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

Reducing the risk of prenatal alcohol exposure and FASD through social services: promising results from the FAR SEAS pilot project

Introduction

Within FAR SEAS, a multi-component evidence-based community intervention was implemented and evaluated in Mazovia (Poland), with the aim of preventing alcohol-exposed pregnancies, and therefore preventing FASD.

Methods

Multi-disciplinary professionals from different services (social, addiction, and psychology), recruited women of child-bearing age (pregnant and not pregnant) in local communities, screened them for alcohol risk, and allocated participants (n = 441) to groups for low- (70%), moderate- (23%), or high-risk (7%) of alcohol exposed pregnancy, to provide interventions tailored to their needs. The non-parametric sign test, testing differences between pairs of observations before and after intervention was used to evaluate the outcomes.

Results

Follow-up data (collected from 93% of participants) indicated positive changes in the key outcome variables: risky alcohol consumption dropped by 81%, contraception use increased by 15% and visiting a gynecologist increased by 39%; as well as in associated psychosocial risk factors (decrease in cigarette and drug use, domestic violence and depressive symptoms). No changes were noted in frequency of other service use (medical, psychological, or social). The most prominent changes were observed in the moderate-risk group.

Discussion

Changing risky behaviors (alcohol consumption and sex without contraception) to prevent alcohol exposed pregnancies is feasible at the local level, even without engagement of medical professionals. Key challenges, related to engaging professionals and local authorities, must be addressed; and procedures should be adapted to local contexts and needs.

Assessing self-stigma levels and associated factors among substance use disorder patients at two selected psychiatric hospitals in Egypt: a cross-sectional study

BACKGROUND

Substance use disorder is a growing problem worldwide, and the stigma associated with it remains a significant barrier to treatment and recovery. This study aimed to assess the perceived stigma among individuals with substance use disorders and its correlation with their socio-demographic characteristics and clinical history Parameters.

METHODS

A cross-sectional study was conducted among 552 patients with substance use disorders admitted to the outpatient clinics of Mansoura University Hospital, Addiction Treatment Unit of the Psychiatry Department, and Port Said Mental Hospital, Addiction Department. Participants completed a self-administered questionnaire, which included demographic information, clinical history parameters, and the Perceived Stigma of Substance Abuse Scale (PSAS).

RESULTS

The study found that almost half of the participants were aged 29 or younger, married, and had a median stigma score of 20. The vast majority of participants were male, had no previous legal problems, and had a median stigma score of 19. The most common type of substance used was opioids, and more than half of the participants were still using drugs. The highest mean stigma scores were for the items "Most people think less of a person who has been in treatment for substance use" and "Most employers will pass over the application of someone who has been treated for substance use in favor of another applicant." The perceived stigma score was significantly correlated with the severity of use but not with age or duration of use.

CONCLUSION

Our study investigates self-stigma in substance use disorder (SUD), revealing its variance across demographics and clinical groups. We found that self-stigma correlates with use severity and possibly decreases with abstinence. Notably, societal bias contributes significantly to self-stigma, necessitating societal interventions. The impact of self-stigma on patient well-being highlights the need for personalized treatments and stigma reduction strategies.

Inpatients in substance use treatment with co-occurring psychiatric disorders: a prospective cohort study of characteristics and relapse predictors

BACKGROUND

The characteristics of substance use disorder (SUD) inpatients with co-occurring psychiatric disorders (COD) have been scantly described in the extant literature. This study investigated psychological, demographic and substance use characteristics in these patients, along with predictors of relapse 3 months post-treatment.

METHODS

Prospective data from a cohort of 611 inpatients were analyzed for demographics, motivation, mental distress, SUD diagnosis, psychiatric diagnoses (ICD-10) and relapse rate at 3 months post-treatment (retention rate = 70%).

RESULTS

Compared to patients without COD (n = 322), those with COD (n = 289) were younger, had higher mental distress, lower education and higher likelihood of no permanent residence. The relapse rate was also higher in patients with COD (39.8%) relative to patients without COD (26.4%) (OR = 1.85, 95% CI: 1.23-2.78). The relapse rate was particularly high for patients with COD who were diagnosed with cannabis use disorder (53.3%). Multivariate analysis revealed that among patients with COD, relapse was more likely for individuals with a cannabis use disorder (OR = 2.31, 95% CI: 1.34-4.00), and less likely for older ages (OR = 0.97, 95% CI: 0.94-1.00), females (OR = 0.56, 95% CI: 0.33-0.98) and for those with higher intrinsic motivation (OR = 0.58, 95% CI: 0.42-0.81).

CONCLUSION

This study showed that among SUD inpatients, those with COD had relatively persistent high levels of mental distress and an increased risk of relapse. Enhanced measures aimed at COD patients' mental health problems during the inpatient stay, along with close and personalized follow-up after discharge from residential SUD treatment may reduce the probability of relapse in this group.

"…he's going to be facing the same things that he faced prior to being locked up": perceptions of service needs for substance use disorders

BACKGROUND

High rates of substance use disorders (SUDs) exist among justice-involved populations (i.e., persons incarcerated or recently released). SUD treatment is crucial for justice-involved populations as unmet treatment need increases reincarceration risk and impacts other behavioral health sequalae. A limited understanding of health needs (i.e. health literacy) can be one reason for unmet treatment needs. Social support is critical to seeking SUD treatment and post-incarceration outcomes. However, little is known about how social support partners understand and influence SUD service utilization among formerly incarcerated persons.

METHODS

This mixed method, exploratory study utilized data from a larger study comprised of formerly incarcerated men (n = 57) and their selected social support partners (n = 57) to identify how social support partners understand the service needs of their loved ones recently released from prison who returned to the community with a diagnosis of a SUD. Qualitative data included 87 semi-structured interviews with the social support partners covering post-release experiences with their formerly incarcerated loved one. Univariates were conducted on the quantitative service utilization data and demographics to complement the qualitative data.

RESULTS

Majority of the formerly incarcerated men identified as African American (91%) averaging 29 years of age (SD = 9.58). Most social support partners were a parent (49%). Qualitative analyses revealed that most social support partners avoided using or did not know the language to use regarding the formerly incarcerated person's SUD. Treatment needs were often attributed to focus on peer influences and spending more time at their residence/housing. Analyses did reveal that when treatment needs were recommended in the interviews, social support partners reported employment and education services to be most needed for the formerly incarcerated person. These findings align with the univariate analysis with their loved ones reporting employment (52%) and education (26%) as their most reported service utilized post-release, compared to only 4% using substance abuse treatment.

CONCLUSION

Results provide preliminary evidence suggesting social support partners do influence the types of services accessed by formerly incarcerated persons with SUD. The findings of this study emphasize the need for psychoeducation during and after incarceration for individuals with SUDs and their social support partners.

A Leg to Stand On: Working With Marginal Decision-making Capacity in a Patient With a Severe Leg Infection and Schizophrenia

Assessment of a patient's capacity to make treatment decisions and working with the wishes of a patient with mental illness against the best medically indicated plan is a complex and dynamic task. It is particularly challenging when the course of deterioration of the illness is meandering and slow, and the time horizon for recovery is uncertain, providing no clear point of entry for definitive crisis intervention. High-impact decisions concerning body integrity, such as the amputation of a leg, further complicate the task. To highlight these challenges and complexities, we present the case of a man who suffered from schizophrenia, with a worsening diabetic foot ulcer and suboptimal acceptance of proper wound care. The patient died as a result of his refusal of a proposed amputation to address his life-threatening infection. Medical system and cultural issues are also considered.

