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

Use of Transdermal Alcohol Sensors in Conjunction With Contingency Management to Reduce Alcohol Consumption in People With Alcohol Dependence Attending Alcohol Treatment Services: Protocol for a Pilot Feasibility Randomized Controlled Trial

BACKGROUND

Wearable technology for objective, continuous, and reliable alcohol monitoring has been developed. These are known as transdermal alcohol sensors (TASs). They can be worn on the wrist or ankle with the sensor pressed against the skin and can measure sweat vapors being emitted from the skin, to record transdermal alcohol concentration (TAC). Previous studies have investigated the accuracy and acceptability of the available TAS brands, but there has been little research into their use in people with alcohol use disorders (AUD).

OBJECTIVE

This feasibility randomized controlled trial aims to explore the feasibility, strengths, and limitations of using a TAS to monitor alcohol consumption in individuals in treatment for AUD with or without contingency management (CM) to promote abstinence or low-level alcohol consumption.

METHODS

The target sample size is 30 (15 randomized to each group). Participants will be recruited through poster adverts at alcohol services. Both groups (control and CM) will wear the TAS (BACtrack Skyn) for 2 weeks in the context of their usual treatment, meeting with the researcher every other weekday. In the last meeting, the participants will complete a postwear survey on their experience of wearing the TAS. The CM group will also receive small financial incentives for low or no alcohol consumption, as measured by the TAS. On days where the TAC peak is below a set threshold (<115.660 g/L), CM group participants will be rewarded with a £5 (US $6.38) voucher. There are financial bonuses if this target is achieved on consecutive days. The researcher will monitor TAC for each day of the study at each research visit and allocate financial incentives to participants according to a set reinforcement schedule.

RESULTS

The first participant was enrolled in June 2023, and the last in December 2023. Data analysis is underway and is estimated to be completed by June 2024. A total of 32 participants were enrolled.

CONCLUSIONS

Most TAS brands have had limited application in clinical settings, and most studies have included healthy adults rather than people with AUD. TAS has the potential to enhance treatment outcomes in clinical alcohol treatment. The accuracy, acceptability, and feasibility of TAS for people with AUD in clinical settings need to be investigated. This is the first study to use TAS in specialized alcohol services with diagnosed AUD individuals currently receiving treatment from a south London alcohol service.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN46845361; https://www.isrctn.com/ISRCTN46845361.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/57653.

Examining Profiles and Treatment Outcomes in Dual Diagnosis: Comparison of Coordinated Treatment With Mental Health Services Versus Addiction Center Alone. A Real-World Data Analysis

OBJECTIVE

The aim of this work was to examine the profile and treatment outcomes of patients with dual pathology depending on whether the patients were attending addiction centers or are being treated in a coordinated model by mental health services.

METHODS

Data from 7225 dual diagnosis patients were used, of whom 2417 (33.5%) received treatment in the mental health coordinated modality. Clinical information was taken from the patients' electronic health record.

RESULTS

Differences were found in patients' sociodemographic and comorbidity profiles according to treatment modality. In general, coordinated care yielded favorable outcomes (higher attendance and lower dropout rates but no differences in retention). The logistic regression analysis identified predictors of patient profiles in coordinated care, emphasizing having a severe mental health disorder (OR = 3.878, 95% CI [3.443, 4.368]; p = .000), being referred by social/health services, or having retired status. Main differences were observed according to the comorbid diagnosis presented, particularly in cases in which the patient had impulse control, hyperkinetic, or cluster C personality disorder.

CONCLUSIONS

While therapeutic outcomes are influenced by associated comorbidities, the disorders prognosis can be favorable with appropriate treatment. Furthermore, analysis of differences according to treatment modality allows for predicting the type of patient who will receive a particular service, which enables the development of tailored treatments.

An International, Multidisciplinary Consensus Set of Patient-Centered Outcome Measures for Substance-Related and Addictive Disorders

Background: In 1990, the United States' Institute of Medicine promoted the principles of outcomes monitoring in the alcohol and other drugs treatment field to improve the evidence synthesis and quality of research. While various national outcome measures have been developed and employed, no global consensus on standard measurement has been agreed for addiction. It is thus timely to build an international consensus. Convened by the International Consortium for Health Outcomes Measurement (ICHOM), an international, multi-disciplinary working group reviewed the existing literature and reached consensus for a globally applicable minimum set of outcome measures for people who seek treatment for addiction. Methods: To this end, 26 addiction experts from 11 countries and 5 continents, including people with lived experience (n = 5; 19%), convened over 16 months (December 2018-March 2020) to develop recommendations for a minimum set of outcome measures. A structured, consensus-building, modified Delphi process was employed. Evidence-based proposals for the minimum set of measures were generated and discussed across eight videoconferences and in a subsequent structured online consultation. The resulting set was reviewed by 123 professionals and 34 people with lived experience internationally. Results: The final consensus-based recommendation includes alcohol, substance, and tobacco use disorders, as well as gambling and gaming disorders in people aged 12 years and older. Recommended outcome domains are frequency and quantity of addictive disorders, symptom burden, health-related quality of life, global functioning, psychosocial functioning, and overall physical and mental health and wellbeing. Standard case-mix (moderator) variables and measurement time points are also recommended. Conclusions: Use of consistent and meaningful outcome measurement facilitates carer-patient relations, shared decision-making, service improvement, benchmarking, and evidence synthesis for the evaluation of addiction treatment services and the dissemination of best practices. The consensus set of recommended outcomes is freely available for adoption in healthcare settings globally.

Effectiveness of residential treatment services for veterans with substance use disorders: A propensity score matching evaluation

BACKGROUND

Prior reviews of substance use disorder (SUD) treatment have found mixed support for residential level of care but are limited by methodology problems and the ethical concerns of randomizing patients with severe SUD to lower levels of care.

METHODS

The present study is the first to use a large archival SUD residential sample with a matched comparison group and one-year follow-up period to examine the benefits of residential treatment provided to adults clinically assessed as warranting SUD residential care. We used propensity score matching in our sample (N = 6177) of veterans with a SUD who were screened and accepted for Veterans Affairs (VA) SUD residential treatment between January 1st, 2019 and June 30th, 2019.

RESULTS

We found evidence that VA SUD residential treatment saves veteran lives with an average 66% all-cause mortality risk reduction during the study period (b = -1.09, exp(b) = 0.34, p <0.001). Medium-to-large residential pre- to post-treatment self-reported mental health and SUD symptom improvements (|SMDrobust| = 0.54-0.93) were sustained by one-year post-screening. These residential treatment improvements were significantly larger than estimated counterfactual outcomes across self-reported SUD and stress disorder symptoms at one-year post-screening (ps <0.001). We found mixed behavioral, service utilization, and other self-reported mental health outcomes.

CONCLUSIONS

We conclude that VA SUD residential treatment is an effective level of care for veterans warranting residential care particularly for SUD symptom improvements and reductions in mortality risk.

Integration of substance use disorder treatment in traditional mental health facilities: Timeseries and cross-sectional evaluations

BACKGROUND

Despite efforts to increase substance use disorder (SUD) treatment provision in the United States (US), the extent to which traditional mental health (MH) facilities offer SUD treatment remains unclear. In the present study, we analyzed the trend in SUD treatment integration among traditional MH facilities in the US from 2014 to 2020 and identified facility-level factors associated with SUD treatment provision.

METHODS

Data were extracted from the National Mental Health Services Survey (N-MHSS). A timeseries logit trend analysis for the multi-year dataset (2014-2020) was conducted to assess a yearly change in odds of SUD treatment provision. With the 2020 survey data, analyses were conducted to identify the differences between facilities offering SUD treatment and facilities not offering such treatment. Finally, exploratory multivariable logistic regression was conducted to estimate odds of SUD treatment provision by facility variables.

