A review of research on residential programs for people with severe mental illness and co-occurring substance use disorders

Perspectives of young adults diagnosed with early psychosis using coordinated specialty care in Texas on substance use and substance use interventions

AIM

Despite known prevalence of substance use (SU) among young people experiencing early psychosis and increasing evidence for the relationship between certain substances (e.g., cannabis) and psychosis, there are no specialized interventions developed for effectively addressing substance use among young people participating in coordinated early psychosis services. This study elicited the perspectives of young people with early psychosis participating in Coordinated Specialty Care (CSC) programs about their substance use, including their motivations and concerns around their use, and their ideas on how to best support young people who are interested in reducing or quitting substance use.

METHODS

We recruited young adults (ages 18 to 30) from CSC programs across Texas through flyers sent to program staff inviting young persons willing to talk about substance use to engage in a 60-90 min person-centered, semi-structured, audio-recorded Zoom interview.

RESULTS

A total of 22 young adults were recruited and 18 completed an interview. Participants described mixed positive and negative responses to substance use, and while many understood the importance of discontinuing substance use, many expressed ambivalence related to social, contextual, mental and physical factors that motivated them to keep using. Participants desired practical substance use information, opportunities to explore their substance use ambivalence in supportive relationships, positive peer communities to support healthy choices, help engage, with work, school, and hobbies, and strategies for addressing psychological and physical pain that did not include substance use.

CONCLUSION

Study findings illuminate what motivates young people with early psychosis to initiate, continue, or cut back on substance use, and ideas for CSC practices for exploring substances and helping young people to reduce substance use.

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.

Characteristics of a Southern Intensive Trauma- and Psychiatric-Focused Recovery Program

OBJECTIVES

Treatment of substance use disorders (SUDs) is complex, involving biological, psychological, and social factors to be considered when designing effective programs. Trauma-informed psychiatric care integrated with a developmentally appropriate intensive 12-step approach is being used at A Reprieve for Women (Reprieve), a long-term intensive residential recovery program for female emerging adults with SUDs located in Tuscaloosa, Alabama. The Reprieve treatment philosophy focuses on long-term intensive care, treatment of coexisting trauma and psychiatric disorders, and development of life skills. The purpose of this article is to outline Reprieve's programmatic features and report Reprieve's 1- and 2-year sobriety rates for women who completed the 6-month residential program and compare it with national sobriety rates for other residential SUD treatment programs.

METHODS

Reprieve provided 1- and 2-year sobriety rates and duration of treatment from 110 deidentified participants who completed Reprieve's 6-month residential program between September 2016 and November 2020. The researchers defined sobriety as complete abstinence from any addictive substances. Reprieve staff contacted program graduates to determine sobriety status following completion of the program. This research, approved by the University of Alabama's institutional review board, involved usable data points from 68 of the 110 participants.

RESULTS

We determined that Reprieve has a 75% 1-year sobriety rate and a 63% 2-year sobriety rate. The national average sobriety rate for people completing SUD treatment in residential programs is 40%.

CONCLUSIONS

Reprieve's higher-than-national sobriety rates make it a valuable program to study. Its emphasis on the treatment of coexisting psychiatric problems and past traumas, development of life skills, and the unique needs of female emerging adults may contribute to the program's success. It is hoped that this program description and preliminary analysis of outcomes will provide valuable information for future SUD treatment program development. More rigorous study is needed to delineate the effects of specific programmatic features on sobriety.

"It's Stable but Not Stable": A Conceptual Framework of Subjective Housing Stability Definition Among Individuals with Co-occurring Mental Health and Substance Use Disorders

Objective: Despite increasing efforts to improve housing stability, research has largely defined housing stability in a narrow sense and heavily relied on objective measures, such as housing types and housing duration. The present study constructed a conceptual framework for a subjective housing stability definition from the perspectives of individuals with co-occurring mental health and substance use disorders and their behavioral health service providers. Methods: Following the principles of grounded theory, we collected and analyzed qualitative data through semistructured interviews with 24 individuals with serious mental illness and substance use problems and three focus groups with 22 behavioral health service providers. Results: We developed a conceptual framework with two domains of subjective housing stability: functional stability and experiential stability. The functional stability domain includes four theoretical concepts: meeting basic needs, housing quality, housing affordability, and housing permanence. The experiential stability domain includes four theoretical concepts: autonomy and independence, connectedness, safety, and supportiveness. Conclusions: The conceptual framework can inform future research, practices, and policies to move beyond focusing on merely providing housing to consider the diverse and underlying needs in improving housing stability and well-being among those experiencing or at risk of housing instability.

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.

Influence of ADHD, especially attention-deficit characteristics, on the course of alcohol-dependent individuals

BACKGROUND

While several studies have revealed that neurodevelopmental disorders have a high probability of overlapping with substance use disorders, the effects of neurodevelopmental disorders on the courses of substance use disorders have hardly been examined.

METHODS

This study targeted 637 alcohol-dependent individuals who received inpatient treatment and whose drinking situations were followed for 12 months after hospital discharge using mailed questionnaires. The comorbidity of psychiatric disorders and the characteristics associated with the neurodevelopmental disorders were assessed using several measurements at the time of hospital admission. The effects of neurodevelopmental disorders on the drinking courses of the subjects were then estimated.

RESULTS

The presence of a current depressive episode or any anxiety disorder significantly lowered the abstinence rates during the follow-up period (p = 0.0195 and p = 0.0214, respectively). ADHD traits as assessed using the ADHD Self-report Scale (ASRS) predicted a significantly poorer abstinence rate (p = 0.0296). Similarly, attention-deficit characteristics assessed objectively through interviews predicted a significantly lower abstinence rate (p = 0.0346), and a sensitivity analysis enhanced these results (p = 0.0019). When the drinking patterns were classified into three groups, the subjects with attention-deficit characteristics had a significantly higher rate of "Recurrence" and lower rates of "Abstinence" and "Controlled drinking" (p = 0.013). In a multivariate proportional hazards analysis, the ASRS score was significantly correlated with the re-drinking risk (p = 0.003).

CONCLUSION

ADHD traits had significant effects on not only abstinence rates, but also on drinking pattern. The presence of ADHD traits, especially attention-deficit characteristics, influenced the drinking courses of alcohol-dependent individuals after hospital treatment.