Development of the motivational thought frequency scale for alcohol abstinence (MTF-A)

BACKGROUND AND AIMS

For most treatment-seeking patients with severe Alcohol Use Disorder (AUD), abstinence is the clinically indicated goal. Existing AUD motivation scales are non-specific about treatment consumption goals, which limit their effectiveness. Desires and mental imagery are relevant in the motivation for AUD treatment engagement. The Motivational Thought Frequency Scale for an abstinence goal (MTF-A) was adapted from the MTF for controlled drinking (MTF-CD). This study psychometrically evaluated the MTF-A in an alcohol-dependent sample engaged in treatment with a goal of abstinence. To enhance the clinical utility of the scale, a secondary aim was to evaluate a psychometrically equivalent short version of the MTF-A.

METHOD

A sample N of 329 treatment-seeking patients with AUD (mean age of 44.44 years, SD = 11.89 years, 72% male) who were undertaking a cognitive behavioral treatment (CBT) program for abstinence completed the Motivational Thought Frequency Scale for Abstinence (MTF-A) and the Severity of Alcohol Dependence Questionnaire (SADQ). The MTF-A measured motivation for abstinence through four factors: intensity, self-efficacy imagery, incentives imagery, and availability. Confirmatory factor analyses (CFAs) were conducted to examine factor structure and model fit. Cronbach's alpha assessed internal consistency. Predictive validity was determined by logistic regression predicting first-session treatment non-attendance and alcohol consumption between baseline assessment and commencement of treatment, controlling for potential confounds.

RESULTS

A four-factor structure provided the best fit for the MTF-A, compared with one- and three-factor models. A shortened 9-item MTF-A scale (S-MTF-A) provided better fit than the 13-item MTF-A scale. Both MTF-A and S-MTF-A displayed good internal consistency. Although both MTF-A and S-MTF-A successfully predicted first-session treatment non-attendance, neither predicted alcohol consumption between the baseline assessment and commencement of treatment.

CONCLUSIONS

The model fit of the four-factor, 9-item S-MTF-A was superior to the original 13-item MTF-A. Both scales were predictive of participation of AUD treatment. Desires and mental imagery play an important role in AUD treatment motivation.

Substance Use in Relation to Mental Illness: A Study of Mexican-Origin Latinos with Schizophrenia and Their Family Members

Little is known about family context and substance use behaviors among Latinos with schizophrenia. Learning about patient and family caregiver perceptions of use is critical to our understanding of how best to support these vulnerable patients and family caregivers. This study explored perceptions of substance use in relation to mental illness among Latinos primarily of Mexican origin with schizophrenia and their family caregivers. Semistructured interviews were conducted with 34 participants (20 family caregivers; 14 patients) with direct and indirect substance use experience, in their preferred language. Data were analyzed using thematic analysis, which consisted of comparing codes across and within patient and family caregiver transcripts. Findings revealed that substance use affected well-being, particularly patient recovery and caregiver burden. Strategies to address well-being included limiting substance use, being vigilant about patient use, and communicating the negative impact of use. The environmental impact and stigma of substance use were major contextual challenges. Patients addressed these by limiting their socialization. Family social context was important to how substance use was perceived and managed by patients and caregivers. As such, treatment models should consider a holistic perspective that incorporates family context when addressing substance use among Latinos with schizophrenia.

Identification of the return-to-work mode in unemployed workers with mental health issues: A focus group study among occupational health professionals

BACKGROUND: Return-to-work (RTW) perceptions and attitudes are predictive for future work participation in workers with mental health issues. OBJECTIVE: To identify what RTW perceptions and attitudes occupational health professionals recognize in sick-listed unemployed workers with mental health issues and how these perceptions and attitudes can be systematically assessed. METHODS: Four focus group sessions, each involving five-six different occupational health professionals, were held. The audio records were transcribed verbatim and coded by two researchers independently. A thematic analysis was conducted. RESULTS: Professionals recognized RTW perceptions and attitudes in sick-listed unemployed workers with mental health issues. These perceptions and attitudes were described as characteristics of three modes in a process regarding RTW: the passive, ambivalent and active RTW mode. A passive RTW mode includes perceptions about not being able to work and an expectant attitude. The ambivalent RTW mode is characterized by uncertainty and ambivalence regarding RTW with a desire for occupational support. Workers in an active RTW mode have positive RTW perceptions and show job search behavior. A main theme was the flexible nature of RTW attitudes and perceptions, with workers switching between the passive, ambivalent and active RTW modes. For the assessment of the RTW mode, the professionals preferred personal contact, possibly with support of a tool. This enables them to ask specific questions and to observe non-verbal signs. CONCLUSIONS: Recurring assessments of the RTW mode can be helpful in identifying unemployed workers with mental health issues at risk of long-term sickness absence and for starting targeted RTW interventions.

Review of barriers and interventions to promote treatment engagement for pediatric attention deficit hyperactivity disorder care

Attention deficit hyperactivity disorder (ADHD) is a common and impairing behavioral health disorder, impacting over 5% of children worldwide. There are multiple evidence-based pharmacological and psychosocial treatments for ADHD, and greater service utilization is associated with improved acute and long-term outcomes. However, long-term outcomes are suboptimal as multimodal treatments are often not accessed and most care ends prematurely. This narrative review discusses barriers to engagement for children and adolescents with ADHD and their families as well as interventions to overcome these barriers. Families face a variety of structural and attitudinal barriers, ranging from cost and access to stigma and low self-efficacy to successfully implement change. There are multiple interventions that may enhance engagement with ADHD care including psychoeducation, integration of behavioral services in general medical settings, telehealth as well as specific adaptations to existing ADHD treatments, such as the use of motivational interviewing or shared decision making. Integration of behavioral health into general medical settings and telehealth have been found in controlled studies to increase access by reducing both structural and attitudinal barriers. Adding motivational interviewing, shared decision making and other engagement interventions to evidence-based ADHD treatments has been found to reduce attitudinal barriers that translates into improved participation and satisfaction while enhancing outcomes. However, little is known about how to promote extended engagement with ADHD services even though a chronic care model for ADHD is recommended.

Structural competency in the post-prison period for people who inject drugs: A qualitative case study

INTRODUCTION

Access to services is key to successful community (re-)integration following release from prison. But many people experience disengagement from services, including people who inject drugs (PWID). We use a case study approach and the notion of structural competency to examine influences on access to services among a group of PWID recently released from prison.

METHODS

This qualitative study recruited participants from SuperMIX, (a longitudinal cohort study in Victoria, Australia).

INCLUSION CRITERIA

aged 18+; lifetime history of injecting drug use; incarcerated for > three months and released from custody < 12 months previously. From 48 participants, five case studies were selected as emblematic of the complex and intersecting factors occurring at the time participants missed an appointment at a service.

