Substance Abuse With Mental Disorders: Specialized Public Systems And Integrated Care

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Integrated behavioral treatments for comorbid anxiety and substance use disorders: A model for understanding integrated treatment approaches and meta-analysis to evaluate their efficacy

INTRODUCTION

Substance use disorders (SUD) and anxiety disorders are highly comorbid, and this comorbidity is associated with poor clinical outcomes. Emerging research in the last decade has shifted from addressing these problems separately to the development and evaluation of behavioral treatments that integrate care for anxiety disorders (or elevated symptoms of anxiety) and SUD.

METHODS

An extensive literature search revealed a sufficient number of studies (K=11) to conduct a meta-analysis comparing the efficacy of integrated SUD/anxiety disorder behavioral treatment to SUD treatment alone on substance use and anxiety symptom outcomes. Randomized clinical trials including those with SUD and either anxiety disorders or elevations in constructs implicated in the maintenance of anxiety disorder/SUD comorbidity were included. This study meta-analyzes the effects of these studies.

RESULTS

Integrated treatments outperformed SUD treatments alone on both substance use and anxiety outcomes, with small to moderate effects favoring integrated treatments. There was no significant heterogeneity across studies in the primary analyses, such that moderator analyses to identify variables that yielded differential patterns of effect sizes were not conducted.

DISCUSSION

Integrated treatments for SUD/anxiety disorders demonstrate an incremental but significant and clinically meaningful improvement over SUD treatment alone for SUD/anxiety disorder comorbidity. Implications for future research and clinical practice paradigm shifting are discussed.

Health outcomes and service use patterns associated with co-located outpatient mental health care and alcohol and other drug specialist treatment: A systematic review

ISSUES

Despite long-standing recommendations to integrate mental health care and alcohol and other drug (AOD) treatment, no prior study has synthesised evidence on the impact of physically co-locating these specialist services on health outcomes.

APPROACH

We searched Medline, PsycINFO, Embase, Web of Science and CINAHL for studies examining health outcomes associated with co-located outpatient mental health care and AOD specialist treatment for adults with a dual diagnosis of substance use disorder and mental illness. Due to diversity in study designs, patient populations and outcome measures among the included studies, we conducted a narrative synthesis. Risk of bias was assessed using the MASTER scale.

KEY FINDINGS

Twenty-eight studies met our inclusion criteria. We found provisional evidence that integrated care that includes co-located mental health care and AOD specialist treatment is associated with reductions in substance use and related harms and mental health symptom severity, improved quality of life, decreased emergency department presentations/hospital admissions and reduced health system expenditure. Many studies had a relatively high risk of bias and it was not possible to disaggregate the independent effect of physical co-location from other common aspects of integrated care models such as care coordination and the integration of service processes.

IMPLICATIONS

There are few high-quality, peer-reviewed studies establishing the impact of co-located mental health care and AOD specialist treatment on health outcomes. Further research is required to inform policy, guide implementation and optimise practice.

CONCLUSION

Integrated care that includes the co-location of mental health care and AOD specialist treatment may yield health and economic benefits.

Resources for the Assessment and Treatment of Substance Use Disorder in Adolescents

Substance Use Disorder (SUD) is understood as the persistent use of substances to the detriment of the individual's livelihood and wellness. SUD can have serious mental, physical, and social ramifications if not properly addressed. Though SUD can develop at any age, it is especially important to address in adolescents, given rising prevalence of certain substances (e.g. cannabis) in that age group and poor prognosis associated with early-onset SUD.[1][2] Data from the National Survey on Drug Use and Health show the lifetime use of illicit drugs in people ages 12-17 is 20.9%.[3] The same survey found the rate of Substance Use Disorder in the past year for people ages 12-17 who used illicit drugs or alcohol to be 6.3% in 2020.[3] This paper is intended for clinicians and lay people to gain a deeper understanding of SUD in adolescents, particularly relating to alcohol, cannabis, nicotine, and opioids. Though alcohol, cannabis, and nicotine are the substances most commonly used by this age demographic nationally,[4] opioid use – and resulting deaths – have been on the rise. According to the Centers for Disease Control and Prevention (CDC), opioids were connected to about 75% of the nearly 92,000 drug deaths in 2020.[5] Beyond significant death rates in the general population, recent spikes in adolescent death rate tied to the synthetic opioid fentanyl – which held a relatively stable death rate from 2010 to 2019 until seeing a 94% increase from 2019 to 2020 and additional 20% increase to 2021 - warrants inquiry into opioids for this population.[6] Each of these substances can have adverse, long-lasting effects on health if not managed properly, resulting in seriously compromised lifelong wellbeing.[7] This article explores SUD prevalence and reviews diagnostic criteria in relation to adolescence, including a synopsis of changes in SUD classification between the DSM-IV and DSM-5 and discussion of ICD-11 and the Research Domain Criteria (RDoC) as a basis for research related to substance use. Effective assessment and consideration of co-occurring disorders are covered as well. Although the prognosis of SUD varies by an individual's environment and circumstances, a modal developmental course for SUD is discussed. Finally, a curated list of nationally recognized resources including hotlines, treatment locators, informational sites, and support groups is provided, along with tools to compile local resources. By addressing these aspects of adolescent SUD, the research team offers a broader view of its prevalence in the United States, key warning signs and comorbidities, and possible assessments and treatments for adolescents with SUD.

A Scoping Review of Data Sources for the Conduct of Policy-Relevant Substance Use Research

OBJECTIVE

Existing administrative and survey data are critical for understanding the effects of exigent policies on population health outcomes related to opioid, cannabis, and other substance use disorders (SUDs). The objective of this study was to determine the state of the data available for evaluating SUD-related health outcomes.

METHODS

We performed a scoping review of national and state government data sources to measure and evaluate the effects of state policy changes on substance use and SUD-related health outcomes and health care use. We used Massachusetts as a case study for availability of relevant state-level data as well as national datasets with state-level indicators available to measure outcomes. We compared key features of each dataset to assess their usefulness for research and policy evaluation. We conducted our review during November 2018-March 2019, and we updated data availability as of March 2019 for all data sources.

RESULTS

We identified 11 survey datasets, 12 national administrative datasets, and 10 state administrative datasets as being suitable for policy-relevant research and practice purposes. These datasets varied substantially in their usefulness for evaluation and research. Despite substantial data limitations, including prohibitive regulatory and monetary costs to obtain the data and limited availability, these data can be mined to examine a diversity of policy-relevant questions.

CONCLUSIONS

Findings provide a comprehensive resource for using survey and administrative data to evaluate the health effects of SUD-related policies and interventions. The construction of state-level public health data warehouses or record linkage projects connecting individual-level information in state data sources is valuable for analyzing the effects of policy changes. Understanding strengths and limitations of available data sources is important for ongoing research and evaluation.