RESULTS

US MH facility SUD treatment provision went from 51.7 % (2014) to 57.9 % (2020). A mean sample of 12,312 US MH facilities over seven years, demonstrated a significant but small yearly increase in SUD treatment provision (OR = 1.04, 95 % CI = 1.03, 1.04). Important facility characteristics related to SUD treatment provision for facilities without a core SUD focus were MH diagnostics offered (OR = 2.03), dual-diagnosis program offered (OR = 3.65), state drug/alcohol license maintained (OR = 6.66), and VA setting (OR = 7.94).

CONCLUSIONS

Despite incremental progress in integrating SUD treatment services into US MH facilities, the SUD treatment gap remains large. Training and service development incentives for identified characteristics could help further reduce the treatment gap.

Critical appraisal and systematic review of genes linked with cocaine addiction, depression and anxiety

Recent lifestyle changes have resulted in tremendous peer pressure and mental stress, and increased the incidences of chronic psychological disorders; like addiction, depression and anxiety (ADA). In this context, the stress-tolerance levels vary amongst individuals and genetic factors play prominent roles. Vulnerable individuals may often be drawn towards drug-addiction to combat stress. This systematic review critically appraises the relationship of various genetic factors linked with the incidences of ADA development. For coherence, we focused solely on cocaine as a substance of abuse in this study. Online scholarly databases were used to screen pertinent literature using apt keywords; and the final retrieval included 42 primary-research articles. The major conclusion drawn from this systematic analysis states that there are 51 genes linked with the development of ADA; and 3 (BDNF, PERIOD2 and SLC6A4) of them are common to all the three aspects of ADA. Further, inter-connectivity analyses of the 51 genes further endorsed the central presence of BDNF and SLC6A4 genes in the development of ADA disorders. The conclusions derived from this systematic study pave the way for future studies for the identification of diagnostic biomarkers and drug targets; and for the development of novel and effective therapeutic regimens against ADA.

Assessing Substance Use Disorder Among Social Security Administration Disability Applicants

OBJECTIVE

Co-occurrence of substance use disorder and mental illness complicates treatment and is associated with increased disability. However, identification of substance use disorder in populations recently engaged in treatment can be challenging. This study aimed to examine traditional screening tools for substance use disorder and proxy characteristics (i.e., demographic characteristics, behaviors, and diagnoses) as predictors of clinician-observed substance use disorder.

METHODS

The Supported Employment Demonstration, funded by the Social Security Administration, studied 2,960 adults whose applications for disability benefits because of mental illness were recently denied. In a subsample (N=1,354) for whom substance use disorder was determined by community-based teams during follow-up, the authors used logistic regression to identify baseline predictors of observed substance use disorder and compared the sensitivity and specificity of detection by using standardized screening tools (Alcohol Use Disorder Identification Test [AUDIT], 10-item Drug Abuse Screening Test [DAST-10]) with detection via decision trees based on proxy characteristics.

RESULTS

Using decision trees based on a combination of personal characteristics (sensitivity=0.47, specificity=0.83, area under the curve [AUC]=0.71) or personal characteristics including diagnostic data (sensitivity=0.54, specificity=0.81, AUC=0.72) provided more accurate identification of substance use disorder than using a combination of the AUDIT and DAST-10 (sensitivity=0.34, specificity=0.88, AUC=0.61). Adding the combined AUDIT and DAST-10 substance use disorder indicator to either tree negligibly improved accuracy.

CONCLUSIONS

In populations recently engaged in treatment, for whom standardized substance use disorder screening tools are less accurate than expected, consideration of personal characteristics could improve the detection of substance use disorder essential for treatment planning.

MANEMOS. The Trigger Situations Inventory. Validation of a Measure Helping Relapse Prevention in the Treatment of Alcohol Use Disorders

Background: Relapse Prevention (RP) is a cognitive-behavioral approach that aims to identify situations at high risk of relapse and to support patients with alcohol use disorders (AUDs) in developing coping strategies for the maintenance of desired behavioral changes. Based on this framework, the present study aims to assess and validate the psychometric properties of the MANEMOS, a 24-item inventory of alcohol relapse triggering situations. Methods: The internal consistency and factor structure of the MANEMOS were analyzed in a sample of 313 (27.7% women) in-patients and out-patients, attending alcohol treatment programs in Italian addiction treatment facilities. Results: The results support the internal reliability and validity of the measure. A confirmative factor analysis has revealed the existence of eight distinct dimensions measuring relapse risk situations: namely, Pleasant emotions, Unpleasant emotions, Craving, Conflicts with others, Occasions, Social Pressure, Personal Control, and Physical Discomfort. The patients' assessment of the riskiness of the situation showed some significant differences depending on gender and on type of treatment received. Conclusions: The findings indicate that MANEMOS is a valid measure for identifying and reflecting on patients' high relapse-risk situations. This easy and flexible assessment measure may have important implications for prevention and clinical intervention.

Does knowledge of liver fibrosis affect high-risk drinking behaviour (KLIFAD): an open-label pragmatic feasibility randomised controlled trial

Background

Early identification followed by effective behaviour interventions is pivotal to changing the natural history of alcohol-related liver disease. We examined the feasibility of using transient elastography based advice and alcohol recovery video stories (ARVS) to change drinking behaviour in community alcohol services.

Methods

A feasibility randomised control trial (RCT) was conducted in three community alcohol services. Adults 18+ years presenting with a primary alcohol problem were randomised (1:1) to receive either usual care (control group) or usual care and the KLIFAD Intervention, consisting of advice tailored to liver stiffness measure and access to ARVS (intervention group). Data were collected at baseline and six months. To establish definitive trial feasibility, recruitment and retention rates, study procedure safety and extent of effectiveness were measured (Start date: 02.10.2019, End date: 30.11.2022, ISRCTN.com: 16922410).

Findings

382 service users were screened, 184 were randomised (intervention: 93, control: 91), and baseline data were collected for 128 (intervention: 71, control: 59). Six months follow-up data were available in 87 (intervention: 53, control: 34). Intervention compared to the control group had a longer duration of engagement with services (mean difference 8.6 days SD = 18.4), was more likely to complete the allocated treatment program and reduced or stop drinking (54.9% vs 43.9%) and reduce AUDIT category (71.7% vs 61.8%). There were no reported serious adverse reactions, one intervention group participant reported an increase in AUDIT category.

Interpretation

Integration of transient elastography in community alcohol services is feasible. It may improve engagement with services, retention in clinical trials and supplement the reduction in self-reported alcohol consumption. A definitive RCT is supported.

Funding

National Institute for Health and Care Research (NIHR201146).

Implementing clinical guidelines for co-occurring substance use and major mental disorders in Swedish forensic psychiatry: An exploratory, qualitative interview study with mental health care staff

INTRODUCTION

Patients with substance use disorders (SUD) and co-occurring mental disorders (COD) within forensic psychiatric care often suffer poor treatment outcomes and high rates of criminal recidivism, substance use, and psychiatric problems. This study aimed to describe the conditions for, and mental health care staff's experiences with, implementing integrated SUD-focused clinical guidelines, including assessment and treatment for patients with COD at a high-security forensic mental health services (FMHS) facility in Sweden.

METHODS

Study staff conducted nineteen semi-structured interviews with health care staff experienced in administering the new SUD assessment and treatment. The study conducted a thematic analysis to describe the health care staff's experiences with these guidelines and suggestions for improvement.

