Detection of substance use disorders in severely mentally ill patients

Cardio-respiratory fitness is associated with a verbal factor across cognitive domains in schizophrenia

OBJECTIVE

We investigated whether the relationship between cardio-respiratory fitness (CRF) and cognition in schizophrenia is general, or due to selective relationships between CRF and specific aspects of cognitive function.

METHOD

Eighty outpatients with schizophrenia spectrum disorders participated. Neurocognition was assessed with the Wechsler Adult Intelligence Scale version 4 General Ability Index (WAIS GAI), the MATRICS Consensus Cognitive Battery (MCCB) and the Emotion in Biological Motion (EBM) test. CRF was assessed with peak oxygen uptake measured directly during maximum exercise using a modified Balke protocol. Partial correlations, controlling for sex and age, were obtained for the perceptual and the verbal indices of WAIS GAI, six cognitive domains of MCCB, and the EBM total score. A factor analysis was conducted on all 15 subtests of the WAIS GAI and the MCCB, and the factors were subjected to separate regression analyses with CRF as predictor.

RESULTS

Significant, moderately sized correlations were found between CRF and all cognitive domains except processing speed. The correlation appeared strongest for CRF and the Verbal Comprehension Index of WAIS GAI (r = 0.29, p = .005). The factor analysis identified three factors: one speed/attention/executive function factor, one verbal factor, and one perceptual factor. Regression analyses showed that VO_2peak explained a significant amount of variance in the verbal factor only (R² = 0.06, β = 0.329, p = .03).

CONCLUSION

The results indicate that the relationship between CRF and cognition in schizophrenia is selectively tied to a modality-specific association with verbal cognitive abilities. These findings have implications for understanding the relation between cognitive factors and physical health in schizophrenia. ClinicalTrials.gov reg. number NCT02205684 (clinicaltrials.gov/ct2/show/NCT02205684).

Substance use comorbidity in bipolar disorder: A qualitative review of treatment strategies and outcomes

BACKGROUND AND OBJECTIVES

Substance use disorders (SUDs) are present in up to 70% of patients with bipolar disorder (BD) and contribute to high rates of disability, morbidity, and treatment non-adherence. Despite this prevalence, few trials have investigated targeted psychosocial interventions for comorbid BD and SUDs.

METHODS

Using PubMed and PsycINFO, we conducted a search of the literature up to January 2018 for psychosocial interventions targeted to patients with comorbid BD and SUDs. We identified eight total trials. Of these studies, four randomized and two open trials targeted the types of substance use (alcohol and illicit drugs) of primary concern to mood stability; the remaining two studies, both open trials, targeted smoking cessation.

RESULTS

None of the randomized trials provided consistent evidence for management of both mood symptoms and substance use though integrated group therapy (IGT) demonstrated consistent beneficial effects on substance use outcomes. Other treatments showed benefit for mood symptoms without benefits for alcohol or illicit substance use. Small pilot studies of combined treatments for smoking cessation provided some initial promise.

CONCLUSIONS

At present, IGT is the most-well validated and efficacious approach if substance use is targeted in an initial treatment phase. For a subsequent phase, additional psychosocial BD treatments may be needed for mood and functioning benefits.

SCIENTIFIC SIGNIFICANCE

This review synthesizes the psychosocial interventions that have been conducted in comorbid BD and SUDs while also providing a perspective on which intervention elements are helpful for addressing substance use versus mood symptoms in patients with these co-occurring conditions. (Am J Addict 2018;27:188-201).

An Investigation of Diagnostic Accuracy and Confidence Associated with Diagnostic Checklists as Well as Gender Biases in Relation to Mental Disorders

This study examines the utility of checklists in attaining more accurate diagnoses in the context of diagnostic decision-making for mental disorders. The study also aimed to replicate results from a meta-analysis indicating that there is no association between patients’ gender and misdiagnoses. To this end, 475 psychotherapists were asked to judge three case vignettes describing patients with Major Depressive Disorder (MDD), Generalized Anxiety Disorder, and Borderline Personality Disorder. Therapists were randomly assigned to experimental conditions in a 2 (diagnostic method: with using diagnostic checklists vs. without using diagnostic checklists) × 2 (gender: male vs. female case vignettes) between-subjects design. Multinomial logistic and linear regression analyses were used to examine the association between the usage of diagnostic checklists as well as patients’ gender and diagnostic decisions. The results showed that when checklists were used, fewer incorrect co-morbid diagnoses were made, but clinicians were less likely to diagnose MDD even when the criteria were met. Additionally, checklists improved therapists’ confidence with diagnostic decisions, but were not associated with estimations of patients’ characteristics. As expected, there were no significant associations between gender and diagnostic decisions.