RESULTS

Numerous, concurrent, and interdependent structural influences in participants' lives coincided with their difficulty accessing and maintaining contact with services and resulted in missed appointments. The key factors involved in the cases presented here include policies around opioid agonist treatment, inadequate, unsuitable and unsafe housing, the management of mental health and side effects of treatment, the lack of social support or estrangement from family, and economic hardship. The support available from service workers to navigate these structural issues was inconsistent. One dissenting case is examined in which missing appointments is anticipated and accommodated.

CONCLUSIONS

A case study approach enabled a holistic and in-depth examination of upstream structural elements that intersect with limited social and economic resources to exacerbate the challenges of community re-entry. These results highlight structural issues that have a disproportionate impact on the choices and opportunities for PWID. The incorporation of a structural competency framework in design of services and in staff training could support person-centred and coordinated service provision that take into account PWID's experiences post-release to overcome structural barriers to service engagement.

Evaluation of an online motivational interviewing training program for rehabilitation professionals: A pilot study

OBJECTIVE

To investigate the feasibility and effectiveness of an online motivational interviewing training program for rehabilitation professionals.

DESIGN

Pre-post design with two groups.

SETTING

Private rehabilitation hospital and an academic medical center.

SUBJECTS

Group 1 included 19 motivational interviewing-experienced rehabilitation professionals. Group 2 included 25 motivational interviewing-naïve rehabilitation professionals.

INTERVENTIONS

Group 1 was exposed to an online motivational training program and Group 2 was exposed to an online motivational training program and a live booster session.

MAIN MEASURES

Motivational interviewing communication skills were measured with an adapted Helpful Responses Questionnaire. Knowledge and attitudes were measured with an adapted Motivational Interviewing Knowledge and Attitudes Test. Confidence, importance, and feasibility for implementing motivational interviewing were measured using the Motivational Interviewing Rulers.

RESULTS

Group 1 showed improvement in communication skills (2.6/5-3.3/5; P < 0.05) and confidence (6.0/01-7.4/10; P < 0.01) after online training. Improvements seen in skills and confidence were maintained at three months. Group 2 showed improvement in skills (2.1/5-3.3/5; P < 0.001), knowledge (7.7/10-8.5/10; P < 0.01), confidence (6.4/10-7.5/10; P < 0.01), and importance (8.3/10-8.9/10; P < 0.05) after online training. At three-months post-booster, improvements in communication skills and knowledge were maintained.

CONCLUSIONS

Online training can be a cost and time effective approach to improve rehabilitation professionals' skills in motivational interviewing. Follow-up training activities are needed to maintain the level of knowledge and skill improvement.

Development and validation of the Readiness for Therapy Questionnaire (RTQ)

BACKGROUND

Motivational factors are generally regarded as an important ingredient for change in therapy. However, there is currently a lack of available instruments that can measure clients' readiness for change in therapy.

AIM

The objective of this paper was to create an instrument, the Readiness for Therapy Questionnaire (RTQ), which could measure clients' readiness for change.

METHOD

The RTQ was created by researchers following analysis of themes drawn from a review of the literature and interviews with patients at the end of therapy. This included both people who completed therapy and those who dropped out. As part of the standard assessment process, the RTQ was administered to 349 participants (69.6% female and 30.4% male; mean age 37.1 years; 90.5% Caucasian) who were patients at a psychological therapy service for common mental health difficulties.

RESULT

An initial 12-item scale was reduced to 6 items. This scale significantly correlated with post-therapy PHQ-9 and GAD-7 scores and changes in these scores across therapy. After controlling for baseline scores and demographic variables, a logistic regression showed that scores on this 6-item measure pre-therapy significantly predicted three outcome variables: completing therapy, being recovered on both PHQ-9 and GAD-7 post-therapy, and having a reliable change in both the PHQ-9 and GAD-7 post-therapy. However, receiver operating characteristic (ROC) curve analysis showed the measure had poor sensitivity and specificity. Symptom severity did not have a significant impact on motivation to change.

CONCLUSION

The RTQ is potentially a valid measure with useful clinical applications in treatment of common mental health difficulties.

The Cal-DSH diversion guidelines

The Cal-DSH Diversion Guidelines provide 10 general guidelines that jurisdictions should consider when developing diversion programs for individuals with a serious mental illness (SMI) who become involved in the criminal justice system. Screening for SMI in a jail setting is reviewed. In addition, important treatment interventions for SMI and substance use disorders are highlighted with the need to address criminogenic risk factors highlighted.

Attitudes about medications for alcohol use disorder among individuals with serious mental illness: A health belief model analysis

BACKGROUND

Medications for alcohol use disorder (MAUD) are underutilized in mental health settings. Increasing use of MAUD requires increasing both the availability of these medications and the demand by individuals who could benefit. Few studies have explored the views of individuals with severe mental illness and alcohol use disorder about MAUD. We sought to examine, among individuals treated in publicly funded community mental health clinics, perceived need for and attitudes toward MAUD.

METHODS

We conducted 8 focus groups with 87 participants treated in public mental health clinics in Los Angeles County. We aimed to include individuals with a current or past AUD diagnosis and individuals helping others (e.g., a family member) who drink. We examined responses using domains associated with the Health Belief Model to identify factors that shape acceptance of MAUD.

RESULTS

Participants were 53% female; most were minorities. Average age was 47 years (SD = 11). Twenty-four reported never drinking, 13 of whom had a current or past diagnosis of AUD. Twenty-two reported drinking 4 or more times per week. Three-quarters had not heard of naltrexone. Participants understood that alcohol use has severe adverse consequences and perceived themselves to be highly susceptible to these consequences. Regarding attitudes toward MAUD, participants described an internal locus of control (e.g., their own desires, actions, and effort) as central to addressing problem drinking; this shaped their views that MAUD would have only modest benefits and potentially high burden. Those individuals who had tried MAUD expressed the most optimism about its effectiveness.

CONCLUSIONS

Participants worried MAUD would impede the development of self-control over drinking by fostering dependence on medication and undermining self-discipline. Client education and counseling that emphasizes MAUD as a tool to build clients' self-control may increase demand for these medications in mental health settings.

Clinical and cost-effectiveness of contingency management for cannabis use in early psychosis: the CIRCLE randomised clinical trial

BACKGROUND

Cannabis is the most commonly used illicit substance amongst people with psychosis. Continued cannabis use following the onset of psychosis is associated with poorer functional and clinical outcomes. However, finding effective ways of intervening has been very challenging. We examined the clinical and cost-effectiveness of adjunctive contingency management (CM), which involves incentives for abstinence from cannabis use, in people with a recent diagnosis of psychosis.

METHODS

CIRCLE was a pragmatic multi-centre randomised controlled trial. Participants were recruited via Early Intervention in Psychosis (EIP) services across the Midlands and South East of England. They had had at least one episode of clinically diagnosed psychosis (affective or non-affective); were aged 18 to 36; reported cannabis use in at least 12 out of the previous 24 weeks; and were not currently receiving treatment for cannabis misuse, or subject to a legal requirement for cannabis testing. Participants were randomised via a secure web-based service 1:1 to either an experimental arm, involving 12 weeks of CM plus a six-session psychoeducation package, or a control arm receiving the psychoeducation package only. The total potential voucher reward in the CM intervention was £240. The primary outcome was time to acute psychiatric care, operationalised as admission to an acute mental health service (including community alternatives to admission). Primary outcome data were collected from patient records at 18 months post-consent by assessors masked to allocation. The trial was registered with the ISRCTN registry, number ISRCTN33576045.

