of substance use disorders in patients admitted to a psychiatric inpatient unit between 1998 and 2020.

METHODS

This is a retrospective study based on the registry of 18,367 hospitalizations and 7,124 patients with a mental health disorder admitted during the period 1998 to 2020 in Malaga, Spain. Time trend analysis by gender and substance used was calculated using a segmented regression model. The permutation test was used to determine inflection points. A sensitivity analysis was performed based on the assumptions of autocorrelation and homoscedasticity.

RESULTS

A total of 22.2% of admissions had a diagnosis of mental health disorder and co-occurring substance use disorders. Prevalence was higher among males (30.0%) than females (9.4%; p < .001). Patients with both disorders had a shorter length of stay by 2 days (p < .001) and a younger age at first admission (by 6.5 years; p < .001) compared to patients without substance use disorders. There was no difference in the total number of hospitalizations between the two groups. Psychotic disorders and multiple drug use disorders were the most prevalent diagnoses in men compared to women, whereas personality disorders and alcohol use were the most common diagnoses in women. We observed an increase in the prevalence of dual diagnosis between 2005 and 2020. There was a 3.0% increase in cannabis-related admissions per year during the whole study period (p < .001). Cannabis and cocaine use disorders have become the most prevalent in the last 10 years, while opioid and alcohol use disorders have decreased.

CONCLUSIONS

Co-occurring substance use disorders are highly prevalent among hospitalized patients. In recent years, the pattern of substance use has shifted, with cannabis being the most prevalent, while opiates and alcohol substance use have decreased. We need to devise a specialized approach and integrative treatment for patients with co-occurring disorders.

Cannabis Vapor Exposure Alters Neural Circuit Oscillatory Activity in a Neurodevelopmental Model of Schizophrenia: Exploring the Differential Impact of Cannabis Constituents

Cannabis use is highly prevalent in patients with schizophrenia and worsens the course of the disorder. To understand how exposure to cannabis changes schizophrenia-related oscillatory disruptions, we investigated the impact of administering cannabis vapor containing either Δ9-tetrahydrocannabinol (THC) or balanced THC/cannabidiol (CBD) on oscillatory activity in the neonatal ventral hippocampal lesion (NVHL) rat model of schizophrenia. Male Sprague Dawley rats underwent lesion or sham surgeries on postnatal day 7. In adulthood, electrodes were implanted targeting the cingulate cortex (Cg), the prelimbic cortex (PrLC), the hippocampus (HIP), and the nucleus accumbens (NAc). Local field potential recordings were obtained after rats were administered either the "THC-only" cannabis vapor (8-18% THC/0% CBD) or the "Balanced THC:CBD" cannabis vapor (4-11% THC/8.5-15.5% CBD) in a cross-over design with a 2-week wash-out period between exposures. Compared to controls, NVHL rats had reduced baseline gamma power in the Cg, HIP, and NAc, and reduced HIP-Cg high-gamma coherence. THC-only vapor exposure broadly suppressed oscillatory power and coherence, even beyond the baseline reductions observed in NHVL rats. Balanced THC:CBD vapor, however, did not suppress oscillatory power and coherence, and in some instances enhanced power. For NVHL rats, THC-only vapor normalized the baseline HIP-Cg high-gamma coherence deficits. NHVL rats demonstrated a 20 ms delay in HIP theta to high-gamma phase coupling, which was not apparent in the PrLC and NAc after both exposures. In conclusion, cannabis vapor exposure has varying impacts on oscillatory activity in NVHL rats, and the relative composition of naturally occurring cannabinoids may contribute to this variability.

The magnitude of disability in patients with schizophrenia in North West Ethiopia: A multicenter hospital-based cross-sectional study

Objective

To assess the magnitude of disability and its associated factors among patients with schizophrenia in North West Ethiopia in selected hospitals, 2019.

Design

Multicenter hospital-based cross-sectional study.

Setting

Gondar, Felege Hiwot, and Debre Tabor hospitals.

Participants

We recruit 420 participants for interviews using a systematic random sampling technique.

Measurement

We collect the data by face-to-face interview. Disability was measured using the World Health Organization Disability Assessment Scale 2.0. Coded variables were entered into Epi data V.4.4.2 and exported to SPSS V.24 for analysis. Bivariate and multivariate logistic regressions with OR and 95% CI were employed.

Result

A total of 423 participants were interviewed, with a response rate of 99.3%. The magnitude of disability in this study was 41.7 % (95 %CI: 36.9, 46.4). Current use of alcohol (AOR = 2.47,n95CI; 1.36,4.48), being jobless (AOR = 3.27, 95CI; 1.80, 5.93), had negative symptoms (AOR = 13.05,95CI, 7.58,22.45), had 5 and more years of illness (AOR = 2.75,95CI; 1.29,5.86), and had 5 and more years of untreated psychosis (AOR = 3.78,95CI, 1.85,7.75) were predictors of disability.

Conclusion and recommendation

The magnitude of disability in this study was 41.7 %. Avoidance of alcohol usage, early initiation of treatment, creating job opportunities, and giving special emphasis to patients having negative symptoms is recommended.

Food addiction comorbid to mental disorders: A nationwide survey and register-based study

OBJECTIVE

Substance use disorder is highly prevalent among individuals with mental disorders. However, it remains largely unknown whether this is also the case for "food addiction"-a phenotype characterized by an addiction-like attraction to predominantly highly processed foods with a high content of refined carbohydrates and fat. Therefore, the primary aim of this study was to estimate the weighted prevalence of food addiction among individuals with mental disorders.

