Co-occurring disorders: policy and practice in Germany

Factors associated with the successful completion of a substance rehabilitation programme at a psychiatric training hospital

Background

Comorbid psychiatric and substance use disorders are common and present several treatment challenges.

Aim

The aim of this study was to determine which patient and substance factors are associated with the completion of a substance rehabilitation programme in psychiatric inpatients.

Setting

The study was conducted at the Substance Rehabilitation Unit (SRU) at Weskoppies Hospital, a psychiatric training hospital in South Africa, which offers a 6-week programme at the hospital for psychiatric inpatients.

Methods

This descriptive, retrospective hospital-based study was carried out comparing completers and non-completers of the SRU programme with respect to patient and substance factors. All patients accepted into the SRU during 2013–2014 were included (n = 119). Data were collected over a year (2016–2017) from the clinical files, SRU referral forms, SRU attendance register, hospital computerised demographic records, nursing notes and administration files using a data collection sheet designed by the researchers for this study. Comparison between completers and non-completers was performed using Chi-Square or Fisher’s Exact tests.

Results

The SRU accepted 119 patients from January 2013 to December 2014. The majority of the sample were involuntary patients (n = 39), 30–49 years old (n = 57), male (n = 89), unmarried (n = 112), never having received a disability grant (n = 27), unemployed (n = 96) and with a Grade 8–11 education (n = 49). Substance-induced psychotic disorders (n = 39), schizophrenia (n = 29) and bipolar disorders (n = 22) were found to be common. Frequent medical comorbidities included head injury (n = 27), cardiovascular disease (n = 18) and HIV reactivity (n = 7). Cannabis (n = 98), alcohol (n = 94) and nicotine (n = 90) were the most frequently used substances. Level of education (p = 0.004), disability grant status (p = 0.004), Nyaope use (p = 0.001) and nicotine use (p = 0.049) were statistically seen to be significantly associated with completion. Psychiatric diagnoses and general medical comorbidity were not associated with completion.

Conclusions

This study has yielded several results in areas that have not yet been well researched in South Africa. Risk factors for non-completion may include lower levels of education, being on a disability grant and using Nyaope or nicotine, but may vary in different settings. Future research should focus on identifying further factors that may affect completion of substance rehabilitation in psychiatric inpatients, the role of disability grants in patients with co-occurring disorders and the effect of Nyaope and nicotine use on treatment outcomes in this population. Effective and accessible interventions to assist vulnerable patients also need to be identified.

Wie geht’s weiter nach der Entzugsbehandlung?

Zusammenfassung. Theoretischer Hintergrund: Bisher existieren keine systematischen ambulanten Angebote für Alkoholpatient_innen mit Doppeldiagnosen, die direkt nach Qualifizierter Entzugsbehandlung (QE) einsetzen. Fragestellung: Diese Pilotstudie untersucht, ob durch nahtlos beginnende integrierte ambulante Psychotherapie Alkoholtrinktage und komorbide psychopathologische Symptomatik bei Alkoholpatient_innen mit Doppeldiagnosen reduziert werden können. Methode: 30 alkoholabhängige Patient_innen mit Doppeldiagnose (F3 oder F4) wurden vor Entlassung aus der QE randomisiert (T1) in Experimentalgruppe (n = 15, nahtlos nach Entzugsbehandlung beginnende integrierte ambulante Psychotherapie) oder Kontrollgruppe (n = 15, Warte-Kontrollgruppe). Drei Monate nach QE (T2) wurden alle Patient_innen hinsichtlich Alkoholtrinktage (Timeline Followback, TLFB) und komorbider Symptomatik (Brief Symptom Inventory, BSI; Beck Depression Inventory, BDI) nachuntersucht. Resultate: Im Gruppenvergleich reduzierten sich die Trinktage von T1 zu T2 in der Experimentalgruppe signifikant stärker (92 % vs. 35 %). Psychische Belastung und Depressivität reduzierten sich deutlicher in der Experimentalgruppe. Schlussfolgerung: Integrierte Therapieformen sollten weiterentwickelt und evaluiert werden, um die ambulant-psychotherapeutische Versorgung dieser Patient_innengruppe zu verbessern.

Cognitive-behavioral therapies for depression and substance use disorders: An overview of traditional, third-wave, and transdiagnostic approaches

BACKGROUND

The co-occurrence of depression and substance use disorders (SUD) is highly prevalent and associated with poor treatment outcomes for both disorders. As compared to individuals suffering from either disorder alone, individuals with both conditions are likely to endure a more severe and chronic clinical course with worse treatment outcomes. Thus, current practice guidelines recommend treating these co-occurring disorders simultaneously.

OBJECTIVES

The overarching aims of this narrative are two-fold: (1) to provide an updated review of the current empirical status of integrated psychotherapy approaches for SUD and depression comorbidity, based on models of traditional cognitive-behavioral therapy (CBT) and newer third-wave CBT approaches, including acceptance- and mindfulness-based interventions and behavioral activation (BA); and (2) to propose a novel theoretical framework for transdiagnostic CBT for SUD-depression, based upon empirically grounded psychological mechanisms underlying this highly prevalent comorbidity.