RESULTS

Five hundred fifty-one participants were recruited between June 2012 and April 2016. Primary outcome data were obtained for 272 (98%) in the CM (experimental) group and 259 (95%) in the control group. There was no statistically significant difference in time to acute psychiatric care (the primary outcome) (HR 1.03, 95% CI 0.76, 1.40) between groups. By 18 months, 90 (33%) of participants in the CM group, and 85 (30%) of the control groups had been admitted at least once to an acute psychiatric service. Amongst those who had experienced an acute psychiatric admission, the median time to admission was 196 days (IQR 82, 364) in the CM group and 245 days (IQR 99, 382) in the control group. Cost-effectiveness analyses suggest that there is an 81% likelihood that the intervention was cost-effective, mainly resulting from higher mean inpatient costs for the control group compared with the CM group; however, the cost difference between groups was not statistically significant. There were 58 adverse events, 27 in the CM group and 31 in the control group.

CONCLUSIONS

Overall, these results suggest that CM is not an effective intervention for improving the time to acute psychiatric admission or reducing cannabis use in psychosis, at least at the level of voucher reward offered.

Motivation to Change and Treatment Participation Among Syringe Service Program Utilizers in Rural Kentucky

PURPOSE

Kentucky experiences a disproportionate burden of substance use disorder (SUD), particularly in rural areas of the state. Multiple factors increase vulnerability to SUD and limit access to services in rural communities. However, the recent implementation and expansion of syringe service programs (SSPs) in rural Kentucky may provide a leverage point to reach at-risk people who inject drugs (PWID).

METHODS

Data were collected as part of an ongoing NIDA-funded study designed to examine uptake of SSPs among PWID in Appalachian Kentucky. Using Respondent Driven Sampling (RDS), the study enrolled a sample of 186 PWID SSP attenders across 3 rural Appalachian Kentucky counties and conducted face-to-face interviews regarding health behaviors, injecting practices, SSP utilization, and treatment services. Using logistic regression analyses, we examined consistent SSP use, as well as importance and confidence to reduce substance use as predictors of current treatment participation.

FINDINGS

For the prior 6 months, 44.6% of the sample reported consistent SSP use. Consistent use of SSPs was associated with treatment participation in the unadjusted logistic regression models. Significant predictors of treatment participation in the adjusted model included high confidence to reduce substance use, and not reporting primary methamphetamine injection.

CONCLUSIONS

Rurally located SSPs may play an important role in supporting confidence and motivation to change substance use behaviors among PWID impacted by SUD. SSPs may be critical venues for integration and expansion of prevention, health promotion, and treatment linkage services for this underserved population.

Text-Messaging, Online Peer Support Group, and Coaching Strategies to Optimize the HIV Prevention Continuum for Youth: Protocol for a Randomized Controlled Trial

BACKGROUND

America's increasing HIV epidemic among youth suggests the need to identify novel strategies to leverage services and settings where youth at high risk (YAHR) for HIV can be engaged in prevention. Scalable, efficacious, and cost-effective strategies are needed, which support youth during developmental transitions when risks arise. Evidence-based behavioral interventions (EBIs) have typically relied on time-limited, scripted, and manualized protocols that were often delivered with low fidelity and lacked evidence for effectiveness.

OBJECTIVE

This study aims to examine efficacy, implementation, and cost-effectiveness of easily mountable and adaptable, technology-based behavioral interventions in the context of an enhanced standard of care and study assessments that implement the guidelines of Centers for Disease Control and Prevention (CDC) for routine, repeat HIV, and sexually transmitted infection (STI) testing for high-risk youth.

METHODS

Youth aged between 12 and 24 years (n=1500) are being recruited from community-based organizations and clinics serving gay, bisexual, and transgender youth, homeless youth, and postincarcerated youth, with eligibility algorithms weighting African American and Latino youth to reflect disparities in HIV incidence. At baseline and 4-month intervals over 24 months (12 months for lower-risk youth), interviewers monitor uptake of HIV prevention continuum steps (linkage to health care, use of pre- or postexposure prophylaxis, condoms, and prevention services) and secondary outcomes of substance use, mental health, and housing security. Assessments include rapid diagnostic tests for HIV, STIs, drugs, and alcohol. The study is powered to detect modest intervention effects among gay or bisexual male and transgender youth with 70% retention. Youth are randomized to 4 conditions: (1) enhanced standard of care of automated text-messaging and monitoring (AMM) and repeat HIV/STI testing assessment procedures (n=690); (2) online group peer support via private social media plus AMM (n=270); (3) coaching that is strengths-based, youth-centered, unscripted, based on common practice elements of EBI, available over 24 months, and delivered by near-peer paraprofessionals via text, phone, and in-person, plus AMM (n=270); and (4) online group peer support plus coaching and AMM (n=270).

RESULTS

The project was funded in September 2016 and enrollment began in May 2017. Enrollment will be completed between June and August 2019. Data analysis is currently underway, and the first results are expected to be submitted for publication in 2019.

CONCLUSIONS

This hybrid implementation-effectiveness study examines alternative models for implementing the CDC guidelines for routine HIV/STI testing for YAHR of acquiring HIV and for delivering evidence-based behavioral intervention content in modular elements instead of scripted manuals and available over 24 months of follow-up, while also monitoring implementation, costs, and effectiveness. The greatest impacts are expected for coaching, whereas online group peer support is expected to have lower impact but may be more cost-effective.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03134833; https://clinicaltrials.gov/ct2/show/NCT03134833 (Archived by WebCite at http://www.webcitation.org/76el0Viw9).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/11165.

The Stepped Care Intervention to Suppress Viral Load in Youth Living With HIV: Protocol for a Randomized Controlled Trial

Background

Among youth living with HIV (YLH) aged 12-24 years who have health care in the United States, only 30% to 40% are virally suppressed. YLH must achieve viral suppression in order to reduce the probability of infecting others as well as increasing the length and quality of their own life.

Objective

This randomized controlled trial aimed to evaluate the efficacy of an Enhanced Standard Care condition (n=110) compared to an Enhanced Stepped Care intervention condition (n=110) to increase viral suppression among YLH aged 12-24 years with established infection (not acutely infected).

Methods

YLH (N=220) who are not virally suppressed will be identified at homeless shelters, health clinics, and gay-identified community-based organizations in Los Angeles, CA, and New Orleans, LA. Informed consent will be obtained from all participants. YLH will be randomly assigned to one of two study conditions: Enhanced Standard Care, which includes standard clinical care plus an automated messaging and monitoring intervention (AMMI), or an Enhanced Stepped Care, which includes three levels of intervention (AMMI, Peer Support via social media plus AMMI, or Coaching plus Peer Support and AMMI). The primary outcome is viral suppression of HIV, and YLH will be assessed at 4-month intervals for 24 months. For the Enhanced Stepped Care intervention group, those who do not achieve viral suppression (via blood draw, viral load<200 copies/mL) at any 4-month assessment will “step up” to the next level of intervention. Secondary outcomes will be retention in care, antiretroviral therapy adherence, alcohol use, substance use, sexual behavior, and mental health symptoms.