Cognitive-Behavioral Interventions Targeting Alcohol or Other Drug Use and Co-Occurring Mental Health Disorders: A Meta-Analysis

AIMS

This meta-analysis reviewed 15 clinical trials (18 study sites/arms), examining the efficacy of an integrated cognitive-behavioral intervention (CBI) delivered to individuals with an alcohol or other drug use disorder and a co-occurring mental health disorder (AOD/MHD). Outcomes were alcohol or other drug use and mental health symptoms at post-treatment through follow-up.

METHODS

The inverse-variance weighted effect size was calculated for each study and pooled under random effects assumptions.

RESULTS

Integrated CBI showed a small effect size for AOD (g = 0.188, P = 0.061; I2 = 86%, τ2 = 0.126, k = 18) and MHD (g = 0.169, P = 0.024; I2 = 58%, τ2 = 0.052, k = 18) outcomes, although only MHD outcomes were statistically significant. Analysis by subgroup suggested that effect magnitude varied by type of contrast condition (integrated CBI + usual care vs. usual care only; integrated CBI vs. a single-disorder intervention), follow-up time point (post-treatment vs. 3-6 months) and primary AOD/MHD diagnosis, although these sub-groups often contained significant residual heterogeneity. In a series of mixed effects, meta-regression models, demographic factors were non-significant predictors of between-study heterogeneity. For AOD outcomes, greater effects were observed in higher quality studies, but study quality was not related to effect size variability for MHD outcomes.

CONCLUSIONS

The current meta-analysis shows a small and variable effect for integrated CBI with the most promising effect sizes observed for integrated CBI compared with a single disorder intervention (typically an AOD-only intervention) for follow-up outcomes, and for interventions targeting alcohol use and/or post-traumatic stress disorder. Given the clinical and methodological variability within the sample, results should be considered a preliminary, but important step forward in our understanding of treatment for co-occurring AOD/MHD.

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

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

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

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

Patient-public engagement interventions for health system improvement in Sub-Saharan Africa: A systematic scoping review protocol

BACKGROUND

Research has found health system improvement cannot be achieved without continuously engaging patients, their families and all stakeholders in the design, management and delivery of health care services. Following the Alma Ata declaration on Primary Health Care in 1978, the focus of health system improvement has tended to shift from physician or hospital-centric approaches to a more democratic vision of engaging the public and/or patients in the commissioning, planning, organisation, operation and control of the health care system. Thus, patient-public engagement (PPE) has become an important tool in health system improvement particularly for countries with poor health outcomes including countries in sub-Saharan Africa which carries an estimated 24% of the global burden of diseases in both human and financial costs. The aim of this scoping review is to describe and systematically map PPE research in sub-Saharan Africa, and then to synthesise this research in relation to key theories of PPE, identify the key drivers and barriers of PPE and to identify the knowledge gaps that may usefully be addressed by future research.

METHODS

This scoping review will follow Arksey and O'Malley's best guidelines for conducting scoping reviews and also follow the standard guidelines for reporting using the Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews checklist. A systematic search of peer-reviewed English language literature published between January 1999 and December 2019 will be conducted on four databases: Scopus, CINAHL, Medline (Ovid) and Embase. The initial screening of titles and abstracts will be undertaken independently by two reviewers, followed by full text screening involving three independent reviewers. A thematic framework synthesis will be employed in the analysis of data to identify the various PPE interventions, and outcomes mapped to a framework of engagement continuum to understand its overall effect on health system improvement in sub-Saharan Africa.

DISCUSSION

To our knowledge, this scoping review will be the first to systematically investigate PPE interventions implemented across sub-Saharan Africa, map the outcomes of identified interventions to a framework of engagement continuum and to understand its overall effect on health system improvement. Findings of this review will be published in an open-access peer review journal and disseminated at scientific conferences.

Using actor-partner interdependence modeling to understand recent illicit opioid use and injection drug use among men in community supervision and their female partners in New York City

BACKGROUND

The United States' opioid crisis disproportionately affects individuals in the criminal justice system. Intimate partners can be a source of social support that helps reduce substance use, or they can serve as a driver of continued or increased substance use. Better understanding of the association between intimate partner characteristics and illicit opioid use and injection drug use among individuals in community supervision could be vital to developing targeted interventions.

METHODS

Using actor-partner interdependence models, we examined individual and partner characteristics associated with recent illicit opioid use and injection drug use among males in community supervision settings in New York City (n = 229) and their female partners (n = 229).

RESULTS

Higher levels of depression (aOR 1.98, 95% CI [1.39-2.82], p ≤ 0.01) and anxiety (aOR 1.98, 95% CI [1.42-2.75], p ≤ 0.01) were associated with recent opioid use among males in community supervision. Females with a partner having higher levels of anxiety were more likely to have recently used opioids (aOR 1.52, 95% CI [1.06-2.16], p ≤ 0.05). Males with a female partner with higher levels of anxiety (aOR 2.16, 95% CI [1.31-3.56], p ≤ 0.01) or depression (aOR 1.70, 95% CI [1.01-2.86], p ≤ 0.05) were more likely to recently inject drugs. Women with a male partner who had been in prison were more likely to have recently injected drugs (aOR 3.71, 95% CI [1.14-12.12], p ≤ 0.05), but women who had a male partner who had been arrested in the past three months were less likely to have recently injected (aOR 0.08, 95% CI [0.02-0.46], p ≤ 0.01).

CONCLUSIONS

Results suggest that recent individual illicit opioid use and injection drug use is associated not only with individual-level factors, but also with partner factors, highlighting the need for couple-based approaches to address the opioid epidemic.

Concurrent Disorder Management Guidelines. Systematic Review

Concurrent disorder refers to a diverse set of combinations of substance use disorders and mental disorders simultaneously in need of treatment. Concurrent disorders are underdiagnosed, undertreated, and more complex to manage, practicing the best recommendations can support better outcomes. The purpose of this work is to systematically assess the quality of the current concurrent disorders’ clinical recommendation management guidelines. Literature searches were performed by two independent authors in electronic databases, web, and gray literature. The inclusion criteria were English language clinical management guidelines for adult concurrent disorders between 2000 and 2020. The initial search resulted in 8841 hits. A total of 24 guidelines were identified and assessed with the standardized guidelines assessment tool: AGREE II (Appraisal of Guidelines for Research and Evaluation). Most guidelines had acceptable standards, however, only the NICE guidelines had all detailed information on all AGREE II Domains. Guidelines generally supported combinations of treatments for individual disorders with a very small evidence base for concurrent disorders, and they provided little recommendation for further structuring of the field, such as level of complexity or staging, or evaluating different models of treatment integration.