RESULTS

Most participants reported appreciation for the implementation of clinical guidelines with an SUD focus, an area they considered to have previously been neglected, but also noted the need for more practical guidance in the administration of the assessments. Participants reported the dual roles of caregiver and warden as difficult to reconcile and a similar, hindering division was also present in the health care staff's attitudes toward SUD. Participants' reports also described an imbalance prior to the implementation, whereby SUD was rarely assessed but treatment was still initiated. One year after the implementation, an imbalance still existed, but in reverse: SUD was more frequently assessed, but treatment was difficult to initiate.

CONCLUSIONS

Despite indications of some ambivalence among staff regarding the necessity of the assessment and treatment guidelines, many participants considered it helpful to have a structured way to assess and treat SUD in this patient group. The imbalance between frequent assessment and infrequent treatment may have been due to difficulties transitioning patients across the "gap" between assessment and treatment. To bridge this gap, mental health services should make efforts to increase patients' insight concerning their SUD, flexibility in the administration of treatment, and the motivational skills of the health care staff working with this patient group. Participants considered important for enhancing treatment quality a shared knowledge base regarding SUD, and increased collaboration between different professions and between in- and outpatient services.

Management of Mental Health in Cystic Fibrosis

This article is intended for use among all cystic fibrosis care team members. It covers common mental health concerns and their unique presentations in persons with cystic fibrosis (pwCF) in areas such as depression, anxiety, trauma, behavioral disorders emerging in childhood, sleep, problematic eating patterns, and the impact of substance use. Furthermore, the authors address ways to manage these mental health symptoms through risk assessment, psychological interventions, and/or psychotropic medications. Quick reference tables are provided for evidence-based psychological interventions and medications often used for mental health conditions in pwCF.

Substance Use Disorder, Bail Reform, and Failure to Appear in Court: Results From a Naturalistic Study

Most adults processed through local correctional facilities report symptoms consistent with substance use disorder and there is growing interest in bail reform to reduce or eliminate financial conditions as a requirement for release from detention in local jails. These practices are endorsed for their ability to reduce jail populations and enhance judicial efficiency, but failure to appear in court has become a major area of concern under these new procedures. The current study examined the associations between substance use disorder, financial release conditions, and failure to appear in court in the context of a naturalistic study of bail reform in one judicial district. Multivariate logistic regression results demonstrate significantly higher odds of failure to appear in court among adults with substance use disorder who received a nonfinancial release from jail. Findings suggest bail reform initiatives must address substance use disorder and provide person-centered services during the pretrial release period to become effective.

In the centre or caught in the middle? - Social workers' and healthcare professionals' views on user involvement in Coordinated Individual Plans in Sweden

Fragmentation of social service and healthcare services has been given attention in many countries and a variety of strategies and models are used in attempts to remedy the problem. In a parallel development, demands have been made that users/patients should have more influence over their own care, and research has shown that user involvement can support the recovery process. This article focuses on how professionals view user involvement in collaborative efforts in care planning, using the Coordinated Individual Plan (CIP) in Sweden as an example. Since 2009, social service and healthcare agencies are required to draw up CIPs when they are judged to be needed, with the purpose of improving the care process. An additional purpose is to increase users' involvement in their own care. Semi-structured interviews were conducted in 2019 with 20 professionals working within social service and healthcare agencies for people with mental health and/or substance abuse problems in the Stockholm region. Analysis was by qualitative content analysis. Findings show that professionals study experience ambivalence concerning user involvement in care planning. On the one hand, they support the user´s own demands of services and, on the other hand, they correct the user´s demands to fit the range of services and organisation of care. The user/patient's position is expressed as vulnerable, caught between caregivers who often safeguard their organisational duties and economical restrictions. These findings reflect the conflict predicted by Lipsky's theory of street-level bureaucracy. Professionals are expected to act as advocates for the user/patient, while at the same time exercising a controlling and gatekeeping function. The question is raised whether a model such as CIP provides sufficiently for factors which can counterbalance the power of the professionals relative to the user/patient in care planning.

The Effect of Vocational Counseling Interventions for Adults with Substance Use Disorders: A Narrative Review

The authors reviewed the research literature evaluating the effectiveness of vocational counseling interventions focused on employment for consumers with substance use disorders. This review included 11 articles related to vocational counseling interventions, which are either incorporated with substance use treatment or not. The results of this review revealed that vocational counseling services have been highly efficacious in resulting in part-time and full-time jobs. The study designs had some limitations, and few studies employed randomized control trials (RCT).

Determinants of Quality of Life and Treatment Satisfaction During Long-Term Involuntary In-patient Treatment of Dual-Diagnosis Patients

INTRODUCTION

Treatment resistance and disengagement from mental health services are major obstacles in the treatment of dual diagnosis patients with Severe Mental Illness. The patients in this study were admitted to a long-term involuntary treatment facility.

AIM OF THE STUDY

To study which patient experiences and perceptions are related to the outcome measures Subjective Quality of Life (SQOL) and Treatment Satisfaction (TS) during the long-term involuntary treatment.

METHODS

Patients were invited for an interview by an independent researcher, which included self-report questionnaires. The structured interviews included self-assessing Helping Alliance, Insight, Attitude toward involuntary admission, Perceived coercion and Perceived benefit were studied as determinants of SQOL and TS. The relationship between the determinants and the outcomes were analyzed by linear regression analysis.

RESULTS

Patient reported outcomes from dual diagnosis patients in a long-term treatment facility, showed that most of the patients, in spite of the involuntary character of the treatment, were satisfied with the treatment. With respect to the determinants of SQOL and TS the perceptions that "My opinion is taken into account" and "Perceived benefits of the treatment" are strong predictors of both the outcomes.

CONCLUSIONS

The current study shows that the most important aspects for treatment satisfaction and quality of life of dual-diagnosis patients admitted involuntary to long-term treatment, are being listened to (being taken seriously) and experiencing improvements during treatment. These qualities reflect the goals of Shared Decision Making and Perceived Procedural Justice in treatment. The study also corroborates earlier findings that even when treated involuntarily, patients might not hold particular negative views regarding their treatment.

African American/Black and Latino Adults with Detectable HIV Viral Load Evidence Substantial Risk for Polysubstance Substance Use and Co-occurring Problems: A Latent Class Analysis

Substance use problems are highly prevalent among persons living with (PLWH) in the United States and serve as serious barriers to engagement in HIV care. Yet, in contrast to studies of single substances, little is known about patterns of polysubstance use in this population. Moreover, other risk factors (e.g., financial hardship, incarceration, homelessness, and mental health distress) are also prevalent and complicate HIV management. The present study drew on a cross-sectional survey with African American/Black and Latino (AABL) adult PLWH from low socioeconomic status backgrounds in New York City who were insufficiently engaged in HIV care and evidenced detectable HIV viral load (N = 512). We used latent class analysis (LCA) to explore patterns of polysubstance use and their relationships to financial hardship, incarceration, homelessness, and mental health. LCA yielded three substance use classes: Class 1, a high polysubstance use/high-risk substance use class (9%); Class 2, a polysubstance use/moderate substance use risk class (18%); and Class 3, a moderate polysubstance use/moderate-to-low-risk substance use class (74%). Mental health symptoms were prevalent in all classes, but Class 1 had greater mental health distress than the other two classes. Current homelessness was more prevalent in Classes 1 and 2. We cannot end the HIV epidemic without engaging and treating AABL PLWH who have serious barriers to engagement along the HIV care continuum, and who evidence polysubstance use along with co-occurring risk factors. Clinical settings can develop outreach and engagement approaches to bring this subpopulation of PLWH into care settings, and further, specialized services are needed to successfully screen, treat, and retain them.

Integrated treatment of dual disorders in The Netherlands: a qualitative study of client experiences

Purpose

Many clients who suffer from severe mental health problems also struggle with alcohol and drug use. And although there seems to be a consensus in most European countries that integrated treatment models (especially the integrated treatment of dual disorder clients model) are best fitted to help these clients, none of these have strong evidence, mostly owing to methodological limitations in the studies. This study aims to contribute to the knowledge of why integrated treatment is helpful by conducting in-depth interviews with dual disorder clients who are currently receiving integrated treatment.