METHOD

A total of 5,000 individuals aged 18-62 were randomly drawn from eight categories of major mental disorders from the Danish Psychiatric Central Research Register and invited to participate in an online questionnaire-based survey, which included the Yale Food Addiction Scale 2.0. Data on health care and sociodemographics from the Danish registers were linked to all invitees-enabling comprehensive attrition analysis and calculation of the weighted prevalence of food addiction.

RESULTS

A total of 1,394 (27.9%) invitees participated in the survey. Across all diagnostic categories, 23.7% met the criteria for food addiction. The weighted prevalence of food addiction was highest among individuals with eating disorders (47.7%, 95%CI: 41.2-54.2), followed by affective disorders (29.4%, 95%CI: 22.9-36.0) and personality disorders (29.0%, 95%CI: 22.2-35.9). When stratifying on sex, the prevalence of food addiction was higher among women in most diagnostic categories.

DISCUSSION

Food addiction is highly prevalent among individuals with mental disorders, especially in those with eating disorders, affective disorders and personality disorders. Food addiction may be an important target for efforts aimed at reducing obesity among individuals with mental disorders.

Food insecurity and work impairment in people with severe mental disorders in a rural district of Ethiopia: a cross-sectional survey

PURPOSE

In this study, we aimed to identify factors associated with severe food insecurity and work impairment in people with severe mental disorders (SMD) in a rural African setting, with a view to identifying potential areas for intervention.

METHODS

A community-based, cross-sectional survey was conducted in Sodo district, south central Ethiopia. Key informant-identified people with possible SMD were referred for assessment by trained primary care workers and received confirmatory psychiatric diagnoses from psychiatric nurses using a standardized clinical interview. Food insecurity was measured using a locally validated measure, the Household Food Insecurity Access Scale (HFIAS). Work impairment was assessed using the Longitudinal Interval Follow-up Evaluation-Range of Impaired Functioning Tool. Potential moderator variables were specified a priori.

RESULTS

A total of 282 people with SMD participated in the study. The proportion of participants reporting severe food insecurity was 32.5% (n = 94), with 53.6% (n = 147) of participants reporting severe work impairment. In the multivariable model, severe food insecurity was associated with poor social support, experience of negative discrimination, higher disability and lower household annual income, but not with symptom severity or work impairment. Work impairment was associated significantly with symptom severity and disability.

CONCLUSION

Work impairment and food insecurity were associated with distinct explanatory factors: predominantly social factors associated with food insecurity and clinical factors associated with work productivity. Longitudinal and intervention studies are needed to evaluate the extent to which clinical interventions need to be augmented by social interventions to alleviate food insecurity in people with SMD.

Effectiveness of Integrated Dual Diagnosis Treatment (IDDT) in severe mental illness outpatients with a co-occurring substance use disorder

Integrating substance use disorder treatment with psychiatric treatment is considered more favourable then treating these disorders parallel or sequential, but the evidence base is inconclusive. We examined the effectiveness of Integrated Dual Diagnosis Treatment (IDDT) on substance use in severe mental illness outpatients with substance use disorders. IDDT is a collaborative, multidisciplinary team approach in which motivational interviewing is a key element. In addition, we also examined the effects of IDDT implementation on skills and knowledge of mental health care professionals. A randomized controlled stepped-wedge cluster trial was performed in 6 functional assertive cummunity treatment teams. We included 37 clinicians who were given a three-day IDDT training. Our primary outcome was days of substance use at follow up, 12 months after IDDT implementation. This was assessed in 154 included patients and was measured with the Measurement in the Addiction for Triage and Evaluation. After implementation of IDDT we found a reduction in the number of days patients used alcohol or drugs, but no improvements on other secondary outcomes such as psychopathology, functioning, therapeutic alliance or motivation to change. Also, IDDT training did not seem to improve clinicians' knowledge, attitudes and motivational interviewing skills. Effects on our secondary outcomes may have been limited by the absence of a training effect in our clinicians. Our study clearly underlines the complexity of disseminating IDDT and in particular motivational interviewing.

Residential Transience and Substance Use Disorder Are Independently Associated with Suicidal Thoughts, Plans, and Attempts in a Nationally Representative Sample of U.S. Adults

This study tests the association between past-year residential transience (RT), substance use disorder (SUD), major depressive episode (MDE), and suicidal outcomes in a nationally representative sample of noninstitutionalized, civilian, community-dwelling adults who participated in the 2008-2013 National Surveys on Drug Use and Health. RT, SUD, and MDE were each significantly associated with suicidal thoughts, plans, and attempts in models adjusted for each other and sociodemographic covariates. Because RT is independently associated with each suicidal outcome, even when there is no co-occurring SUD or MDE, assessment of RT should occur when screening for suicide.

Substance use among Danish psychiatric patients: a cross-sectional study

BACKGROUND

Patients with psychiatric disorders have a greater risk of mortality than the general population. Use or abuse of substances, including alcohol, play a crucial part in this context. Moreover, it is well known that drug use can worsen psychopathology and reduce treatment compliance. However, the magnitude of these problems among Danish psychiatric patients has not been studied previously.

AIMS

The aim of this study is to investigate substance use among psychiatric patients in the Capital Region of Denmark.

METHODS

Outpatients from five psychiatric units were asked to complete a questionnaire regarding their use of alcohol and other drugs of abuse. The questionnaire was based on the Alcohol Use Disorder Identification Test (AUDIT), supplemented by questions regarding use of tobacco and illicit drugs. The results were compared with those uses in the general population.

RESULTS

In total, 412 psychiatric patients participated in the study, and 33% had an AUDIT-score ≥8, indicating problematic alcohol use according to the AUDIT guidelines. The mean weekly alcohol intake was 9.7 ± 28.3 standard drinks, and 47% were current smokers with a mean daily use of 19.9 ± 13.8 cigarette equivalents. Compared to the general population, the psychiatric patients had higher odds of being current smokers and having used illicit drugs within the past month. Women with psychiatric disorders were twice as likely to binge drink on a monthly basis. No significant difference was found in the patients' AUDIT scores compared to the general population.

