Dartmouth Assessment of Lifestyle Instrument (DALI): a substance use disorder screen for people with severe mental illness

A systematic review of validity of US survey measures for assessing substance use and substance use disorders

BACKGROUND

The steep rise in substance use and substance use disorder (SUD) shows an urgency to assess its prevalence using valid measures. This systematic review summarizes the validity of measures to assess the prevalence of substance use and SUD in the US estimated in population and sub-population-based surveys.

METHODS

A literature search was performed using nine online databases. Studies were included in the review if they were published in English and tested the validity of substance use and SUD measures among US adults at the general or sub-population level. Independent reviews were conducted by the authors to complete data synthesis and assess the risk of bias.

RESULTS

Overall, 46 studies validating substance use/SUD (n = 46) measures were included in this review, in which 63% were conducted in clinical settings and 89% assessed the validity of SUD measures. Among the studies that assessed SUD screening measures, 78% examined a generic SUD measure, and the rest screened for specific disorders. Almost every study used a different survey measure. Overall, sensitivity and specificity tests were conducted in over a third of the studies for validation, and 10 studies used receiver operating characteristics curve.

CONCLUSION

Findings suggest a lack of standardized methods in surveys measuring and reporting prevalence of substance use/SUD among US adults. It highlights a critical need to develop short measures for assessing SUD that do not require lengthy, time-consuming data collection that would be difficult to incorporate into population-based surveys assessing a multitude of health dimensions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022298280.

Co-occurring opioid use disorder and serious mental illness: A selective literature review

OBJECTIVE

The overarching goal of this review is to provide a clinical overview of epidemiology, diagnosis, and treatment, and to discuss the public health impact, social determinants including access to care, and implications for health care delivery and research. It is estimated that approximately 1 in 4 individuals suffering from a serious mental illness (SMI) may have a co-occurring opioid use disorder (OUD). In these individuals, the overall disease burden is higher and clinical outcomes are worse compared to those without a co-occurring illness, making an integrated approach to diagnosis and treatment an urgent priority.

METHODS

We conducted a selective review of the literature to investigate prevalence, etiology for co-occurring OUD and SMI, and diagnostic and clinical guidelines in the United States, and consideration special populations.

FINDINGS

Our findings suggest that, despite the high prevalence of co-occurring OUD and SMI, contemporary diagnostics and treatment approaches are underutilized in this patient population. The literature also suggests that both pharmacological and psychosocial treatment approaches need to be tailored to optimize clinical management, and that integrated treatment is pivotal for improving overall outcomes, yet comprehensive clinical guidelines for co-occurring OUD and SMI are lacking at this time.

Blood cell count in antipsychotic-naive patients with non-affective psychosis

BACKGROUND

Schizophrenia is a complex medical entity with a reduced life expectancy, mostly due to an increased prevalence of cardiovascular diseases compared to the general population. An unbalanced immune response and a pro-inflammatory state might underlie this process. In treated patients, abnormal white blood cell (WBC), lymphocyte and neutrophil count suggests atypical immune response related to clinical variables. We aimed to test the hypothesis that newly diagnosed naïve patients with non-affective psychosis would show abnormal blood cell count values after controlling for potential confounding factors compared to matched controls.

METHODS

Seventy-five patients were compared with 80 controls matched for age, gender, body mass index and smoking. Analyses were conducted before and after controlling for smoking.

RESULTS

Patients and controls displayed similar mean values (×10³ /μL [SD]) for WBC count 7.02 [2.2] vs 6.50 [1.7] (P = .159), neutrophil count 4.25 [1.8] vs 3.84 [1.3] (P = .110) and monocyte count 0.43 [0.2] vs 0.40 [0.1] (P = .326). After controlling for smoking, 38 non-smoking patients showed a higher WBC and neutrophil count compared with 49 matched controls. Respective means of 7.01 [2.2] vs 5.97 [1.4] (P = .011) for WBC and 4.24 [1.9] vs 3.51 [1.2] (P = .028) for neutrophil count. Monocyte count showed an increased mean value 0.43 [0.2] vs 0.36 [0.1] with a trend towards signification (P = .063).

CONCLUSIONS

These results suggest that abnormal immune response is present before the effects of medication and other confounders had taken place. Increased immune parameters might underlie the high ratio of medical co-morbidities described in schizophrenia.

Intensive case management for severe mental illness

BACKGROUND

Intensive Case Management (ICM) is a community-based package of care aiming to provide long-term care for severely mentally ill people who do not require immediate admission. Intensive Case Management evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (fewer than 20) and high-intensity input.

