Case management in aftercare of involuntarily committed patients with substance abuse. A randomized trial

Mental distress following inpatient substance use treatment, modified by substance use; comparing voluntary and compulsory admissions

Background

Treatment services to patients with substance use disorders (SUDs), including those mandated to treatment, needs to be evaluated and evidence based. The Norwegian Municipal Health Care Act (NMHCA) calls for compulsory treatment for persons with “severe and life-threatening substance use disorder” if these individuals are not otherwise willing to be voluntarily treated and consequently risk their lives over drug use. Mental distress is known to be high among SUD patients admitted to inpatient treatment. The purpose of this study is to describe changes in mental distress from admission to a 6-month follow-up in patients with SUDs, which underwent either voluntary or compulsory treatment.

Method

This prospective study followed 202 hospitalized patients with SUDs who were admitted voluntarily (VA; n = 137) or compulsorily (CA; n = 65). Levels of mental distress were assessed with SCL-90-R. Of 123 patients followed-up at 6 months, 97 (62 VA and 35 CA) had rated their mental distress at admission, discharge and follow-up. Sociodemographics and substance use severity were recorded with the use of The European Addiction Severity Index (EuropASI). We performed a regression analysis to examine factors associated with changes in psychiatric distress at the 6-month follow-up.

Results

The VA group exhibited higher mental distress than the CA group at admission, but both groups improved significantly during treatment. At the 6-month follow-up, the VA group continued to show reduced distress, but the CA group showed increases in mental distress to the levels observed before treatment. The deterioration appeared to be associated with higher scores that reflected paranoid ideas, somatization, obsessive-compulsive symptoms, interpersonal sensitivity, and depression. Active substance use during follow-up was significantly associated with increased mental distress.

Conclusion

In-patient treatment reduces mental distress for both CA and VA patients. The time after discharge seems critical especially for CA patients regarding active substance use and severe mental distress. A greater focus on continuing care initiatives to assist the CA patients after discharge is needed to maintain the reduction in mental distress during treatment. Continuing-care initiatives after discharge should be intensified to assist patients in maintaining the reduced mental distress achieved with treatment.

Trial registration

ClinicalTrials.gov NCT 00970372 December 02, 2016.

Effect of Case Management Interventions for Patients with Substance Use Disorders: A Systematic Review

BACKGROUND

Substance use disorder (SUD) is an important health problem that requires a complex range of care because of the chronic nature of the disorder and the multiple psychosocial problems involved. Current outpatient programs often have difficulties in delivering and coordinating ongoing care and access to different health-care providers. Various case management (CM) models have been developed, first for patients in other psychiatric domains and then for patients with SUD, in order to improve treatment outcomes.

AIM

This paper aims to assess the effectiveness of CM for patients with SUD.

METHODS

We performed a systematic review of CM interventions for patients with SUD by analyzing randomized controlled studies published on the subject between 1996 and 2016 found on the electronic database PubMed.

RESULTS AND CONCLUSION

Fourteen studies were included in the analysis. Differences between studies in outcome measures, populations included, and intervention characteristics made it difficult to compare results. Most of these studies reported improvement in some of the chosen outcomes. Treatment adherence mostly improved, but substance use was reported to decrease in only a third of the studies. Overall functioning improved in about half of the studies. The heterogeneity of the results might be linked to these differences between studies. Further research is needed in the field.

Community-based case management effectiveness in populations that abuse substances

BACKGROUND

The number of persons who are substance abusing has been increasing globally. A majority of them remain in their communities, untreated. Empirical studies have shown some positive impacts of case management on substance abuse. However, studies that systematically synthesize the effectiveness of community-based case management with populations that abuse substances are limited.

AIM

To review evidence of the impact of case management in improving treatment of substance abuse among adults in community settings.

METHODS

The Cochrane processes guided this systematic review. PubMed, CINAHL, PsycINFO, Ovid and the Web of Science were searched to retrieve primary studies published from 2000 to 2013. All randomized controlled trials were considered for review. The methodological quality of the studies was assessed.

RESULTS

The initial unfiltered search identified 506 references. A total of seven randomized controlled trials were selected for review. Findings show that, compared with clinical case management and usual care, community-based case management services significantly improved clients' ability to abstain from drug use, reduced social problems, supported unmet service needs and improved satisfaction. Studies also showed reduced use of healthcare services, but results were mixed.

CONCLUSIONS

There is an evidence base for practicing case management among adults who are substance abusing. In general, studies concluded that case management is an active and assertive method of care coordination for formal substance abuse treatment. Further research is needed to assess case management's cost-effectiveness and the impact of dosage on client outcomes.

IMPLICATIONS FOR NURSING POLICY

Because of the complexity of population health management across settings and over long time frames, evidence-based strategies are required to achieve health improvements. Because it provides continuous and timely care, healthcare leaders and policymakers should consider community-based case management as an important strategy for coordinating the care in populations that are substance abusing.