CONCLUSIONS

Our findings demonstrate a substantial and problematic use of tobacco and illicit drugs among Danish psychiatric patients, greater than in the general population.

The opioid crisis: past, present and future policy climate in Ontario, Canada

BACKGROUND

Addressing opioid use disorder has become a priority in Ontario, Canada, because of its high economic, social and health burden. There continues to be stigma and criticism relating to opioid use disorder and treatment options. The result has been unsystematic, partial, reactive policies and programs developed based on divergent points of view. The aim of this manuscript is to describe how past and present understandings, narratives, ideologies and discourse of opioid use, have impacted policies over the course of the growing opioid crisis.

COMMENTARY

Assessing the impact of policy is complex. It involves consideration of conceptual issues of what impacts policy change. In this manuscript we argue that the development of polices and initiatives regarding opioids, opioid use disorder and opioid agonist treatment in the last decade, have been more strongly associated with the evolution of ideas, narratives and discourses rather than research relating to opioids. We formulate our argument using a framework by Sumner, Crichton, Theobald, Zulu, and Parkhurs. We use examples from the Canadian context to outline our argument such as: the anti- drug legislation from the Canadian Federal Conservative government in 2007; the removal of OxyContin™ from the drug formulary in 2012; the rapid expansion of opioid agonist treatment beginning in the early 2000s, the unilateral decision made regarding fee cuts for physicians providing opioid agonist treatment in 2015; and the most recent implementation of a narcotics monitoring system, which are all closely linked with the shifts in public opinion and discourse at the time of which these policies and programs are implemented.

CONCLUSION

We conclude with recommendations to consider a multifactorial response using evidence and stakeholder engagement to address the opioid crisis, rather than a reactive policy approach. We suggest that researchers have an important role in shaping future policy by reframing ideas through knowledge translation, formation of values, creation of new knowledge and adding to the quality of public discourse and debate.

Jail-to-community treatment continuum for adults with co-occurring substance use and mental disorders: study protocol for a pilot randomized controlled trial

BACKGROUND

Adults with co-occurring mental and substance use disorders (CODs) are overrepresented in jails. In-custody barriers to treatment, including a lack of evidence-based treatment options and the often short periods of incarceration, and limited communication between jails and community-based treatment agencies that can hinder immediate enrollment into community care once released have contributed to a cycle of limited treatment engagement, unaddressed criminogenic risks, and (re)arrest among this vulnerable and high-risk population. This paper describes a study that will develop research and communication protocols and adapt two evidence-based treatments, dual-diagnosis motivational interviewing (DDMI) and integrated group therapy (IGT), for delivery to adults with CODs across a jail-to-community treatment continuum.

METHODS/DESIGN

Adaptations to DDMI and IGT were guided by the Risk-Need-Responsivity model and the National Institute of Corrections' implementation competencies; the development of the implementation framework and communication protocols were guided by the Evidence-Based Interagency Implementation Model for community corrections and the Inter-organizational Relationship model, respectively. Implementation and evaluation of the protocols and adapted interventions will occur via an open trial and a pilot randomized trial. The clinical intervention consists of two in-jail DDMI sessions and 12 in-community IGT sessions. Twelve adults with CODs and four clinicians will participate in the open trial to evaluate the acceptability and feasibility of, and fidelity to, the interventions and research and communication protocols. The pilot controlled trial will be conducted with 60 inmates who will be randomized to either DDMI-IGT or treatment as usual. A baseline assessment will be conducted in jail, and four community-based assessments will be conducted during a 6-month follow-up period. Implementation, clinical, public health, and treatment preference outcomes will be evaluated.

DISCUSSION

Findings have the potential to improve both jail- and community-based treatment services for adults with CODs as well as inform methods for conducting rigorous pilot implementation and evaluation research in correctional settings and as inmates re-enter the community. Findings will contribute to a growing area of work focused on interrupting the cycle of limited treatment engagement, unaddressed criminogenic risks, and (re)arrest among adults with CODs.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02214667 . Registered on 10 August 2014.

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.

Prevalence of substance use disorders in psychiatric patients: a nationwide Danish population-based study

PURPOSE

The present study established the national prevalence of substance use disorders (SUDs) among Danish psychiatric patients. Furthermore, patients with SUDs and those without SUDs were compared on a range of socio-demographic, clinical, and treatment characteristics.

METHODS

Data were obtained from several Danish population-based registers. The study population was defined as all individuals with incidents of schizophrenia, schizotypal disorder, other psychoses, bipolar disorder, depression, anxiety, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and personality disorders since 1969. The prevalence of SUDs was examined for the following psychoactive substances: alcohol, opioids, cannabis, sedatives, cocaine, psycho-stimulants and hallucinogens.

RESULTS

A total of 463,003 patients were included in the analysis. The prevalence of any lifetime SUD was: 37 % for schizophrenia, 35 % for schizotypal disorder, 28 % for other psychoses, 32 % for bipolar disorder, 25 % for depression, 25 % for anxiety, 11 % for OCD, 17% for PTSD, and 46 % for personality disorders. Alcohol use disorder was the most dominating SUD in every psychiatric category (25 % of all included patients). Patients with SUDs were more often men, had fewer years of formal education, more often received disability pension and died due to unnatural causes.

CONCLUSIONS

The study was the most comprehensive of its kind so far to estimate the prevalence of SUDs in an unselected population-based cohort, and it revealed remarkably high prevalence among the psychiatric patients. The results should encourage continuous focus on possible comorbidity of psychiatric patients, as well as specialised and integrated treatment along with increased support of patients with comorbid disorders.