Results

Recruitment for this study began in June 2017 and is ongoing. We estimate data collection to be completed by the end of 2020.

Conclusions

This is the first known application of an Enhanced Stepped Care intervention model for YLH. By providing the lowest level of intervention needed to achieve viral suppression, this model has the potential to be a cost-effective method of helping YLH achieve viral suppression and improve their quality of life.

Trial Registration

ClinicalTrials.gov NCT03109431; https://clinicaltrials.gov/ct2/show/NCT03109431

International Registered Report Identifier (IRRID)

DERR1-10.2196/10791

Processes of Change and Nonsuicidal Self-Injury: A Qualitative Interview Study With Individuals at Various Stages of Change

Nonsuicidal self-injury (NSSI) is a pervasive and potentially lethal behavior that affects many youth and adolescents. Effective treatment and prevention efforts are critical but often lack a nuanced understanding of the behavior change process. To address this gap, this research employs a stage of change model to identify and understand the most salient and widespread processes that facilitate NSSI behavior change. Thirty-one semi-structured interviews were conducted with individuals with current or past self-injury. Individuals were recruited to represent all stages of change including those who have not thought about changing behavior to those who have been NSSI-free for years. We employ a directed content analysis to code for dimensions derived from the model and an inductive approach to surface more nuanced change levers. Four organizing dimensions emerged: relational, behavioral, self-knowledge, and barriers. Common change levers of value in clinical practice or in intervention modalities are discussed.

State Clean Indoor Air Laws and smoking among adults with poor mental health

Persons with mental illness smoke at twice the rate of the general United States (US) population and die an average of 25-years younger, often from preventable diseases. This study seeks to determine whether disparities in smoking have increased over the past decade and whether Clean Indoor Air Laws (CIALs) are associated with changes in smoking among those with poor mental health. We used a fixed-effects model for estimation. CIALs were associated with 15 per cent decreased odds of smoking among adults in the US. Among those with poor mental health, these same laws had no effect. Between 2000 and 2010, the disparity in smoking rates between these two populations has steadily increased from 1.8 to 2.2 times greater. Given the lack of association between tobacco laws and smoking among those with poor mental health, alternative and more targeted tobacco reduction efforts may be necessary.

Understanding the role of emotion-oriented coping in women's motivation for change

This study tested a sequential mediation model that emotion-oriented coping and motivation for change mediate the relations between anxiety and depressive symptoms and the change in substance use. Data included 183 substance using women, randomly assigned to family therapy (N=123) or individual therapy (N=60). They reported their baseline anxiety and depressive symptoms, emotion-oriented coping, as well as motivation for change throughout treatment, and substance use over a time period of 1.5years. Latent growth curve modeling showed that increased baseline motivation was associated with a faster decline in alcohol and drug use. Moreover, higher baseline anxiety and depressive symptoms were associated with a faster decrease in drug use through higher emotion-oriented coping and higher baseline motivation. This study underscores the importance of emotion-oriented coping in increasing clients' motivation and reducing their drug use.

Stopping the rise of HIV among adolescents globally

PURPOSE OF REVIEW

Adolescents, in particular those that are most disenfranchised, are increasingly at risk of acquiring HIV and, when acquiring HIV, have worse outcomes than adults. This article reviews the recent approaches to combination prevention aiming to optimize the HIV prevention and HIV treatment continua.

RECENT FINDINGS

There are dramatic sociodemographic differences in the HIV epidemics in low and middle-income countries (young women in sub-Saharan Africa) compared with high-income countries (predominantly gay, bisexual, transgendered youth, especially black and Latino youth). Researchers and clinicians are designing developmentally tailored interventions that anticipate youths' engagement with mobile technologies and build on the common features of evidence-based interventions that predate the use of antiretroviral therapies (ARV) for prevention and treatment.

SUMMARY

Evidence-based HIV prevention and treatment programs that are cost-effective need to be broadly diffused globally. Substantial investments must be made in understanding how to implement programs, which have clinically meaningful impact and continuously monitor intervention quality over time.

Characteristics and clinical treatment of tobacco smokers enrolled in a VA substance use disorders clinic

Individuals with a substance use disorder (SUD) diagnosis are more than twice as likely to smoke cigarettes as the general population. Emerging research has suggested that treating a substance use disorder simultaneously with tobacco use leads to a higher rate of treatment success for both substances. Despite this, substance use treatment protocols tend not to focus on tobacco use; in fact, traditional substance use treatments often discourage patients from attempting to quit smoking. One rationale is that patients may not be motivated to quit smoking. In the current study, data from veterans enrolled in outpatient treatment for a SUD were examined to assess for general characteristics of smokers as compared to non-smokers as well as to examine motivation to quit smoking. Baseline (i.e., pre-treatment) data from 277 Veterans were used. Charts of smokers in the SUD clinic (SUDC) were reviewed to assess how smoking is handled by SUDC providers, and if smokers attempt cessation. Of 277, 163 (59%) SUDC patients reported that they currently smoke cigarettes (M=16.3 cigarettes per day, SD=11.1). Smokers in the clinic reported greater general impairment than nonsmokers on the Short Index of Problems, F(1248)=8.9, p=0.003, as well as greater specific impairment: Physical Problems, F(1258)=13.5, p=0.000; Interpersonal Problems, F(1262)=5.6, p=0.019; Intrapersonal Problems, F(1260)=6.5, p=0.011, and Social Responsibility, F(1262)=14.7, p=0.000. Smokers in the sample were marginally more anxious than their non-smoking counterparts as measured by the GAD-7, F(1254)=4.6, p=0.053, though they were not significantly more depressed (p=0.19). On a 1-10 scale, smokers reported moderate levels of importance (M=5.4, SD=3.1), readiness (M=5.6, SD=3.2), and confidence (M=5.0, SD=3.0) regarding quitting smoking. Review of smokers' medical records reveal that while SUDC providers assess tobacco use at intake (90%) and offer treatment (86.5%), a substantially small portion of smokers attempt cessation (41.1%) while enrolled in SUDC. Moreover, no patients were enrolled in smoking-specific behavioral interventions while in SUDC, though 78 patients did obtain nicotine replacement or another smoking cessation medication (41% were prescribed by a SUDC provider). Contrary to the belief that treatment-seeking substance users are not motivated to quit smoking, these preliminary analyses demonstrate that Veterans were at least contemplating quitting smoking while they were enrolled in substance use treatment. Further, there is evidence that cigarette smokers have greater impairment caused by substance use, suggesting that this subgroup is of particular high need. Specific treatment recommendations are discussed, including how behavioral health providers in SUD clinics may be better able to capitalize on patients' moderate motivation to quit at intake.