Psychosocial functioning, quality of life and clinical correlates of comorbid alcohol and drug dependence syndromes in people with schizophrenia across Europe

Little is known about the correlates of comorbid drug and alcohol dependence in people with schizophrenia outside the USA. We tested hypotheses that dependence on alcohol/drugs would be associated with more severe symptoms, and poorer psychosocial functioning and quality of life. The EuroSC Cohort study (N=1204), based in France, Germany and the UK, used semi-structured clinical interviews for diagnoses, and standardized tools to assess correlates. We used mixed models to compare outcomes between past-year comorbid dependence on alcohol/drugs, controlling for covariates and modelling both subject and country-level effects. Participants dependent on alcohol or drugs had fewer negative symptoms on PANSS than their non-dependent counterparts. However, those dependent on alcohol scored higher on PANSS general psychopathology than those who were not, or dependent only on drugs. People with schizophrenia dependent on drugs had poorer quality of life, more extrapyramidal side effects, and scored worse on Global Assessment of Functioning (GAF) than those without dependence. People with alcohol dependence reported more reasons for non-compliance with medication, and poorer functioning on GAF, though not on Global Assessment of Relational Functioning. In people with schizophrenia, comorbid dependence on alcohol or drugs is associated with impaired clinical and psychosocial adjustment, and poorer quality of life.

Attempted suicide in people with co-occurring bipolar and substance use disorders: systematic review and meta-analysis

BACKGROUND

Both individuals with bipolar (BD) and those with alcohol (AUD) and other substance (SUD) use disorders are likely to attempt suicide. Comorbidity of BD and AUD/SUD may increase the likelihood of suicide attempts. We conducted a meta-analysis to estimate the association of comorbid AUD/SUD and suicide attempts in subjects with BD in the literature to date.

METHODS

Electronic databases through January 2013 were searched. Studies reporting rates of suicide attempts in people with co-occurring BD and AUD/SUD were retrieved. Comorbid AUD and SUD and suicide attempts rates as well as demographic, clinical, and methodological variables were extracted from each publication or obtained directly from its authors.

RESULTS

Twenty-nine of 222 studies assessed for eligibility met the inclusion criteria, comprising a total of 31,294 individuals with BD, of whom 6308 (20.1%) had documented suicide attempts. There were consistent findings across the studies included. As compared to controls, subjects with BD and comorbid AUD/SUD were more likely to attempt suicide. The cross-sectional association estimates showed random-effects pooled crude ORs of 1.96 (95% CI=1.56-2.47; p<0.01), 1.72 (95% CI=1.52-1.95; p<0.01), and 1.77 (95% CI=1.49-2.10; p<0.01), for combined AUD/SUD, AUD, and SUD. There was no publication bias and sensitivity analyses based on the highest quality studies confirmed core results.

LIMITATIONS

The effects of the number and the type of suicide attempts could not be investigated due to insufficient information.

CONCLUSIONS

Comorbid AUD and SUD in individuals with BD are significantly associated with suicide attempts. Individuals with this comorbidity should be targeted for intensive suicide prevention efforts.

Correlates of dependence and treatment for substance use among people with comorbid severe mental and substance use disorders: findings from the "Psychiatric and Addictive Dual Disorder in Italy (PADDI)" Study

OBJECTIVE

People with severe mental illness (SMI) have often comorbid alcohol and other substance disorders but substantial barriers to addiction care remain. The study is aimed at describing correlates associated with dependence and with treatment for substance use among people with SMI and comorbid substance disorders cared in community mental health teams (CMHTs).

METHODS

This study capitalized on data from a national survey on comorbid severe mental and substance use disorders, among 2235 subjects in 42 CMHTs nationwide.

RESULTS

26% of people with SMI and comorbid misuse suffered from dependence on alcohol and 21% on any other substance. Use of opioids, liver diseases, involvement with criminal justice system, but also area of residence, all were associated with dependence in people with SMI. As regards treatment for substance use, only 50% of comorbid people with SMI were treated by specialist services in the past 12 months. This was associated with opioids and cocaine use, as well as with liver diseases, and involvement with criminal justice. People with schizophrenia and those living in Central and Southern Italy, had the lowest chances to be treated for their comorbid substance use disorder.

CONCLUSIONS

There are extensive unmet treatment needs among comorbid individuals with SMI. Better integration of substance abuse and mental health care systems, and more effective reciprocal referral procedures, are needed.

Regional cortical thinning may be a biological marker for borderline personality disorder

OBJECTIVE

We investigated cerebral cortical thickness and its relation to measurements of difficulties with identifying and describing emotions in patients with borderline personality disorder (BPD).

METHOD

Eighteen SCID-II-diagnosed female patients with BPD and 21 healthy female controls underwent magnetic resonance imaging and completed the Toronto Alexithymia Scale (TAS). First, regional cortical thickness across the cerebral surface was compared between patients and healthy controls. Then, analyses of the association between cortical thickness and TAS subscales were performed in patients.