Premorbid Personality Disorders in Male Schizophrenic Patients with or without Comorbid Substance Use Disorder: Is Dual Diagnosis Mediated by Personality Disorder?

INTRODUCTION

Although substance abuse is an important clinical problem in schizophrenic patients, very little evidence explains why these patients use drugs and alcohol. This study therefore aimed to examine whether premorbid personality disorders affect substance abuse.

METHODS

The sample included 40 male schizophrenic patients with and 40 male schizophrenic patients without substance use disorder comorbidity who had applied to Ankara Numune Research and Training Hospital. Each participant and a family member were interviewed in a structured clinical interview that addressed premorbid personality disorders.

RESULTS

Altogether, 32 patients (80%) in the group with comorbidity and 28 (70%) in the group without comorbidity had a premorbid personality disorder. Antisocial (35% vs. 0%; p<.001) and borderline (37.5% vs. 5%; p=.001) personality disorders were more often detected in the group with comorbidity, while avoidant (10% vs. 35%; p=.014) and obsessive-compulsive (0% vs. 15%; p=.026) personality disorders were less frequently found in this group. Comparing the group with comorbidity with premorbid personality types, schizophrenic patients with premorbid antisocial personality disorder were more frequently unemployed and hospitalized as well as had an earlier onset age of schizophrenia (p=.034, p=.038 and p=.035, respectively). Schizophrenic patients with premorbid borderline personality disorder had a significantly earlier onset age of substance use (19±5; p=.028).

CONCLUSION

Schizophrenic patients with substance use comorbidity variously differ from those without comorbidity and some of these differences may be associated with premorbid personality disorders.

Trends in dual diagnosis of severe mental illness and substance use disorders, 1996-2010, Israel

OBJECTIVES

(1) To examine the trends in the incidence of dual diagnosis (DD) of severe mental illness and substance-related disorders among inpatients in Israel, and (2) the demographic and clinical correlates of DD patients.

METHOD

Using data from the National Psychiatric Case Register, we identified 56,774 inpatients aged 15-64 whose first psychiatric hospitalization occurred between 1996 and 2010. We compared the characteristics of inpatients having DD with drugs, alcohol or drug/alcohol abuse with those with mental disorder only.

RESULTS

Over the period, DD with drugs decreased from 8.2% in 1996 to 6% in 2010; DD with alcohol increased from 3% to 4% and DD with drugs/alcohol from 2% to 4%. DD with drugs was highest, whereas DD with alcohol was lowest for the youngest age- group in 1996 but increased to the same as other age-groups in 2006-2010. Male gender, a previous suicide attempt, compulsory hospitalizations and marital status were positive predictors for all DD. Immigrant status was a positive predictor of DD with alcohol, but the opposite for DD with drugs; being Jewish and psychotic diagnosis was a positive predictor of DD with drugs, but negative for DD with alcohol.

CONCLUSIONS

Over the study period, DD with drugs has decreased among young patients, although it is still higher than among older groups. However, DD with alcohol or drugs/alcohol has increased in the younger group. The clinical-demographic profile of DD patients was similar to that from the relevant literature, except for immigrant status that was negatively associated with DD with drugs.

Safer-drinking strategies used by chronically homeless individuals with alcohol dependence

Chronically homeless individuals with alcohol dependence experience severe alcohol-related consequences. It is therefore important to identify factors that might be associated with reduced alcohol-related harm, such as the use of safer-drinking strategies. Whereas effectiveness of safer-drinking strategies has been well-documented among young adults, no studies have explored this topic among more severely affected populations, such as chronically homeless individuals with alcohol dependence. The aims of this study were thus to qualitatively and quantitatively document safer-drinking strategies used in this population. Participants (N=31) were currently or formerly chronically homeless individuals with alcohol dependence participating in a pilot study of extended-release naltrexone and harm-reduction counseling. At weeks 0 and 8, research staff provided a list of safer-drinking strategies for participants to endorse. Implementation of endorsed safer-drinking strategies was recorded at the next appointment. At both time points, strategies to buffer the effects of alcohol on the body (e.g., eating prior to and during drinking) were most highly endorsed, followed by changing the manner in which one drinks (e.g., spacing drinks), and reducing alcohol consumption. Quantitative analyses indicated that all participants endorsed safer-drinking strategies, and nearly all strategies were implemented (80-90% at weeks 0 and 8, respectively). These preliminary findings indicate that chronically homeless people with alcohol dependence use strategies to reduce harm associated with their drinking. Larger randomized controlled trials are needed to test whether interventions that teach safer-drinking strategies may reduce overall alcohol-related harm in this population.

Efficacy of dual focus mutual aid for persons with mental illness and substance misuse

BACKGROUND

Previous studies have indicated that persons with co-occurring mental health and substance use problems can benefit by attending dual-focus mutual aid groups. However, to date, a trial to test the efficacy of these groups has not been published.

METHOD

This study randomly assigned 203 substance misusing clients attending a mental health or dual-diagnosis facility to either a dual-focus 12-step group (Double Trouble in Recovery; DTR) or a waiting list control group. Participants were followed for 3-6 months. The primary outcome was substance use (days used in the past 30 with saliva testing to detect under-reporting); secondary outcomes included psychiatric medication adherence, attendance at traditional (single-focus) 12-step meetings (e.g., AA/NA); and improvement in mental health and substance use problems (quality of life). Multilevel model (MLM) regression was used to analyze the nested effect of participants within 8 facilities (7 in New York City and 1 in Michigan). Regression imputation was used to adjust for drug use under-reporting.