OBJECTIVES

To assess the effects of ICM as a means of caring for severely mentally ill people in the community in comparison with non-ICM (caseload greater than 20) and with standard community care. We did not distinguish between models of ICM. In addition, to assess whether the effect of ICM on hospitalisation (mean number of days per month in hospital) is influenced by the intervention's fidelity to the ACT model and by the rate of hospital use in the setting where the trial was conducted (baseline level of hospital use).

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (last update search 10 April 2015).

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community care setting, where ICM is compared to non-ICM or standard care.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, assessed quality, and extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated mean difference (MD) between groups and its 95% CI. We employed a random-effects model for analyses.We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect. We assessed overall quality for clinically important outcomes using the GRADE approach and investigated possible risk of bias within included trials.

MAIN RESULTS

The 2016 update included two more studies (n = 196) and more publications with additional data for four already included studies. The updated review therefore includes 7524 participants from 40 randomised controlled trials (RCTs). We found data relevant to two comparisons: ICM versus standard care, and ICM versus non-ICM. The majority of studies had a high risk of selective reporting. No studies provided data for relapse or important improvement in mental state.1. ICM versus standard careWhen ICM was compared with standard care for the outcome service use, ICM slightly reduced the number of days in hospital per month (n = 3595, 24 RCTs, MD -0.86, 95% CI -1.37 to -0.34,low-quality evidence). Similarly, for the outcome global state, ICM reduced the number of people leaving the trial early (n = 1798, 13 RCTs, RR 0.68, 95% CI 0.58 to 0.79, low-quality evidence). For the outcome adverse events, the evidence showed that ICM may make little or no difference in reducing death by suicide (n = 1456, 9 RCTs, RR 0.68, 95% CI 0.31 to 1.51, low-quality evidence). In addition, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment due to very low-quality evidence (n = 1129, 4 RCTs, RR 0.70, 95% CI 0.49 to 1.0, very low-quality evidence).2. ICM versus non-ICMWhen ICM was compared with non-ICM for the outcome service use, there was moderate-quality evidence that ICM probably makes little or no difference in the average number of days in hospital per month (n = 2220, 21 RCTs, MD -0.08, 95% CI -0.37 to 0.21, moderate-quality evidence) or in the average number of admissions (n = 678, 1 RCT, MD -0.18, 95% CI -0.41 to 0.05, moderate-quality evidence) compared to non-ICM. Similarly, the results showed that ICM may reduce the number of participants leaving the intervention early (n = 1970, 7 RCTs, RR 0.70, 95% CI 0.52 to 0.95,low-quality evidence) and that ICM may make little or no difference in reducing death by suicide (n = 1152, 3 RCTs, RR 0.88, 95% CI 0.27 to 2.84, low-quality evidence). Finally, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment as compared to non-ICM (n = 73, 1 RCT, RR 1.46, 95% CI 0.45 to 4.74, very low-quality evidence).3. Fidelity to ACTWithin the meta-regression we found that i.) the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36, 95% CI -0.66 to -0.07); and ii.) the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20, 95% CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but the 'baseline hospital use' result still significantly influences time in hospital (regression coefficient -0.18, 95% CI -0.29 to -0.07, P = 0.0027).

AUTHORS' CONCLUSIONS

Based on very low- to moderate-quality evidence, ICM is effective in ameliorating many outcomes relevant to people with severe mental illness. Compared to standard care, ICM may reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. Intensive Case Management is at least valuable to people with severe mental illnesses in the subgroup of those with a high level of hospitalisation (about four days per month in past two years). Intensive Case Management models with high fidelity to the original team organisation of ACT model were more effective at reducing time in hospital.However, it is unclear what overall gain ICM provides on top of a less formal non-ICM approach.We do not think that more trials comparing current ICM with standard care or non-ICM are justified, however we currently know of no review comparing non-ICM with standard care, and this should be undertaken.

Previous Homelessness as a Risk Factor for Recovery from Serious Mental Illnesses

This paper argues that the experience of homelessness is inherently traumatic and thus has the potential to affect the manifestation of mental illness. The experiences related to being homeless might act as specific and unique sources of vulnerability. This study included 424 people diagnosed with serious mental illnesses living in supported housing programs in South Carolina. Three hierarchical regression analyses measuring the impact of homelessness on three types of outcomes revealed the following: (1) ever experiencing homelessness as well as the amount of time spent homeless were related to higher levels of psychiatric distress, (2) ever experiencing homelessness was related to higher levels of reported alcohol use, and (3) total amount of time spent homeless was related to lower perceived recovery from mental illness. These findings suggest that experiencing homelessness might contribute to psychosocial vulnerability to negative mental health outcomes. Future investigations examining this concept of risk and vulnerability as a result of homelessness are in order.