Addressing treatment capacity of uninsured adults with co-occurring disorders

Purpose

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

Design/methodology/approach

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

Findings

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

Practical implications

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

Originality/value

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

Integrated dual diagnosis treatment among United States mental health treatment facilities: 2010 to 2018

OBJECTIVE

Little is known about the correlates of and recent trends in implementation of Integrated Dual Diagnosis model, an evidence-based approach for dual diagnosis services, in US mental health facilities between 2010 and 2018.

METHODS

Changes over time in Integrated Dual Diagnosis Treatment use were examined using multiple waves of a national survey of mental health treatment facilities that reported offering any substance use services. State and facility correlates of offering integrated dual diagnosis services among these facilities in 2018 were examined.

RESULTS

The proportion of mental health treatment facilities that reported offering any substance use services increased significantly from 50.1% in 2010 to 57.1% in 2018. Among these facilities, significantly fewer reported offering Integrated Dual Diagnosis Treatment in 2018 (74.8%) than in 2010 (79.6%). The prevalence of Integrated Dual Diagnosis Treatment use increased in more recent years in tandem with increase in substance use services, though the increases in Integrated Dual Diagnosis Treatment have not matched the expansion of substance use services. Mental health facilities with substance use services more commonly offered other mental health services and had more funding sources available. Facilities with any substance use disorder services that offered Integrated Dual Diagnosis Treatment were more commonly licensed by State Substance Agencies and more commonly offered psychotropics and group therapies. Facilities located in states that implemented the Integrated Dual Diagnosis Treatment model had a higher odds of offering this model.

CONCLUSIONS

The growth in the co-location of substance use treatment services within mental health treatment facilities has not been matched by true integration of these treatments, highlighting the need for further efforts to comprehensively address the complex needs of dually diagnosed patients.

Interventions to integrate care for people with serious mental illness and substance use disorders: a systematic scoping review protocol

INTRODUCTION

People with serious mental illness (SMI) and/or substance use disorders (SUDs) have an elevated risk of premature mortality compared with the general population. This has been attributed to higher rates of chronic illness among these individuals, but also to inequities in healthcare access and treatment. Integrated care has the potential to improve the health of people with SMI/SUDs. The aims of this scoping review are to: (1) identify empirical investigations of interventions designed to integrate care for people with SMI/SUDs; (2) describe the underlying theories, models and frameworks of integrated care that informed their development; and (3) determine the degree to which interventions address dimensions of a comprehensive and validated framework of integrated care.

METHODS AND ANALYSIS

Guidelines for best practice and reporting of scoping reviews will be followed using the framework of Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review checklist. An iterative and systematic search of peer-reviewed publications reporting empirical research findings will be conducted. This literature will be identified by searching five databases: Medline (Ovid), PsycINFO, CINAHL, Embase (Ovid) and Scopus. The search will be restricted to articles published between January 2000 and April 2019. Two reviewers will independently screen publications in two successive stages of title and abstract screening, followed by full-text screening of eligible publications. A tabular summary and narrative synthesis will be completed using data extracted from each included study. A framework synthesis will also be conducted, with descriptions of interventions mapped against a theoretical framework of integrated care.

ETHICS AND DISSEMINATION

This review will identify the extent and nature of empirical investigations evaluating interventions to integrate care for people with SMI/SUDs. Ethical approval was not required. A team of relevant stakeholders, including people with lived experience of mental health conditions, has been established. This team will be engaged throughout the review and will ensure that the findings are widely disseminated. Dissemination will include publication of the review in a peer-reviewed journal. The review protocol has been registered through Open Science Framework and can be accessed at https://osf.io/njkph/.

Behavioral health treatment utilization among individuals with co-occurring opioid use disorder and mental illness: Evidence from a national survey

BACKGROUND

Past research shows that among individuals with substance use disorders, the presence of a co-occurring mental illness can influence the initiation, course, and success of behavioral health treatment, but little research has examined people with opioid use disorder (OUD) specifically.

METHODS

Using the 2008-2014 National Survey on Drug Use and Health, this study examines the utilization of substance use disorder and mental health treatment among individuals with OUD and different degrees of mental illness severity. The study also examined types of treatment, perceived unmet need for treatment, and barriers to care.

RESULTS

47% of individuals with OUD and co-occurring mild/moderate mental illness did not receive any behavioral health treatment, and 21% of those with co-occurring serious mental illnesses did not receive any behavioral health treatment. Among those with OUD and co-occurring mild/moderate mental illness, 16% reported receiving both substance use disorder and mental health treatment; among those with co-occurring serious mental illness the rate was 32%. The most common form of treatment was prescription medication for mental health, and this was true regardless of whether or not the individual had any mental illness. More than 50% of the study population reported financial difficulties as a barrier to treatment.

CONCLUSION

A high proportion of individuals with OUD and co-occurring mental illness are not receiving needed care. However, nearly one in five of those with OUD but no diagnosed mental illness is receiving prescription medication for mental illness. These findings suggest that there is a need to better facilitate access to and coordinate behavioral health care across settings for individuals with OUD.

Substance Use, Homelessness, Mental Illness and Medicaid Coverage: A Set-up for High Emergency Department Utilization

Introduction

Frequent users of emergency departments (ED) account for 21–28% of all ED visits nationwide. The objective of our study was to identify characteristics unique to patients with psychiatric illness who are frequent ED users for mental health care. Understanding unique features of this population could lead to better care and lower healthcare costs.

Methods

This retrospective analysis of adult ED visits for mental healthcare from all acute care hospitals in California from 2009–2014 used patient-level data from California’s Office of Statewide Health Planning and Development. We calculated patient demographic and visit characteristics for patients with a primary diagnosis of a mental health disorder as a percentage of total adult ED visits. Frequent ED users were defined as patients with more than four visits in a 12-month period. We calculated adjusted rate ratios (aRR) to assess the association between classification as an ED frequent user and patient age, sex, payer, homelessness, and substance use disorder.

Results

In the study period, 846,867 ED visits for mental healthcare occurred including 238,892 (28.2%) visits by frequent users. Patients with a primary mental health diagnosis and a co-occurring substance use diagnosis in the prior 12 months (77% vs. 37%, aRR [4.02], 95% confidence interval [CI] [3.92–4.12]), homelessness (2.9% vs 1.1%, odds ratio [1.35], 95% [CI] [1.27–1.43]) were more likely to be frequent users. Those covered by Medicare (aRR [3.37], 95% CI [3.20–3.55]) or the state’s Medicaid program Medi-Cal (aRR [3.10], 95% CI [2.94–3.25]) were also more likely to be frequent users compared with those with private insurance coverage.

Conclusion

Patients with substance use disorders, homelessness and public healthcare coverage are more likely to be frequent users of EDs for mental illness. Substance use and housing needs are important factors to address in this population.

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.

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.