Design/methodology/approach

This study is a qualitative thematic analysis using a timeline tool to elicit participants’ responses. In the interviews, dual diagnosis clients with severe problems reflected on their situation at admission, the care they received in integrated treatment and their opinions on positive and negative elements. The interviews were coded and analysed with MAXQDA.

Findings

In the analyses of the interviews, this study found three clusters of elements that clients indicated were the most helpful during their treatment and recovery process: trusting and meaningful relationship with the team, components of integrated treatment and organisation of care.

Originality/value

The findings emphasized the importance of working relationship in the treatment of complex and long-term problems. This has implications for the evaluation of these integrated treatment models which so far mainly focuses on specific interventions.

Early childhood trauma, substance use and complex concurrent disorders among adolescents

PURPOSE OF REVIEW

To highlight the interdependence between early childhood trauma, substance use and complex concurrent disorders among adolescents and discuss the delayed response and gaps in the healthcare system.

RECENT FINDINGS

High-risk behavior such as suicidality, self-harm and hazardous substance use including overdose and the use of psychotropic substances for self-medication of mental health challenges is a growing concern. These symptoms are often related to early childhood trauma, substance use and complex concurrent disorders. Most countries do not have a youth mental healthcare system, there are no specific guidelines and only few programs addressing high-risk substance use are in place.

SUMMARY

In addition to the significance of traumatic experience for high-risk substance use and addiction, most parts of the system of care ignore the trauma aspect in treatment of substance use and focus on abstinence. There are hardly any early intervention programs, broader prevention strategies or evidence-based or target-group-oriented treatment offers.

Organizational Capacity and Readiness to Provide Medication for Individuals with Co-Occurring Alcohol Use Disorders in Public Mental Health Settings

Alcohol use disorders (AUD) in individuals with mental illness are largely untreated. The purpose of this study was to identify gaps in organizational capacity and readiness to provide medications for AUD in outpatient public mental health clinics. We selected a purposive sample of eight publicly funded outpatient mental health clinics operated by the Los Angeles County Department of Mental Health; clinics were chosen to maximize heterogeneity. Guided by theories of organizational capacity and readiness and research on the adoption of pharmacotherapy for AUD in primary and specialty care treatment settings, we conducted semi-structured interviews and focus groups with administrators, providers and staff, and a qualitative analysis of the results. Respondents described significant organizational capacity and behavioral readiness constraints to providing medication treatment for AUD. Both groups articulated a perception that mental health clinics were not designed to provide co-occurring AUD treatment because of large caseloads, staffing configurations, and time constraints that did not support the delivery of appropriate treatment, and a lack of protocols and workflow procedures. We documented organizational capacity and readiness constraints which impede the delivery of medication treatment for AUD in a large mental helth system. While some constraints have straightforward solutions, others require structural changes to the way care is delivered, and state-level funding and policy changes.

Psychosocial Interventions for Amphetamine Type Stimulant Use Disorder: An Overview of Systematic Reviews

Introduction: Amphetamine-type stimulants (ATS) use is a global concern due to increased usage and the harm to physical, mental, and social well-being. The objective of this overview of systematic reviews is to summarise trial results of psychosocial interventions and describe their efficacy and safety. Methods: We searched seven bibliographic databases to November 2020 for systematic reviews examining ATS misuse treatment by psychosocial interventions. Given the apparent incompleteness of the included reviews, we undertook a supplemental meta-analysis of all eligible primary studies. Results: We included 11 systematic reviews of moderate to high quality and 39 primary studies which assessed the outcomes of psychosocial interventions on people who use ATS. The key findings include: (1) There were conflicting results about the effectiveness of psychosocial interventions among reviews, which may confuse decision-makers in selecting treatment. (2) In the supplemental meta-analysis, relative to usual care (only counselling or self-help materials), membership of a psychological intervention group was associated with an important reduction in drug usage [risk ratio (RR) 0.80, 95% CI: 0.75 to 0.85]. Patients in psychological interventions used injectables substantially less [odds ratio (OR) 0.35, 95% CI: 0.24 to 0.49]. The risk of unsafe sex in the psychosocial intervention group was lower than in the control group (RR 0.49, 95% CI: 0.34 to 0.71). The combination of therapies reduced 1.51 day using drugs in the preceding 30 days (95% CI: -2.36 to -0.67) compared to cognitive behavioural therapy intervention alone. (3) Compared to usual care, cognitive behavioural therapy was less likely to be retained at follow-up (RR 0.89, 95% CI: 0.82 to 0.97; high-quality evidence). However, the additional of contingency management strategy can make an important improvement upon retention (RR 1.42, 95%CI: 1.25 to 1.62). Authors' Conclusions: Integrated models are more effective than a single-treatment strategy. Comprehensive and sustained psychosocial interventions can help to reduce use of ATS and other drugs, risk behaviours and mental disorders, and significantly improve treatment adherence.

Sexual orientation and gender identity disparities in co-occurring depressive symptoms and probable substance use disorders in a national cohort of young adults

This study examined sexual orientation and gender identity differences in co-occurring depressive symptoms and substance use disorders (SUDs) among young adults in the Growing Up Today Study national cohort (n = 12,347; ages 20-35; 93% non-Hispanic white). Self-administered questionnaires assessed recent co-occurring depressive symptoms and probable nicotine dependence, alcohol use disorder, and drug use disorder. Multinomial logistic regressions with generalized estimating equations quantified differences in prevalences of depressive symptoms only, SUDs only, and co-occurrence, among sexual minorities (mostly heterosexual; lesbian, gay, and bisexual [LGB]) compared to completely heterosexual participants, and gender minorities compared to cisgender participants. Analyses stratified by sex assigned at birth revealed sexual minorities evidenced greater odds of co-occurrence than their completely heterosexual counterparts (assigned female AORs: 3.11-9.80, ps < 0.0001; assigned male AORs: 2.90-4.87, ps < 0.001). Sexual orientation differences in co-occurrence were pronounced among LGB participants assigned female at birth who evidenced nearly 10 times the odds of co-occurring depressive symptoms with nicotine dependence and drug use disorders than did heterosexual participants assigned female at birth. Relationships between gender identity and co-occurrence were generally weaker, possibly due to low power. Gender minorities assigned male at birth, however, evidenced greater odds of co-occurring depressive symptoms and alcohol use disorders (AOR 2.75, p = 0.013) than their cisgender counterparts. This study adds to the limited research quantifying sexual orientation or gender identity differences in recent co-occurring depressive symptoms and SUDs among young adults and suggests sexual and gender minority young adults should be prioritized in prevention and treatment of co-occurring depression and SUDs.

Staff experiences of encountering and treating outpatients with substance use disorder in the psychiatric context: a qualitative study

Background

High comorbidity exists between mental illness and substance use disorders (SUD). Patients in psychiatry living with problematic alcohol or drug consumption can experience a sense of exclusion, where seeking help for SUD can be perceived as stigmatizing. The aim of this study is to illuminate staff experiences of encountering patients with SUD within the psychiatric outpatient context.

Methods

The study was exploratory, with a qualitative design. Interviews with outpatient psychiatry managers and focus groups with clinical staff focused on the experience of encountering patients with SUD. Data were evaluated using content analysis inspired by phenomenological-hermeneutic methodology.

Results

Three themes were identified and each illuminated by two sub-themes. Bridging the organizational gap included sub-themes of having an established collaboration and facing difficulties in the collaboration; Having beliefs about the patient you encounter included sub-themes of working with patients who are exposed to prejudicial thoughts and expressing prejudicial thoughts about the patient. Striving to achieve a therapeutic alliance included sub-themes of having a feeling of developing together and supporting the patient towards recovery.