Impact of socioeconomic deprivation on rate and cause of death in severe mental illness

BACKGROUND

Socioeconomic status has important associations with disease-specific mortality in the general population. Although individuals with Severe Mental Illnesses (SMI) experience significant premature mortality, the relationship between socioeconomic status and mortality in this group remains under investigated. We aimed to assess the impact of socioeconomic status on rate and cause of death in individuals with SMI (schizophrenia and bipolar disorder) relative to the local (Glasgow) and wider (Scottish) populations.

METHODS

Cause and age of death during 2006-2010 inclusive for individuals with schizophrenia or bipolar disorder registered on the Glasgow Psychosis Clinical Information System (PsyCIS) were obtained by linkage to the Scottish General Register Office (GRO). Rate and cause of death by socioeconomic status, measured by Scottish Index of Multiple Deprivation (SIMD), were compared to the Glasgow and Scottish populations.

RESULTS

Death rates were higher in people with SMI across all socioeconomic quintiles compared to the Glasgow and Scottish populations, and persisted when suicide was excluded. Differences were largest in the most deprived quintile (794.6 per 10,000 population vs. 274.7 and 252.4 for Glasgow and Scotland respectively). Cause of death varied by socioeconomic status. For those living in the most deprived quintile, higher drug-related deaths occurred in those with SMI compared to local Glasgow and wider Scottish population rates (12.3% vs. 5.9%, p = <0.001 and 5.1% p = 0.002 respectively). A lower proportion of deaths due to cancer in those with SMI living in the most deprived quintile were also observed, relative to the local Glasgow and wider Scottish populations (12.3% vs. 25.1% p = 0.013 and 26.3% p = <0.001). The proportion of suicides was significantly higher in those with SMI living in the more affluent quintiles relative to Glasgow and Scotland (54.6% vs. 5.8%, p = <0.001 and 5.5%, p = <0.001).

CONCLUSIONS

Excess mortality in those with SMI occurred across all socioeconomic quintiles compared to the Glasgow and Scottish populations but was most marked in the most deprived quintiles when suicide was excluded as a cause of death. Further work assessing the impact of socioeconomic status on specific causes of premature mortality in SMI is needed.

Screening for substance use disorders in first-episode psychosis: implications for readmission

INTRODUCTION

Screening of substance use may prove useful to prevent readmission after the first episode of psychosis. The aim of the present study was to evaluate the influence of drug use on readmission risk in a first-episode psychosis sample, and to determine whether the cannabis/cocaine subscale of the Dartmouth Assessment of Lifestyle Inventory (DALI) is a better predictive instrument than urinary analysis.

METHODS

After admission, first-episode psychotic patients were interviewed for substance use and assessed with the DALI scale. They also underwent blood and urine sampling. Time to readmission was studied as a dependent outcome. The Kaplan-Meier estimator was applied to estimate the survival curves for bivariate analysis. The Cox proportional hazards model for multivariate analysis was assessed in order to control for potential confounders. ROC curve and validity parameters were used to assess validity to detect readmission.

RESULTS

Fifty-eight patients were included. The DALI cannabis/cocaine subscale and urinalysis were associated with increased readmission risk in survival curves, mainly the first five years of follow-up. After controlling for potential confounding variables for readmission, only the DALI cannabis/cocaine subscale remained as a significant risk factor. In terms of validity, the DALI cannabis/cocaine subscale was more sensitive than urinalysis. Alcohol assessments were not related to readmission.

CONCLUSIONS

The findings demonstrated that a quick screening self-report scale for cannabis/cocaine use disorders is superior to urinary analysis for predicting readmission. Future research should consider longitudinal assessments of brief validated screening tests in order to evaluate their benefits in preventing early readmission in first-episode psychosis.

Abnormal glucose tolerance, white blood cell count, and telomere length in newly diagnosed, antidepressant-naïve patients with depression

Chronic mood disorders have been associated with a shortened telomere, a marker of increased mortality rate and aging, and impaired cellular immunity. However, treatment may confound these relationships. We examined the relationship of glucose tolerance, white blood cell count and telomere length to depression in newly diagnosed, antidepressant-naïve patients. Subjects with major depression (n=15), and matched healthy control subjects (n=70) underwent a two-hour oral glucose tolerance test and evaluation of blood cell count and telomere content. The depression group had significantly higher two-hour glucose concentrations and a lower lymphocyte count than control subjects (respective means [SD] for two-hour glucose were 125.0mg/dL [67.9] vs 84.6 [25.6] (p<.001); for lymphocyte count 2.1×10(9)/L [0.6] vs 2.5×10(9)/L [0.7] p=.028). Telomere content was significantly shortened in the depression group (87.9 [7.6]) compared to control subjects (101.0 [14.3]; p<0.01). Abnormal glucose tolerance, lymphopenia and a shortened telomere are present early in the course of depression independently of the confounding effect of antidepressant treatment, supporting the concept of major depression as an accelerated aging disease.