RESULTS

At follow-up 79% of the subjects were interviewed. In intent to treat analysis, DTR subjects compared with control subjects used alcohol (p=.03) and any substances (p=.02) on fewer days. DTR compared with control subjects were also more likely to rate themselves as experiencing better mental health and fewer substance use problems (p=.001). There were no effects for DTR on drug use only, medication adherence or NA/AA attendance.

CONCLUSION

Findings reported in previous studies on the association between exposure to DTR and reductions in substance use were partially supported in this efficacy trial.

Risk factors for medication non-adherence among psychiatric patients with substance misuse histories

Medication non-adherence among psychiatric patients is known to be associated with poorer treatment outcomes. The study examined a comprehensive set of modifiable risk factors for non-adherence in a theoretical framework among a diverse, high risk sample of psychiatric patients with substance misuse histories (N=299). Medication side effects and excessive alcohol use were related to lower medication adherence and higher motivation for mental health treatment and recovery support were related to greater adherence. The results suggest that a multifaceted model for intervention to increase psychiatric medication adherence should be developed and tested.

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.

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

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

Consumers' Experiences in Dual Focus Mutual Aid for Co-occurring Substance Use and Mental Health Disorders

Mutual aid fellowships have been shown to improve outcomes for those with co-occurring substance use and mental illness disorders. Processes associated with usefulness include helper therapy (the assumption of a helping role to foster commitment) and reciprocal learning (the sharing of problems and solutions among members). The present qualitative investigation used focus groups comprised a subset of participants in Double Trouble in Recovery (DTR), a 12-step mutual aid group for those with co-occurring disorders, to gather their subjective perceptions of the groups. Participants emphasized that in linking them to others with similar problems, the DTR groups played a vital emotional role in their lives and provided a needed venue for information sharing that might have been otherwise unavailable.

Psychosocial treatments for schizophrenia

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

Treatment of co-occurring psychotic and substance use disorders

People with psychotic disorders and other serious mental illnesses, such as schizophrenia, bipolar disorder, and severe major depression, have high rates of co-occurring substance use disorder, which can wreak havoc in their lives. In this article the authors describe strategies for assessing substance use problems in people with serious mental illnesses, and then address the treatment of these co-occurring disorders. The authors review principles of treatment of co-occurring disorders, including integration of mental health and substance abuse services, adopting a low-stress and harm-reduction approach, enhancing motivation, using cognitive-behavioral therapy strategies to teach more effective interpersonal and coping skills, supporting functional recovery, and engaging the social network. The authors include a section on how social workers may play a key role in assessment, treatment, or referral for co-occurring disorders in a variety of settings. Throughout the article the authors emphasize that belief in the possibility of recovery from co-occurring disorders and instilling hope in clients, their family members, and other treatment providers, are vital to the effective treatment of co-occurring disorders.

Antisocial Personality Disorder in People with Co-Occurring Severe Mental Illness and Substance Use Disorders: Clinical, Functional, and Family Relationship Correlates

Antisocial personality disorder (ASPD) is an important correlate of substance abuse severity in the addiction population and in people with co-occurring serious mental illness and addiction. Because family members often provide vital supports to relatives with co-occurring disorders, this study explored the correlates of ASPD in 103 people with co-occurring disorders (79% schizophrenia-schizoaffective, 21% bipolar disorder) in high contact with relatives participating in a family intervention study. Clients with ASPD were more likely to have bipolar disorder and to have been married, but less likely to have graduated from high school. ASPD was associated with more severe drug abuse and depression, worse functioning, and less planning-based social problem solving. The relatives of clients with ASPD also reported less planning-based problem solving, worse attitudes towards the client, and worse mental health functioning. Client ASPD was associated with less long-term exposure to family intervention. The findings suggest that clients with ASPD in addition to co-occurring disorders are a particularly disadvantaged group with greater illness severity, more impaired functioning, and more strained family relationships. These difficulties may pose special challenges to delivering family intervention for this group.

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

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

Effect of comorbid alcohol and drug use disorders on premature death among unipolar and bipolar disorder decedents in the United States, 1999 to 2006

OBJECTIVE

The aim of this study was to quantify the effect of comorbid alcohol and drug use disorders on premature death, as reflected by the manner of death (suicide and other unnatural death versus natural death) and the age at death, among decedents with unipolar and bipolar disorders.

METHODS

This study is based on the US Multiple Cause of Death public-use data files for 1999 to 2006. Secondary data analysis was conducted comparing decedents with unipolar/bipolar disorders and decedents with all other causes of death, based on the death records of 19,052,468 decedents in the Multiple Cause of Death data files who died at 15 years and older. Poisson regression models were used to derive prevalence ratios to assess the effect of comorbid substance use disorders (SUD) on the risks for being an unnatural death among mood disorder deaths. Multiple-cause life table analysis and mean age at death were used to quantify the effect of comorbid SUDs on premature mortality among mood disorder deaths.

RESULTS

Prevalence of comorbid SUDs was higher among unipolar and bipolar disorder deaths than that among all other deaths. Among unipolar and bipolar disorder deaths, comorbid SUDs were associated with elevated risks for suicide and other unnatural death in both men and women (prevalence ratios ranging 1.49-9.46, P < .05). They also were associated with reductions in mean ages at death (ranging 11.7-33.8 years, P < .05). In general, these effects were much stronger for drug use disorders than for alcohol use disorders. Both SUDs had stronger effects on suicide among women, whereas their effects on other unnatural deaths were stronger among men.

CONCLUSIONS

This study is among the first to provide population mortality-based evidence to further establish comorbid SUD as one of the key risk factors for premature death among individuals with unipolar or bipolar disorders in the United States. Clinicians need to be aware of the potentially lethal risk associated with these comorbid conditions.