The Use of the Addiction Severity Index Psychiatric Composite Scores to Predict Psychiatric Inpatient Admissions

The high prevalence of co-occurring mental health and substance use disorders indicates a need for integrated behavioral health treatment that addresses both types of disorder simultaneously. One component of this integrated treatment is the use of an assessment process that can concurrently identify the presence of each class of disorder. The Addiction Severity Index (ASI) has been extensively used and researched in the field of substance use disorders for over 30 years. The ASI has seven sections, including a section on substance use disorders and a section on psychiatric symptoms, making it a potential candidate for a co-occurring screen during intake. The following study utilized a receiver operating characteristic curve analysis to determine an optimal cutoff score on the ASI psychiatric composite score to identify which individuals seeking substance use disorder treatment were admitted to the Milwaukee County Behavioral Health Division's psychiatric hospital in the year subsequent to their ASI administration. Of the 19,320 individuals who completed an initial ASI in our system, 343 had an inpatient admission. The receiver operating characteristic curve was statistically significant, with an area under the curve of 0.75. A cutoff of 0.27 had a sensitivity of 0.77 and a specificity of 0.61, such that over 60% (11,963/19,320) of the sample was excluded. These results suggest that the ASI psychiatric composite score may be a useful initial screen to identify those with potential mental health problems/needs in a behavioral health system attempting to integrate addiction and mental health services.

Treatment of Cognition in the Schizophrenia Spectrum: The Context of Psychiatric Rehabilitation

Evidence-based approaches and modalities for targeting and treating the cognitive impairments of schizophrenia have proliferated over the past 15 years. The impairments targeted are distributed across the cognitive spectrum, from elemental perception, attention, and memory, to complex executive and social-cognitive functioning. Cognitive treatment is most beneficial when embedded in comprehensive programs of psychiatric rehabilitation. To personalize comprehensive treatment and rehabilitation of schizophrenia spectrum disorders, practitioners and participants must select from a rapidly expanding array of particular modalities and apply them in the broad context of the participant's overall recovery. At present, no particular treatment, cognitive or otherwise, can be considered more important or primary than the context in which it is applied. Persistent difficulty in dissemination of new technology for severe and disabling mental illness compounds the significance of the context created by a full treatment array. In this article, a case-study of a mental health service system is described, showing the broad-ranging effects of degrading the rehabilitative context of treatments, obviating the benefits of cognitive treatment and other modalities. To realize the promise of cognitive treatment, the problems that prevent dissemination and maintenance of complete psychiatric rehabilitation programs have to be addressed.

Parenting Efficacy and Support in Mothers With Dual Disorders in a Substance Abuse Treatment Program

OBJECTIVE

Approximately 73% of women entering treatment for substance use disorders are mothers of children younger than 18, and the high rate of mental health disorders among mothers with substance use disorders increases their vulnerability to poor parenting practices. Parenting efficacy and social support for parenting have emerged as significant predictors of positive parenting practices among families at risk for child maltreatment. The purpose of the current study was to examine the impact of parenting support and parenting efficacy on the likelihood of out-of-home placement and custody status among the children of mothers with dual substance use and mental health disorders.

METHODS

This study examined the impact of parenting efficacy and assistance with childcare on the likelihood of child out-of-home placement and custody status among 175 mothers with diagnosed dual substance and mental health disorder and in treatment for substance dependence. Logistic regression was utilized to assess the contributions of parenting efficacy and the number of individuals in mothers' social networks who assist with childcare to the likelihood of out-of-home placement and custody loss of children. Parenting efficacy was also examined as a mediator using bootstrapping in PROCESS for SPSS.

RESULTS

Greater parenting efficacy was associated with lower likelihood of having at least one child in out-of-home placement (B = -.064, SE = .029, p = .027) and lower likelihood of loss of child custody (B = -.094, SE = .034, p = .006). Greater number of children in the 6 to 18 age range predicted greater likelihood of having at least one child in the custody of someone else (B = .409, SE = .171, p = .017) and in out-of-home placement (B = .651, SE = .167, p < .001). In addition, mothers who identified as African American were less likely to have a child in out-of-home placement (B = .927, SE = .382, p = .015) or to have lost custody of a child (B = -1.31, SE = .456, p = .004). Finally, parenting efficacy mediated the relationship between parenting support and likelihood of out-of-home placement (effect = -.0604, SE = .0297, z = 2.035, p = .042) and between parenting support and likelihood of custody loss (effect = -.0332, SE = .0144, z = -2.298, p = .022).

CONCLUSIONS

Implications for practice include the utilization of personal network interventions, such as increased assistance with childcare, and increased attention to efficacy among mothers with dual disorders.

Classifying substance use disorder treatment facilities with co-located mental health services: A latent class analysis approach

BACKGROUND

The Affordable Care Act calls for increased integration and coordination of behavioral health services, as people with co-occurring disorders (CODs), meeting criteria for both substance use and psychiatric disorders, are overrepresented in treatment samples. Nationwide estimates of mental health (MH) service co-location in substance use disorder (SUD) treatment facilities are needed. We empirically derived a multiple-indicator categorization of services for CODs in SUD treatment facilities.

METHODS

We used latent class analysis to categorize 14,037 SUD treatment facilities in the United States and territories included in the 2012 National Survey of Substance Abuse Treatment Services. Latent class indicators included MH screening and diagnosis, MH support services, psychiatric medications, groups for CODs, and psychosocial approaches. Multinomial logistic regression compared facility-identified primary focus (i.e., SUD, MH, mix of SUD-MH, and general/other) and other facility characteristics across classes.

RESULTS

A four-class solution was chosen with the following classes: Comprehensive MH/COD Services (25%), MH without COD Services (25%), MH Screening Services (21%), and Limited MH Services (29%). The former two classes with co-located MH services were less likely to report a SUD-primary focus than the latter classes reporting only MH screening or Limited MH Services. Only the Comprehensive MH/COD Services class also had a high probability of providing special groups for CODs.

CONCLUSIONS

Approximately half of SUD treatment facilities were in classes with co-located mental health services, but only a quarter provided comprehensive COD services. Future studies should assess differences in patient experiences and treatment outcomes across facilities with and without COD services.

Leadership and Licensure for Drug Treatment and the Implementation of Co-Occurring Disorder Treatment in Community Mental Health Centers

Using a random sample of 48 outpatient mental health programs in low-income and racial and ethnic minority communities, this study examined directorial leadership, drug treatment licensure, and implementation of evidence-based protocols and practices to address co-occurring mental health and substance abuse disorders (COD). Understanding of findings was enhanced with focus groups at six clinics. Most programs (81 %) offered COD treatment. Directorial leadership was positively associated with COD treatment (β = 0.253, p = 0.047, 95 % CI 0.003, 0.502) and COD supervision and training (β = 0.358, p = 0.002, 95 % CI 0.142, 0.575). Licensure was negatively associated with COD treatment (β = -0.235, p = 0.041, 95 % CI -0.460, -0.010) and COD supervision and training (β = -0.195, p = 0.049, 95 % CI -0.389, -0.001). Although lack of financial integration may limit the effect of licensing on COD treatment implementation, the response of leaders to regulation, funding, and human resources issues may encourage COD treatment practices. Implications for leadership interventions and policy are discussed in the context of health care reform.