RESULTS

Compared with controls, patients exhibited clusters of significantly reduced cortical thickness in the left medial and lateral prefrontal cortex, left temporoparietal junction, bilateral temporal poles, and bilateral paracentral lobules. Significant negative associations were observed between cortical thickness and the 'Difficulties Describing Feelings' TAS subscale (DDF) scores in patients. The anatomical distribution of these associations was highly overlapping with the group differences in cortical thickness.

CONCLUSION

The pattern of regions exhibiting cortical thinning in patients resembles a network of cortical structures repeatedly shown to be involved in social cognition. The results of the DDF analyses suggest that the thinning may partly be related to interpersonal dysfunction in patients with BPD. The pattern of thinning may represent a potential biological marker for BPD.

Screening for substance use disorders in neurodevelopmental disorders: a clinical routine?

Evidence suggests that substance use disorders (SUD) tend to be underdiagnosed in psychiatry. The objective of this study was to investigate whether drug and alcohol screening is a clinical routine in the assessment of two prominent neurodevelopmental disorders, namely ADHD and autism spectrum disorder (ASD). We surveyed drug and alcohol screening routines in 34 general child and adolescent (only practice for adolescents, not children, was assessed) and 29 adult psychiatric outpatient departments in Stockholm County, Sweden. Structured telephone interviews mapping SUD screening procedures were conducted with department representatives in charge. Only a minority of child and adolescent departments regularly used SUD screening questionnaires (6 %) in ADHD and ASD assessment, while this was more common in adult psychiatry (55 %). Urine/blood-based toxicology tests were always used in 28 % and sometimes or in case of clinical suspicion in 38 % of the adult units. Such tests were used sometimes or in case of clinical suspicion in 15 % of the child psychiatric departments, but never routinely. Findings reveal that screening for SUD in ADHD and ASD is not an integral part of routine clinical assessments in psychiatry, although increasingly an integral part of many clinical guidelines. Thus, SUD might be underdiagnosed in neurodevelopmental disorders, which could be particularly true for child and adolescent psychiatry settings.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

The lifetime and past-year prevalence of dual diagnosis in people with schizophrenia across Europe: findings from the European Schizophrenia Cohort (EuroSC)

Relatively little is known about rates of comorbid drug and alcohol problems in people with schizophrenia outside the USA. Most studies have recruited from single countries. Newly available data provided an unmatched opportunity to investigate the prevalence of comorbid dependence on alcohol and other psychoactive substances in people with schizophrenia in France, Germany and the UK at the same time. The European Schizophrenia Cohort study data set used semi-structured clinical interviews to establish DSM-IV diagnoses. 1,208 patients were interviewed in nine centres. The lifetime rate for comorbid dependence on any substance was highest in the UK (35 %), but considerably lower in Germany (21 %) and in France (19 %), and generally more than double the past-year rates. Dependence on alcohol and on other psychoactive substances showed similar variations (comorbid alcohol dependence: UK 26 %; Germany 18 %; France 14 %; comorbid drug dependence: UK 18 %; Germany 8 %; France 7 %). Differences within countries persisted after controlling for individual characteristics. The relative odds of dependence were higher than in the general population, but varied between countries and centres. Dependence disorders are a common problem in people with schizophrenia in Western Europe, although effective service configurations have yet to be developed. Overall, these European rates are less than those reported from the USA. Research comparing people with current comorbidity with those who are no longer dependent is needed.

Using brief self-reports and clinician scales to screen for substance use disorders in psychotic patients

AIMS

The aims of this study were to examine evidence for the concurrent validity of two self-report measures and two staff-report measures measuring alcohol and drug problems in seriously mentally ill people and to examine if psychotic patients under-report their alcohol and drug problems in an early intervention clinic.

METHODS

This is a cross-sectional study of 48 patients (26 inpatients and 22 outpatients) from an early intervention clinic for psychosis. To examine the sensitivity and specificity, we compared both the staff-report measures Clinical Alcohol Use Scale (AUS) and Clinical Drug Use Scale (DUS) and the self-report measures Short Michigan Alcohol Screening Test (SMAST-13) and Drug Abuse Screening Test (DAST-20), with the current ICD-10 diagnostic criteria as the gold-standard for alcohol and drug problems. To examine whether the patients under-report their alcohol and drug problems, we also compared the self-report measures SMAST-13 and DAST-20 with the staff-report measures AUS and DUS and ICD-10 consensus substance abuse diagnoses.

RESULTS

The results show that the concurrent validity compared with ICD-10 diagnoses was moderate for both the staff-report measures AUS and DUS and for the self-report measures SMAST-13 and DAST-20. Three out of seven patients under-report alcohol problems and one patient out of seven under-report drug use problems according to consensus ICD-10 substance abuse diagnoses.