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.

What treatment and services are effective for people who are homeless and use drugs? A systematic 'review of reviews'

BACKGROUND

People who experience homelessness and those vulnerably housed experience disproportionately high rates of drug use and associated harms, yet barriers to services and support are common. We undertook a systematic 'review of reviews' to investigate the effects of interventions for this population on substance use, housing, and related outcomes, as well as on treatment engagement, retention and successful completion.

METHODS AND FINDINGS

We searched ten electronic databases from inception to October 2020 for reviews and syntheses, conducted a grey literature search, and hand searched reference lists of included studies. We selected reviews that synthesised evidence on any type of treatment or intervention that reported substance use outcomes for people who reported being homeless. We appraised the quality of included reviews using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses and the Scale for the Assessment of Narrative Review Articles. Our search identified 843 citations, and 25 reviews met the inclusion criteria. Regarding substance use outcomes, there was evidence that harm reduction approaches lead to decreases in drug-related risk behaviour and fatal overdoses, and reduce mortality, morbidity, and substance use. Case management interventions were significantly better than treatment as usual in reducing substance use among people who are homeless. The evidence indicates that Housing First does not lead to significant changes in substance use. Evidence regarding housing and other outcomes is mixed.

CONCLUSIONS

People who are homeless and use drugs experience many barriers to accessing healthcare and treatment. Evidence regarding interventions designed specifically for this population is limited, but harm reduction and case management approaches can lead to improvements in substance use outcomes, whilst some housing interventions improve housing outcomes and may provide more stability. More research is needed regarding optimal treatment length as well as qualitative insights from people experiencing or at risk of homelessness.

Where did the specialty behavioral health workforce grow between 2011 and 2019? Evidence from census data

IMPORTANCE

Given that mental health and substance use conditions are ongoing major public health problems in the United States, it is important for researchers to understand the behavioral health treatment workforce landscape and to assess whether increases in treatment capacity exist in areas with public health needs.

OBJECTIVES

This study quantified national and county-level changes in specialty behavioral health (SBH) workforce outcomes and assessed associations between these measures and age-adjusted drug mortality rate.

DESIGN

Using a novel longitudinal dataset from the U.S. Census Bureau, this study described SBH workforce outcomes in 3130 U.S. counties between 2011 and 2019. The study stratified workforce outcomes, including the number of establishments, likelihood of having establishments, mean number of workers, and average wage of workers per county, by service settings: outpatient, residential, and hospital. The study fitted outcome data at the county level to ordinary least squares regression models as a function of the country's previous year age-adjusted drug mortality rate and county sociodemographic characteristics.

RESULTS

The number of SBH establishments, their workforce, and their wages have increased steadily between 2011 and 2019, with the largest increases occurring in the following settings: outpatient (number of establishments and employment) and residential (average wage). County-level growth of residential SBH establishments was positively and significantly associated with the county's previous year county age-adjusted drug mortality rate. We did not observe a similar positive association between either employment or wages and the mortality rate.

CONCLUSIONS

The increase in the number of SBH establishments in recent years may indicate that the SBH workforce is responding to increased need for treatment; however, more work needs to be done to close behavioral health workforce gaps in areas with an elevated drug overdose mortality rate.

Scope, quality and inclusivity of international clinical guidelines on mental health and substance abuse in relation to dual diagnosis, social and community outcomes: a systematic review

OBJECTIVE

It is estimated that up to 75% of patients with severe mental illness (SMI) also have substance use disorder (SUD). The aim of this systematic review was to explore the scope, quality and inclusivity of international clinical guidelines on mental health and/or substance abuse in relation to diagnosis and treatment of co-existing disorders and considerations for wider social and contextual factors in treatment recommendations.

METHOD

A protocol (PROSPERO CRD42020187094) driven systematic review was conducted. A systematic search was undertaken using six databases including MEDLINE, Cochrane Library, EMBASE, PsychInfo from 2010 till June 2020; and webpages of guideline bodies and professional societies. Guideline quality was assessed based on 'Appraisal of Guidelines for Research & Evaluation II' (AGREE II) tool. Data was extracted using a pre-piloted structured data extraction form and synthesized narratively. Reporting was based on PRISMA guideline.

RESULT

A total of 12,644 records were identified. Of these, 21 guidelines were included in this review. Three of the included guidelines were related to coexisting disorders, 11 related to SMI, and 7 guidelines were related to SUD. Seven (out of 18) single disorder guidelines did not adequately recommend the importance of diagnosis or treatment of concurrent disorders despite their high co-prevalence. The majority of the guidelines (n = 15) lacked recommendations for medicines optimisation in accordance with concurrent disorders (SMI or SUD) such as in the context of drug interactions. Social cause and consequence of dual diagnosis such as homelessness and safeguarding and associated referral pathways were sparsely mentioned.

CONCLUSION

Despite very high co-prevalence, clinical guidelines for SUD or SMI tend to have limited considerations for coexisting disorders in diagnosis, treatment and management. There is a need to improve the scope, quality and inclusivity of guidelines to offer person-centred and integrated care.

The Individualized Addictions Consultation Team Residential Program: A Creative Solution for Integrating Care for Veterans With Substance Use Disorders Too Complex for Other Residential Treatment Programs

The Veterans Affairs (VA) healthcare system is one of the main providers of substance use treatment within the United States, and many veterans with a substance use disorder (SUD) present with co-occurring diagnoses or other concerns. Though there has been increasing recognition of the need for integration of treatments for SUD and comorbid mental illness, there have been limited studies of such programs, particularly within the VA healthcare system. To address that gap in the literature, this paper examines treatment outcomes in an integrated model of dual diagnosis residential treatment for veterans: the Individualized Addictions Consultation Team (I-ACT) program. Methods: The current paper draws from clinical outcome evaluation data within a residential treatment program at a large Midwestern VA Medical Center (VAMC). The I-ACT program provides residential substance abuse treatment to individuals with a primary SUD and other factors that interfere with the successful completion of a traditional residential rehabilitation program. Between 2017 and 2018, 130 individuals (97.7% men, average age = 60.62 years) entered the I-ACT program. As part of standard measurement-based care, veterans were administered the Brief Addiction Monitor and the Patient Health Questionnaire-9 at admission and discharge. Results: Most individuals (74.6%) who entered I-ACT completed the residential program (average length of stay 34.2 days). Scores on both measures significantly decreased from intake to discharge (p < .001), with the change in depression scores indicating clinically significant improvement. Those with an additional mental health diagnosis achieved similar decreases in substance use symptoms and had lower depression scores at discharge than those with a SUD alone. Conclusions: Our results indicate that even for veterans who may not benefit from traditional SUD treatment programs, a more integrated and personalized residential program can be effective.