Conclusion

A life-world perspective, used to interpret results, indicated that caring for patients with SUD in psychiatry was perceived as difficult, where collaboration between psychiatry and addiction care was often experienced as problematic. Based on these findings, we believe that the current gap between the psychiatry and addiction care could be reduced to some extent by offering patients digital treatment for SUD. In this way, patients could remain under the care of their regular psychiatric clinic without having to physically visit SUD services. Thus, a virtual bridge could be established to bring psychiatry and addiction care closer to each other for the patients’ benefit.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-021-00235-9.

Sustained Sobriety: A Qualitative Study of Persons with HIV and Chronic Hepatitis C Coinfection and a History of Problematic Drinking

For persons diagnosed with HIV and who are coinfected with hepatitis C virus (HCV), chronic liver disease is a leading cause of death and excessive consumption of alcohol can be a contributing factor. Little is known about the factors these individuals identify as key to achieving sustained sobriety. In this qualitative study, fourteen HIV/HCV coinfected persons who endorsed past problematic drinking were interviewed about their path to sustained sobriety. In open-ended interviews, participants often described their drinking in the context of polysubstance use and their decision to become sober as a singular response to a transcendent moment or a traumatic event. All articulated specific, concrete strategies for maintaining sobriety. The perceived effect of the HIV or HCV diagnosis on sobriety was inconsistent, and medical care as an influence on sobriety was rarely mentioned. Qualitative interviews may offer new insights on interventions and support strategies for heavy-drinking persons with HIV/HCV coinfection.

LVV-hemorphin-7 (LVV-H7) plays a role in antinociception in a rat model of alcohol-induced pain disorders

Alcohol can increase the sensitivity to painful stimulation or convert insensibility to pain at different stages. We hypothesized that chronic alcohol consumption changes the level of LVV-hemorphin-7 (abbreviated as LVV-H7, an opioid-like peptide generated from hemoglobin β-chain), thereby affecting pain sensation. We established a chronic alcohol-exposed rat model to investigate the effects of LVV-H7. Adult male Sprague-Dawley rats were subjected to daily intraperitoneal injection of 10 % ethanol (w/v) at 0.5 g/kg for 15 days and subsequent alcohol withdrawal for 5 days. Using different pharmacological strategies to affect the LVV-H7 level, we investigated the correlation between LVV-H7 and pain-related behavior. Tail-flick and hot plate tests were employed to investigate alcohol-induced pain-related behavioral changes. The serum level of LVV-H7 was determined by ELISA. Our results showed that alcohol first induced an analgesia followed by a hyperalgesia during alcohol withdrawal, which could be driven by the quantitative change of LVV-H7. A positive correlation between the level of LVV-H7 and Δtail-flick latency (measured latency minus basal latency) confirmed this finding. Moreover, we revealed that the LVV-H7 levels were determined by the activity of cathepsin D and red blood cell/hemoglobin counts, which could be affected by alcohol. These results suggest that the deterioration of anti-nociception induced by alcohol is correlated to the decreased level of LVV-H7, and this could be due to alcohol-induced anemia. This study may help to develop LVV-H7 structure-based novel analgesics for treating alcohol-induced pain disorders and thus ameliorate the complications in alcoholics.

Impact of Personality Disorder on the Treatment of Psychiatric Disorders in People Receiving Methadone-Assisted Treatment

This study evaluates personality disorder as a moderator of psychiatric treatment response in people receiving methadone-assisted treatment. Participants (N = 125) were enrolled in a 12-week parent study that evaluated the impact of incentives on attendance to psychiatric care. All participants had a current DSM IV-R Axis I disorder and were classified based on presence of an Axis II disorder: Axis I-only (n = 46) versus Axis I + II (n = 79). All participants received an identical protocol of psychiatric and substance use disorder care. Although Axis I + II participants endorsed more psychiatric distress (on the Hopkins Symptom Checklist-Revised) throughout treatment, they reported significant reductions in distress that paralleled reductions reported by Axis I-only participants. Rates of substance use were low and similar across groups. Results support the benefits of integrated psychiatric and substance use care for people with opioid use disorder, with or without a co-occurring personality disorder.

A randomized comparison of 4 vs. 16 weeks of psychosocial treatment for stimulant users

Controlled studies provide little empirical evidence to inform clinical recommendations for the optimal duration (i.e., "dosage") of psychosocial treatment for substance use disorders (SUDs). The current study prospectively examined the relationships among treatment dosage, participant adherence to the treatment regimen, and treatment outcomes in a population of adults with stimulant use disorder (cocaine and/or methamphetamine). The study randomly assigned eighty-five participants to receive either 4 weeks or 16 weeks of standardized outpatient treatment. The treatment consisted of cognitive behavioral therapy (CBT) and content covered was identical for each condition; only the planned duration of participation differed. Although both groups reduced stimulant use over time, participants in the 16-week condition were significantly more likely than those in the 4-week condition to provide stimulantnegative urine specimens 26 and 52 weeks following randomization. Participant adherence to treatment correlated significantly with drug-use outcomes: we observed a greater likelihood of stimulant-negative urine tests among those who completed treatment, irrespective of group assignment. Both the number of sessions attended and the percentage of prescribed sessions attended were associated with reductions in stimulant-use frequency 26 and 52 weeks after admission.

Support Services for Young Adults With Substance Use Disorders

In summarizing the proceedings of a longitudinal meeting of experts in substance use disorders (SUDs) among young adults, this special article reviews principles of care concerning recovery support services for this population. Young adults in recovery from SUDs can benefit from a variety of support services throughout the process of recovery. These services take place in both traditional clinical settings and settings outside the health system, and they can be delivered by a wide variety of nonprofessional and paraprofessional individuals. In this article, we communicate fundamental points related to guidance, evidence, and clinical considerations about 3 basic principles for recovery support services: (1) given their developmental needs, young adults affected by SUDs should have access to a wide variety of recovery support services regardless of the levels of care they need, which could range from early intervention services to medically managed intensive inpatient services; (2) the workforce for addiction services for young adults benefits from the inclusion of individuals with lived experience in addiction; and (3) recovery support services should be integrated to promote recovery most effectively and provide the strongest possible social support.

Patterns of substance use among adolescents: A systematic review

PURPOSE

This review characterizes empirically derived patterns of multiple (multi-) substance use among adolescents. A secondary objective was to examine the extent to which mental health symptomatology was included in the empirical analyses examining substance use patterns.

METHODS

Eligible studies included those that used cluster-based approaches, included the assessment of at least two different substances, and were based on study samples with mean ages between 11 and 18 years. 4665 records were screened including 461 studies for full-text screening.

RESULTS

70 studies were included with common clusters being: low use, single or dual substance use, moderate general multi-use, and high multi-use. The most common patterns of single or multi-substance use were: alcohol only, alcohol with cannabis and/or tobacco, and use of alcohol, tobacco, and cannabis with and without other drugs. Lower socioeconomic status, older age, and male gender were consistent predictors of multi-use clusters. Only 37 % of studies compared differences in levels of mental health across clusters with symptoms consistently associated with a greater likelihood of multi-use. Only 29 % of studies included mental health indicators in cluster-based analyses, with over half identifying distinct mental health and substance use clusters. Fit indices in cluster analyses and measurement properties of substance use were heterogeneous and inconsistently reported across studies.

CONCLUSIONS

Distinct patterns of substance use were derived but methodological differences prevented direct comparison and reduced capacity to generalize across studies. There is a need to establish standardized methodological approaches to identify robust patterns of substance use to enhance etiological, prognostic, and intervention research.