CONCLUSIONS

We conclude that the SMAST-13 and DAST-20 in combination with the AUS and DUS, which are easy and quick to perform, are helpful in establishing a common understanding of the patient's alcohol and drug problems in an early intervention clinic.

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

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

Variations in rates of comorbid substance use in psychosis between mental health settings and geographical areas in the UK. A systematic review

BACKGROUND

Comorbid substance misuse in psychosis is associated with significant clinical, social and legal problems. An epidemiologically informed approach to planning service delivery requires an understanding of which clinical populations are at particularly high risk for such 'dual diagnosis'. Evidence has now been accumulating in the UK since the early 1990s, and allows a relatively comprehensive comparison of rates between service settings, geographical areas and social contexts in terms of ethnic background.

METHODS

A literature search was carried out with the aim of investigating: (a) comorbid alcohol and drug misuse rates in people with established psychosis in different mental health and addiction settings in the UK, (b) variations in such rates between different population groups.

RESULTS

There are wide variations in reported drug and alcohol misuse rates in psychosis. Most recent UK studies report rates between 20 and 37% in mental health settings, while figures in addiction settings are less clear (6-15%). Rates are generally not as high as in US studies, but appear to be especially high in inpatient and crisis team settings (38-50%) and forensic settings. In terms of geography, rates appear highest in inner city areas. Some ethnic groups are over-represented among clinical populations of people with dual diagnosis.

CONCLUSIONS

Rates of substance misuse in psychosis are likely to be influenced by service setting, population composition and geography. Acute and forensic settings are especially appropriate for the development of targeted interventions.

Substance use disorders among psychotic patients admitted to inpatient psychiatric care

Previous epidemiological and clinical studies have shown high rates of substance use disorders in patients with psychotic disorders. There are few studies from the Scandinavian countries. The aim of this study was to investigate the rate of substance use disorders in a group of Norwegian psychotic inpatients from a specific catchment area. Sixty patients, aged 18-40 years, were interviewed through standardized methods: the Addiction Severity Index (EuropASI) and the Structured Clinical Interview for DSM-IV axis I disorders (SCID-I). Urine toxicology screens confirmed patients' self-report of recent substance use. The lifetime rate of substance use disorders was 70% when all psychotic disorders were included and 62.5% when substance-induced psychotic disorders were excluded. Fifty percent of all the patients studied had current substance use disorders. The majority of substance use disorders were dependence disorders. Alcohol, amphetamine and cannabis were the dominant substances. The level of comorbidity found in this study is comparable with that found in American studies, despite lower prevalence of substance use in the Norwegian population. The high rate of substance use disorders in psychotic inpatients has implications for the treatment and the organization of psychiatric care for these patients.

Violence and the costs of caring for a family member with severe mental illness

Drawing on the stress paradigm and using data from the Duke Mental Health Study, this paper investigates the links between violence by and against persons with severe mental illness and their caregivers' financial burden (e.g., number of financial contributions and perceived financial strain). In addition to violence, substance use and medication noncompliance are included in a series of multivariate regression models predicting caregiver financial burden that include measures for disruptive behaviors, personal needs, social supports, and caregiver characteristics. The findings show that violent perpetration and violent victimization increase the number of financial contributions and perceived financial strain. Nonviolent victimization, in contrast, decreases caregiver financial burden. Number of financial contributions and perceived financial strain are greatest when the family member is violent and extremely disruptive or needs assistance with personal care. Neither substance use nor medication noncompliance contributed to caregiver financial burden. Co-residence, female sex, parenthood, and instrumental social support were also associated with financial burden.

Clozapine use and relapses of substance use disorder among patients with co-occurring schizophrenia and substance use disorders

BACKGROUND

Previous correlational research with schizophrenic patients has suggested that the second-generation antipsychotic medication clozapine helps to induce remissions of substance use disorder in patients with co-occurring psychosis and substance abuse. This research, however, could be biased by selection factors. Studying patients who are currently in substance abuse remission could control for level of motivation to stop using substances and other methodological confounds.

METHODS

To test whether clozapine was associated with prevention of substance abuse relapses, we examined patients with schizophrenia or schizoaffective disorder who were in their first 6-month remission of substance use disorder during a prospective 10-year follow-up study. All patients received yearly multimodal assessments of substance use. Antipsychotic medications were prescribed by community doctors as part of usual clinical care.

RESULTS

Patients using clozapine at the first 6-month period of substance abuse remission (n = 25) were much less likely to relapse over the next year compared with those on other antipsychotic medications (n = 70): 8.0% vs 40.0%, chi(2) = 8.73 (df = 1), P = .003. Although medication assignment was not randomized, several potential confounders were similar between the groups.