Algorithm-Driven Substance Use Disorder Treatment for Inner-City Clients With Serious Mental Illness and Multiple Impairments

ABSTRACT

Mental health clients with serious mental illness in urban settings experience multiple chronic stresses related to poverty, unemployment, discrimination, homelessness, incarceration, hospitalization, posttraumatic stress disorder, pain syndromes, traumatic brain injury, and other problems. Substance use disorder exacerbates these difficulties. This study examined the efficacy of algorithm-driven substance use disorder treatments for 305 inner-city mental health clients with multiple challenges. Researchers assessed substance use quarterly using a combination of standardized self-reports and case manager ratings. Of the 305 multiply impaired clients who began treatment, 200 (66%) completed 2 years of treatment. One fourth (n = 53) of the completers were responders who developed abstinence and improved community function; one half (n = 97) were partial responders, who reduced substance use but did not become abstinent; and one fourth (n = 50) were nonresponders. Evidence-based interventions for substance use disorder can be effective for multiply impaired, inner-city clients, but numerous complications may hinder recovery.

Remission From Unhealthy Drinking Among Patients With an Alcohol Use Disorder: A Longitudinal Study Using Systematic, Primary Care-Based Alcohol Screening Data

OBJECTIVE

Using electronic health record (EHR) data from a systematic, primary care-based alcohol screening, brief intervention, and referral to treatment (SBIRT) initiative within a health system, we examined correlates of remission from unhealthy drinking among patients with an alcohol use disorder (AUD).

METHOD

We conducted a longitudinal study of 4,078 adults with AUD who screened positive for unhealthy drinking between October 1, 2015, and September 30, 2016. We extracted EHR data up to 3 years after screening until October 1, 2018. We used survival analysis to examine associations between remission (i.e., reporting abstinence or low-risk drinking at a subsequent screening) and patient characteristics, comorbidities, and treatment utilization.

RESULTS

The median time to remission from unhealthy drinking was 1.7 years. Factors significantly associated with greater odds of remitting from unhealthy drinking during follow-up were female gender; older age (50-64 years); Black or Latino/Hispanic race/ethnicity; having more medical comorbidities; not having a comorbid drug use disorder; lower alcohol consumption levels; and receiving addiction medicine treatment before the index screening. In the first follow-up year, individuals with mental health comorbidities were more likely to remit, but those in psychiatric treatment were less likely. Receiving addiction treatment during follow-up was not associated with remission.

CONCLUSIONS

Ethnic minorities and individuals with mental illness were more likely to remit, which is encouraging given the health disparities observed among these clinically important subgroups and warrants further research. Our findings may inform research on AUD recovery and clinical practice, as remission from unhealthy drinking is a crucial component of the early stages of recovery.

An exploratory study of culture in treatment for Aboriginal Australian men in residential drug and alcohol rehabilitation services

The objectives of the research are to describe the cultural activities offered in residential drug and alcohol rehabilitation for Aboriginal Australian men, along with client perceptions of the benefits associated with these cultural activities. Participants were 101 Australian Aboriginal male clients attending five residential drug and alcohol rehabilitation services in New South Wales. Participants completed a semi-structured interview and questionnaires that included the Growth and Empowerment Measure, the Aboriginal Cultural Engagement Survey, Clinical Global Impressions, and two questionnaires regarding cultural engagement while in treatment. Service users indicated that the most beneficial cultural activities offered within services were traditional art/craft, culturally-focused talks/meetings, and being on the land. Hierarchical multiple regression analysis indicated that cultural engagement in everyday life significantly predicted empowerment but not other measures of mental ill-health. The opinions of service users are presented, and recommendations are made regarding ways to enhance the effectiveness of cultural activities within drug and alcohol rehabilitation programs.

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.

Alcohol Use Disorder and Schizophrenia or Schizoaffective Disorder

Schizophrenia and schizoaffective disorder are schizophrenia spectrum disorders that cause significant disability. Among individuals who have schizophrenia or schizoaffective disorder, alcohol use disorder (AUD) is common, and it contributes to worse outcomes than for those who do not have co-occurring substance use disorder. Common neurobiological mechanisms, including dysfunction in brain reward circuitry, may explain the high rates of co-occurrence of schizophrenia and AUD or other substance use disorders. Optimal treatment combines pharmacologic intervention and other therapeutic modalities to address both the psychotic disorder and AUD. Further research on the etiology of these co-occurring disorders and on treatment of affected individuals is needed.

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.

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.

The effectiveness of residential treatment services for individuals with substance use disorders: A systematic review

BACKGROUND

Residential treatment is a standard treatment for individuals with severe and complex substance use problems. However, there is limited evidence on best practice approaches to treatment in these settings. This review provides a comprehensive update on the evidence base for residential treatment, and directions for future research and clinical practice.

METHOD

A systematic review of all studies published between January 2013 and December 2018 was conducted. Public health and psychology databases (Medline, CINAHL, PsycARTICLES and PsycINFO) were systematically searched, and forward and backward snowballing were used to identify additional studies. Studies were included if they were quantitative, assessed the effectiveness of residential substance treatment programs for adults, were published in the English language and in peer-reviewed journals. The Effective Public Health Practice Project's Quality Assessment Tool for Quantitative Studies was used to assess methodological quality.

RESULTS

Our search identified 23 studies. Eight were rated as methodologically strong, five as moderate and ten rated as weak. Quality ratings were impacted by attrition at follow-up and research design. Despite limitations, results provide moderate quality evidence for the effectiveness of residential treatment in improving outcomes across a number of substance use and life domains.

CONCLUSION

With caution, results suggest that best practice rehabilitation treatment integrates mental health treatment and provides continuity of care post-discharge. Future research and practice should focus on better collection of outcome data and conducting data linkage of key health, welfare and justice agency administrative data to enhance understanding of risk and recovery trajectories.

