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Treatment development for psychosis and co-occurring substance misuse: A descriptive review
Journal of Mental Health
Abstract
Background: It is common for people with psychosis to have co-occurring drug or alcohol problems. This combination of problems is associated with poor outcomes for clients and presents many challenges for services. Aims: This review aims to discuss contextual issues underlying treatment difficulties, to briefly review the treatment literature to date and to describe a randomized controlled treatment trial (RCT) currently being conducted in the UK. Methods: A descriptive review. Results: Consensus agreement emphasizes the need for integrated treatment strategies that match the client's current level of motivation. There have been encouraging results from recent studies evaluating motivational strategies, either alone or in combination with CBT. Whilst for many clients with established illness and substance using histories, brief therapy does not seem to be adequate, longer term interventions show promise. A current RCT evaluating motivational interviewing with CBT is described. Conclusions: The evidence base for treatment recommendations is still quite small. The MIDAS trial will hopefully make a significant contribution to the literature on treatment options for this high risk group. Declaration of interest: The MIDAS trial is funded by the Medical Research Council and the Department of Health.
... Interpersonal conflicts are often associated with dual diagnoses. Friends and families may be frustrated with ongoing substance misuse that the users themselves may not see as problematic [13][14][15][16]. ...
... Those in contact with dual-diagnosis persons may also experience distress, tension, and conflict within these relationships. Interpersonal conflicts are often associated with dual diagnoses [3,15,17,18]. ...
... Many studies of cognitive behavioral therapy (CBT) and motivational interviewing (MI) with contingency management or standard care, comprising 6 months of supportive group therapy, revealed positive outcomes [15]. ...
... Clinicians should address these motives, thus reducing the need for patients to use cannabis, and therefore reducing the risk of relapse. The application of such interventions to individuals with SMH problems may require adaption to take account of any cognitive or affective difficulties they may experience (Barrowclough et al., 2006). ...
... suggest that future research aims to control for the effect of the motivational intervention by comparing one intervention consisting of an integrated psychosocial intervention which includes motivational interviewing with the same integrated intervention which does not include motivational interviewing, thereby controlling for the presence of the motivational intervention. Motivational interviewing is considered as most helpful in the early stages of working with dually diagnosed clients(Barrowclough, Haddock, Fitzsimmons & Johnson, 2006), therefore in such a comparative study the motivational intervention should be administered first. Booster sessions should be regularly incorporated and to measure whether the effect is maintained.I suggest that future designs recruit a sufficiently large sample of participants with a variety of severe mental health diagnoses so that sub-analyses by diagnosis, and by baseline levels of motivation and substances used, can be performed. ...
... Mcintosh & Lawrie, 2005;Arseneault, Cannon, Witton & Murray, 2004;Degenhardt, Hall & Lynskey, 2003;Linszen, Dingemans & Lenior, 1994); exacerbate cognitive impairment and medication side effects (for example, D'Sousa, Abi-Saab, Madonick, Forselius-Bielen, Doesrch, Braley, Gueorguieva,Cooper & Krystal, 2005) and is associated with increased relapses and hospitalisations(Barrowclough, Haddock, Fitzsimmons & Johnson, 2006).Dixon, Haas, Weiden, Sweeney and Frances, (1990) defined the clinical problem as continued cannabis use frequently exacerbates severe mental health problems, yet many individuals with a SMH problem also derive beneficial effects from cannabis and continue to use it. Epidemiological studies have consistently reported a higher prevalence of ...
... The terms dual diagnosis and co-occurring disorders are used interchangeably. The literature informing this article was identified through (1) electronic searches of CINAHL, MEDLINE, PsycINFO, and PubMed of English articles from 1976 to present using MeSH terms and various combinations of the following keywords: dual diagnosis, comorbidity, schizophrenia, bipolar, depression, severe mental illness, randomized control trial, drug or substance use, alcoholism, motivational, CBT, program, and services; (2) literature acquired during a Cochrane review on psychosocial interventions for people with both severe mental illnesses and substance misuse; 4,5 and (3) examination of reference lists, including several recent reviews on this topic, [6][7][8][9][10][11][12][13] to identify any additional relevant articles. Key themes were distilled from the retrieved articles above, and an inclusive approach was used to review empirical treatment studies involving patients with serious mental illnesses and substance misuse. ...
... These consequences include increased rates of treatment noncompliance, relapse, distorted perception and cognition, suicidal ideation, social exclusion, homelessness, aggression, injury, HIV, hepatitis, and cardiovascular, liver, and gastrointestinal disease. 6,[21][22][23][24][25][26][27][28][29][30][31] A common factor contributing to the refusal or avoidance of treatment by dual-diagnosis clients is their low motivation to reduce substance use. 6 As a result, their mental health is especially vulnerable, for their substance disorder may destabilize their illness, undermine treatment adherence, and contribute to psychosocial instability. ...