CONCLUSION

Clozapine should be considered for the treatment of patients with schizophrenia and co-occurring substance use disorder to prevent relapses to substance abuse.

The long-term level of functioning in patients admitted for psychotic disorders with and without substance abuse

The main objective of this study was to compare life skills between psychotic patients with substance abuse problems and psychotic patients without substance abuse problems. This is a cross-sectional study of 48 patients (26 inpatients and 22 outpatients) in a clinic for early intervention in psychosis. Patients were grouped into two categories based on if they had a substance abuse problem or not. Twenty-one (43.8%) had a substance abuse problem and 27 (56.2%) had not. We used several scales to measure substance abuse and the Life Skills Profile to measure aspects of functioning. A parametric test (t-test) was used to compare continuous variables. A non-parametric chi-square test was used to compare frequencies. The self-care subscore and the non-turbulence subscore were higher in the group with psychosis alone. These results were not significant controlling for age. The social contact subscore, the communication subscore, the responsibility subscore and the Life Skills Profile total score did not differ significantly between the groups. The abusers did not differ from the non-abusers in functioning in any area measured.

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.

Three-year outcomes of long-term patients with co-occurring bipolar and substance use disorders

Little is known about the long-term outcomes of patients in the public mental health system who are disabled by co-occurring bipolar and substance use disorders. This article reports on the 3-year course of 51 patients with co-occurring bipolar and substance use disorders in the New Hampshire Dual Diagnosis Study. Participants received integrated dual disorders treatments in the state mental health system and were independently assessed with standardized measures at baseline and every 6 months for 3 years. Though psychiatric symptoms improved only modestly, participants improved steadily in terms of remission from substance abuse (61% in full remission at 3 years); they also achieved greater independent living (average 239 days in third year), competitive employment (49% in third year), regular social contacts with nonsubstance abusers (46% at 3 years), and quality of life (56% satisfied with life at 3 years). Different domains of outcome were only weakly related to each other. Long-term, disabled patients with co-occurring bipolar and substance use disorders have potential for remission from substance abuse and substantial improvements in functioning and quality of life.

Utility of the Time-Line Follow-Back to assess substance use among homeless adults

Assessing substance use of homeless persons is a critical task. This study examines the test-retest reliability, concurrent validity, and sensitivity to change of the Time-Line Follow-Back interview, a calendar instrument used to assess days and quantities of alcohol use and days of illicit drug use, in the multisite Collaborative Program to Prevent Homelessness (CPPH). The Time-Line Follow-Back was reliable for assessing use during the past month and the recent 6 months. Results from the Time-Line Follow-Back were correlated with other self-reports of use, with research diagnoses of substance use disorder, and with clinician ratings of severity of substance abuse. The Time-Line Follow-Back detected changes in clients with severe mental illness and in those with less severe psychiatric problems.

Co-occurring psychosocial distress and substance abuse in community clients: initial validity and reliability of self-report measures

The current study examines the self-reports of 227 community support clients using a paper and pencil questionnaire that included the South Shore Problem Inventory-revised (a brief multidimensional psychosocial distress scale), a one-item index of self-rated substance abuse (SRSA), a quantity-frequency index for alcohol consumption (QFI), and a one-item index measuring the frequency of marijuana use. Results support the factor structure and internal consistency of the SSPI-r, and show significant correlations among the substance use indices. Implications for including brief mental health and substance abuse measures are discussed within the context of routine assessment and practice evaluation.

Decision making for health care professionals: use of decision trees within the community mental health setting

AIM OF THE PAPER

To examine the application of the decision tree approach to collaborative clinical decision-making in mental health care in the United Kingdom (UK).

BACKGROUND

While this approach to decision-making has been examined in the acute care setting, there is little published evidence of its use in clinical decision-making within the mental health setting. The complexities of dual diagnosis (schizophrenia and substance misuse in this case example) and the varied viewpoints of different professionals often hamper the decision-making process. This paper highlights how the approach was used successfully as a multiprofessional collaborative approach to decision-making in the context of British community mental health care.

DESIGN

A selective review of the relevant literature and a case study application of the decision tree framework.

CONCLUSIONS

The process of applying the decision tree framework to clinical decision-making in mental health practice can be time consuming and client inclusion within the process is not always appropriate. The approach offers a method of assigning numerical values to support complex multiprofessional decision-making as well as considering underpinning literature to inform the final decision. Use of the decision tree offers a common framework that can assist professionals to examine the options available to them in depth, while considering the complex variables that influence decision-making in collaborative mental health practice. Use of the decision tree warrants further consideration in mental health care in terms of practice and education.

Utility of collateral information in assessing substance use among psychiatric outpatients

PURPOSE

This study addressed the utility of collateral informants for validating self-reported substance use by psychiatric outpatients.