Service supply chains for population health: Overcoming fragmentation of service delivery ecosystems

INTRODUCTION

Population health involves integration of health, education, and social services to keep a defined population healthy, to address health challenges holistically, and to assist with the realities of being mortal. The fragmentation of the US population health delivery system is addressed. The impacts of this fragmentation on the treatment of substance abuse in the United States are considered. Innovations needed to overcome this fragmentation are proposed.

APPROACH

Treatment capacity issues, including scheduling practices, are discussed. Costs of treatment and lack of treatment are considered. Models of integrated care delivery are reviewed. Potential innovations from systems science, behavioral economics, and social networks are considered. The implications of these innovations are discussed in terms of information technology (IT) systems and governance.

CONCLUSIONS

Enormous savings are possible with more integrated treatment. Based on a range of empirical findings, it is argued that investments of these resources in integrated delivery of care have the potential to dramatically improve health outcomes, thereby significantly reducing the costs of population health.

An evaluation of the maintenance to abstinence (MTA) program in achieving abstinence in opioid users and improving mental health and quality of life

BACKGROUND

Residential opioid rehabilitation aims to improve the mental health and quality of life of opioid users through abstinence and residential program participation. This study aimed to determine the depression, anxiety, stress and quality of life amongst maintenance to abstinence (MTA) program residents. Secondary study aims were to assess the personal characteristics of MTA clients, addiction and risk taking behaviours, factors associated with program completion, as well as to assess the reliable change in participants' mental health and quality of life on exit.

METHODS

Retrospective analysis of routinely collected data (2013-2017) from surveys completed by 100 clients. Outcome measures were: Depression, Anxiety, Stress Score (DASS-42), World Health Organisation Quality of Life 8 questions (WHOQOL-8) and Kessler Psychological Distress Scale (K10). Other variables included demographics, drug use, other addictions, aggression, self-harm, suicidal ideation/attempts, and risk taking behaviours. Statistical methods included Chi-square, Fisher's exact, t-tests, repeated measures analysis of variance and the Reliable Change Index.

RESULTS

All mean DASS-42, WHOQOL-8 and K10 scores improved significantly in all participants from entry to exit (p < 0.001). The majority of participants demonstrated reliable improvement across all psychometric measures. Completion rates for the MTA program were 51%. Depression (p = 0.023), anxiety (p = 0.010) and stress (p = 0.015) DASS-42 scores decreased significantly more in completers compared to non-completers. The rate of improvement in mean WHOQOL-8 scores and psychological distress scores (K10) was not statistically significantly different between completers and non-completers over time. There was no significant difference between completers and non-completers on socio-demographics, self-reported drug addiction or risk taking behaviour on program entry, except for suicidal thoughts while intoxicated (p = 0.033). Completers were more satisfied with their relationships (p = 0.044) and living place (p = 0.040) on program entry.

CONCLUSION

Overall, completers and non-completers demonstrated improved mental health and quality of life from entry to exit, regardless of program completion. Depression, anxiety and stress reduced more markedly in program completers. Policy makers and programmers could use these findings to further validate their own programs to improve mental health and quality of life of opioid users.

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

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

Personality, Schizophrenia, and Violence: A Longitudinal Study

The aims of this study were (a) to investigate the presence of clinically significant personality traits and personality disorders (PD) in patients living in residential facilities, with or without a history of violence (69 and 46, respectively); and (b) to investigate any associations between clinically significant personality traits and PDs, aggression, impulsivity, hostility, and violent behavior during a 1-year follow-up. The most frequent primary diagnoses were schizophrenia (58.3%) and PD (20.9%). Those with a history of violence demonstrated more antisocial and alcohol dependence features and lower depressive PD symptoms than the control group. Hostility levels, antisocial symptoms, and drug dependence, as well as a Structured Clinical Interview for DSM-IV Axis II diagnosis of PD, predicted aggressive and violent behavior during follow-up. The study confirms the relevance of assessing PDs both to evaluate the risk of violent behavior and to plan appropriate preventive and treatment intervention.

Understanding remote Aboriginal drug and alcohol residential rehabilitation clients: Who attends, who leaves and who stays?

INTRODUCTION AND AIMS

Aboriginal residential rehabilitation services provide healing for Aboriginal people who misuse substances. There is limited available research that empirically describes client characteristics of these services. This study examined 5 years of data of a remote Aboriginal residential rehabilitation service.

DESIGN AND METHODS

Retrospective analysis of 329 client admissions to Orana Haven Drug and Alcohol Rehabilitation Centre from 2011 to 2016. Multinomial and binary logistic regressions were conducted to identify trends in the data.

RESULTS

There were 66 admissions recorded annually, of which most identified as Aboriginal (85%). Mean length of stay was 56 days, with one in three (36%) discharging within the first month. A third (32%) completed, 47% self-discharged and 20% house-discharged from the program. Client age significantly increased over time (P = 0.03), with most aged from 26 to 35. Older clients were significantly more likely to readmit (P < 0.002) and stay longer than 90 days (P = 0.02). Most clients were referred from the criminal justice system, significantly increasing from 79% (2011-2012) to 96% (2015-2016) (P < 0.001) and these clients were more likely to self-discharge (P < 0.01). Among a subset of clients, most (69%) reported concerns with polysubstance use and half (51%) reported mental illness.

DISCUSSION AND CONCLUSIONS

The current study makes a unique contribution to the literature by empirically describing the characteristics of clients of a remote Aboriginal residential rehabilitation service to more accurately tailor the service to the client's needs. Key recommendations include integrating these empirical observations with staff and client perceptions to co-design a model of care, standardise data collection, and routinely following-up clients to monitor treatment effectiveness.

Implementación y funcionamiento de hogares protegidos para personas con trastornos mentales graves en Iquitos, Perú (2013-2016)

Objetivo

Evaluar el proceso de implementación y funcionamiento de los hogares protegidos para las personas con trastornos mentales graves en Iquitos, con base en el beneficio y la mejora en la calidad de vida percibida.

