Dual diagnosis: a treatment model for substance abuse and major mental illness

Readiness-to-change cluster profiles among adults with mental illness who were homeless participating in a life skills intervention

This longitudinal study examined differences in intervention outcomes based on readiness-to-change cluster profiles among 73 adults with a mental illness at risk for homelessness participating in a manualized life skills intervention. Intervention topics included money management, food management, safe community participation, and room- and self-care. Life skill knowledge and readiness-to-change, measured using the University of Rhode Island Change Assessment, was examined at baseline, post-intervention, and 3-6 months later. Two scoring patterns emerged for readiness-to-change at each time point: Pre-Engaged and Engaged. Participants who were Engaged at the time of assessment scored significantly better than Pre-Engaged on post-intervention life skill testing, however group identification changed over time. Baseline readiness-to-change did not predict future performance or attrition, and therefore may not provide accurate indication of client investment for future learning or participation. Further investigation is needed to determine what factors contribute to Engaged membership.

Estudo de comorbidade: sofrimento psíquico e abuso de drogas em pessoas em centros de tratamento, Macaé - Brasil

Estudo da prevalência de sofrimento psíquico entre pessoas em tratamento em um serviço de atenção diário público e dois centros de internação privados, sendo um prestador de serviços ao Sistema Único de Saúde, da cidade de Macaé, Rio de Janeiro, Brasil. Estudo transversal. Foi aplicado questionário para caracterização dos participantes, adaptado do formulário EULAC-CICAD. A escala de Kessler-10 foi utilizada para rastreamento do sofrimento psíquico. Participaram 60 pessoas, sendo 88,3% homens. Do total, 51,5% estavam na faixa de 24 a 39 anos de idade. Depressão foi o principal diagnóstico prévio referido em 35%, seguido por ansiedade em 33,33%. Durante o tratamento atual, a ansiedade foi o principal diagnóstico referido em 8,3%, seguido de depressão em 28,3%. Dos entrevistados, 34% apresentaram níveis severos e 27,2% muito severos de sofrimento psiquico. Conclui-se que os níveis de sofrimento psíquico severo e muito severo em 61,2% encontrados com a escala K-10, especialmente sensível para ansiedade e depressão, são semelhantes para esta população nos estudos internacionais.

El distrés psicológico y abuso de drogas en pacientes en centros de tratamiento del gran Valparaíso - Chile: implicaciones para las políticas y los programas

El objetivo fue determinar la prevalencia de comorbilidad entre distrés psicológico y abuso/dependencia de drogas en pacientes en centros de tratamiento. Este estudio epidemiológico, multicéntrico, de corte transversal, realizado en 107 pacientes mayor es de 18 años, en tratamiento por abuso/dependencia de drogas, en centros de tratamiento de Valparaíso, Chile, mostró además otros factores involucrados como: aspectos sociodemográficos, funcionalidad familiar, características del consumo de drogas y aspectos de la atención otorgada. Para recolección de datos se usó el EULAC (Instrumento para diagnostico rápido de situación de tratamiento para problemas por consumo de drogas en el ámbito local) el K 10 y Apgar familiar. Resultados: 48.6% presentaron distrés psicológico; 88.8% refirieron satisfacción por el tratamiento actual. 66.4% pertenece a una familia normo funcional. Los resultados obtenidos permitirán mejorar las intervenciones en pacientes que están en tratamiento y rehabilitación en los centros de tratamiento.

Estudio de la comorbilidad entre el distrés psicológico y abuso de drogas en pacientes en centros de tratamiento, ciudad de Panamá - Panamá

Se trata de un estudio epidemiológico multicéntrico de corte transversal, dirigido a personas en tratamiento por abuso/dependencia de drogas en la República de Panamá. Se estudia la comorbilidad. La muestra consta de 167 internos en 11 Centros de tratamiento. Los datos fueron colectados en un cuestionario, mediante encuesta o entrevista. El 71.3% reportó uso de alcohol, 73.9% cannabis, 62.3% cocaína en polvo, 40.7% crack o piedra, 14.4% pasta base o bazuco. La prevalencia del distrés psicológico es de 49.1% de personas con distrés psicológico leve, y 28.8% de distress psicológico severo y muy severo. Existen evidencias de comorbilidad en la población internada en los Centros de tratamiento por abuso/dependencia de droga en Panamá, ya que 44.1% de los internados por abuso de alcohol, tienen también un diagnóstico de trastornos psiquiátricos y 73% de los internados por consumo de drogas ilícitas también poseen un diagnóstico de trastorno psiquiátrico.

Why do patients with psychosis use cannabis and are they ready to change their use?

Numerous studies have shown that patients with psychosis are more likely to use illicit drugs than the general population, with cannabis being the most popular. There exists overwhelming evidence that cannabis use can contribute to the onset of schizophrenia and poor outcome in patients with established psychosis. Therefore, understanding why patients use cannabis and whether they are motivated to change their habits is important. The evidence is that patients with psychosis use cannabis for the same reasons the general population does, to 'get high', relax and have fun. There is little support for the 'self-medication' hypothesis, while the literature points more towards an 'alleviation of dysphoria' model. There is a lack of research reporting on whether psychotic patients are ready to change their use of cannabis, which has obvious implications for identifying which treatment strategies are likely to be effective.