METHODS

Participants were 92 men and women with severe and persistent Axis I disorders, attending outpatient programs at a public psychiatric facility. As part of a substance use assessment, each participant identified a collateral who would provide information about the participant's substance use in the last month. The collaterals consisted of family (35%), peers (23%), and others (40%) who were primarily mental health staff.

RESULTS

Comparisons of participant and collateral reports showed high percent agreement with significant but modest measures of association. The likelihood that collateral reports will have information value (i.e., corroborate or exceed self-reports) was greater when the topic is illicit drug use and the frequency of contact is once a week or more. In this sample, siblings were more likely to be uninformative than other types of collaterals, whereas treatment staff were comparable to other types of collaterals in the information value of their corroborative reports. Overall, the collateral reports rarely provided more information than was provided by the participants themselves.

IMPLICATIONS

This pattern is consistent with the pattern observed in non-psychiatric samples and supports the accuracy of self-reported substance use by psychiatric outpatients.

Is the substance abuse of inpatients with schizophrenia overlooked?

The utility of medical records and clinician reports for assessing substance abuse among inpatients with schizophrenia or schizoaffective disorder was assessed in a sample of 296 patients recruited from four general hospitals in New York City. Measures derived from the medical record, the discharge summary, and primary clinician reports are compared to the results of a structured diagnostic interview. Analysis of the sensitivity, specificity, positive predictive value, and overall accuracy of the nondiagnostic sources found unexpectedly high levels of detection. Discharge summaries had the lowest sensitivity when compared to the diagnostic interview, raising concern that inpatient staff and clinicians may fail to communicate substance abuse problems to outpatient providers.

Level of burden among women diagnosed with severe mental illness and substance abuse

Women diagnosed with severe mental illness and substance abuse may face a variety of associated difficulties that require intervention, including other health-related problems, housing instability or homelessness, and a history of or current physical or sexual abuse. This article expands upon the concept of "level of burden" by specifically examining issues for women with multiple vulnerabilities in a sample of 577 women participating in a residential substance abuse treatment program. Two types of outcomes were examined for the women. In Study 1, the effects of severe mental illness as well as overall level of burden on retention in treatment were examined. Cox regression analyses revealed that severe mental illness was significantly related negatively to retention in treatment; those women diagnosed with severe mental illness tended to stay in treatment less time than those without such a diagnosis. In Study 2, staff ratings of the women's status at departure from residential treatment for a subsample of 311 women were examined with respect to overall retention in treatment and severe mental illness. Ratings of client status at program exit were significantly related to time in program but were not related to having a severe mental illness diagnosis. For a few indicators (e.g., leaving treatment against advice, having scattered or disorganized thoughts, and having no specific plans for life outside of treatment), there was an interaction between time in program and severe mental illness such that women with severe mental illness who were retained for less than 180 days were more likely to demonstrate negative outcomes. Implications for the treatment of multiply-diagnosed women are discussed.

Gender differences in homeless persons with schizophrenia and substance abuse

The purpose of this study was to test the generalizability of previous research on gender differences between men and women with co-occurring schizophrenia and substance abuse. One hundred eight patients with schizophrenia or schizo-affective disorder involved in a study of treatment for homeless persons were interviewed for information regarding substance use, social functioning and support, comorbid disorders, victimization, medical illness, and legal troubles. We found that women had more children and were more socially connected than men. Women also had higher rates of sexual and physical victimization, comorbid anxiety and depression, and medical illness than men. We conclude that homeless women with dual disorders, like women with substance use disorders in the general population, have distinct characteristics, vulnerabilities, and treatment needs compared with men. In addition to comprehensive treatment of psychiatric and substance use disorders, gender-specific services should be developed, including prevention and treatment of victimization and related problems as well as help with accessing medical services.

Severe mental illness and addictions: assessment considerations

This article provides a selective overview of the empirical literature on substance use assessment for persons with severe mental illness. We organize the review around key questions related to three assessment goals. With regard to screening, we address what screening tools are appropriate for use in psychiatric settings, and what methodological concerns arise regarding their use in these contexts. With regard to diagnosis, we discuss why diagnosing comorbid disorders is difficult and how clinicians can enhance the reliability and validity of their diagnoses. With regard to the related goals of treatment planning and outcome evaluation, we consider what are appropriate outcome measures, and how assessment information can assist in treatment planning. Finally, we outline three promising directions for future research: (a) evaluating the psychometric properties of established substance-related measures in persons with severe mental illness, (b) identifying the conditions under which self-report information is more or less accurate, and (c) improving the population relevance of substance assessment instruments.

Efficiency and validity of commonly used substance abuse screening instruments in public psychiatric patients

BACKGROUND

The more commonly used screening instruments for substance abuse were largely developed for addictive populations. We compared several alcohol and drug abuse scales to determine their efficiency and validity for psychiatric patients.