Demographic and clinical profile of patients utilising a transitional care intervention in the Western Cape, South Africa

Background

The World Health Organization’s action plan for 2020 has identified the need for service-based data to motivate for more appropriate community-based services. To date, there is no published data from step-up or step-down facilities in South Africa.

Aim

To describe the demographic and clinical profile of all patients admitted to New Beginnings between 01 January 2011 and 31 December 2015.

Setting

New Beginnings is an intermediary care facility focused on psychosocial rehabilitation and accommodates 40 patients in a step-up or step-down setting.

Methods

In this retrospective audit, we reviewed the medical records of all patients (N = 730) admitted to New Beginnings between 01 January 2011 and 31 December 2015.

Results

Most admissions were male (n = 600; 82.2%), unmarried (92.1%) and unemployed (92.7%) patients with a mean age of 28 years. Only 20.7% had completed their schooling and 37.9% were receiving a disability grant. Most patients lived in the Cape Town Metro area (89%) with their families (94.7%), and 75.6% had no children. Schizophrenia (53.7%) was the most common primary psychiatric diagnosis, and most patients were on a combination of oral and depot treatment (46.8%). Illicit substances were used by 75.9% of patients with 30% using both cannabis and methamphetamine. Most patients (74.9%) had only one admission to New Beginnings.

Conclusions

These baseline data could inform improved service delivery. Further research is needed to evaluate the success of New Beginnings and highlight the need for more of these facilities in the Western Cape and across South Africa.

Course, remission and recovery in patients with severe psychotic disorders with or without comorbid substance use disorders: Long-term outcome in evidence-based integrated care (ACCESS II study)

OBJECTIVES

People with psychotic disorders have a high prevalence of comorbid mental disorders, especially if severe mental illness (SMI) criteria are fulfilled. Substance Use Disorders (SUD) are the most common comorbidity. The aim of the study is to investigate whether SMI patients with and without comorbid SUD have a comparable course, remission and recovery rates within evidence-based care.

METHODS

ACCESS is an integrated care model for patients with severe nonaffective and affective psychotic disorders. Treatment trajectories of patients, who have been in ACCESS care for at least 4 years, with and without SUD were compared with regard to the course of illness using Mixed Model Repeated Measures (MMRM) as well as recovery rates and its predictors.

RESULTS

187 of 312 patients (60%) were at least 4 years in ACCESS. Of these, 126 (67.4%) had a comorbid SUD at admission. Patients had on average 2.96 SUD, 87 (69%) had a dependence. Both groups improved significantly over 4 years in all outcome parameters. However, patients with substance dependence showed significantly worse outcomes in psychopathology (p < 0.001), functioning (p = 0.006) and quality of life (p = 0.026). Using LOCF, 44 patients (23.5%) fulfilled recovery criteria at endpoint. Comorbid substance use dependence was the only significant predictor for non-recovery (OR = 0.462, p = 0.048).

CONCLUSION

SUD and especially substance dependence are common in psychotic disorders with SMI. Evidence-based integrated care also leads to long-term improvement in these patients, but to a lesser extent than in patients without SUD. In particular, the "optimal" outcome recovery is made more difficult by SUD dependence.

The Relationship Between Housing Status and Substance Use and Sexual Risk Behaviors Among People Currently Seeking or Receiving Services in Substance Use Disorder Treatment Programs

Although HIV risk behaviors such as substance use and condomless sex are prevalent among people currently seeking or receiving services at substance use disorder (SUD) treatment programs, associations with housing status in this population have not been well studied. We examined the associations between housing status, substance use and HIV-related sexual risk behaviors among 1281 participants from 12 US community-based SUD programs. In addition, substance use was examined as a potential mediator of the relationship between housing status and sexual risk behaviors. We conducted Chi-square, univariate and multivariate logistic regression models on data from the National Drug Abuse Treatment Clinical Trials Network HIV Rapid Testing and Counseling study. Path analysis was used to test the mediation and indirect effects. Unstable housing was significantly associated with having multiple concurrent condomless sex partners, condomless sex with non-primary partners, and partners of unknown HIV serostatus. Homelessness was significantly associated with condomless vaginal sex and condomless sex with any substance use. The path between unstable housing and sexual risk behaviors was mediated by problematic drug use, particularly by cocaine, opioids, and marijuana use. Because housing status impacts HIV risk behaviors for individuals in SUD treatment programs, both housing status and substance use behaviors should be assessed upon program entry in order to identify and mitigate risk behaviors.

Addressing treatment capacity of uninsured adults with co-occurring disorders

Purpose

The purpose of this paper is to report on the success of an initiative involving the transformation of a group of small substance use treatment only or mental health treatment only provider agencies serving uninsured adults into providers of co-occurring disorder treatment.

Design/methodology/approach

The paper uses a case study narrative to describe the initiative and the transformation of the participant agencies from being providers of mental health or substance use treatment to providers of co-occurring disorders.

Findings

Six agencies serving uninsured adults expanded their scope of patient treatment services to include the capacity to treat adults with co-occurring disorders. This was achieved with modest support funding from a local foundation. The initiative has been ongoing for five years.

Practical implications

The outcome of this initiative demonstrates the financial and practical feasibility of improving and expanding treatment services to low-resourced patient populations. The participating agencies were able to improve their capacity to treat patients with substance use or mental health issues that previously they were not prepared to treat and thus increased their ability to provide integrated care.

Originality/value

The initiative described here shows that the treatment of concomitant substance use and mental health disorders is within the range of many small-scale treatment providers, if provided the leadership and support. Delivery of effective treatments to populations experiencing co-occurring disorders that are underserved and undertreated are achievable in community-based clinical practices. This has implications for developing treatment capacity outside of hospital settings to enable treatment of co-occurring disorders to become more accessible.

HRD indicators and branding practices: a viewpoint on the employer brand building process

Purpose

The concept of employer branding has drawn the attention of both academicians and practitioners over a decade. However, inaction, the objective of the employer brand managers were hardly tapped. Therefore, this paper aims to explore the views of HR manager on employer branding activities and its implementation.

Design/methodology/approach

This study is a case research of three multinational companies in India. A semi-structured interview method has been adopted to collect the data and a content analysis technique was used for analyzing the data into identified themes.

Findings

The HR managers of the studied company were discussed with multiple activities related to employer branding practice and implementation in their workplace. The key observations and discussions from the interviews were themed after the analysis as meaningfulness and visibility, employer brand awareness and differentiator and human resource development (HRD) parameters.

Research limitations/implications

The combined effect of branding theories and HRD practices will establish the most attractive and successful employer brand building process in place. Involving the potential and existing employees in the psychological contract formation; consistency among the internal and external communication systems; and top management approach with the brand highlighted the need for research and theory development in employment branding.

Practical implications

Communication breakdown, strategic mismatch, long-term disconnects and sustained success are the strategic concerns that every company who believe in the idea of employer branding may face and need to well-handled.

Originality/value

The study concluded with the belief of the human resources managers from all the three organizations as stated – adopting a community based strategic approach to the organization’s brand and clear about what the employer brand stand across the employment lifecycle drives businesses into success.

Differences in Availability and Use of Medications for Opioid Use Disorder in Residential Treatment Settings in the United States

Importance

While many individuals with opioid use disorder seek treatment at residential facilities to initiate long-term recovery, the availability and use of medications for opioid use disorder (MOUDs) in these facilities is unclear.

Objective

To examine differences in MOUD availability and use in residential facilities as a function of Medicaid policy, facility-level factors associated with MOUD availability, and admissions-level factors associated with MOUD use.

Design, Setting, and Participants

This cross-sectional study used deidentified facility-level and admissions-level data from 2863 residential treatment facilities and 232 414 admissions in the United States in 2017. Facility-level data were extracted from the 2017 National Survey of Substance Abuse Treatment Services, and admissions-level data were extracted from the 2017 Treatment Episode Data Set-Admissions. Statistical analyses were conducted from June to November 2019.