Métodos

Estudio con enfoque cualitativo y transversal. Se realizaron 36 entrevistas a profundidad a residentes del hogar, cuidadores, vecinos y profesionales de salud. Se llenó una ficha sociodemográfica y clínica por cada residente y una ficha de procesos de gestión por cada hogar protegido. Se realizaron grupos focales con gestores y cuidadores.

Resultados

El tiempo de estancia prolongada manicomial previa de los residentes de hogares protegidos fue de 7 años y 3 meses. Solo 28 % habían presentado recaída clínica durante el último año. Los residentes percibieron mejoría en su calidad de vida y mayor satisfacción en la estancia en hogar protegido respecto a la estancia manicomial previa. Los hogares evaluados se encuentran en lugares accesibles a servicios sociales y comunitarios, con adecuado acceso a medios de transporte. Se realizaron supervisiones periódicas a los cuidadores, infraestructura y mantenimiento del hogar.

Conclusiones

Existe percepción favorable de cuidadores, gestores, residentes y vecinos sobre el funcionamiento de los hogares protegidos.

The development of a healing model of care for an Indigenous drug and alcohol residential rehabilitation service: a community-based participatory research approach

BACKGROUND

Given the well-established evidence of disproportionately high rates of substance-related morbidity and mortality after release from incarceration for Indigenous Australians, access to comprehensive, effective and culturally safe residential rehabilitation treatment will likely assist in reducing recidivism to both prison and substance dependence for this population. In the absence of methodologically rigorous evidence, the delivery of Indigenous drug and alcohol residential rehabilitation services vary widely, and divergent views exist regarding the appropriateness and efficacy of different potential treatment components. One way to increase the methodological quality of evaluations of Indigenous residential rehabilitation services is to develop partnerships with researchers to better align models of care with the client's, and the community's, needs. An emerging research paradigm to guide the development of high quality evidence through a number of sequential steps that equitably involves services, stakeholders and researchers is community-based participatory research (CBPR). The purpose of this study is to articulate an Indigenous drug and alcohol residential rehabilitation service model of care, developed in collaboration between clients, service providers and researchers using a CBPR approach.

METHODS/DESIGN

This research adopted a mixed methods CBPR approach to triangulate collected data to inform the development of a model of care for a remote Indigenous drug and alcohol residential rehabilitation service.

RESULTS

Four iterative CBPR steps of research activity were recorded during the 3-year research partnership. As a direct outcome of the CBPR framework, the service and researchers co-designed a Healing Model of Care that comprises six core treatment components, three core organisational components and is articulated in two program logics. The program logics were designed to specifically align each component and outcome with the mechanism of change for the client or organisation to improve data collection and program evaluation.

CONCLUSION

The description of the CBPR process and the Healing Model of Care provides one possible solution about how to provide better care for the large and growing population of Indigenous people with substance misuse issues. [corrected].

Canadian Schizophrenia Guidelines: Schizophrenia and Other Psychotic Disorders with Coexisting Substance Use Disorders

OBJECTIVE

Persons with schizophrenia and other psychotic disorders frequently have coexisting substance use disorders that require modifications to treatment approaches for best outcomes. The objectives of this review were to identify evidence-based practices best practices that improve outcomes for individuals with schizophrenia and substance used disorders.

METHOD

We reviewed guidelines that were published in the last 5 years and that included systematic reviews or meta-analyses. Most of our recommendations came from 2 publications from the National Institute for Health and Care Excellence (NICE): the 2011 guidance titled Coexisting Severe Mental Illness (Psychosis) and Substance Misuse: Assessment and Management in Healthcare Settings and the 2014 guidance titled Psychosis and Schizophrenia in Adults: Prevention and Management. We placed these recommendations into the Canadian context to create this guideline.

RESULTS

Evidence supports the inclusion of individuals with coexisting substance use disorders in first-episode psychosis programs. The programs should integrate psychosis and substance use treatments, emphasizing ongoing monitoring of both substance use and patterns and symptoms. The best outcomes are achieved with combined use of antipsychotic medications and addiction-based psychosocial interventions. However, limited evidence is available to recommend using one antipsychotic medication over another or one psychosocial intervention over another for persons with schizophrenia and other psychotic disorders with coexisting substance use disorders.

CONCLUSIONS

Treating persons who have schizophrenia and other psychotic disorders with coexisting substance use disorders can present clinical challenges, but modifications in practice can help engage and retain people in treatment, where significant improvements over time can be expected.

Integrating Addiction and Mental Health Treatment within a National Addiction Treatment System: Using Multiple Statistical Methods to Analyze Client and Interviewer Assessment of Co-Occurring Mental Health Problems

Aims

For a Swedish national sample of 12,833 individuals assessed for a substance use disorder (SUD) (2002-2008) in the Swedish welfare system, client self-report and clinical staff Addiction Severity Index (ASI) assessment data were used to assess mental health problem severity and needs.

Methods

Analysis of client self-report data using regression methods identified demographic characteristics associated with reporting significant mental health problems. Clinical staff assessment data from the ASI Interviewer Severity Rating (ISR) score were used to develop a K-means cluster analysis with three client cluster profiles: Narcotics (n=4795); Alcohol (n=4380); and Alcohol and Psychiatric Problems (n=3658). Chi-square and one-way ANOVA analyses identified self-reported mental health problems for these clusters.

Results

44% of clients had a history of using outpatient mental health treatment, 45% reported current mental health symptoms, and 19% reported significant mental health problems. Women were 1.6 times more likely to report significant mental health problems than men. Staff assessed that 74.8% of clients had current mental health problems and that 13.9% had significant mental health problems. Client and staff results were congruent in identifying that clients in the Alcohol profile were less likely (5%) to report having significant mental health problems compared to the other two profiles (30% each).

Conclusions

About 19% of clients with SUDs reported significant mental health problems, need integrated addiction and mental health treatment, and these clients are clustered in two population groups. An additional 25% of the addiction treatment population report current mental health symptoms and have at some point used mental health treatment. This national level assessment of the extent and severity of co-occurring disorders can inform decisions made regarding policy shifts towards an integrated system and the needs of clients with co-occurring disorders.

Comparative Analysis of Treatment Conditions upon Psychiatric Severity Levels at Two Years Among Justice Involved Persons

PURPOSE

The aim of this investigation was to compare the effects of two types of community-based, residential treatment programs among justice involved persons with dual diagnoses.