Psychosocial factors associated with successful transition into HIV case management for those without primary care in an urban area

The purpose of this study was to identify the psychosocial factors which influence transitioning HIV positive clients without primary medical care to a case management agency within 6 weeks by a city brokerage agency. People living with HIV who reported being in a social support group and those who requested assistance with meeting their basic needs were significantly more likely to attend their first case management appointment within 6 weeks (adjusted OR 1.91 95% CI 1.22-2.97 and OR 1.24 95% CI 1.01-1.54, respectively). Individuals requesting medical care or substance abuse treatment were less likely to accomplish transitioning (adjusted OR 0.75 95% CI 0.59-0.95 and adjusted OR 0.70 95% CI 0.53-0.91, respectively). The implications of this study for improving the effectiveness of brokering case management for those with HIV are discussed.

Motivation and the stages of change among individuals with severe mental illness and substance abuse disorders

A complicating factor affecting the treatment of individuals with coexisting substance use problems and serious mental illness is their motivation for change and how these interacting, chronic conditions affect the entire process of intentional behavior change. This selective review explores conceptual and assessment issues related to readiness to modify substance use and readiness to initiate behaviors helpful for managing mental illness in the search for a better understanding of patient motivation for change. The recent but limited research on motivation and stages of change among dually diagnosed patients indicates that these individuals appear to access and use an intentional behavior change process. However, it is not completely clear how this process works and what precise adaptations are needed to assess and to access motivation to change to encourage sustained behavior change in this population. Nevertheless, motivation and readiness to change are important dimensions that need to be addressed in treatment and research with dually diagnosed populations.

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

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

Factors associated with interest in initiating treatment for hepatitis C Virus (HCV) infection among young HCV-infected injection drug users

OBJECTIVE

We sought to identify factors associated with interest in receiving therapy for hepatitis C virus (HCV) infection among HCV-infected injection drug users (IDUs) in 3 United States cities.

METHODS

IDUs aged 18-35 years who were HCV-infected and seronegative for human immunodeficiency virus underwent surveys on behaviors, experience, and interest in treatment for HCV infection and readiness to quit drug use.

RESULTS

Among treatment-naive IDUs (n=216), 81.5% were interested in treatment for HCV infection, but only 27.3% had seen a health-care provider since receiving a diagnosis of HCV infection. Interest in treatment for HCV infection was greater among IDUs with a high perceived threat of progressive liver disease, those with a usual source of care, those without evidence of alcohol dependence, and those with higher readiness scores for quitting drug use. Interest in treatment for HCV infection was 7-fold higher among IDUs who were told by their health-care provider that they were at risk for cirrhosis or liver cancer.

CONCLUSIONS

Improving provider-patient communication and integrating treatments for substance abuse and HCV may increase the proportion of IDUs who initiate treatment for HCV infection.

Use of the Transtheoretical Model for individuals with co-occurring disorders

Because of the interactive nature between their mental disorder and their substance-use disorder, individuals with co-occurring disorders may experience factors that complicate behavioral change, such as considering abstinence from alcohol and drugs. This study examined the relationships between the stages-of-change and the processes of change, constructs of the Transtheoretical Model by Prochaska and DiClemente. There was partial support for the theory. The findings suggest that individuals with co-occurring disorders require support and clinical interventions throughout the entire change process.

Dual Diagnosis Motivational Interviewing: a modification of Motivational Interviewing for substance-abusing patients with psychotic disorders

Motivational Interviewing (MI) is a brief treatment approach for helping patients develop intrinsic motivation to change addictive behaviors. While initially developed to target primary substance using populations, professionals are increasingly recognizing the promise this approach has for addressing the motivational dilemmas faced by patients who have co-occurring psychiatric and psychoactive substance use disorders. Unfortunately, this recognition has not lead to a clear explication of how MI might be adopted for specific diagnostic populations of dually diagnosed patients. In this article we describe how we have applied the principles and practices of MI to patients who have psychotic disorders and co-occurring drug or alcohol use problems. Specifically, we provide two supplemental guidelines to augment basic MI principles (adopting an integrated dual diagnosis approach, accommodating cognitive impairments and disordered thinking). We present recommended modifications to primary MI skill sets (simplifying open-ended questions, refining reflective listening skills, heightening emphasis on affirmation, integrating psychiatric issues into personalized feedback and decisional balance matrices). Finally, we highlight other clinical considerations (handling psychotic exacerbation and crisis events, recommended professional qualifications) when using MI with psychotic disordered dually diagnosed patients.

Achieving effective treatment of patients with chronic psychotic illness and comorbid substance dependence

OBJECTIVE

The changing effectiveness of a treatment program for dual-diagnosis patients was evaluated over a 2-year period with the use of a sequential study group design.

METHOD

The treatment outcome of 179 consecutively enrolled patients with chronic psychotic illness and comorbid substance dependence who entered a specialized day hospital dual-diagnosis treatment program from Sept. 1, 1994, to Aug. 31, 1996, was evaluated. The 24 months were divided into four successive 6-month periods for comparing the evolving effectiveness of the program for groups of patients entering the day hospital during these four periods. Treatment attendance, hospital utilization, and twice weekly urine toxicology analyses were used as outcome measures.

RESULTS

The initial treatment engagement rate, defined as at least 2 days of attendance in the first month, increased significantly from group 1 to group 4, more than doubling. Thirty-day and 90-day treatment retention rates also substantially increased from group 1 to group 4. More patients had no hospitalization in the 6 months after entering the day hospital program than in the 6 months before entering the day hospital program. Urine toxicology monitoring indicated that the patients in group 4 were more likely than those in group 1 to remain abstinent at follow-up.

CONCLUSIONS

The evolving clinical effectiveness of a developing program can be quantified by using a sequential group comparison design. The sequential outcome improvements may be related to the incremental contributions of assertive case management and skills training for relapse prevention.