Exposures

Admissions for opioid use disorder at residential treatment facilities in the United States that identified opioids as the patient's primary drug of choice.

Main Outcomes and Measures

Availability and use of 3 MOUDs (ie, extended-release naltrexone, buprenorphine, and methadone).

Results

Of 232 414 admissions, 205 612 (88.5%) contained complete demographic data (166 213 [80.8%] aged 25-54 years; 136 854 [66.6%] men; 151 867 [73.9%] white). Among all admissions, MOUDs were used in only 34 058 of 192 336 (17.7%) in states that expanded Medicaid and 775 of 40 078 (1.9%) in states that did not expand Medicaid (P < .001). A relatively low percentage of the 2863 residential treatment facilities in this study offered extended-release naltrexone (854 [29.8%]), buprenorphine (953 [33.3%]), or methadone (60 [2.1%]). Compared with residential facilities that offered at least 1 MOUD, those that offered no MOUDs had lower odds of also offering psychiatric medications (odds ratio [OR], 0.06; 95% CI, 0.05-0.08; Wald χ21 = 542.09; P < .001), being licensed by a state or hospital authority (OR, 0.39; 95% CI, 0.27-0.57; Wald χ21 = 24.28; P < .001), or being accredited by a health organization (OR, 0.28; 95% CI, 0.23-0.33; Wald χ21 = 180.91; P < .001). Residential facilities that did not offer any MOUDs had higher odds of accepting cash-only payments than those that offered at least 1 MOUD (OR, 4.80; 95% CI, 3.47-6.64; Wald χ21 = 89.65; P < .001).

Conclusions and Relevance

In this cross-sectional study of residential addiction treatment facilities in the United States, MOUD availability and use were sparse. Public health and policy efforts to improve access to and use of MOUDs in residential treatment facilities could improve treatment outcomes for individuals with opioid use disorder who are initiating recovery.

The interRAI Suite of Mental Health Assessment Instruments: An Integrated System for the Continuum of Care

The lives of persons living with mental illness are affected by psychological, biological, social, economic, and environmental factors over the life course. It is therefore unlikely that simple preventive strategies, clinical treatments, therapeutic interventions, or policy options will succeed as singular solutions for the challenges of mental illness. Persons living with mental illness receive services and supports in multiple settings across the health care continuum that are often fragmented, uncoordinated, and inadequately responsive. Appropriate assessment is an important tool that health systems must deploy to respond to the strengths, preferences, and needs of persons with mental illness. However, standard approaches are often focused on measurement of psychiatric symptoms without taking a broader perspective to address issues like growth, development, and aging; physical health and disability; social relationships; economic resources; housing; substance use; involvement with criminal justice; stigma; and recovery. Using conglomerations of instruments to cover more domains is impractical, inconsistent, and incomplete while posing considerable assessment burden. interRAI mental health instruments were developed by a network of over 100 researchers, clinicians, and policy experts from over 35 nations. This includes assessment systems for adults in inpatient psychiatry, community mental health, emergency departments, mobile crisis teams, and long-term care settings, as well as a screening system for police officers. A similar set of instruments is available for child/youth mental health. The instruments form an integrated mental health information system because they share a common assessment language, conceptual basis, clinical emphasis, data collection approach, data elements, and care planning protocols. The key applications of these instruments include care planning, outcome measurement, quality improvement, and resource allocation. The composition of these instruments and psychometric properties are reviewed, and examples related to homeless are used to illustrate the various applications of these assessment systems.

A health promotion intervention to improve lifestyle choices and health outcomes in people with psychosis: a research programme including the IMPaCT RCT

Background

People with psychotic disorders have reduced life expectancy largely because of physical health problems, especially cardiovascular disease, that are complicated by the use of tobacco and cannabis.

Objectives

We set out to (1) chart lifestyle and substance use choices and the emergence of cardiometabolic risk from the earliest presentation with psychosis, (2) develop a pragmatic health promotion intervention integrated within the clinical teams to improve the lifestyle choices and health outcomes of people with psychosis and (3) evaluate the clinical effectiveness and cost-effectiveness of that health promotion intervention.

Design

We performed a longitudinal cohort study of people presenting with their first episode of psychosis in three mental health trusts and followed up participants for 1 year [work package 1, physical health and substance use measures in first episode of psychosis (PUMP)]. We used an iterative Delphi methodology to develop and refine a modular health promotion intervention, improving physical health and reducing substance use in psychosis (IMPaCT) therapy, which was to be delivered by the patient’s usual care co-ordinator and used motivational interviewing techniques and cognitive–behavioural therapy to improve health choices of people with psychosis (work package 2). We then conducted a multicentre, two-arm, parallel-cluster, randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of using the intervention with people with established psychosis (work package 3: IMPaCT randomised controlled trial) in five UK mental health trusts. The work took place between 2008 and 2014.

Participants

All people aged between 16 and 65 years within 6 months of their first presentation with a non-organic psychosis and who were proficient in English were eligible for inclusion in the PUMP study. Participants in the work package 2 training development were staff selected from a range of settings, working with psychosis. Participants in the phase 3 Delphi consensus and manual development comprised three expert groups of (1) therapists/researchers recruited from the local and national community, (2) clinicians and (3) service users, each of whom took part in two iterative review and feedback sessions. For work package 3, IMPaCT randomised controlled trial, care co-ordinators in participating community mental health teams who were permanently employed and had a minimum of four eligible patients (i.e. aged between 18 and 65 years with a diagnosis of a psychotic disorder) on their caseload were eligible to participate. In studies 1 and 3, patient participants were ineligible if they were pregnant or had a major illness that would have had an impact on their metabolic status or if they had a significant learning disability. All participants were included in the study only after giving written confirmed consent.

Main outcome measures

Cardiometabolic risk markers, including rates of obesity and central obesity, and levels of glycated haemoglobin (HbA1c) and lipids, were the main outcomes in work package 1 (PUMP), with descriptive data presented on substance use. Our primary outcome measure for the IMPaCT randomised controlled trial was the physical or mental health component Short Form questionnaire-36 items quality-of-life scores at 12 months.

Results

Obesity rates rose from 18% at first presentation with psychosis to 24% by 1 year, but cardiometabolic risk was not associated with baseline lifestyle and substance use choices. Patterns of increase in the levels of HbA1c over the year following first presentation showed variation by ethnic group. We recruited 104 care co-ordinators, of whom 52 (with 213 patients) were randomised to deliver IMPaCT therapy and 52 (with 193 patients) were randomised to deliver treatment as usual, in keeping with our power calculations. Of these 406 participants with established psychosis, 318 (78%) and 301 (74%) participants, respectively, attended the 12- and 15-month follow-ups. We found no significant effect of IMPaCT therapy compared with treatment as usual on the physical or mental health component Short Form questionnaire-36 items scores at either time point in an intention-to-treat analysis [physical health score (‘d’) –0.17 at 12 months and –0.09 at 15 months; mental health score (‘d’) 0.03 at 12 months and –0.05 at 15 months] or on costs. Nor did we find an effect on other cardiovascular risk indicators, including diabetes, except in the case of high-density lipoprotein cholesterol, which showed a trend for greater benefit with IMPaCT therapy than with treatment as usual (treatment effect 0.085, 95% confidence interval 0.007 to 0.16; p = 0.034).

Limitations

Follow-up in work package 1 was challenging, with 127 out of 293 participants attending; however, there was no difference in cardiometabolic measures or demographic factors at baseline between those who attended for follow-up and those who did not. In work package 3, the IMPaCT randomised controlled trial, care co-ordinators struggled to provide additional time to their patients that was devoted to the health promotion intervention on top of their usual clinical care contact with them.