... 6,[21][22][23][24][25][26][27][28][29][30][31] A common factor contributing to the refusal or avoidance of treatment by dual-diagnosis clients is their low motivation to reduce substance use. 6 As a result, their mental health is especially vulnerable, for their substance disorder may destabilize their illness, undermine treatment adherence, and contribute to psychosocial instability. 32 The mixture of psychosis, strong emotions, and the continuing resort to alcohol and other readily available substances will exacerbate social alienation and increase the potential for violent lashing out. ...
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.
... Once initiated, cravings are higher in individuals with SMD [10,[13][14][15]. Also, individuals with SMD may use cannabis as a coping mechanism to temper their symptoms [16][17][18][19], as well as to help them suppress negative emotions and stress [20,21]. Thus, in the absence of a better emotion regulation strategy, substance use can be used as an avoidance strategy since it could suppress distress and reduce the intensity of negative emotions [17,19,22]. ...
... Also, individuals with SMD may use cannabis as a coping mechanism to temper their symptoms [16][17][18][19], as well as to help them suppress negative emotions and stress [20,21]. Thus, in the absence of a better emotion regulation strategy, substance use can be used as an avoidance strategy since it could suppress distress and reduce the intensity of negative emotions [17,19,22]. Moreover, this population is more likely to endure negative consequences associated with cannabis use, including exacerbation of psychiatric symptoms, reduced adherence to treatment, and increased hospitalization rates [23][24][25][26][27][28][29]. ...
Background: The dual diagnosis of cannabis use disorder (CUD) and severe mental disorder (SMD) results in clinically complex individuals. Cannabis use is known to have negative consequences on psychiatric symptoms, medication compliance, and disease prognosis. Moreover, the effectiveness of currently available psychotherapeutic treatments is limited in this population. In this context, our research team developed avatar intervention, an approach using virtual reality as a therapeutic tool to treat CUD in individuals with SMD. Objective: This pilot clinical trial aimed to evaluate, until the 1-year follow-up, the efficacy of avatar intervention for CUD among 32 participants with a dual diagnosis of SMD and CUD. Methods: Over the course of the 8 intervention sessions, participants were given the opportunity to enter a dialogue in virtual reality with an avatar representing a person with a significant role in their consumption, who was animated in real time by a therapist. The primary outcomes were the quantity of cannabis consumed and the frequency of use. Secondary outcomes included severity of problematic cannabis use, motivation for change, protective strategies for cannabis use, consequences of cannabis use, psychiatric symptoms, and quality of life. Changes in reported outcomes during the assessment periods before the intervention; postintervention; and 3, 6, and 12 months after the end of the intervention were assessed using a linear mixed-effects model. Results: Significant reductions were observed in the quantity of cannabis consumed, and these were maintained until the 12-month follow-up visit (d=0.804; P<.001; confirmed by urine quantification). Frequency of cannabis use showed a small significant reduction at the 3-month follow-up (d=0.384; P=.03). Moreover, improvements were observed in the severity of CUD, cannabis-related negative consequences, the motivation to change cannabis use, and the strategies used to mitigate harms related to cannabis use. Finally, moderate benefits were observed for quality of life and psychiatric symptoms. Conclusions: Overall, this unique intervention shows promising results that seem to be maintained up to 12 months after the end of the intervention. With the aim of overcoming the methodological limitations of a pilot study, a single-blind randomized controlled trial is currently underway to compare the avatar intervention for CUD with a conventional addiction intervention.
... [1][2][3] Of all types of substances, alcohol and cannabis are the most commonly used, 1,2 with polydrug use being a common pattern of use. 4 Substance use disorder not only poses a clinical challenge in and of itself but also exacerbates the existing psychotic symptomatology. [5][6][7] Coexisting psychosis and substance use disorder are associated with a wide spectrum of problems, including severe mental distress, suicidal ideations, poor psychosocial functioning, low antipsychotic adherence, delayed treatment seeking, heightened risks of medical diseases, frequent hospitalizations, housing problems, violence, and victimization. ...
... In fact, psychosocial interventions in general (including MI) have small effects where psychiatric disorders and substance use disorder coexist (eg, Dumaine 72 : effect size = 0.22; Riper et al 73 : g's = 0.17 and 0.27). In line with previous suggestions, 4 polysubstance use is common in our samples (up to 58% of participants used more than 1 substance), which could further increase the difficulty in treating patients with coexisting psychosis and substance use disorder. ...