RESULTS

Traditional CBT approaches for the treatment of SUD-depression are well-studied. Despite advances in the development and evaluation of various third-wave psychotherapies, more work needs to be done to evaluate the efficacy of such approaches for SUD-depression.

CONCLUSION

Informed by this summary of the evidence, we propose a transdiagnostic therapy approach that aims to integrate treatment elements found in empirically supported CBT-based interventions for SUD and depression. By targeting shared cognitive-affective processes underlying SUD-depression, transdiagnostic treatment models have the potential to offer a novel clinical approach to treating this difficult-to-treat comorbidity and relevant, co-occurring psychiatric disturbances, such as posttraumatic stress.

Implementing Key Strategies for Successful Network Integration in the Quebec Substance-Use Disorders Programme

BACKGROUND

Fragmentation and lack of coordination often occur among organisations offering treatment for individuals with substance-use disorders. Better integration from a system perspective within a network of organisations offering substance-use disorder services can be developed using various integration strategies at the administrative and clinical levels. This study aims to identify integration strategies implemented in Quebec substance-use disorder networks and to assess their strengths and limitations.

METHODS

A total of 105 stakeholders representing two regions and four local substance-use disorder networks participated in focus groups or individual interviews. Thematic qualitative and descriptive quantitative analyses were conducted.

RESULTS

Six types of service integration strategies have been implemented to varying degrees in substance-use disorder networks. They are: 1) coordination activities-governance, 2) primary-care consolidation models, 3) information and monitoring management tools, 4) service coordination strategies, 5) clinical evaluation tools and 6) training activities.

CONCLUSION

Important investments have been made in Quebec for the training and assessment of individuals with substance-use disorders, particularly in terms of support for emergency room liaison teams and the introduction of standardised clinical evaluation tools. However, the development of integration strategies was insufficient to ensure the implementation of successful networks. Planning, consolidation of primary care for substance-use disorders and systematic implementation of various clinical and administrative integration strategies are needed in order to ensure a better continuum of care for individuals with substance-use disorders.

Dual diagnosis resource needs in Spain: a national survey of professionals

OBJECTIVE

Since provision of integrated services for patients with dual pathology or dual disorders (coexistence of an addictive disorder and another mental health disorder) is an important challenge in mental health, this study assessed health care professionals' perceptions and knowledge of the current state of specific resources for patients with dual pathology in Spain.

METHODS

We conducted a national survey of health care professionals seeing patients with dual pathology in treatment facilities throughout Spain. Participants completed a specific online questionnaire about the needs of and available resources for patients with dual pathology.

RESULTS

A total of 659 professionals, mostly psychologists (n = 286, 43.4%) or psychiatrists (n = 217, 32.9%), participated in the study. Nearly all participants who responded to these items reported that specific resources for dual pathology were needed (n = 592/635, 93.2%); 76.7% (n = 487) identified intermediate resources, 68.8% (n = 437) acute detoxification units, and 64.6% (n = 410) medium-stay rehabilitation units as particularly necessary. In the opinion of 54.0% of respondents (n = 343), integrated mental health and addiction treatment services were available. Of the participants who answered these items, only a small proportion (n = 162/605, 26.8%) reported that there were appropriate outpatient programs for dual pathology, 30.4% (n = 184/605) specific hospitalization units, 16.9% (n = 99/587) subacute inpatient units, 34.2% (n = 201/587) outpatient intermediate resources, 15.5% (n = 91/587) day hospitals, and 21.5% (n = 126/587) day centers. Conversely, 62.5% (n = 378/587) of participants reported a greater presence of specific detoxification/withdrawal units, 47.3% (n = 286/587) psychiatric acute admission units, and 41.9% (n = 246/587) therapeutic communities. In the professionals' opinion, the presence of specialty programs was low; 11.6% of respondents (n = 68/587) reported that vocational programs and 16.7% (n = 98/587) reported that occupational rehabilitation programs were available. Employee turnover was common: 51.9% of respondents (n = 314/605) stated that employee turnover was occasional to frequent.

CONCLUSIONS

According to the professionals surveyed, specific health care resources for the management of dual pathology are currently insufficient, underlining the need for additional efforts and strategies for treating individuals with comorbid disorders.

Reflections on capacity‐building initiatives in an Australian state

Purpose

The integration of health or social services is an enduring challenge and especially so in relation to people experiencing “dual diagnosis”, the co‐occurrence of mental health and substance use problems. The emergence of the “dual diagnosis” concept has highlighted the tension between specialist treatment for single problems and complex, individualised care. The purpose of this paper is to examine the evolving nature of dual diagnosis initiatives in an Australian state during recent decades.