"Shotgunning" in a population of patients with severe mental illness and comorbid substance use disorders

"Shotgunning" refers to the practice of one individual forcibly exhaling smoke into the mouth of another, and may increase the risk of transmission of respiratory pathogens. The extent of shotgunning among individuals with co-occurring serious mental illness and substance use is unknown. We included questions about shotgunning in an interview of 236 participants of a study testing a model to prevent and treat HIV and hepatitis. Shotgunning was common (61% [145/236]) and correlated with increased substance use severity and several high-risk behaviors. Only 8% (11/145) understood that shotgunning could transmit disease. Further research and patient education on shotgunning is warranted.

Prolactin concentrations in newly diagnosed, antipsychotic-naïve patients with nonaffective psychosis

BACKGROUND

Previous studies have found increased prolactin concentrations in antipsychotic-naïve patients with schizophrenia. However, the roles of other hormones, and of potentially confounding variables such as gender and smoking, have not been considered.

METHODS

Blood from newly diagnosed, antipsychotic-naïve patients with nonaffective psychosis (13 women and 20 men) and matched controls (12 women and 21 men) was assayed for prolactin, as well as three other hormones that impact prolactin concentrations: thyrotropin-stimulating hormone (TSH), ghrelin, and cortisol.

RESULTS

Patients had significantly higher prolactin concentrations: female patients had a mean [SD] of 37.1 ng/mL [24.9] vs. 13.5 ng/mL [7.2] for female control subjects (p=.001), while male patients had a mean of 15.3 ng/mL [9.5] vs. 7.6 ng/mL [2.2] for male control subjects (p=.006). Patients and control subjects did not differ on concentrations of TSH, ghrelin, or cortisol. The group differences could not be attributed to differences in age, gender, smoking, body mass index, ethnicity, or the socioeconomic status of the family of origin.

CONCLUSIONS

Increased prolactin concentrations in antipsychotic-naïve patients do not appear to be due to important confounding variables, or to the effects of elevated TSH, ghrelin, or cortisol.

Testosterone in newly diagnosed, antipsychotic-naive men with nonaffective psychosis: a test of the accelerated aging hypothesis

OBJECTIVE

Schizophrenia has been associated with age-related abnormalities, including abnormal glucose tolerance, increased pulse pressure, increased inflammation, abnormal stem cell signaling, and shorter telomere length. These metabolic abnormalities and other findings suggest that schizophrenia and related disorders might be associated with accelerated aging. Testosterone activity has a progressive decline with increasing age.

METHODS

We tested the hypothesis that circulating biologically active testosterone is lower in newly diagnosed, antipsychotic-naive male patients with nonaffective psychosis than in matched control subjects.

RESULTS

Patients (n = 33) were matched to control subjects (n = 33) for age, sex, body mass index, socioeconomic status of the family of origin, and smoking. The free androgen index, a measure of biologically active testosterone, was significantly lower in the psychosis group (mean [standard deviation] = 57.7% [26.1]) than in control subjects (71.6% [27.0], p = .04), with an effect size of 0.53. Multivariate analysis also supported the findings. In the psychosis group, free androgen index had a significant negative correlation with the conceptual disorganization item (r = -0.35, p = .049) but not with reality distortion (r = -0.21, p = .24), negative symptoms (r = 0.004, p = .98), or depression (r = -0.014, p = .94).

CONCLUSIONS

Lower testosterone level is consistent with accelerated aging in nonaffective psychosis, but further testing of this hypothesis is needed.

Assessing the STIRR model of best practices for blood-borne infections of clients with severe mental illness

OBJECTIVES

People with co-occurring severe mental illness and a substance use disorder are at markedly elevated risk of infection from HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV), but they generally do not receive basic recommended screening or preventive and treatment services. Barriers to services include lack of programs offered by mental health providers and client refusal of available services. Clients from racial-ethnic minority groups are even less likely to accept recommended services. The intervention tested was designed to facilitate integrated infectious disease programming in mental health settings and to increase acceptance of such services among clients.