The effects of psychiatric distress, inhibition, and impulsivity on decision making in patients with substance use disorders: A matched control study

In the present study, the decision making abilities of patients with substance use disorders were compared to those of healthy controls and, subsequently, the impact of psychiatric distress, behavioral inhibition, and impulsivity on Iowa Gambling Task (IGT) performance were evaluated. A total of 31 patients and 31 matched healthy controls performed the IGT and completed the Symptom Checklist-90-Revised (SCL-90-R) and the Behavioral Inhibition System/Behavioral Activation System (BIS/BAS). The results confirmed that the patient group had severe impairments on the IGT relative to the controls, which appeared to be virtually unrelated to the employed measures. It is concluded that self-reported psychiatric symptoms, behavioral inhibition, and impulsivity have no impact on the IGT performance in this patient sample.

Effects of cannabis use on age at onset in schizophrenia and bipolar disorder

BACKGROUND

Cannabis use may decrease age at onset in both schizophrenia and bipolar disorder, given the evidence for substantial phenotypic and genetic overlap between both disorders.

METHODS

766 patients, aged 16 to 65 years, were assessed with the Composite International Diagnostic Interview (CIDI) for substance abuse/use. 676 subjects were diagnosed with schizophrenia and 90 subjects with bipolar disorder. The influence of cannabis use on age at onset in both schizophrenia and bipolar disorder was examined using regression analysis.

RESULTS

Cannabis and other substance use was more frequent in patients with schizophrenia compared to the bipolar group. Both cannabis use and a schizophrenia diagnosis predicted earlier age at onset. There was a significant interaction between cannabis use and diagnosis, cannabis having a greater effect in bipolar patients. Age at onset in users of cannabis was comparable in both diagnostic groups whereas bipolar non-users were significantly older than schizophrenia non-users at onset.

CONCLUSION

Cannabis use may decrease age at onset in both schizophrenia and bipolar patients and reduce the effect of diagnosis. This is consistent with the view that cannabis use may unmask a pre-existing genetic liability that is partly shared between patients with schizophrenia and bipolar disorder.

Treatment With Acamprosate in Patients With Schizophrenia Spectrum Disorders and Comorbid Alcohol Dependence

OBJECTIVE

Alcohol use disorders and schizophrenia frequently co-occur with rates higher than in the general population. There is no consensus on the best treatment for patients with these comorbid conditions. Several clinical trials have shown that acamprosate is superior to placebo in reducing drinking and is particularly effective in sustaining abstinence. No study to date has examined the efficacy of acamprosate in patients with alcohol dependence and comorbid schizophrenia. The aims of this study are to assess the efficacy of acamprosate when compared to placebo in reducing drinking and to examine its effects on schizophrenic symptoms.

METHODS

This was a double-blind, randomized, 12-week treatment trial of acamprosate versus placebo. Twenty-three recently abstinent patients with diagnosed alcohol dependence and comorbid schizophrenia, schizoaffective disorder, or psychosis not otherwise specified were included in this study.

RESULTS

All participants significantly decreased their drinking during medication treatment, although acamprosate was not superior to placebo in increasing consecutive days of abstinence. There was a significant difference favoring the acamprosate group on obsessive thoughts of drinking but no significant group X time interaction. Overall, medication treatment significantly reduced positive symptoms of schizophrenia, but there were no group differences.

CONCLUSIONS

Acamprosate was not more effective than placebo in reducing drinking or symptoms of schizophrenia. It can be safely used in patients with alcohol dependence and comorbid schizophrenia spectrum disorders.

The Effectiveness of Supported Employment in People With Dual Disorders

OBJECTIVE: This study compared the effectiveness of the Individual Placement and Support (IPS) model of supported employment to control vocational rehabilitation programs for improving the competitive work outcomes of people with a severe mental illness and co-occurring substance use disorder. METHODS: A secondary data analysis was conducted drawing from four randomized controlled trials comparing IPS supported employment to conventional vocational rehabilitation programs for severe mental illness, and focusing on the 106 clients with a recent (past 6 months) substance use disorder. Competitive work outcomes were tracked across an 18-month follow-up period. Analyses compared the IPS and comparison vocational programs on cumulative work over the 18 months, including attainment of work, hours and weeks worked, job tenure, wages earned, and days to first job. RESULTS: In the total study group, clients who participated in IPS had better competitive work outcomes than those who participated in a comparison program, with cumulative employment rates of 60% vs. 24%, respectively. Among clients who obtained work during the study period, those receiving IPS obtained their first job significantly more quickly and were more likely to work 20 or more hours per week at some point during the 18-month follow-up. CONCLUSIONS: The IPS model of supported employment is more effective than alternative vocational rehabilitation models at improving the competitive work outcomes of clients with a dual disorder.

Validity study of Kessler's psychological distress scales conducted among patients admitted to French emergency department for alcohol consumption-related disorders

BACKGROUND

Alcohol-related disorders (ARD) encountered in emergency departments (ED) have a high prevalence and are underestimated. It is necessary to provide professionals with a tool to identify patients in whom there is a risk that alcohol-related and mental health problems may be associated. Kessler's K6/10 psychological distress scales are fast, easy-to-use, and have been shown to achieve a good performance in the identification of psychological distress associated with ARD.

AIM

The aim of this study was to evaluate the psychometric properties of the Kessler scales, version 6 and 10, with a sample of patients admitted to EDs for alcohol consumption.

METHODS

On the day after their admission, with a zero "blood" alcohol concentration, 71 patients were randomly assigned to be assessed using 6 or 10 items version. The internal consistency and factor structure of the K6/10 versions were examined. Convergent validity was measured using the Hospital Anxiety and Depression Scale (HADS) and the Hamilton Depression Rating Scale (HDRS).