The development and efficacy of a group intervention program for individuals with serious mental illness in jail

Providing cost-effective means to treat the influx of individuals with serious mental illness entering the correctional system is a major challenge. Failure to provide appropriate mental health treatment may lead to poor outcomes, including recidivism and suicide. Group intervention is an effective and cost efficient way to provide mental health treatment. However, it has been understudied in jail settings. To meet the needs of jail-inmates with serious mental illness, an eight-week group-based module curriculum was developed and studied through analyses of perceived usefulness, retention of key material, and associations with cognitive ability, improvement in psychiatric symptoms, and level of motivation. One week after the completion of a group session, the participants remembered the group topic and at least one key point from the group the majority of the time. Better recall of group material was associated with better overall cognitive ability and motivation at discharge. Participants found the groups to be somewhat to extremely useful 88.4% of the time. Higher levels of usefulness were associated with reduced psychopathology and psychiatric improvement, as well as higher motivation at discharge. The findings provide support for the group intervention and implementation in a jail setting. Further implications are discussed.

Motivation deficits and use of alcohol and illicit drugs among individuals with schizophrenia

This study examined the impact of substance use on intrinsic motivation and evaluated the association between intrinsic motivation and substance use recovery among individuals with schizophrenia. Alcohol and illicit drug use and intrinsic motivation were evaluated at baseline and 6-months for 1434 individuals with schizophrenia from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) using self-rated substance use assessments and a derived motivation measure from the Heinrichs-Carpenter Quality of Life Scale. Results revealed patients had moderate motivation deficits overall and a considerable number were using alcohol or illicit drugs at baseline (n=576; 40.2%). Regression models at baseline showed patients with low levels of motivation had higher odds of substance use and those who were using substances had greater motivation deficits. At 6-months, substance using patients continued to demonstrate greater motivation deficits; however, those with high levels of motivation exhibited a greater reduction in their use of substances. Findings remained significant after adjusting for clinical confounds and were consistent across any substance, alcohol, and cannabis use. Our results emphasize concerns about substance use compounding motivation deficits in schizophrenia, and suggest that disentangling the motivation-substance use relationship in schizophrenia may facilitate efforts aimed at ameliorating these challenges and improving outcomes.

Achieving digital health sustainability: Breaking Free and CGL

Purpose

Multiple challenges remain in achieving sustainability of digital health innovations, with many failing to realise their potential due to barriers to research, development and implementation. Finding an approach that overcomes these challenges is important if society is to derive benefit from these new approaches to healthcare. Having been commissioned by local authorities, NHS Trusts, prisons, charities, and third sector providers across the UK, Breaking Free Group, who in 2010 launched Breaking Free Online (BFO), a computer-assisted therapy programme for substance misuse, have overcome many of these challenges. This has been possible through close collaborative working with partner organisations, to overcome barriers to implementation and sustainability. The paper aims to discuss these issues.

Design/methodology/approach

This paper synthesises findings from a series of qualitative studies conducted by Breaking Free Group in collaboration with health and social care charity, Change, Grow, Live (CGL), which explore barriers and facilitators of implementation and sustainability of BFO at CGL. Data are analysed using thematic analyses with findings conceptualised using behavioural science theory.

Findings

This partnership has resulted in UK wide implementation of BFO at CGL, enhanced focus on digital technologies in substance misuse recovery, and a growing body of published collaborative research.

Originality/value

Valuable lessons have been learnt through the partnership between Breaking Free Group and CGL, which will be of interest to the wider digital health community. This paper outlines those lessons, in the hope that they will provide guidance to other digital health developers and their partners, to contribute to the continued evolution of a sustainable digital health sector.

Applying Behavior Change Theories and Qualitative Methods in Substance Misuse Implementation Research: Conceptualizing the Adoption of Breaking Free Online in Real-World Clinical Practice

There is insufficient research examining the implementation of complex novel interventions within health care. This may be due to a lack of qualitative research providing subjective insights into these implementation processes. The authors investigate the advantages of applying behavior change theories to conceptualize qualitative data describing the processes of implementation of complex interventions. Breaking Free Online (BFO), a digital treatment intervention for substance misuse, is described as an example of a complex intervention. The authors review previous qualitative research which explored initial diffusion, or spread, of the BFO program, and its subsequent normalization as part of standard treatment for substance misuse within the health and social care charity, "Change, Grow, Live" (CGL). The use of behavior change models to structure qualitative interview findings enabled identification of facilitators and barriers to the use of BFO within CGL. These findings have implications for the development of implementation research in novel health care interventions.

Effectiveness of a psychoeducational programme in enhancing motivation to change alcohol-addictive behaviour

AIMS AND OBJECTIVES

To evaluate the effectiveness of a psychoeducational programme in enhancing motivation to change alcohol-addictive behaviour.

BACKGROUND

The prevalence of alcohol abuse has increased over the past 10 years, and the age of initial alcohol use has decreased gradually in Taiwan. Alcohol dependence is one of the leading causes of disability and has led to increases in the incidence of crime and violence, with alcohol abuse identified as a problem in society.

DESIGN

A quasi-experimental design with nonequivalent pre/post-testing was used.

METHODS

Alcohol-dependent inpatients undergoing alcohol treatment were selected from the psychiatric ward of a teaching hospital in northern Taiwan. The effectiveness of the psychoeducational programme in enhancing motivation to change alcohol-addictive behaviour was evaluated with the Severity of Alcohol Dependence Data Questionnaire and the Stages of Change Readiness and Treatment Eagerness Scale. In total, 24 and 51 participants were recruited to the experimental and control groups, respectively, for the baseline survey, and 14 and 17 were in the final survey, respectively.

RESULTS

After adjustment for baseline survey scores, the experimental group showed significantly greater increases in recognition and ambivalence relative to those observed in the control group.

CONCLUSIONS

The results not only showed that the psychoeducational programme was effective in reinforcing addicted inpatients' motivation for changing their drinking behaviour but also provided clinical nurses with practical methods via which to enhance patient motivation.

RELEVANCE TO CLINICAL PRACTICE

The psychoeducational programme could assist clinical nurses in helping alcohol-dependent patients to recognise the nature of their problematic drinking; increase participants' ambivalence towards their drinking behaviour, leading to the contemplation of change; and strengthen the possibility that they will change their addictive behaviour.

Treatment Engagement From the Perspective of the Offender

A systematic review of the reasons why detained adult offenders fail to attend or successfully complete treatment programme(s) was conducted. An initial search of the literature identified 2,827 articles, which following evaluation against explicit inclusion/exclusion criteria and a quality assessment was reduced to 13 studies. Extracted data from the 13 studies were synthesised using a qualitative approach. Despite the 13 studies being heterogeneous in design, there was consensus on the reasons offenders gave for completion/noncompletion of treatment. The majority were consistent with the factors outlined in the Multifactor Offender Readiness Model (MORM) and included a perceived lack of self-efficacy, negative perceptions of treatment, staff and peers, an inability to regulate emotions, and a lack of perceived choice and control. A lack of opportunity to engage in established, professionally run, groups, as well as perceived inadequate support from members of staff, was also associated with poor engagement and noncompletion of treatment.

Development and application of culturally appropriate decision aids for smoking cessation in Korea: a pragmatic clustered randomization crossover trial

INTRODUCTION

In Asian countries, reluctance to seek pharmacological intervention is a major barrier for smoking cessation. Culturally appropriate decision aids are expected to help people in the decision making for the use of smoking cessation medication.