METHODS

A randomized controlled trial (N=236) compared enhanced treatment as usual (control) with a brief intervention to deliver best-practice services for blood-borne diseases in an urban sample of clients with co-occurring disorders who were largely from racial-ethnic minority groups. The "STIRR" intervention included Screening for HIV and HCV risk factors, Testing for HIV and hepatitis, Immunization against hepatitis A and B, Risk reduction counseling, and medical treatment Referral and support at the site of mental health care.

RESULTS

Clients randomly assigned to the STIRR intervention had high levels (over 80%) of participation and acceptance of core services. They were more likely to be tested for HBV and HCV, to be immunized against hepatitis A virus and HBV, and to increase their knowledge about hepatitis and reduce their substance abuse. However, they showed no reduction in risk behavior, were no more likely to be referred to care, and showed no increase in HIV knowledge. Intervention costs were $541 per client (including $234 for blood tests).

CONCLUSIONS

STIRR appears to be efficacious in providing a basic, best-practice package of interventions for clients with co-occurring disorders.

Overview and initial validation of two detailed, multidimensional, retrospective measures of substance use: the Lifetime Substance Use Recall (LSUR) and Longitudinal Substance Use Recall for 12 Weeks (LSUR-12) Instruments

Research on comorbidities between substance use disorders and serious mental illnesses would be facilitated by new methods for collecting comprehensive data on substance use, including data on onset, progression, frequency, amounts, and consequential behaviors. Given substantial limitations of available instruments, and a nearly complete absence of methodologies that allow derivation of continuous measures that estimate dose or cumulative exposure, this report describes the development and initial validation of two interviewer-administered, multidimensional measures of substance use, the Lifetime Substance Use Recall (LSUR) and Longitudinal Substance Use Recall for 12 Weeks (LSUR-12) Instruments. Participants (n=60) in an ongoing study of first-episode psychosis were evaluated with the LSUR, LSUR-12, and a number of other concurrent measures pertaining to substance use, substance use disorder diagnoses, select demographic features, and two personality traits. Specific a priori hypothesis tests were selected to demonstrate validity, relying on effect sizes to estimate strengths of association, considering small-to-medium correlations (e.g., ρ) as |.20-.50| and medium-to-large effect sizes as >|.50|. Numerous associations were observed between key nicotine-, alcohol-, and cannabis-related variables from the LSUR and LSUR-12 and scores from other concurrently administered measures. These findings provide a thorough initial validation of scores obtained with the new multidimensional instruments. Although validity of the two new measures of lifetime and past 12-week substance use was demonstrated, empirical data on inter-rater and test-retest reliability are needed. Careful development, and demonstration of psychometric properties, of these and related instruments may advance the fields of addiction and comorbidity research.

Intensive case management for severe mental illness

BACKGROUND

Intensive Case Management (ICM) is a community based package of care, aiming to provide long term care for severely mentally ill people who do not require immediate admission. ICM evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (less than 20) and high intensity input.

OBJECTIVES

To assess the effects of Intensive Case Management (caseload <20) in comparison with non-Intensive Case Management (caseload > 20) and with standard community care in people with severe mental illness. To evaluate whether the effect of ICM on hospitalisation depends on its fidelity to the ACT model and on the setting.

SEARCH STRATEGY

For the current update of this review we searched the Cochrane Schizophrenia Group Trials Register (February 2009), which is compiled by systematic searches of major databases, hand searches and conference proceedings.

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community-care setting, where Intensive Case Management, non-Intensive Case Management or standard care were compared. Outcomes such as service use, adverse effects, global state, social functioning, mental state, behaviour, quality of life, satisfaction and costs were sought.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For binary outcomes we calculated relative risk (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data we estimated mean difference (MD) between groups and its 95% confidence interval (CI). We employed a random-effects model for analyses.We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect.