Conclusions

Cardiometabolic risk is prominent even soon after first presentation with psychosis and increases over time. Lifestyle choices and substance use habits at first presentation do not predict those who will be most cardiometabolically compromised 1 year later. Training and supervising care co-ordinators to deliver a health promotion intervention to their own patients on top of routine care is not effective in the NHS for improving quality of life or reducing cardiometabolic risk.

Future work

Further work is needed to develop and evaluate effective, cost-effective and affordable ways of preventing the emergence of and reversing existing cardiometabolic risk indicators in people with psychosis.

Trial registration

Current Controlled Trials ISRCTN58667926.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.

Assessing factors associated with discharge from opioid agonist therapy due to incarceration in the United States

The following study investigates factors associated with discharge from OAT due to incarceration in a sample of 64,331 discharges in the United States. Multinomial regression investigated the association between demographic factors, prior arrest, referral source (i.e criminal justice agency) intravenous drug use, types of drug used, length of prior treatment and discharge due to incarceration compared to completing treatment or discharge due to other reasons. African Americans, Latinx, and Native Americans were at greater risk of discharge due to incarceration compared to whites. Referral to OAT from criminal justice agencies and self-referral was associated with increased risk of discharge from OAT due to incarceration compared to referral from a health care provider. Substance use of heroin, benzodiazepines, synthetic opioids, cocaine and non-prescription use of methadone were associated with discharge due to incarceration. Risk of discharge due to incarceration was higher for patients who reported intravenous drug use and who reported a co-morbid psychiatric problem. These findings enrich a nascent body of literature on mechanisms associated with attrition from OAT due to incarceration and emphasize the need for programs to divert people with OUD from incarceration to increase engagement and retention in OAT.

Understanding Helpful Nursing Care From the Perspective of Mental Health Inpatients With a Dual Diagnosis: A Qualitative Descriptive Study

BACKGROUND: An estimated 30% to 50% of people with a mental illness also have a substance use problem. Referred to as having a dual diagnosis, these patients experience high levels of unmet needs, poor health outcomes, and require specialized care during psychiatric hospitalization. Research on nursing inpatients with a dual diagnosis is limited and patient perceptions of helpful care during hospitalization are unknown. AIMS: What nursing interventions, attitudes, actions, and/or behaviors are perceived as helpful by patients with a dual diagnosis during psychiatric hospitalization? METHODS: A qualitative-descriptive design was used. Twelve adult inpatients with a dual diagnosis were recruited using purposive sampling. Individual, semistructured interviews were conducted, and interview data were analyzed using content analysis. RESULTS: Helpful nursing occurred across three themes: (1) promoting health in everyday living, (2) managing substance use in tandem with mental illness, and (3) building therapeutic relationships. CONCLUSIONS: Specific examples of helpful interventions and their reported outcomes reinforce the critical role that nurses play in the health and recovery of inpatients with a dual diagnosis. The importance of collaborative, strengths-based approaches is highlighted, and expanding the nurse's role to include evidence-based responses to substance use is recommended.

Psychosocial interventions for people with both severe mental illness and substance misuse

BACKGROUND

Even low levels of substance misuse by people with a severe mental illness can have detrimental effects.

OBJECTIVES

To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care.

SEARCH METHODS

The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison.

MAIN RESULTS

Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence).

AUTHORS' CONCLUSIONS

We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.

Psychiatric comorbidities in alcohol use disorder

Alcohol use disorder is a major contributor to the morbidity and mortality burden worldwide. It often coexists with other psychiatric disorders; however, the nature of this comorbidity is still a matter of debate. In this Series paper, we examine the main psychiatric disorders associated with alcohol use disorder, including the prevalence of co-occurring disorders, the temporal nature of the relationship, and mechanisms that might explain comorbidity across the lifespan. Overall, this disorder co-occurs with a wide range of other psychiatric disorders, especially those disorders involving substance use and violent or aggressive behaviour. The causal pathways between alcohol use disorder and other psychiatric disorders are heterogeneous. Hypotheses explaining these relationships include reciprocal direct causal associations, shared genetic and environmental causes, and shared psychopathological characteristics of broader diagnostic entities (eg, externalising disorders). Efforts to untangle the associations between alcohol use disorder and other disorders across the lifespan remain a crucial avenue of research.

Psychological treatment for methamphetamine use and associated psychiatric symptom outcomes: A systematic review

BACKGROUND

Regular methamphetamine use is associated with increased rates of psychiatric symptoms. Although there has been a substantial body of research reporting on the effectiveness of psychological treatments for reducing methamphetamine use, there is a paucity of research examining the effects of these treatments on co-occurring psychiatric symptoms. We addressed this gap by undertaking a systematic review of the evidence of the effectiveness of psychological treatments for methamphetamine use on psychiatric symptom outcomes in randomized controlled trials.

METHODS

A narrative synthesis of studies was conducted following the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement to inform methodology. Eight electronic peer-reviewed databases were searched. Ten eligible studies were assessed.

RESULTS

Most studies found an overall reduction in levels of methamphetamine use and psychiatric symptoms among samples as a whole. Although brief interventions were effective, there is evidence that more intensive interventions have greater impact on methamphetamine use and/or psychiatric symptomatology. Intervention attendance was variable.

CONCLUSIONS

The evidence suggests that a variety of psychological treatments are effective in reducing levels of methamphetamine use and improving psychiatric symptoms. Future research should consider how psychological treatments could maximize outcomes in the co-occurring domains of methamphetamine use and psychiatric symptoms, with increasing treatment attendance as a focus. PROSPERO registration number: CRD42016043657.

Clinical effects and treatment outcomes of long-term compulsory in-patient treatment of treatment-resistant patients with severe mental illness and substance-use disorder

BACKGROUND

The treatment of homeless dual-diagnosis patients (i.e., those with severe mental illness and substance-use disorder) is difficult and often fails. For patients in the Netherlands who had not responded to earlier voluntary and compulsory treatment, a new treatment facility - Sustainable Residence (SuRe) - was developed to offer long-term compulsory in-patient treatment.

AIM OF THE STUDY

To study patterns of changes in clinical and functional outcomes during treatment at SuRe and how these relate to eventual treatment outcome.

METHODS

On the basis of the intensity of care needed after four years, three groups of patients were distinguished (total n = 165): those discharged to a less restrictive and less supportive setting (n = 70, 42%), those still hospitalized at SuRe at the end of the four-year study period (n = 69, 42%) and those referred to a more appropriate setting (n = 26, 16%). Random coefficient analysis was used to examine differences between groups regarding changes in clinical and functional outcomes during treatment. During treatment, outcomes were monitored using Routine Outcome Assessment.

RESULTS

All three groups made small but significant improvements on global psychosocial functioning, distress and therapeutic alliance (effect sizes (ES) 0.11 to 0.16 per year). Patients who were discharged to a less restrictive setting showed small to moderate improvement in risk to self and others, psychiatric symptoms, and skills for daily living (ES 0.19-0.33 per year and 0.42-0.73 for their mean 2.2-year treatment period). Patients remaining at SuRe showed a small increase in risk to self (ES 0.20 per year; 0.80 for their treatment period of four years or more). Oppositional behaviour was consistently greater in referred patients than in the other groups (ES 0.74-0.75).

CONCLUSION

Long-term compulsory treatment appeared to have helped improve clinical and functional outcomes in a substantial proportion (42%) of previously severely dysfunctional, treatment-resistant dual-diagnosis patients, who could then be discharged to a less restrictive and less supportive environment. However, risk-to-self increased in a similar proportion. A smaller number of patients (16%) showed marked oppositional behaviour and needed a higher level of care and protection in another facility.