RESULTS

The prevalence of psychological distress in our sample was approximately 60%. The selected threshold scores were 10 for K6 (Sensitivity: 0.92; Specificity: 0.62) and 14 for K10 (Sensitivity: 0.95; Specificity: 0.54). The Cronbach coefficients for K6 and K10 were 0.76 and 0.84, respectively. The factor analyses indicated the multidimensional nature of K6/10. The 2 versions, containing 6 and 10 items respectively, correlated better with the HADS (0.83 and 0.70, respectively) than with the HDRS (0.51 and 0.49, respectively). The areas under the ROC Curve indicated a high level of accuracy for both the K6 (0.87) and the K10 (0.77). The difference was not statistically significant.

CONCLUSIONS

This study confirms the good psychometric characteristics of Kessler's psychological distress scale. Even though similar performances were observed for K6/10, the brevity of the K6 makes it more suitable for use in EDs.

Substance Use and Mental Health Outcomes for Comorbid Patients in Psychiatric Day Treatment

The study's purpose was to determine treatment outcomes for patients who present with drug use vs. those presenting with no drug use at admission to a psychiatric day treatment program. Consecutively admitted patients completed confidential interviews which included psychological distress and quality of life measures and provided urine specimens for toxicology at admission and six month follow-up. Subjects positive by past 30 day self-report or urinalysis were categorized as drug users. Major psychiatric diagnoses were: major depression 25%; bipolar, 13%; other mood 13%; schizoaffective 13%; schizophrenia 13%. Drug use at admission was: cocaine 35%; marijuana 33%; opiates 18%, (meth)amphetamines, 6% For each of these drugs, the percentage of patients positive at admission who remitted from using the drug significantly exceeded the percentage negative at baseline who initiated using the drug. Overall, there were significant decreases in psychological distress and significant improvement on quality of life, but no change on positive affect. There were no significant differences between drug users and non-drug users on symptom reduction and improvement in quality of life. Psychiatric day treatment appears to benefit comorbid patients by reducing the net number of patients who actively use certain common drugs and by improving psychological status and quality of life to the same degree as for non-drug using patients.

Implementing integrated treatment for co-existing substance use and severe mental health problems in assertive outreach teams: training issues

This study sought to evaluate systematically training and implementation of a specific integrated treatment approach for co-occurring problem substance use and mental health within existing assertive outreach (AO) teams. The AO team was treated as a whole unit rather than as individual clinicians. They were provided with training and supervision to deliver a cognitive--behavioural integrated treatment approach. In a quasi-experimental time-lag design three teams were trained immediately and two others after an 18-month delay. There was evidence that teams acquired confidence and skills relevant to working with combined problems and that these gains were maintained over time. These results were replicated in the two teams trained after the delay. This study suggests that training mental health staff to use an integrated treatment approach is well received and produces lasting changes in confidence and skills. However, there are a number of issues related to staff training, shifting attitudes and implementation of integrated approaches into routine mental health practice. These issues are considered and suggestions made for staff training.

Work, recovery, and comorbidity in schizophrenia: a randomized controlled trial of cognitive remediation

Employment is central to the concept of recovery in severe mental illness. However, common comorbid conditions present significant obstacles to consumers seeking employment and benefiting from vocational rehabilitation. We review research on the effects of three common comorbid conditions on work and response to vocational rehabilitation, including cognitive impairment, substance abuse, and medical conditions, followed by research on vocational rehabilitation. We then present the results of a randomized controlled trial evaluating the effects of adding cognitive remediation to a vocational rehabilitation program compared with vocational rehabilitation alone in 34 consumers with severe mental illness. Consumers who received both cognitive remediation and vocational rehabilitation demonstrated significantly greater improvements on a cognitive battery over 3 months than those who received vocational rehabilitation alone and had better work outcomes over the 2-year follow-up period. Substance abuse was associated with worse employment outcomes, but did not interact with treatment group, whereas medical comorbidity was not related to work outcomes. More research is warranted to evaluate the interactions between substance abuse and medical comorbidity with vocational rehabilitation and cognitive remediation.

Prevalence and profile of people with co-occurring mental and substance use disorders within a comprehensive mental health system

OBJECTIVE

To examine the prevalence and profile of people with co-occurring mental and substance use disorders in relation to numerous demographic, diagnostic, and needs-related variables across a comprehensive system of mental health services using a standard methodology.

METHOD

Data were collected on cases (n = 9839) sampled from specialty tertiary inpatient, specialty outpatient, and community-based mental health programs. Status with respect to co-occurring disorders was based on recorded diagnosis of substance use disorder and the substance abuse measure within the Colorado Client Assessment Record. The demographic and needs profile was compared across groups with or without co-occurring disorders within each level of care.

RESULTS

Overall, the prevalence of co-occurring disorders was 18.5%, and highest among clients receiving specialty tertiary inpatient care (28%), and within selected subpopulations such as younger adults (55%) and those with personality disorders (34%). There were few differences between groups based on co-occurring disorders in the specialty inpatient programs. For outpatient and community settings, the clients with co-occurring disorders were distinguished by a more impaired and complex needs profile and more likely to be young, single, male, and of low education. Across all levels of care, having a co-occurring disorder was strongly associated with antisocial and challenging behaviour, legal involvement, and risk of suicide or self-harm.

CONCLUSION

The prevalence estimate of co-occurring disorders is likely representative of a multilevel system of care that serves a large, mixed urban and rural population. Results highlight the need to focus on specific subpopulations and sectors in pursuit of more integrated treatment and support for their mental health and addictions problems.

Reasons for using substances in adolescents with and without psychosis

AIM

To increase our understanding of substance use among adolescents with psychosis by comparing their reasons for use with those of typically developing adolescents.