Implementation of integrated therapies for comorbid post-traumatic stress disorder and substance use disorders in community substance abuse treatment programs

ISSUES

The high prevalence of trauma and post-traumatic stress disorder (PTSD) in individuals with substance use disorders (SUDs) presents a number of treatment challenges for community treatment providers and programs in the USA. Although several evidence-based, integrated therapies for the treatment of comorbid PTSD/SUD have been developed, rates of utilisation of such practices remain low in community treatment programs.

APPROACH

The goal of this article was to review the extant literature on common barriers that prevent adoption and implementation of integrated treatments for PTSD/SUD among substance abuse community treatment programs.

KEY FINDINGS

Organisational, provider-level and patient-level factors that drive practice decisions were discussed, including organisational philosophy of care policies, funding and resources, as well as provider and patient knowledge and attitudes related to implementation of new integrated treatments for comorbid PTSD and SUD.

IMPLICATIONS AND CONCLUSIONS

Understanding and addressing these community treatment challenges may facilitate use of evidence-based integrated treatments for comorbid PTSD and SUD.

Barriers to serving clients with co-occurring disorders in a transformed mental health system

OBJECTIVE

The publication of the President's New Freedom Commission Report in 2003 led to hope and anticipation that system transformation would address barriers that have impeded the delivery of integrated services for clients with co-occurring mental health and substance use disorders. Have problems been resolved? This study analyzed providers' perspectives on serving clients with co-occurring disorders in a large mental health system that has undergone transformation.

METHODS

Six focus groups were conducted with providers at specialty mental health treatment organizations that received funding to transform services. Using content analysis, the authors identified major themes of the focus group discussions.

RESULTS

Participants reported several barriers within the mental health system and challenges associated with collaborating with specialty substance abuse treatment providers that impede the delivery of integrated care.

CONCLUSIONS

In spite of efforts to improve co-occurring disorder service delivery in a transformed mental health system, barriers that have historically impeded integrated treatment persist.

Comorbid depression and substance abuse among safety-net clients in Los Angeles: a community participatory study

OBJECTIVE

Depression and substance abuse are common among low-income adults from racial-ethnic minority groups who receive services in safety-net settings, although little is known about how clients differ by service setting. This study examined characteristics and service use among depressed, low-income persons from minority groups in underresourced communities who did and did not have a substance abuse history.

METHODS

The study used cross-sectional baseline client data (N=957) from Community Partners in Care, an initiative to improve depression services in Los Angeles County. Clients with probable depression (eight-item Patient Health Questionnaire) from substance abuse programs were compared with depressed clients with and without a history of substance abuse from primary care, mental health, and social and community programs. Sociodemographic, health status, and services utilization variables were examined.

RESULTS

Of the 957 depressed clients, 217 (23%) were from substance abuse programs; 269 (28%) clients from other sectors had a substance abuse history, and 471 (49%) did not. Most clients from substance abuse programs or with a substance abuse history were unemployed and impoverished, lacked health insurance, and had high rates of arrests and homelessness. They were also more likely than clients without a substance abuse history to have depression or anxiety disorders, psychosis, and mania and to use emergency rooms.

CONCLUSIONS

Clients with depression and a substance abuse history had significant psychosocial stressors and high rates of service use, which suggests that communitywide approaches may be needed to address both depression and substance abuse in this safety-net population.

Treatment seeking and barriers to treatment for alcohol use in persons with alcohol use disorders and comorbid mood or anxiety disorders

PURPOSE

This study compared the prevalence and patterns of treatment seeking and barriers to alcohol treatment among individuals with alcohol use disorders (AUD) with and without comorbid mood or anxiety disorders.

METHODS

We used data from the national epidemiologic survey on alcohol and related conditions to examine alcohol treatment seeking, treatment settings and providers, perceived unmet need for treatment and barriers to such treatment. Our sample consisted of 5,003 individuals with AUD with a comorbid mood or anxiety disorder and 6,734 individuals with AUD but without mood or anxiety disorder comorbidity.

RESULTS

The group with mood or anxiety disorder comorbidity was more likely to seek alcohol treatment than the group without such comorbidity (18 vs. 12 %, p < 0.001). The comorbid group was also more likely to perceive an unmet need for such treatment (8 vs. 3 %, p < 0.001) and to report a larger number of barriers (2.81 vs. 2.20, p = 0.031). Individuals with AUD with comorbid mood or anxiety disorders were more likely than those without to report financial barriers to alcohol treatment (19 vs. 10 %, p = 0.032).

CONCLUSIONS

Individuals with AUD and comorbid mood or anxiety disorders would likely benefit from the expansion of financial access to alcohol treatments and integration of services envisioned under the Affordable Care Act.

Do improvements in substance use and mental health symptoms during treatment translate to long-term outcomes in the opposite domain?

Providers who treat adolescents with co-occurring substance use and mental health issues may prioritize treatment of one set of symptoms believing that improvements in one domain will result in improvements of the other. However, limited empirical data for adolescents provide evidence of such "spillover effects." Using data from 2900 youth in an outpatient treatment, we examined whether during-treatment changes in substance use or mental health symptoms predicted 12-month outcomes in the analogous and opposite domains. There was very little evidence of spillover effects, only that youth with no internal distress at 0 and 3 months reported lower levels of substance use problems at 12-months relative to youth with internal distress that stayed the same from 0 to 3 months. These findings suggest that providers treat both sets of substance use and mental health symptoms in an integrated manner given that these symptoms commonly co-occur among youth with either set.

Treatment outcome in substance use disorder patients with and without comorbid posttraumatic stress disorder: A systematic review

We investigated the role of comorbid posttraumatic stress disorder (CO-PTSD) in substance use disorder (DSM-IV/ICD-10 substance abuse or dependence, SUD) treatment. We conducted a systematic review of treatment outcome studies in SUD patients with and without CO-PTSD from 2000 to 2011. The N = 22 studies found differed clearly with regard to methodology and the sufficiency of provided study information, limiting their comparability. Remarkably, no consistent indication of a negative effect of CO-PTSD on the reported SUD treatment outcome was found. In addition to CO-PTSD, we point out possible further effect modifiers which need to be better understood. Finally, we emphasize the requirements for future research such as methodological standardization and a focus on long-term studies.

Treatment for illegal drug use disorders: the role of comorbid mood and anxiety disorders

BACKGROUND

Our aim was to examine whether comorbid mood and anxiety disorders influence patterns of treatment or the perceived unmet need for treatment among those not receiving treatment for illegal drug use disorders.