Design/methodology/approach

Interpretive, case study analysis of policy documents and key informant interviews (19) illuminates the experience of dual diagnosis initiatives.

Findings

In the case of Victoria, dual diagnosis responsiveness has evolved slowly over the last 20 years, delayed by the inherent difficulty of practice change, a weak perception of need, interprofessional tensions and shortcomings in data collection, coordination and resources. Key enablers have been champions and leaders in policy, management and clinical practice, directive government policy and targeted funding. Achieving a wrap‐around service system entails investment in interpersonal relationship‐building and stigma reduction, as well as technical or structural changes.

Originality/value

The paper presents a unique and independent view of a 20‐year period and indicates progress in attitudinal change that merits wider acknowledgement and application to other settings throughout health and social care.

Counselor training in several evidence-based psychosocial addiction treatments in private US substance abuse treatment centers

BACKGROUND

Given that most addiction counselors enter the field unprepared to implement psychosocial evidence-based practices (EBPs), surprisingly little is known about the extent to which substance abuse treatment centers provide their counselors with formal training in these treatments. This study examines the extent of formal training that treatment centers provide their counselors in cognitive behavioral therapy (CBT), motivational interviewing (MI), contingency management (CM), and brief strategic family therapy (BSFT).

METHODS

Face-to-face interviews with 340 directors of a nationally representative sample of privately funded US substance abuse treatment centers.

RESULTS

Although a substantial number of treatment centers provide their counselors with formal training in EBPs that they use with their clients, coverage is far from complete. For example, of those centers that use CBT, 34% do not provide their counselors with any formal training in CBT (either initially or annually), and 61% do not provide training in CBT that includes supervised training cases. Sizable training gaps exist for MI, CM, and BSFT as well.

CONCLUSIONS

The large training gaps found in this study give rise to concerns regarding the integrity with which CBT, MI, CM, and BSFT are being delivered by counselors in private US substance abuse treatment centers. Future research should examine the generalizability of our findings to other types of treatment centers (e.g., public) and to the implementation of other EBPs.

Cost and cost-effectiveness of three strategies for training clinicians in motivational interviewing

OBJECTIVE

To evaluate the cost and cost-effectiveness of three strategies for teaching community program clinicians motivational interviewing (MI): self-study (SS), expert-led (EX), and train-the-trainer (TT).

METHODS

This economic analysis was conducted as part of a three-arm clinician training trial comprising 12 community treatment programs randomly assigned to the three conditions (n=92 clinician participants). EX and TT conditions used skill-building workshops and three monthly supervision sessions. SS provided clinicians MI training materials only. The primary outcome measure was the number of clinicians meeting MI performance standards at 12-week follow-up. Unit costs were obtained via surveys administered at the 12 participating programs. Resource utilizations and clinician outcomes were obtained from the training trial. Costs and outcomes were normalized to account for differing numbers of clinicians across programs and conditions. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were used to evaluate the relative cost-effectiveness of the three training strategies.

RESULTS

SS is likely to be the most cost-effective training strategy if the threshold value to decision makers of an additional clinician meeting MI performance standards at 12-week follow-up is less than approximately $2870, and EX is likely to be the most cost-effective strategy when the threshold value is greater than approximately $2870.

CONCLUSIONS

This study provides accurate estimates of the economic costs and relative cost-effectiveness of three different strategies for training community program clinicians in motivational interviewing and should be of interest to decision makers seeking to implement empirically supported addiction treatments with scarce resources.

Teaching community program clinicians motivational interviewing using expert and train-the-trainer strategies

AIMS

The effectiveness of expert-led (EX) and train-the-trainer (TT) strategies was compared to a self-study approach (SS) for teaching clinicians motivational interviewing (MI).

DESIGN

Twelve community treatment programs were assigned randomly to the three conditions. EX and TT conditions used skill-building workshops and three monthly supervision sessions guided by treatment integrity ratings, performance feedback and coaching techniques. Trainers in TT were first trained and certified in MI and then prepared carefully to deliver the workshops and supervise MI at their programs. Clinicians in SS only received the training materials.

SETTING

Licensed out-patient and residential addiction and mental health treatment programs in the US state of Connecticut were involved in the study.

PARTICIPANTS

Ninety-two clinicians who provided addiction treatment within these programs and had limited experience with MI participated in the study.

MEASUREMENTS

Primary outcomes were the clinicians' MI adherence and competence and the percentage of clinicians meeting clinical trial standards of MI performance. Assessments occurred at baseline, post-workshop, post-supervision and at 12-week follow-up.

FINDINGS

The study found EX and TT, in comparison to SS, improved clinicians' adherence and competence significantly, with higher percentages of clinicians reaching clinical trial standards of MI performance and few differences between EX and TT.

CONCLUSIONS

This study supports the combined use of workshops and supervision to teach community program clinicians MI and suggests the train-the-trainer approach may be a feasible and effective strategy for disseminating empirically supported treatments.