METHODS

Participants were 35 outpatient adolescents, recently admitted for a first episode of psychosis to an early psychosis programme, and 35 typically developing adolescents. Measures used included the Personal Experience Screening Questionnaire and Reasons for Use Scale.

RESULTS

Adolescents with psychosis used significantly more substances than adolescents without psychosis (P<0.01). Reasons for use in the two groups were similar.

CONCLUSIONS

Although adolescents with psychosis report using substances for the same reasons as other adolescents, they may also use to self-medicate secondary morbidity associated with psychosis. These results have a number of implications for prevention and treatment.

The interaction of co-occurring mental disorders and recovery management checkups on substance abuse treatment participation and recovery

This article examines the effectiveness of quarterly Recovery Management Checkups (RMCs) for people with substance disorders by level of co-occurring mental disorders (34% none, 27% internalizing disorders, and 39% internalizing and externalizing) across two randomized experiments with 92% to 97% follow-up. The 865 participants are 82% African American, 53% female, and age 37 on average. RMC involves identification of those in need of treatment, motivational interviews, and treatment linkage assistance. It is effective in linking participants in need to treatment, with equal or better outcomes among those with more mental disorders. The data support the utility of monitoring and re-intervention for clients with co-occurring disorders.

Effectiveness of dual focus mutual aid for co-occurring substance use and mental health disorders: a review and synthesis of the "Double Trouble" in Recovery evaluation

Over 5 million adults in the United States have a co-occurring substance use disorder and serious psychological distress. Mutual aid (self-help) can usefully complement treatment, but people with co-occurring substance use and psychiatric disorders often encounter a lack of empathy and acceptance in traditional mutual aid groups. Double Trouble in Recovery (DTR) is a dual focus fellowship whose mission is to bring the benefits of mutual aid to persons recovering from co-occurring disorders. An evaluation of DTR was conducted by interviewing 310 persons attending 24 DTR meetings in New York City (NYC) in 1998 and following them up for 2 years, in 1999 and 2000. The evaluation produced 13 articles in 12 peer-reviewed journals, the main results of which are summarized here. The sample's characteristics were as follows: mean age, 40 years; women, 28%; black, 59%; white, 25%; Hispanic, 14%; never married, 63%; live in supported community residence, 53%; high school graduate or GED, 60%; arrested as adult, 63%; diagnoses of: schizophrenia, 39%; major depression, 21%; or bipolar disorder, 20%; currently prescribed psychiatric medication, 92%; primary substance used, current or past: cocaine/crack, 42%; alcohol 34%; or heroin, 11%. Overall, the findings indicate that DTR participation has both direct and indirect effects on several important components of recovery: drug/alcohol abstinence, psychiatric medication adherence, self-efficacy for recovery, and quality of life. The study also identified several "common" therapeutic factors (e.g., internal motivation and social support) and unique mutual aid processes (helper-therapy and reciprocal learning) that mediate the influence of DTR participation on recovery. For clinicians, these results underline the importance of fostering stable affiliation with specialized dual focus 12-step groups for their patients with co-occurring disorders, as part of a comprehensive recovery-oriented treatment approach.

Naturalistic follow-up of co-morbid substance use in schizophrenia: the West London first-episode study

BACKGROUND

The impact of co-morbid substance use in first-episode schizophrenia has not been fully explored.

METHOD

This naturalistic follow-up of a cohort of 152 people with first-episode schizophrenia examined substance use and clinical outcome in terms of symptoms and social and neuropsychological function.

RESULTS

Data were collected on 85 (56%) of the patient cohort after a median period of 14 months. Over the follow-up period, the proportion of smokers rose from 60% at baseline to 64%. While 30% reported lifetime problem drinking of alcohol at baseline, only 15% had problem drinking at follow-up. Furthermore, while at baseline 63% reported lifetime cannabis use and 32% were currently using the drug, by the follow-up assessment the latter figure had fallen to 18.5%. At follow-up, persistent substance users had significantly more severe positive and depressive symptoms and greater overall severity of illness. A report of no lifetime substance use at baseline was associated with greater improvement in spatial working memory (SWM) at follow-up.

CONCLUSIONS

Past substance use may impede recovery of SWM performance in people with schizophrenia in the year or so following first presentation to psychiatric services. The prevalence of substance use other than tobacco tends to diminish over this period, in the absence of specific interventions. Persistent substance use in first-episode schizophrenia is associated with more severe positive and depressive symptoms but not negative symptoms, and should be a target for specific treatment intervention.

Long-term follow-up of people with co-existing psychiatric and substance use disorders: patterns of use and outcomes

The aims of this study were to document long-term patterns of substance use among people with co-existing psychiatric and substance use disorders and to explore differences in psychosocial outcomes for groups with different substance use outcome profiles (persistent hazardous, intermittent hazardous and non-hazardous users). An opportunistic long-term (4 - 6 years) follow-up interview was conducted with participants from a previous study who were recruited during their inpatient admission at a public psychiatric hospital in Newcastle, New South Wales, Australia. Follow-up data were obtained from 47 people from the original study and combined with their existing baseline, 6-month and 12-month data. The follow-up interview included demographic variables and measures of substance use, psychiatric symptomatology and a range of psychosocial variables. Alcohol, cannabis and amphetamines were the most commonly misused substances. Persistent hazardous users experienced poorer outcomes in the domains of social functioning and psychiatric symptomatology, including depression, than intermittently hazardous or non-hazardous users. An unusually high mortality rate of 10% among the males in the original sample (12/120) was an unexpected finding, particularly as this was likely to be an underestimate. Given the differences in outcomes between groups with varied gradations of substance use, a harm minimisation approach for research and practice among people with co-existing psychiatric and substance use disorders is endorsed.