OBJECTIVE

The aim of this study was to develop a culturally tailored decision aid for smoking cessation and evaluate its effect on the use of smoking cessation medication.

PATIENTS AND METHODS

A 7-minute video on smoking cessation information and options was developed. Physicians were randomized into intervention and control groups. The decision aid was provided to patients in the intervention group, and they watched it, while those in the control group were provided usual medical care for smoking cessation. The primary outcome was the proportion of smokers who were prescribed smoking cessation medication within 1 month after consultation. The secondary outcomes were abstinence rate and use of smoking cessation medication within 6 months. A logistic regression analysis was used to assess the effect of the decision aid on the outcomes.

RESULTS

In total, 414 current smokers (intervention group: 195; control group: 219) were enrolled. The mean age of the participants was 48.2 years, and 381 subjects (92%) were males. In total, 11.8% of the participants in the intervention group and 10.5% in the control group were prescribed smoking cessation medications within 1 month. The odds ratio was 1.02 (95% CI: 0.40-2.63) after adjustment for baseline characteristics. Within 6 months, 17.4% of the participants in the intervention group and 15% in the control group were prescribed medication (adjusted odds ratio 1.12, 95% CI: 0.59-2.13).

CONCLUSION

The culturally tailored smoking cessation decision aid developed in this study did not show a significant impact on the decision to use smoking cessation medication. Further research to develop more effective and more interactive interventions is expected.

Mental health consumers' perceptions of quality of life and mental health care

Research spanning the past decade consistently reports that people with severe mental illnesses experience lower quality of life than the general population, however, little is known about what "quality of life" means to consumers, or how quality of life can be promoted in mental health care. This study measured the Quality of Life of mental health consumers receiving care from a Mental Health Nurse Incentive Program, and examined consumer perceptions of quality of life. The study used an exploratory design incorporating the WHOQOL-brèf survey and four additional qualitative questions for data collection. Data were analysed using descriptive and correlational statistics. Participants (n = 49) reported lower quality of life scores on all four domains of the WHOQOL-brèf and lower overall ratings for "quality of life" than the general population. Having basic needs met, good relationships with family and friends, regular support, and improved social connectedness were identified by consumers as important to their quality of life.

Interaction of motivation and psychiatric symptoms on substance abuse outcomes in sober living houses

BACKGROUND

Studies show residents of sober living recovery houses (SLHs) make improvements in a variety of areas including alcohol and drug use, arrests, and employment. Longitudinal measures of motivation (assessed as costs and benefits of continuing sobriety) have been shown to be associated with alcohol and drug outcomes in SLHs. However, how motivation interacts with other potentially important factors, such as psychiatric severity, is unclear.

OBJECTIVE

The present study aimed to assess how perceived costs and benefits of sobriety among residents of SLHs differed by psychiatric severity. The study also aimed to assess how costs and benefits interacted with psychiatric severity to influence outcome.

METHODS

Two hundred forty-five residents of SLHs were assessed at baseline and 6, 12, and 18 months.

RESULTS

High psychiatric severity was associated with higher severity of alcohol and drug problems and higher perceived costs of sobriety at all data collection time points. Perceived costs and benefits of sobriety were strong predictors of alcohol and drug problems for participants with low psychiatric severity. Perceived costs, but not perceived benefits, predicted outcomes for residents with high psychiatric severity. CONCLUSIONS/IMPORTANCE: High psychiatric severity is a serious impediment for some residents in SLHs. These individuals perceive sobriety as difficult and that perception is associated with worse outcome. Finding ways to decrease perceived costs and challenges to sustained sobriety among these individuals is essential as is collaboration with local mental health services. SLHs should consider whether additional onsite services or modifications of SLH operations might help this population.

The effect of nurse-led motivational interviewing on medication adherence in patients with bipolar disorder

PURPOSE

The purpose of this study was to test the effect of motivational interviewing (MI) on medication adherence in patients with bipolar disorder (BD) in an outpatient setting.

DESIGN AND METHODS

Pretest-posttest design was used. The 3-week MI intervention consisted of one face-to-face session and two follow-up telephone interventions. Outcome measures included medication adherence, self-efficacy, and motivation to change.

FINDINGS

Participants demonstrated significant improvement in medication adherence, self-efficacy, and motivation to change after receiving the MI.

PRACTICE IMPLICATIONS

MI shows promising results as a treatment approach to improve medication adherence in adults with BD. Psychiatric-mental health nurse practitioners could improve client health outcomes by implementing MI techniques.

Culturally sensitive risk behavior prevention programs for African American adolescents: a systematic analysis

The current review conducted a systematic assessment of culturally sensitive risk prevention programs for African American adolescents. Prevention programs meeting the inclusion and exclusion criteria were evaluated across several domains: (1) theoretical orientation and foundation; (2) methodological rigor; (3) level of cultural integration; (4) program target or domain (e.g., schools, communities, families); (5) outcome change level assessed (e.g., addressing change in beliefs/values or behaviors); and (6) program effects on risk behaviors. Thirteen studies (N = 13) with adolescent participants ranging from 10 to 18 years were identified and evaluated. Analyses suggested that more effective culturally sensitive risk prevention programs included the following: (1) a clearly articulated theoretical orientation, which utilized both universal (e.g., behavioral theories) and culturally specific (e.g., Africultural theories) frameworks; (2) a rigorous methodological design (e.g., inclusion of control group, utilization of program manuals, valid and reliable study measures); (3) an integration of culture at multiple levels (e.g., accessibility, delivery, and content) of programming; (4) consideration of the influence of multiple contexts and domains (e.g., family, community, school); (5) multiple behavior change outcomes (e.g., behaviors, relationships, values); and (6) sustained program effects over time. Recommendations for increasing the effectiveness and efficacy of culturally sensitive prevention programs are discussed.

Comorbid psychiatric disorders and stages of change in cannabis-dependent, treatment-seeking patients

OBJECTIVES

To determine whether and to what extent cannabis dependence is associated with comorbid psychiatric disorders and specific stages of change in treatment-seeking patients.

METHODS

We evaluated 80 cannabis-dependent, treatment-seeking patients residing in an urban area. Data on cannabis dependence, psychiatric disorders, and motivation were obtained using the Schedules for Clinical Assessment in Neuropsychiatry and the University of Rhode Island Change Assessment (URICA).

RESULTS

A diagnosis of schizophrenia was found to correlate with lower motivation scores (p = 0.038), which could have a negative effect on adherence to treatment.

CONCLUSION

The high prevalence of concurrent psychiatric disorders in cannabis-dependent patients should serve as a stimulus for early screening and treatment of such disorders. Health care professionals should be aware of the magnitude of this association to increase the level of motivation in cannabis-dependent patients with severe concurrent psychiatric disorders.

Challenges and outcomes of parallel care for patients with co-occurring psychiatric disorder in methadone maintenance treatment

OBJECTIVE

Most opioid users seeking treatment in community-based substance abuse treatment programs have at least one co-occurring psychiatric disorder, and the presence of psychiatric comorbidity in this population is associated with increased psychological distress, poorer quality of life, and reduced response to substance abuse treatment. This observational study describes clinical outcomes of referring patients receiving methadone maintenance with at least one co-occurring psychiatric disorder to a community psychiatry program located on the same hospital campus.