MAIN RESULTS

We included 38 trials (7328 participants) in this review. The trials provided data for two comparisons: 1. ICM versus standard care, 2. ICM versus non-ICM.1. ICM versus standard care Twenty-four trials provided data on length of hospitalisation, and results favoured Intensive Case Management (n=3595, 24 RCTs, MD -0.86 CI -1.37 to -0.34). There was a high level of heterogeneity, but this significance still remained when the outlier studies were excluded from the analysis (n=3143, 20 RCTs, MD -0.62 CI -1.00 to -0.23). Nine studies found participants in the ICM group were less likely to be lost to psychiatric services (n=1633, 9 RCTs, RR 0.43 CI 0.30 to 0.61, I²=49%, p=0.05).One global state scale did show an Improvement in global state for those receiving ICM, the GAF scale (n=818, 5 RCTs, MD 3.41 CI 1.66 to 5.16). Results for mental state as measured through various rating scales, however, were equivocal, with no compelling evidence that ICM was really any better than standard care in improving mental state. No differences in mortality between ICM and standard care groups occurred, either due to 'all causes' (n=1456, 9 RCTs, RR 0.84 CI 0.48 to 1.47) or to 'suicide' (n=1456, 9 RCTs, RR 0.68 CI 0.31 to 1.51).Social functioning results varied, no differences were found in terms of contact with the legal system and with employment status, whereas significant improvement in accommodation status was found, as was the incidence of not living independently, which was lower in the ICM group (n=1185, 4 RCTs, RR 0.65 CI 0.49 to 0.88).Quality of life data found no significant difference between groups, but data were weak. CSQ scores showed a greater participant satisfaction in the ICM group (n=423, 2 RCTs, MD 3.23 CI 2.31 to 4.14).2. ICM versus non-ICM The included studies failed to show a significant advantage of ICM in reducing the average length of hospitalisation (n=2220, 21 RCTs, MD -0.08 CI -0.37 to 0.21). They did find ICM to be more advantageous than non-ICM in reducing rate of lost to follow-up (n=2195, 9 RCTs, RR 0.72 CI 0.52 to 0.99), although data showed a substantial level of heterogeneity (I²=59%, p=0.01). Overall, no significant differences were found in the effects of ICM compared to non-ICM for broad outcomes such as service use, mortality, social functioning, mental state, behaviour, quality of life, satisfaction and costs.3. Fidelity to ACT Within the meta-regression we found that i. the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36 CI -0.66 to -0.07); and ii. the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20 CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but 'baseline hospital use' result is still significantly influencing time in hospital (regression coefficient -0.18 CI -0.29 to -0.07, p=0.0027).

AUTHORS' CONCLUSIONS

ICM was found effective in ameliorating many outcomes relevant to people with severe mental illnesses. Compared to standard care ICM was shown to reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. ICM is of value at least to people with severe mental illnesses who are in the sub-group of those with a high level of hospitalisation (about 4 days/month in past 2 years) and the intervention should be performed close to the original model.It is not clear, however, what gain ICM provides on top of a less formal non-ICM approach.We do not think that more trials comparing current ICM with standard care or non-ICM are justified, but currently we know of no review comparing non-ICM with standard care and this should be undertaken.

Advisor-Teller Money Manager (ATM) therapy for substance use disorders

OBJECTIVE

Patients with concomitant psychiatric and substance use disorders are commonly assigned representative payees or case managers to help manage their funds, but money management has not been conceptualized as a theory-based treatment. This randomized clinical trial was conducted to determine the effect of a money management-based therapy, advisor-teller money manager (ATM), on substance abuse or dependence.

METHODS

Ninety patients at a community mental health center who had a history of cocaine or alcohol abuse or dependence were assessed after random assignment to 36 weeks of ATM (N=47) or a control condition in which use of a financial workbook was reviewed (N=43). Patients assigned to ATM were encouraged to deposit their funds into a third-party account, plan weekly expenditures, and negotiate monthly budgets. Substance use calendars and urine toxicology tests were collected every other week for 36 weeks and again 52 weeks after randomization.

RESULTS

Patients assigned to ATM had significantly more negative toxicologies for cocaine metabolite over time than patients in the control group, and treating clinicians rated ATM patients as significantly more likely to be abstinent from illicit drugs. Self-reported abstinence from alcohol did not significantly differ between groups. Unexpectedly, patients assigned to ATM were more likely to be assigned a representative payee or a conservator than control participants during the follow-up period (ten of 47 versus two of 43). One patient in ATM assaulted the therapist when his check had not arrived.

CONCLUSIONS

ATM is an efficacious therapy for the treatment of cocaine abuse or dependence among people with concomitant psychiatric illness but requires protection of patient autonomy and staff safety.

Cholesterol and triglycerides in antipsychotic-naive patients with nonaffective psychosis

Patients with psychosis have an increased prevalence of hyperlipidemia. We compared fasting concentrations of lipids in newly diagnosed, antipsychotic-naïve patients with nonaffective psychosis (N=87) and control subjects (N=92). After accounting for gender, age, smoking, socioeconomic status, and body mass index, there was no significant difference between the two groups in total cholesterol, high-density lipoproteins, low-density lipoproteins, or triglycerides.

Advisor-Teller Money Manager (ATM) therapy for substance use disorders

OBJECTIVE

Patients with concomitant psychiatric and substance use disorders are commonly assigned representative payees or case managers to help manage their funds, but money management has not been conceptualized as a theory-based treatment. This randomized clinical trial was conducted to determine the effect of a money management-based therapy, advisor-teller money manager (ATM), on substance abuse or dependence.