METHOD

The subjects were 100 consecutively admitted patients to a public psychiatric facility. DSM-III-R diagnoses, obtained from the alcohol and drug scales of the SCID-P, were the criterion measure. Methods of reliability included inter-rater agreement, estimates of internal consistency, and repeat test administration. Sensitivity, specificity and more infrequently used accuracy indices, such as likelihood ratios and Receiver Operating Characteristic (ROC) analysis, were utilized to assess scale validity.

RESULTS

First, the reliability of all scales was high. Second, the instruments generally demonstrated highly acceptable levels of screening accuracy. Third, the intake evaluation was as reliable and valid as screening after admission on the unit. Finally, instruments were least discriminating for current problems (past 30 days).

CONCLUSIONS

Lifetime measures were found to be reliable and valid for public psychiatric patients but further research is need on increasing the accuracy of screening for current substance abuse problems and the effectiveness of multiple screening approaches.

Violence and severe mental illness: the effects of substance abuse and nonadherence to medication

OBJECTIVE

Violent behavior among individuals with severe mental illness has become an important focus in community-based care. This study examines the joint effect of substance abuse and medication noncompliance on the greater risk of serious violence among persons with severe mental illness.

METHOD

Involuntarily admitted inpatients with severe mental illness who were awaiting a period of outpatient commitment were enrolled in a longitudinal outcome study. At baseline, 331 subjects underwent an extensive face-to-face interview. Complementary data were gathered by a review of hospital records and a telephone interview with a family member or other informant. These data included subjects' sociodemographic characteristics, illness history, clinical status, medication adherence, substance abuse, insight into illness, and violent behavior during the 4 months that preceded hospitalization. Associations between serious violent acts and a range of individual characteristics and problems were analyzed by using multivariable logistic regression.

RESULTS

The combination of medication noncompliance and alcohol or substance abuse problems was significantly associated with serious violent acts in the community, after sociodemographic and clinical characteristics were controlled.

CONCLUSIONS

Alcohol or other drug abuse problems combined with poor adherence to medication may signal a higher risk of violent behavior among persons with severe mental illness. Reduction of such risk may require carefully targeted community interventions, including integrated mental health and substance abuse treatment.

A comparison of clinical and structured interview diagnoses in a homeless mental health clinic

OBJECTIVE

This study compared psychiatric diagnoses ascertained by independent clinicians with structured research interviews of homeless psychiatric patients assessed in a mental health clinic and in the community. Problems of both overdiagnosis and underdiagnosis in structured research interviews compared to clinician assessment were predicted.

METHOD

Over a period of a year, 97 patients referred to a mental health clinic for homeless people were assessed with the Diagnostic Interview Schedule (DIS) administered by a clinical social worker who then completed a full clinical psychiatric social work assessment. These same patients received a thorough and systematic clinical psychiatric evaluation by a psychiatrist or psychologist, both experienced with this population. These clinicians gathered data from multiple sources, often with extended observation over time. The DIS and clinician diagnoses were made blind to one another and then compared; the clinician was often made aware of some of the symptoms that the social worker had elicited, but not whether the elicited material was from the DIS or from the clinical assessment. Diagnoses of 33 clinic patients previously assessed by trained nonclinician DIS interviews in an epidemiologic study of the homeless population in the community were also compared to clinician diagnoses, and no information from these patients' survey DIS interviews was made available to the clinicians.

RESULTS

Compared to clinician assessment, structured interviews underdiagnosed antisocial personality disorder (ASPD) and overdiagnosed major depression. Alcohol use disorder and schizophrenia showed only small discrepancies by assessment method. Drug use disorder revealed no bias according to method of ascertainment, but showed very discrepant kappa levels comparing DIS to clinician assessment in the two different comparison contexts.

CONCLUSIONS

If structured research methods assessing the homeless population actually overestimate depression, underestimate ASPD, and misclassify drug abuse, then policies stemming from structured interview research recommendations may call for levels and types of services not optimally suited to the reality of this population's needs. Because mental illness and substance abuse are thought to be critical factors in the generation and perpetuation of homelessness, the issue of accurate diagnosis is tantamount to understanding and providing workable solutions to the problem of homelessness. Further research is needed to untangle potential confounders of the homeless situation to psychiatric diagnosis.

Unnatural causes of death among drug addicts in Stockholm: an analysis of health care and autopsy records

The aim of this study was to assess causes of death among 258 unnaturally deceased drug addicts who had been part of an earlier longitudinal follow-up of 1,630 patients treated in Stockholm County. An evaluation of the causes of death was carried out on the basis of hospital records and autopsy protocols. The majority of deaths were caused by accidents (39%) and suicides (31%). Intoxications were involved in 67 of the 101 accidents. Violent methods were employed in 40 of the 79 suicides. An exceptionally large proportion (28%) of the fatalities occurred during or immediately after hospitalization, which calls for increased attention to this patient group by the health services.