DESIGN/METHODOLOGY

A randomized clinical trial examined treatment conditions among justice involved persons with substance use disorders who reported high baseline levels of psychiatric severity indicative of diagnosable psychiatric comorbidity. Participants (n = 39) were randomly assigned to one of three treatment conditions upon discharge from inpatient treatment for substance use disorders: a professionally staffed, integrated residential treatment setting (therapeutic community), a self-run residential setting (Oxford House), or a treatment-specific aftercare referral (usual care). Levels of psychiatric severity, a global estimate of current psychopathological problem severity, were measured at two years as the outcome.

FINDINGS

Participants randomly assigned to residential conditions reported significant reductions in psychiatric severity whereas those assigned to the usual care condition reported significant increases. There were no significant differences in psychiatric severity levels between residential conditions.

RESEARCH LIMITATIONS/IMPLICATIONS

Findings suggest that cost-effective, self-run residential settings such as Oxford Houses provide benefits comparable to professionally-run residential integrated treatments for justice involved persons who have dual diagnoses.

SOCIAL IMPLICATIONS

Results support the utilization of low-cost, community-based treatments for a highly marginalized population.

ORIGINALITY/VALUE

Little is known about residential treatments that reduce psychiatric severity for this population. Results extend the body of knowledge regarding the effects of community-based, residential integrated treatment and the Oxford House model.

A Peer Support Scale for Adults Treated for Psychoactive Substance-Use Disorder: A Rasch Analysis

The literature suggests that peer support is protective of relapse for adults treated for substance-use disorder. However, to our knowledge there is no standard measure of peer support. Therefore, the purpose of this research was to use Rasch analysis to assess a 13-item peer support scale used in a group of adults treated for primary psychoactive substance-abuse disorder. The participants (n = 408) are adults who were discharged from an inpatient substance-abuse treatment program from five successive years, 2004-2009. Overall, it is acceptable to surmise that items 1-12 are part of the same dimension for the 13-item scale. Given the prominence of therapeutic communities as a mode of primary treatment and the importance of peer support, it is important to both the academic and treatment communities to have a standard way to measure peer support. The scale presented here can be useful for this purpose.

HIGHLIGHTS

We asses a peer support scale for those treated for substance abuse.We examine characteristics of the peer support scale.We provide an option to measure peer support for those treated for substance abuse.

Patient characteristics and predictors of completion in residential treatment for substance use disorders

Aims and method To identify the patient characteristics and rates of retention in a residential rehabilitation drug and alcohol service (Springhill) based on an eclectic model of care. Patients were assessed using the Alcohol and Drug Outcome Measure (ADOM), a brief tool designed for the New Zealand setting. We looked at correlations between demographic, social and drug use parameters. Logistic regression assessed the relative impact of each variable on completion. Results The 183 patients who completed the data collection did not differ from 47 non-completers by demographic data; 62.2% of patients completed the programme, with equal number of men and women. One in five participants was Maori, the indigenous minority. Alcohol (51.9%) was the commonest drug of misuse, with methamphetamine (16.4%) and cannabis (14.2%) also significant. Completers were more likely to be Maori, have conflict with family and housing problems, although the last became non-significant in logistic regression. Clinical implications Retention rates are higher in Springhill than in comparable programmes. Ethnicity and family conflict predict completion, although the reasons for this are unclear. ADOM is an effective tool that can be used in a clinical setting to enable analysis of service provision.

Mental Health Services and Public Safety: Substance Abuse Outpatient Visits Were Associated with Reduced Crime Rates in a Swedish Cohort

Substance abuse is related to offending and substance abuse treatment has been associated with reductions in criminal behavior. This cohort study aimed to explore the relationship between participation in substance abuse interventions and general criminal recidivism among offenders with a combination of mental health problems and substance use problems. In total, 150 Swedish offenders with self-reported mental health and substance use problems were followed for approximately three years with regard to participation in substance abuse interventions and criminal recidivism. Participants with at least three planned visits to specialized outpatient substance abuse clinics had a substantially reduced risk of reoffending as compared to those with fewer than three such visits (HR = 0.47, 95% CI 0.29-0.77). For those with at least three planned visits, general criminal recidivism was reduced by 75% during periods of participation in outpatient visits, as compared to periods of non-participation (HR = 0.25, 95% CI 0.11-0.60). For offenders with mental health problems and substance use problems, outpatient substance abuse interventions could be regarded as important from a clinical risk management perspective, and be encouraged.

Dropping out of therapeutic community treatment; when is “unsuccessful”, successful?

Purpose

– It is common for people to view dropping out of substance misuse treatment as an unsuccessful attempt at recovery. The existing literature emphasises that those who drop out of treatment do worse than those who complete their treatment programme. More recently, however, those who discharge early are faring better than ever before.

Design/methodology/approach

– In total, 13 service users who discharged early from three residential therapeutic communities were interviewed over the phone to discuss life after treatment. Interview transcripts were analysed using thematic analysis and found four main themes evidencing that “unsuccessful” really can be successful.

Findings

– The study unearthed significant findings in the area of motivation for continued recovery in that 85 per cent of the sample were actively accessing further substance misuse treatment after leaving the service early. Five participants who had entered treatment as opiate users were all abstaining from Class A drugs at the time of interview; indeed 100 per cent of the sample were opiate free. Furthermore, self-reported psychological health had improved following discharge by 78 per cent.

Practical implications

– Recent changes in policy and treatment design within drug treatment services may explain such positive outcomes in that a more responsive programme allows people to gain skills and make changes in a shorter time frame.

Social implications

– Indeed, improved early discharge procedures and increased links to aftercare and follow on treatment may have impacted on this finding.

Originality/value

– This study therefore proposes the notion of “right dose of treatment” as opposed to “time in treatment” and highlights the importance of exit procedures and aftercare.

The feasibility of telephone follow-up interviews for monitoring treatment outcomes of Australian residential drug and alcohol treatment programs

BACKGROUND

Telephone follow-up interviewing is one method of monitoring treatment outcomes of individuals involved in drug and alcohol treatment programs. The present study is the first to examine the feasibility and generalizability of data obtained from telephone follow-up interviews after drug and alcohol treatment in Australia.