METHODS

Ninety patients at a community mental health center who had a history of cocaine or alcohol abuse or dependence were assessed after random assignment to 36 weeks of ATM (N=47) or a control condition in which use of a financial workbook was reviewed (N=43). Patients assigned to ATM were encouraged to deposit their funds into a third-party account, plan weekly expenditures, and negotiate monthly budgets. Substance use calendars and urine toxicology tests were collected every other week for 36 weeks and again 52 weeks after randomization.

RESULTS

Patients assigned to ATM had significantly more negative toxicologies for cocaine metabolite over time than patients in the control group, and treating clinicians rated ATM patients as significantly more likely to be abstinent from illicit drugs. Self-reported abstinence from alcohol did not significantly differ between groups. Unexpectedly, patients assigned to ATM were more likely to be assigned a representative payee or a conservator than control participants during the follow-up period (ten of 47 versus two of 43). One patient in ATM assaulted the therapist when his check had not arrived.

CONCLUSIONS

ATM is an efficacious therapy for the treatment of cocaine abuse or dependence among people with concomitant psychiatric illness but requires protection of patient autonomy and staff safety.

Metabolic profile of antipsychotic-naive individuals with non-affective psychosis

BACKGROUND

Some studies suggest individuals with schizophrenia have an increased risk of diabetes prior to antipsychotic use. Small sample sizes and the potential for confounding by hypercortisolaemia have decreased confidence in those results.

AIMS

To examine diabetes-related factors in newly diagnosed, antipsychotic-naive people with non-affective psychosis.

METHOD

Participants with psychosis (the psychosis group; n = 50) and matched controls (the control group; n = 50) were given a 2 h oral glucose tolerance test. Fasting concentrations were also determined for adiponectin, interleukin-6 and C-reactive protein.

RESULTS

Compared with the control group, the psychosis group had significant increases in 2 h glucose and interleukin-6 concentrations, and in the prevalence of abnormal glucose tolerance (16% of psychosis group v. 0% of control group). Adiponectin and C-reactive protein concentrations did not differ significantly between the two groups. These findings could not be attributed to differences in cortisol concentrations, smoking, gender, neighbourhood of residence, body mass index, aerobic conditioning, ethnicity, socioeconomic status or age.

CONCLUSIONS

Individuals with non-affective psychosis appear to have an increased prevalence of abnormal glucose tolerance prior to antipsychotic treatment, as well as abnormalities in a related inflammatory molecule. These underlying problems may contribute to the metabolic side-effects of antipsychotic medications.

Differences in glucose tolerance between deficit and nondeficit schizophrenia

Some studies suggest that schizophrenia is associated with an increased risk of diabetes independently of antipsychotic use. People with deficit schizophrenia, which is characterized by primary (or idiopathic), enduring negative symptoms, differ from those with nondeficit schizophrenia on course of illness, treatment response, risk factors, and biological correlates. We hypothesized that deficit and nondeficit subjects would also differ with regard to glucose tolerance. Newly diagnosed, antipsychotic-naïve subjects with nonaffective psychosis and matched control subjects were administered a 75 g oral glucose tolerance test (GTT). Two-hour glucose concentrations were significantly higher in the nondeficit patients (N=23; mean [SD] of 121.6 [42.0]) than in deficit (N=23; 100.2 [23.1]) and control subjects (N=59; 83.8 [21.9]); the deficit subjects also had significantly higher two-hour glucose concentrations than did the control subjects. These results provide further support that the deficit group has a distinctive etiopathophysiology.

Glucose abnormalities in the siblings of people with schizophrenia

BACKGROUND

Some studies suggest that schizophrenia may be associated with an increased risk of diabetes, independently of antipsychotic medications and other confounding factors. Previous studies have also suggested that there is an increased prevalence of diabetes in the relatives of schizophrenia probands.

METHOD

First-degree siblings of schizophrenia probands (N=6) and control subjects (N=12) were administered a glucose tolerance test. Subjects were matched for gender, age, body mass index, neighborhood of residence, socio-economic status and smoking habits.

RESULTS

The siblings of schizophrenia probands had a significantly increased two-hour mean glucose concentration compared to the control subjects (respective means [SD] were 100.5 mg/dL [27.7] vs. 78.0 [12.3]; p<0.03). Baseline glucose concentrations did not differ.

CONCLUSIONS

Although confirmation with larger samples is needed, these results and other studies suggest that diabetes may share familial risk factors with schizophrenia.