METHODS

Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, 2001-2002 and 2004-2005, n = 34,653). Lifetime DSM-IV illegal drug use disorder (abuse and dependence), as well as comorbid mood (major depression, dysthymia, manic disorder, hypomanic disorder) and anxiety disorders (panic disorder, agoraphobia, social phobia, specific phobia, generalized anxiety) were ascertained by a standardized psychiatric interview. Treatment for illegal drug use disorders and perceived unmet need for treatment were assessed among individuals with illegal drug use disorder. Odds of treatment and odds of perceived unmet need for treatment were assessed using logistic regression, adjusting for socio-demographic characteristics, treatment for mood and anxiety disorders, and comorbid alcohol use disorder.

RESULTS

Out of 34,653 participants, 1114 (3.2%) had a diagnosis of lifetime illegal drug use disorder: 21.2% had a comorbid mood disorder only, 11.8% a comorbid anxiety disorder only, and 45.9% comorbid mood and anxiety disorders. Comorbid mood and anxiety disorders were not related to treatment for illegal drug use disorders but were associated with an elevated likelihood of unmet need for treatment: compared to participants with no comorbidities, multivariate ORs were 2.21 (95% CI: 1.23- 4.10) for mood disorder only, 2.38 (95% CI: 1.27-4.45) for anxiety disorder only, and 2.90 (95% CI: 1.71-4.94) for both mood and anxiety disorders.

CONCLUSIONS

Individuals with an illegal drug use disorder and comorbid mood or anxiety disorders are disproportionately likely to report unmet need for treatment. Integrated mental health and substance use programs could prove effective in addressing their treatment needs.

Integrating mental health and addictions services to improve client outcomes

Substance use disorders are highly prevalent among adults with mental health disorders. In many health service delivery areas, mental health and addictions services are delivered separately. However, current best practices indicate that integration of mental health and addictions services can lead to better outcomes for clients with co-occurring disorders, including fewer hospitalizations. Service integration in the community can occur in many ways, including full or partial program integration. While the delivery of mental health and addictions services must be responsive to the needs of the local community, fully integrated programs have the strongest evidence base for positive client outcomes.

Dual Diagnosis Capability in Mental Health and Substance Use Disorder Treatment Programs

OBJECTIVE

Improved understanding of the relative strengths and weaknesses of treatment organizations' dual diagnosis capability is critical in order to guide efforts to improve services. This study assesses programs' capacity to meet the needs of clients with dual diagnosis, identifies areas where they are well equipped to serve these clients, and determines where programmatic improvement is needed. The study also undertakes an initial exploration of the potential impact that funding sources have on dual diagnosis capability.

METHODS

We administered Dual Diagnosis Capability in Addiction Treatment (DDCAT) and Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) assessments at 30 treatment programs in two California counties. Seven of the programs received funding to provide both mental health and substance use disorder services, 13 received funding to provide mental health services, and 10 received funding to provide substance use disorder services.

RESULTS

The mean DDCAT/DDCMHT score of programs in the sample was 2.83, and just over 43% of the sample met or exceeded DDCAT/DDCMHT criteria for dual diagnosis capability. Programs scored highest and had the highest rates of dual diagnosis capability in domains related to assessment, training, and staffing, whereas scores were weakest and rates of dual diagnosis capability were lowest in the program structure, treatment, and continuity of care domains. Programs that received funding to provide both mental health and substance use disorder services consistently scored higher than the other programs in the sample, and mental health programs scored higher than substance use disorder treatment programs both on the overall assessments and in most domains.

CONCLUSIONS

Findings suggest that programs in the sample are functioning at a nearly dual diagnosis capable level. However, structural barriers continue to limit providers' capacity to serve clients with co-occurring mental health and substance use disorders, and many organizations have not yet translated their potential to deliver dual diagnosis capable services into practice. By enhancing their program structure, treatment services, and continuity of care services, these treatment organizations should be able to deliver fully dual diagnosis capable services. Observed differences in dual diagnosis capability based on funding source indicate a need for further research to better understand the impact that funding streams have on dual diagnosis capability.

Improving the capability to provide integrated mental health and substance abuse services in a state system of outpatient care

The paper reports on the capability of New York State (NYS) outpatient programs to provide integrated services for co-occurring disorders (COD). Assessments of 447 outpatient clinics, using two dual diagnosis capability indices (one used in addiction settings, the other in mental health settings), produced an overall score of 2.70, interpreted to position NYS clinics closer to "capable" (3.0 = Dual Diagnosis Capable) than to "basic" (1.0 = Alcohol [Mental Health] Only Services). "Assessment" and "Staffing" received the highest scores; i.e., clients with COD were usually identified, and staff (with some additional training and supervision) could treat both disorders effectively. While programs were generally prepared for clients with COD (e.g., welcoming such clients into the program, employing staff with competencies in both disorders, and having established routine screening and assessment to identify COD), results showed that the actual delivery of effective treatment was less satisfactory. The project demonstrated that COD capability can be assessed system-wide, using direct observation.

Impact of Dual Disorders, Trauma, and Social Support on Quality of Life Among Women in Treatment for Substance Dependence

OBJECTIVE

Women with dual disorders report lower levels of social support than women with substance dependence alone, and lower levels of social support have been associated with lower quality of life among individuals with substance use disorders. However, little is known about the impact of trauma symptoms and violence exposure on quality of life for women with dual disorders. The purpose of this study was to examine the impact of dual disorders, trauma, and social support related to recovery on various domains of quality of life among women in substance abuse treatment.

METHODS

This study utilized multiple standardized measures and hierarchical ordinary least squares regression to examine quality of life, trauma, and social support in women with dual disorders. Four domains of quality of life were measured (Physical, Psychological, Social, and Environmental Domains). Participants (N=369) were recruited from three inner city women only addiction treatment programs. IRB approval was obtained prior to sample recruitment.

RESULTS

Presence of a dual disorder was significantly associated with lower quality of life in the Physical and Psychological domains. However, this difference was no longer significant when trauma symptoms were added to the model. Trauma symptoms and Support for Recovery significantly predicted quality of life across all four domains and Friends Support for Abstinence across three domains.

CONCLUSIONS

Findings suggest that the presence of a dual disorder in women may indicate a history of trauma. They also support the importance of both friend's support for abstinence and recovery support as predictors of quality of life in women with dual disorders. Interventions that focus on social support and quality of life in treatment with women with substance use disorders may potentially enhance treatment outcomes.