METHODS

Participants attended 1 of 8 Salvation Army Recovery Service Centres where staff administered outcome measures at intake. Three-month postdischarge telephone follow-up interviews were conducted by researchers from the Illawarra Institute for Mental Health, University of Wollongong.

RESULTS

A sample of 700 clients was obtained for follow-up (582 males; 118 females). A 51% follow-up rate was achieved at a cost of US$82 per completed interview. No significant differences in baseline characteristics between responding and nonresponding participants were found.

CONCLUSIONS

Overall, the telephone methodology was shown to be feasible and relatively inexpensive. However, the introduction of outcome measures at the service level in parallel with follow-up data collection procedures complicated the collection of response data. The burden of introducing outcome measures in residential services may be reduced by utilizing a phased implementation strategy.

Comorbid attention deficit hyperactivity disorder and substance use disorder complexity and chronicity in treatment-seeking adults

INTRODUCTION AND AIMS

Attention deficit hyperactivity disorder (ADHD) is a known risk factor for substance use disorder (SUD); however, the potential additive contribution of comorbid ADHD to drug-specific dependence in SUD populations is largely unknown. The current study aimed to assess this association between ADHD symptoms and drug-specific SUD complexity and chronicity.

DESIGN AND METHODS

A cross-sectional survey was administered to a convenience sample of 489 adults receiving SUD treatment at 16 Australian drug and alcohol treatment centres between September 2010 and August 2011. Participants were screened for adult ADHD symptoms using the Adult ADHD Self-Report Scale. Associations between ADHD screening status and drug-specific SUD complexity and chronicity were assessed using multivariate logistic and modified Poisson regression analysis, controlling for a range of potential confounders.

RESULTS

Overall, 215 (44%) patients screened positive for concurrent adult ADHD and SUD. After Simes' correction, a significant positive association was observed between ADHD screening status and current amphetamine SUD (odds ratio (OR) = 1.85; 95% confidence interval (CI): 1.19-2.36). Patients who screened positive for ADHD were significantly more likely to report SUD history for heavy alcohol use (OR = 2.05; 95% CI: 1.21-3.45) and amphetamine (OR = 1.96; 95% CI: 1.26-3.06) as well as significantly increased risk of moderate (3-4 years) duration for benzodiazepine and amphetamine SUDs and long (≥5 years) duration for alcohol, opiates other than heroin or methadone, and amphetamine SUDs.

DISCUSSION AND CONCLUSIONS

The findings provide evidence that there is increased drug dependence complexity and chronicity in treatment-seeking SUD patients who screen positively for ADHD, specifically for amphetamine, alcohol, opiates other than heroin or methadone, and benzodiazepines.

Developing a dual diagnosis service in Cork, Ireland by way of participatory action research (PAR)

Purpose

– Developing a dual diagnosis service in Cork, Ireland by way of participatory action research (PAR) background: internationally there is a growing consensus regarding the ideal of integrated treatment. In Ireland, recommendations identified the need for multi-disciplinary team integration and client participation being central to service development. Such recommendations collectively fit most appropriately with PAR, the methodological and theoretical framework best suited to achieve the objectives of the inquiry. PAR's inclusive philosophy creates processes of negotiation, self-reflexivity and exploration of power issues with the lived experience of communities. Key elements of this approach facilitate the development of emancipatory and participatory democracy whilst highlighting identified social issues through research, learning and action. The paper aims to discuss these issues.

Design/methodology/approach

– Cyclical processes of planning, action, observation and reflection in cycle one have facilitated the introduction of PAR's methodological framework into the existing public health (Health Service Executive) system of primary care addiction and mental health services. Developing stakeholder relationships in decision making processes has been pivotal in cycle 1 as the process of collective engagement evolves. Stakeholders begin to experience their collective participation in the methods adopted and a collective sense of ownership and commitment to the iterative process begins to take shape. Stakeholders in cycle 1 have participated in multiple data generation methods including: informal interviews, planned discussion and focus groups, multidisciplinary team meetings, testimonials, observations and reflections.

Findings

– Cycle 1 of this PAR inquiry has engaged stakeholders (service users and their families, practitioners including; academic/practitioners, a consultant psychiatrist, psychologist, mental health nurses, an occupational therapist, psychotherapists, an acupuncturist, an addiction counsellor, an art therapist) in an integrated process of inquiry. PAR methods adopted in this cycle have facilitated particular dual diagnosis service developments and emerging initiatives (previously unidentified). Actions collaboratively planned for and illustrated in this paper include: the implementation of a psychotherapy group and implementing direct access to an acupuncture clinic.

Originality/value

– Stakeholders collaboratively experience PAR's methodological and theoretical approach which has facilitated service developments in cycle 1 of the inquiry. This sets the stage for the completion of actions already in motion and for further initiatives to continue to evolve as cycle 2 processes emerge.

Latent class analysis of discordance between results of drug use assessments in the CATIE data

OBJECTIVE

The primary aim is to examine concordant/discordant results of drug use assessments in adults with schizophrenia.

METHODS

Latent class analysis and multinomial logistic regression were used to examine concordance/discordance between drug use measures and identify characteristics differentiating participants across classes.

RESULTS

Four classes - non-users, users, probable users, and RIA discordant - fit best. Age, sex, race/ethnicity, and psychiatric symptoms differed significantly across classes.

CONCLUSIONS

Findings showed that discordance between results occurs at non-trivial rates and is, in part, attributable to individual characteristics. Results suggest the need for strategies to limit discordance and improve detection of drug use in adults with schizophrenia.

Psychosocial interventions for benzodiazepine harmful use, abuse or dependence

BACKGROUND

Benzodiazepines (BZDs) have a sedative and hypnotic effect upon people. Short term use can be beneficial but long term BZD use is common, with several risks in addition to the potential for dependence in both opiate and non-opiate dependent patients.