Effect of Social Security payments on substance abuse in a homeless mentally ill cohort

OBJECTIVES

To determine whether receipt of social supplemental security income (SSI) or Social Security disability income (SSDI) disability payments is associated with increased drug and alcohol use.

DATA SOURCES/STUDY SETTING

Secondary analysis of data from 6,199 participants in the Access to Community Care and Effective Social Supports and Services demonstration for the homeless mentally ill.

DESIGN

Observational, 12-month, cohort study completed over 4 years. Substance abuse and other outcomes were compared between the participants who did not receive SSI or SSDI during the 12-month study, those newly awarded benefits, and those without benefits throughout the 12 months.

DATA COLLECTION METHODS

Social Security administrative records were used to corroborate Social Security benefit status. Drug and alcohol use were measured by self-report and clinician ratings.

PRINCIPAL FINDINGS

Participants who did not receive benefits significantly reduced their substance use over time. In generalized estimating equations models that adjusted for potentially confounding covariates, participants who newly received Social Security benefits showed no greater drug use than those without benefits but had significantly more days housed and fewer days employed. Participants whose benefits antedated the demonstration and continued during the 12 months had more clinician-rated drug use over time than those without benefits.

CONCLUSIONS

In this vulnerable population, participants with newly awarded benefits did not have any different drug use changes than those without benefits, and had relatively more days housed. The hypothesis that Social Security benefits facilitate drug use was not supported by longitudinal data in this high-risk population.

On beyond urine: clinically useful assessment instruments in the treatment of drug dependence

Although there are a wealth of clinically useful, brief, and low-cost assessment instruments available for use with drug-dependent populations, relatively few are broadly used in clinical practice. With an emphasis on: (1). the multidimensional nature of drug users' problems; and (2). assessments that can be integrated into empirically validated treatments, clinically useful assessments in four general categories (evaluation and diagnosis of drug dependence, identifying concurrent disorders and problems, treatment planning, and evaluation of treatment outcome) are briefly summarized. Progress in the field of drug abuse treatment has been significantly hampered by the failure to adopt, across research and clinical settings, a common set of assessments.

The social-environmental context of violent behavior in persons treated for severe mental illness

OBJECTIVES

This study examined the prevalence and correlates of violent behavior by individuals with severe mental illness.

METHODS

Participants (N = 802) were adults with psychotic or major mood disorders receiving inpatient or outpatient services in public mental health systems in 4 states.

RESULTS

The 1-year prevalence of serious assaultive behavior was 13%. Three variables-past violent victimization, violence in the surrounding environment, and substance abuse-showed a cumulative association with risk of violent behavior.

CONCLUSIONS

Violence among individuals with severe mental illness is related to multiple variables with compounded effects over the life span. Interventions to reduce the risk of violence need to be targeted to specific subgroups with different clusters of problems related to violent behavior.

Substance misuse in patients with schizophrenia: epidemiology and management

Substance misuse in individuals with schizophrenia is very common, especially in young men, in communities where use is frequent and in people receiving inpatient treatment. Problematic use occurs at very low intake levels, so that most affected people are not physically dependent (with the exception of nicotine). People with schizophrenia and substance misuse have poorer symptomatic and functional outcomes than those with schizophrenia alone. Unless there is routine screening, substance misuse is often missed in assessments. Service systems tend to be separated, with poor inter-communication, and affected patients are often excluded from services because of their comorbidity. However, effective management of these disorders requires a fully integrated approach because of the close inter-relationship of the disorders. Use of atypical antipsychotics may be especially important in this population because of growing evidence (especially on clozapine and risperidone) that nicotine smoking, alcohol misuse and possibly some other substance misuse is reduced. Several pharmacotherapies for substance misuse can be used safely in people with schizophrenia, but the evidence base is small and guidelines for their use are necessarily derived from experience in the general population.

Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness

OBJECTIVES

This study assessed seroprevalence rates of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) among individuals with severe mental illness.

METHODS

Participants (n = 931) were patients undergoing inpatient or outpatient treatment in Connecticut, Maryland, New Hampshire, or North Carolina.

RESULTS

The prevalence of HIV infection in this sample (3.1%) was approximately 8 times the estimated US population rate but lower than rates reported in previous studies of people with severe mental illness. Prevalence rates of HBV (23.4%) and HCV (19.6%) were approximately 5 and 11 times the overall estimated population rates for these infections, respectively.

CONCLUSIONS

Elevated rates of HIV, HBV, and HCV were found. Of particular concern are the high rates of HCV infection, which are frequently undetected. Individuals with HCV infection commonly fail to receive appropriate treatment to limit liver damage and unknowingly may be a source of infection to others.