Treating depression and substance use: a randomized controlled trial

Few integrated substance use and depression treatments have been developed for delivery in outpatient substance abuse treatment settings. To meet the call for more "transportable" interventions, we conducted a pilot study to test a group cognitive-behavioral therapy (CBT) for depression and substance use that was designed for delivery by outpatient substance abuse treatment counselors. Seventy-three outpatient clients were randomized to usual care enhanced with group CBT or usual care alone and assessed at three time points (baseline and 3 and 6 months postbaseline). Our results demonstrated that the treatment was acceptable and feasible for delivery by substance abuse treatment staff despite challenges with recruiting clients. Both depressive symptoms and substance use were reduced by the intervention but were not significantly different from the control group. These results suggest that further research is warranted to enhance the effectiveness of treatment for co-occurring disorders in these settings.

Psychiatric co-morbidity and substance use disorders: treatment in parallel systems or in one integrated system?

Psychiatric co-morbidity among substance users refers to the simultaneous presence of at least another psychiatric disorder in a person diagnosed with a substance use disorder. Co-morbid patients represent a substantial number of people in treatment and present greater disorder severity from both the clinical and social perspectives than those people diagnosed with only one type of disorder. We present an overview of the current state of the art concerning the choice of site of treatment, the kind of intervention, the length of such treatment, and future goals, aiming to establish a more effective intervention, and finally so as to further improve clinical outcomes.

Comorbilidad entre el distrés psicologico y el abuso de drogas en pacientes en centros de tratamiento, en la ciudad de Leon - Nicaragua: implicaciones para políticas y programas

La presencia de trastornos de salud mental y consumo de drogas ambos se conocen como comorbilidad. Este estudio tuvo como objetivo determinar la prevalencia de la comorbilidad entre el distrés psicológico y el abuso/dependencia de drogas en pacientes de Centros de tratamiento en León, Nicaragua. La mayoría de participantes del estudio eran hombres y 68.5% eran menor de 40 años, solteros (58.5%), con bajo nivel de educación, trabajo de forma autónoma (51.2%), y 41.5% viven con su madre biológica. El 65.9% de los pacientes llegaron al centro por cuenta propia. Las drogas más consumida fueron alcohol, marihuana y crack (59.7%, 58.2% y 53.7%). Los trastornos concurrente más comunes fueron, ansiedad (29.3%), depresión (24.1%), esquizofrenia 9.8% y trastorno bipolar 2,4% y según la escala de Kessler K-10, el 56% de los participantes fueron diagnosticados con distrés psicológico severo. Según la escala de APGAR-familiar, el 26% percibieron familias como disfuncionales.

An effectiveness trial of group cognitive behavioral therapy for patients with persistent depressive symptoms in substance abuse treatment

CONTEXT

Although depression frequently co-occurs with substance abuse, few individuals entering substance abuse treatment have access to effective depression treatment.

OBJECTIVE

The Building Recovery by Improving Goals, Habits, and Thoughts (BRIGHT) study is a community-based effectiveness trial that compared residential substance abuse treatment with residential treatment plus group cognitive behavioral therapy for depression delivered by substance abuse treatment counselors. We hypothesized that intervention clients would have improved depression and substance use outcomes compared with those of clients receiving usual care.

DESIGN

A nonrandomized controlled trial using a quasi-experimental intent-to-treat design in which 4 sites were assigned to alternate between the intervention and usual care conditions every 4 months for 2½ years.

SETTING

Four treatment programs in Los Angeles County.

PARTICIPANTS

We screened 1262 clients for persistent depressive symptoms (Beck Depression Inventory-II score >17). We assigned 299 clients to receive either usual care (n = 159) or usual care plus the intervention (n = 140). Follow-up rates at 3 and 6 months after the baseline interview were 88.1% and 86.2%, respectively, for usual care and 85.7% and 85.0%, respectively, for the intervention group.

INTERVENTION

Sixteen 2-hour group sessions of cognitive behavioral therapy for depression.

MAIN OUTCOME MEASURES

Change in depression symptoms, mental health functioning, and days of alcohol and problem substance use.

RESULTS

Intervention clients reported significantly fewer depressive symptoms (P < .001 at 3 and 6 months) and had improved mental health functioning (P < .001 at 3 months and P < .01 at 6 months). At 6 months, intervention clients reported fewer drinking days (P < .05) and fewer days of problem substance use (P < .05) on days available.

CONCLUSIONS

Providing group cognitive behavioral therapy for depression to clients with persistent depressive symptoms receiving residential substance abuse treatment is associated with improved depression and substance use outcomes. These results provide support for a new model of integrated care.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01191788.

Improving drug abuse treatment delivery through adoption of harmonized electronic health record systems

A great divide currently exists between mainstream health care and specialty substance use disorders (SUD) treatment, concerning the coordination of care and sharing of medical information. Improving the coordination of SUD treatment with other disciplines of medicine will benefit SUD patients. The development and use of harmonized electronic health record systems (EHR) containing standardized person-level information will enable improved coordination of healthcare services. We attempt here to illuminate the urgent public health need to develop and implement at the national level harmonized EHR including data fields containing standardized vocabulary/terminologies relevant to SUD treatment. The many advantages and barriers to harmonized EHR implementation in SUD treatment service groups, and pathways to their successful implementation, are also discussed. As the US Federal Government incentivizes Medicare and Medicaid Service providers nationwide for “meaningful use” of health information technology (HIT) systems, relevant stakeholders may face relatively large and time-consuming processes to conform their local practices to meet the federal government’s “meaningful use” criteria unless they proactively implement data standards and elements consistent with those criteria. Incorporating consensus-based common data elements and standards relevant to SUD screening, diagnosis, and treatment into the federal government’s “meaningful use” criteria is an essential first step to develop necessary infrastructure for effective coordination of HIT systems among SUD treatment and other healthcare service providers to promote collaborative-care implementation of cost-effective, evidence-based treatments and to support program evaluations.

Integrated Substance Abuse and Child Welfare Services for Women: A Progress Review

A review of empirical literature reveals improvements in service utilization and outcomes for women when substance abuse and child welfare services are integrated. The increased use of substances by women involved in the child welfare system has resulted in a call for integrated, coordinated, evidence-based practices. Since the late 1990s, specific system- and service-level strategies have been developed to coordinate and integrate the provision of substance abuse and child welfare services such that women are remaining in treatment longer and are more likely to reduce substance use and be reunited with their children. The strategies reviewed provide useful guidelines for developing components of effective, evidence-based programs for substance-involved women in the child welfare system.

Supporting good practice in the provision of services to people with comorbid mental health and alcohol and other drug problems in Australia: describing key elements of good service models

Background

The co-occurrence of mental illness and substance use problems (referred to as "comorbidity" in this paper) is common, and is often reported by service providers as the expectation rather than the exception. Despite this, many different treatment service models are being used in the alcohol and other drugs (AOD) and mental health (MH) sectors to treat this complex client group. While there is abundant literature in the area of comorbidity treatment, no agreed overarching framework to describe the range of service delivery models is apparent internationally or at the national level. The aims of the current research were to identify and describe elements of good practice in current service models of treatment of comorbidity in Australia. The focus of the research was on models of service delivery. The research did not aim to measure the client outcomes achieved by individual treatment services, but sought to identify elements of good practice in services.