OBJECTIVES

To evaluate the effectiveness of psychosocial interventions for treating BZD harmful use, abuse or dependence compared to pharmacological interventions, no intervention, placebo or a different psychosocial intervention on reducing the use of BZDs in opiate dependent and non-opiate dependent groups.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL- the Cochrane Library issue 12, 2014) which includes the Cochrane Drugs and Alcohol Group Specialized Register; PubMed (from 1966 to December 2014); EMBASE (from 1988 to December 2014); CINAHL Cumulative Index to Nursing and AlliedHealth Literature (1982 to September 2013); PsychINFO (1872 to December 2014); ERIC (Education Resources Information Centre, (January 1966 to September 2013); All EBM Reviews (1991 to September 2013, Ovid Interface); AMED (Allied & Alternative Medicine) 1985 to September 2013); ASSIA (Applied Social Sciences Index & Abstracts (1960 to September 2013); LILACS (January 1982 to September 2013);Web of Science (1900 to December 2014);Electronic Grey Literature Databases: Dissertation Abstract; Index to Theses.

SELECTION CRITERIA

Randomised controlled trials examining the use of a psychosocial intervention to treat BZDs versus pharmacological interventions,no intervention, placebo or a different psychosocial intervention on reducing the use of BZDs in opiate dependent and non-opiate dependent groups.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures outlined in Cochrane Guidelines.

MAIN RESULTS

Twenty-five studies including 1666 people met the inclusion criteria. The studies tested many different psychosocial interventions including cognitive behavioural therapy (CBT) (some studies with taper, other studies with no taper), motivational interviewing (MI),letters to patients advising them to reduce or quit BZD use, relaxation studies, counselling delivered electronically and advice provided by a general practitioner (GP). Based on the data obtained, we performed two meta-analyses in this Cochrane review: one assessing the effectiveness of CBT plus taper versus taper only (575 participants), and one assessing MI versus treatment as usual (TAU) (80 participants).There was moderate quality of evidence that CBT plus taper was more likely to result in successful discontinuation of BZDs within four weeks post treatment compared to taper only (Risk ratio (RR) 1.40, 95% confidence interval (CI) 1.05 to 1.86; nine trials, 423 participants) and moderate quality of evidence at three month follow-up (RR 1.51, 95% CI 1.15 to 1.98) in favour of CBT (taper)for 575 participants. The effects were less certain at 6, 11, 12, 15 and 24 months follow-up. The effect of CBT on reducing BZDs by> 50% was uncertain for all time points examined due to the low quality evidence. There was very low quality evidence for the effect on drop-outs at any of the time intervals; post-treatment (RR 1.05, 95% CI 0.66 to 1.66), three month follow-up (RR 1.71, 95% CI0.16 to 17.98) and six month follow-up (RR 0.70, 95% CI 0.17 to 2.88).Based on the very low quality of evidence available, the effect of MI versus TAU for all the time intervals is unclear; post treatment(RR 4.43, 95% CI 0.16 to 125.35; two trials, 34 participants), at three month follow-up (RR 3.46, 95% CI 0.53 to 22.45; four trials,80 participants), six month follow-up (RR 0.14, 95% CI 0.01 to 1.89) and 12 month follow-up (RR 1.25, 95% CI 0.63 to 2.47).There was very low quality of evidence to determine the effect of MI on reducing BZDs by > 50% at three month follow-up (RR 1.52,95% CI 0.60 to 3.83) and 12 month follow-up (RR 0.87, 95% CI 0.52 to 1.47). The effects on drop-outs from treatment at any of e time intervals between the two groups were uncertain due to the wide CIs; post-treatment (RR 0.50, 95% CI 0.04 to 7.10), three month follow-up (RR 0.46, 95% CI 0.06 to 3.28), six month follow-up (RR 8.75, 95% CI 0.61 to 124.53) and 12 month follow-up(RR 0.42, 95% CI 0.02 to 7.71).The following interventions reduced BZD use - tailored GP letter versus generic GP letter at 12 month follow-up (RR 1.70, 95%CI 1.07 to 2.70; one trial, 322 participants), standardised interview versus TAU at six month follow-up (RR 13.11, 95% CI 3.25 to 52.83; one trial, 139 participants) and 12 month follow-up (RR 4.97, 95% CI 2.23 to 11.11), and relaxation versus TAU at three month follow-up (RR 2.20, 95% CI 1.23 to 3.94).There was insufficient supporting evidence for the remaining interventions.We performed a 'Risk of bias' assessment on all included studies. We assessed the quality of the evidence as high quality for random sequence generation, attrition bias and reporting bias; moderate quality for allocation concealment, performance bias for objective outcomes, and detection bias for objective outcomes; and low quality for performance bias for subjective outcomes and detection bias for subjective outcomes. Few studies had manualised sessions or independent tests of treatment fidelity; most follow-up periods were less than 12 months.Based on decisions made during the implementation of protocol methods to present a manageable summary of the evidence we did not collect data on quality of life, self-harm or adverse events.

AUTHORS' CONCLUSIONS

CBT plus taper is effective in the short term (three month time period) in reducing BZD use. However, this is not sustained at six months and subsequently. Currently there is insufficient evidence to support the use of MI to reduce BZD use. There is emerging evidence to suggest that a tailored GP letter versus a generic GP letter, a standardised interview versus TAU, and relaxation versus TAU could be effective for BZD reduction. There is currently insufficient evidence for other approaches to reduce BZD use.

The association between anxiety sensitivity and motivation to quit smoking among women and men in residential substance use treatment

BACKGROUND

Smoking-attributed mortality is the leading cause of death among individuals in residential substance use treatment. As such, identifying factors that influence smoking cessation is highly relevant and important for this group. Motivation to quit (MTQ) smoking is one such factor that is related to smoking cessation.

OBJECTIVES

In the present study we examine the relationship between Anxiety Sensitivity (AS) and MTQ among individuals enrolled in a residential substance use treatment center in Washington, DC. In light of gender differences in smoking cessation as well as factors that contribute to cessation, we examined this relationship by gender in men and women using multiple group path analysis.

METHODS

Participants (n = 472) completed a measure of MTQ, the structured clinical interview for DSM-IV (SCID-IV-TR), a measure of AS, and self-reported their number of cigarettes smoked per day prior to entering a restricted environment.

RESULTS

RESULTS indicated that AS was significantly related to MTQ in women (standardized path estimate = 0.21, p = .01), but was not significantly related to MTQ in men. Conclusions/Importance: Findings suggest the importance of considering AS as a factor in MTQ for women and subsequent smoking cessation among individuals in residential substance use treatment. RESULTS of this study contribute to the extant literature on predictors of MTQ and highlight the need for tailored cessation interventions with AS as one potential cessation treatment target.