Integrated treatment for dually diagnosed homeless adults

This study examined the effects of integrating mental health, substance abuse, and housing interventions for homeless persons with co-occurring severe mental illness and substance use disorder. With the use of a quasi-experimental design, integrated treatment was compared with standard treatment for 217 homeless, dually diagnosed adults over an 18-month period. The integrated treatment group had fewer institutional days and more days in stable housing, made more progress toward recovery from substance abuse, and showed greater improvement of alcohol use disorders than the standard treatment group. Abuse of drugs other than alcohol (primarily cocaine) improved similarly for both groups. Secondary outcomes, such as psychiatric symptoms, functional status, and quality of life, also improved for both groups, with minimal group differences favoring integrated treatment.

Impact of assertive community treatment on homeless persons with co-occurring severe psychiatric and substance use disorders

This study evaluated the impact of an integrated (mental health/substance abuse) assertive community treatment program on homeless persons with serious mental and substance use disorders. High rates of retention in treatment, housing stability, and community tenure were attained, and all but the most severe substance users appeared to gain these benefits. While the intervention appears to be an effective means of retaining in services and monitoring such difficult-to-treat and costly populations, it did not yield high rates of abstinence and social benefits in severe users.

A new look at an old issue: people with mental illness and the law enforcement system

Most research on encounters between persons with mental illness and the law enforcement system has focused on the extent to which persons with mental illness are shifted between the mental health and law enforcement systems. This article focuses instead on the interplay between the mental health and law enforcement systems for a group of persons with severe mental illness who continue to be actively treated by an Assertive Community Treatment (ACT) program. To better understand the connection between these two systems, profiles were constructed for 100 ACT clients, including data about arrests, other contacts with the law enforcement system, and mental health treatment. Results indicate that although the majority of ACT clients had some contact with the law enforcement system, most police encounters and arrests were for minor infractions. Those clients with the most frequent and serious contacts also received more expensive and intensive mental health treatment. Implications for future research and program design are discussed.

Relationships between symptoms of schizophrenia and substance abuse

Previous work posits that severity of substance abuse and severity of schizophrenic symptoms should be linked by either or both of two mechanisms: self-regulation of symptoms and drug-induced exacerbation of symptoms. Research on these relationships has yielded mixed results. We examined the interrelationships of schizophrenic symptoms and substance abuse in 172 patients with co-occurring disorders. Relationships were weak or nonexistent, without any consistent pattern. Our findings do not support the view that substances are used to self-regulate symptoms. In addition, our results suggest that substance abuse may lead to higher rates of institutionalization through mechanisms other than by exacerbating symptoms.

Self-report and observer measures of substance abuse among homeless mentally ill persons in the cross-section and over time

The comparability of self-report and observer measures of substance abuse among 118 homeless mentally ill persons was assessed using cross-sectional and longitudinal measures. Possible correlates of nondisclosure were identified from demographic variables and clinical indicators. Lifetime abuse reported at baseline was a sensitive predictor of subsequent abuse behavior in the project, but cross-sectional measures based only on self-report or observer ratings failed to identify many abusers. A total of 17% of the subjects never disclosed abuse that was observed during the project. The level of substance abuse is likely to be severely underestimated among homeless mentally ill persons when only one self-report measure is used at just one point in time. This problem can, however, largely be-overcome by incorporating information from observers and from multiple follow-ups or by focusing on lifetime rather than current abuse. We also conclude that underreporting may bias estimates of some correlates of substance abuse.

Neurocognitive function in alcoholic, schizophrenic, and dually diagnosed patients

Neurocognitive functions were compared in alcoholic, schizophrenic, and dually diagnosed (schizophrenic and alcoholic) patients and community control volunteers. Participants (N = 52, n = 13 in each group) completed a brief battery including two measures of neuropsychological function and two affective measures. The neuropsychological tests included the Trail-Making Test Forms A and B and a face-recognition test. The affective measures included assessment of anxiety and depression. The major objective was to compare the patterns of neurocognitive performance among the four groups. The groups did not differ in mean age (35.37) or years of education (12.46). Compared with the community control and alcoholic groups, the schizophrenic groups reported higher mean depression (12.92 vs. 5.54) and mean state anxiety scores (60.73 vs. 46.04). Control subjects were generally, although not always significantly, superior to the other groups. Contrary to expectations, alcoholic patients were not consistently better than the schizophrenic groups, and dually diagnosed participants were not more impaired than schizophrenic patients without substance abuse histories. Thus, the interaction of schizophrenia and substance abuse did not have an additive effect on neurocognitive performance assessed in this study. More research using this complete four-group design and a larger neurocognitive battery is needed.