METHODS

Participants (n = 156) were offered priority referrals to a community psychiatry program that included regularly scheduled psychiatrist appointments, individual and group therapy, and enhanced access to psychiatric medications for 1 year. Psychiatric distress was measured with the Symptom Checklist (SCL-90-R), which participants completed monthly.

RESULTS

While about 80% of the sample (n = 124) initiated psychiatric care, the average length of treatment was only 128.2 days (SD = 122.8), participants attended only 33% of all scheduled appointments (M = 14.9 sessions, SD = 14.1), and 84% (n = 104) did not complete a full year of care. Of those who did not complete a full year, over half (55%, n = 68) left psychiatric care while still receiving substance abuse treatment. Exploratory negative binomial regression showed that baseline cocaine and alcohol use disorder (p = .002 and .022, respectively) and current employment (p = .034) were associated with worse psychiatric treatment retention. Modest reductions in psychiatric distress over time were observed (SCL-90-R Global Severity Index change score = 2.5; paired t = 3.54, df = 121, p = .001).

CONCLUSIONS

Referral of patients with co-occurring psychiatric disorders receiving methadone maintenance to a community psychiatry program is often ineffective, even after reducing common barriers to care. Service delivery models designed to improve attendance and retention, such as integrated care models, should be evaluated. This study is part of a larger clinical trial, registered at www.clinicaltrials.gov under #NCT00787735.

The Burnaby treatment center for mental health and addiction, a novel integrated treatment program for patients with addiction and concurrent disorders: results from a program evaluation

Background

Patients with addictions and concurrent disorders constitute the most underserved population in the system of care. There are numerous reasons why this population has so much difficulty accessing services, including behavioural issues, criminal engagement, and non-compliance with outpatient services. To improve services to this population which is marked by multiple morbidities, high mortality and insufficient access to health care, the government of British Columbia, Canada developed a program for people with both substance use disorder and one or more mental disorders who have not benefited from previous therapies.

Method

In July 2008, the Burnaby Treatment Centre for Mental Health and Addiction (BCMHA), a specialized and integrated tertiary care facility, was opened. The current article provides a description of the treatment program and a clinical profile of the population.

Results

The target population is being served, at intake clients present with high rates of psychopathology, childhood and adult trauma, and substance use.

Conclusion

While preliminary, these results indicate, that the novel approach of the Burnaby Centre may constitute a new path towards providing effective recovery for this population.

Quit intention as a predictor of quit attempts over time in adolescents with psychiatric disorders

BACKGROUND

Rates of smoking among adolescents with psychiatric comorbidity are high, despite the well-known health risks. The current longitudinal study examined patterns of quitting behavior in adolescent smokers with psychiatric comorbidity.

METHODS

The study evaluated 191 inpatient adolescents who had been enrolled in a randomized controlled trial of motivational interviewing versus brief advice for smoking cessation, and assessed their intentions to quit smoking.

RESULTS

Rates of quit attempts at post-hospital, 1-month, and 6-month assessments were 23%, 17%, and 17%, respectively. Adolescents who reported an intention to quit smoking (43%) were significantly more likely to report a quit attempt, regardless of psychiatric symptoms, cognitive factors, or substance use.

CONCLUSIONS

Intention to quit smoking appears to translate to substantial quit behavior, even in a high-risk adolescent population that may otherwise be viewed as uninterested in quitting, suggesting the need to proactively connect this population with adequate services and follow-up support. (Am J Addict 2013;XX:1-6).

To enforce or engage: the relationship between coercion, treatment motivation and therapeutic alliance within community-based drug and alcohol clients

Three fundamental clinical issues are consistently associated with treatment engagement and outcomes in substance using populations; coercion, motivation and therapeutic alliance. It is accepted that these factors play an integral role in the success of substance use treatment and particularly that higher motivation and therapeutic alliance are advantageous to treatment outcomes. The impact of coercion on engagement and treatment outcome, on the other hand, is less clear, and the relationship between these three issues has not been adequately explored. The current study aimed to address this gap, by examining the presenting characteristics of clients attending a community drug and alcohol counselling service in relation to coercion, motivation, therapeutic alliance and substance use, as well as the effect that these variables had on treatment outcomes 15 weeks later. A total of 77 clients recruited from the Central Coast Drug and Alcohol Service participated in the study, completing a phone assessment upon treatment entry and 15 weeks post-baseline. Results indicated that facets of motivation and therapeutic alliance played a significant role in client's substance use upon presentation for treatment, although coercion did not. Coercion was not associated with substance use outcomes at 15 week follow up. However, due to a relatively small sample completing post-baseline assessments (n=33), further research is needed to examine the predictive effects of these variables in community drug and alcohol clients.

Correlates of Readiness to Change in Victims of Intimate Partner Violence

Intimate partner violence (IPV) is a social problem associated with significant morbidity; however, victims don't always utilize treatment and resources. One's readiness to change may be one variable impacting their pursuit of treatment and other resources. The current study investigated correlates of readiness to change, and readiness to change's impact on treatment utilization. Data was collected from 223 women residing in battered women's shelters. Correlational analyses find that generally victims with more psychopathology and distress, as well as more social support, were more ready to change. PTSD symptoms, overall distress, and social support were the strongest predictors of readiness to change. Finally, victims higher in readiness to change were more likely to seek mental health treatment and other IPV-related services.

Engagement in psychosocial treatment: its relationship to outcome and care pathway progress for women in medium-secure settings

BACKGROUND

Engaging patients in treatment in secure settings is a major challenge. Engagement is associated with a shorter length of stay, whereas treatment non-completion is associated with an increased risk of recidivism.

AIMS

The aims of this study were to assess differences between high and low treatment attendees in a women's medium secure unit and to compare progress over the course of their stay.

METHODS

Sixty consecutive admissions to a women's medium secure unit were classified into high and low treatment attendee groups. The two groups were compared in terms of risk behaviours and psychometric measures of symptomatology, impulsivity and personality.

RESULTS

High treatment attendees had a shortened length of stay, showed less disturbed behaviour and made more progress in terms of a reduction in symptoms overall and traumatic stress symptoms specifically. Low treatment attendees were more likely to have a diagnosis of schizophrenia/schizotypal illness than personality disorder, less likely to be impulsive and more likely to have scores indicative of severe disorder on the personality subscales of the Millon Clinical Multiaxial Inventory-III.

CONCLUSION

Attendance at groups in this medium security unit had clear advantages for patients and potential cost savings for services and the community, but we found a subgroup of women who found it difficult to attend. Given the small sample size, we advocate replication, but our findings suggest the following: Implications for practice development of motivational interventions to help patients make a therapeutic alliance more accurate assessment of treatment readiness, to avoid mistimed interventions that are counterproductive more effective deployment of milieu therapeutic approaches to stabilise behaviour at an early stage of hospitalisation abandonment of a 'one size fits all' approach to groups for mixed patient populations. More 'customised' approaches would allow more appropriate 'pacing' of treatment and adaptations of interventions according to need during the treatment course.