Methods

Australian treatment services were identified to take part in the study through a process of expert consultation. The intent was to look for similarities in the delivery models being implemented across a diverse set of services that were perceived to be providing good quality treatment for people with comorbidity problems.

Results

A survey was designed based on a concept map of service delivery devised from a literature review. Seventeen Australian treatment services participated in the survey, which explored the context in which services operate, inputs such as organisational philosophy and service structure, policies and procedures that guide the way in which treatment is delivered by the service, practices that reflect the way treatment is provided to clients, and client impacts.

Conclusions

The treatment of people with comorbidity of mental health and substance use disorders presents complex problems that require strong but flexible service models. While the treatment services included in this study reflected the diversity of settings and approaches described in the literature, the research found that they shared a range of common characteristics. These referred to: service linkages; workforce; policies, procedures and practices; and treatment.

Barriers to comorbidity service delivery: the complexities of dual diagnosis and the need to agree on terminology and conceptual frameworks

This paper draws from a literature review commissioned as part of a larger project evaluating comorbidity treatment service models, which was funded by the Australian Government Department of Health and Ageing as part of the National Comorbidity Initiative. The co-occurrence of mental health and substance use disorders (comorbidity) is a common and complex problem. This paper outlines conceptual and practical complexities and barriers associated with comorbidity treatment service delivery, particularly around the variable nature of comorbidity, and the impacts of the separation of the mental health (MH) and alcohol and other drug (AOD) sectors with their differing institutional cultures, aetiological concepts, philosophical underpinnings, educational requirements, administrative arrangements, and screening and treatment approaches. Issues pertaining to the lack of consistent definitions and conceptual frameworks for comorbidity are discussed, particularly in relation to the reported lack of communication, collaboration, and linkages between the sectors. It is suggested that the adoption of consistent terminology and conceptual frameworks may provide a valuable step towards consistency in service provision and research and could lead to improved capacity to address the many issues relating to comorbidity service provision and treatment efficacy.

Access to treatment for adolescents with substance use and co-occurring disorders: challenges and opportunities

OBJECTIVE

To review the research on economic and systemic barriers faced by adolescents needing treatment for alcohol and drug problems, particularly those with co-occurring conditions.

METHOD

We reviewed the literature on adolescent access to alcohol and drug services, including early intervention, and integrated and specialty mental health treatment for those with co-occurring disorders, examining the role of health care systems, public policy (health reform), treatment financing and reimbursement systems (public and private), implementation of evidence-based practices, confidentiality practices, and treatment costs and cost/benefits.

RESULTS

Barriers to treatment, particularly integrated treatment, are largely rooted in our organizationally fragmented health care system, which encompasses public and private, carved-out and integrated systems, and different funding mechanisms (Medicaid versus block grants versus private insurance that include "high deductible" plans and other cost controls.) In both systems, carved-out programs de-link services from other mental health and general health care. Barriers are also rooted in disciplinary differences and weak clinical linkages between psychiatry, primary care and substance use, and in confidentiality policies that inhibit communication and coordination, while protecting patient privacy.

CONCLUSION

In this era of health care reform, we have the opportunity to increase access for adolescents and develop new models of integrated services for those with co-occurring conditions. We discuss opportunities for improving treatment access and implementation of evidence-based practices, examine implications of health reform and parity legislation for psychiatric and substance use treatment, and comment on key unanswered questions and future research opportunities.

Implementation of evidence-based practices for treatment of alcohol and drug disorders: the role of the state authority

The current climate of increasing performance expectations and diminishing resources, along with innovations in evidence-based practices (EBPs), creates new dilemmas for substance abuse treatment providers, policymakers, funders, and the service delivery system. This paper describes findings from baseline interviews with representatives from 49 state substance abuse authorities (SSAs). Interviews assessed efforts aimed at facilitating EBP adoption in each state and the District of Columbia. Results suggested that SSAs are concentrating more effort on EBP implementation strategies such as education, training, and infrastructure development, and less effort on financial mechanisms, regulations, and accreditation. The majority of SSAs use EBPs as a criterion in their contracts with providers, and just over half reported that EBP use is tied to state funding. To date, Oregon remains the only state with legislation that mandates treatment expenditures for EBPs; North Carolina follows suit with legislation that requires EBP promotion within current resources.

Disparities in use of mental health and substance abuse services by persons with co-occurring disorders

OBJECTIVES

Individuals with co-occurring mental and substance use disorders require psychiatric and substance abuse treatments. A critical question is whether these individuals are treated for both disorders.

METHODS

This study prospectively examined 24-month service utilization patterns of 224 persons with co-occurring disorders who were recruited from crisis residential programs in the mental health treatment system (N=106) and from crisis residential detoxification programs in the substance abuse treatment system (N=118) in San Francisco. Utilization data were collected from the billing-information systems of both treatment systems. Demographic and clinical data were obtained in interviews with participants. Data were analyzed for group differences with chi square tests and logistic, linear, and zero-truncated negative binomial regression.

RESULTS

After the analyses controlled for demographic and clinical factors, participants recruited from the substance abuse treatment system were less likely than those from the mental health treatment system to obtain any mental health services, mental health day treatment, transitional residential care, case management, and other outpatient services (p<.001 for all comparisons). They were more likely to obtain crisis residential detoxification (p=.003), had more days of drug residential treatment (p=.028), but received fewer hours of outpatient services (p=.012).

CONCLUSIONS

There were disparities in patterns of service utilization, although there were no significant diagnostic differences between the two groups. These findings should be valuable in considering systems development and modification. Furthermore, they can contribute to research about factors that underlie results. Study replications should be conducted to assess the robustness of these findings in other locales.

Psychosocial treatments for people with co-occurring severe mental illnesses and substance use disorders (dual diagnosis): a review of empirical evidence

Considerable research documents the health consequences of psychosis and co-occurring substance use disorders. Results of randomized controlled trials assessing the effectiveness of psychosocial interventions for persons with dual diagnoses are equivocal but encouraging. Many studies are hampered by small, heterogeneous samples, high attrition rates, short follow-up periods, and unclear description of treatment components. The treatments available for this group of patients (which can be tailored to individual needs) include motivational interviewing, cognitive-behavioral therapy, contingency management, relapse prevention, case management, and skills training. Regardless of whether services follow integrated or parallel models, they should be well coordinated, take a team approach, be multidisciplinary, have specialist-trained personnel (including 24-hour access), include a range of program types, and provide for long-term follow-up. Interventions for substance reduction may need to be further developed and adapted for people with serious mental illnesses. Further quality trials in this area will contribute to the growing body of data of effective interventions.