Objective: A wealth of evidence has supported the efficacy of motivational interviewing (MI) in reducing substance use as well as other addictive behaviors. In view of the common co-occurrence of substance use disorder among individuals with schizophrenia spectrum disorders, there has been increased attention to applying MI in psychological interventions for individuals with co-occurring psychosis and substance use disorder. This review aims to synthesize the evidence on the efficacy of MI interventions (either as a stand-alone intervention or in combination with other psychological interventions) in reducing substance use and psychotic symptoms.
Data Sources: MEDLINE, PsycINFO, EMBASE, CENTRAL, and CINAHL were searched using keywords related to "psychosis," "substance addiction," and "motivational interviewing" to identify studies published in English from 1984 to May 2021.
Study Selection: Of 1,134 articles identified in the literature, we selected 17 studies for review: 5 studies examined stand-alone MI ("MI-pure"), and 13 studies assessed MI as a major treatment component ("MI-mixed").
Data Extraction: Demographics of participants, intervention characteristics, and outcome data were extracted by the first author and checked by the second author. Random-effects models were used for substance use and psychotic symptom outcomes.
Results: MI-pure interventions did not significantly reduce severity of substance use (g = 0.06, P = .81) or psychotic symptoms (g's for 2 individual studies = 0.16, P = .54; and 0.01, P = .96). The effect of MI-mixed interventions on substance use decrease was statistically significant but small in size (g = 0.15, P = .048), whereas the effect on psychotic symptom improvement was not significant (g = 0.11, P = .22).
Conclusions: With the caveat that only a small number of comparisons were available for the review on MI-pure interventions, the efficacy of MI in treating co-occurring psychosis and substance use disorder was heterogeneous and modest.
... Barrowclough et al give 30 estimates of the ICC for a group therapy, ranging from 0 (95% CI 0-0.29) to a maximum of 0.257 (95% CI 0.02-0.67), with a mean of 0.044 and median of 0. 31 From the width of the confidence intervals, there is appreciable uncertainty regarding these estimates. An ICC of 0.05 approximates to a moderate Cohen effect size (0.5) and this is close to the mean of the estimates from Barrowclough et al. 31 The study is robust against larger values of the intracluster correlation for group treatment. ...
... with a mean of 0.044 and median of 0. 31 From the width of the confidence intervals, there is appreciable uncertainty regarding these estimates. An ICC of 0.05 approximates to a moderate Cohen effect size (0.5) and this is close to the mean of the estimates from Barrowclough et al. 31 The study is robust against larger values of the intracluster correlation for group treatment. For example, if the intracluster correlation coefficient is as large as 0.1, power will still be 86.7%. ...
Background
In the UK, postnatal depression is more common in British South Asian women than White Caucasion women. Cognitive–behavioural therapy (CBT) is recommended as a first-line treatment, but there is little evidence for the adaptation of CBT for postnatal depression to ensure its applicability to different ethnic groups.
Aims
To evaluate the clinical and cost-effectiveness of a CBT-based positive health programme group intervention in British South Asian women with postnatal depression.
Method
We have designed a multicentre, two-arm, partially nested, randomised controlled trial with 4- and 12-month follow-up, comparing a 12-session group CBT-based intervention (positive health programme) plus treatment as usual with treatment as usual alone, for British South Asian women with postnatal depression. Participants will be recruited from primary care and appropriate community venues in areas of high South Asian density across the UK. It has been estimated that randomising 720 participants (360 into each group) will be sufficient to detect a clinically important difference between a 55% recovery rate in the intervention group and a 40% recovery rate in the treatment-as-usual group. An economic analysis will estimate the cost-effectiveness of the positive health programme. A qualitative process evaluation will explore barriers and enablers to study participation and examine the acceptability and impact of the programme from the perspective of British South Asian women and other key stakeholders.
... [13][14][15][16][17][18][19][20] However, individuals with dual diagnoses continue to receive fragmented treatment, 21 often as a result of structural barriers including geographic distance, service time constraints and eligibility. [22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40] Psychosocial instability and heightened distress among this cohort also contribute to low treatment entry and resulting poor treatment outcomes. [23][24][25][26][27][28] Mental health interventions disseminated via, or accessed using, mobile technological devices or processes, also referred to as eHealth or mHealth, have the potential to circumvent some of these aforementioned barriers by providing an easily accessible and flexible treatment alternative. ...
... [22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40] Psychosocial instability and heightened distress among this cohort also contribute to low treatment entry and resulting poor treatment outcomes. [23][24][25][26][27][28] Mental health interventions disseminated via, or accessed using, mobile technological devices or processes, also referred to as eHealth or mHealth, have the potential to circumvent some of these aforementioned barriers by providing an easily accessible and flexible treatment alternative. 29, 30 Such interventions have been utilised on a global scale, 30,31 with controlled trials demonstrating comparable effects for email and chat-based therapies in addition to high levels of disclosure, closeness and consumer satisfaction, particularly among disparate populations. ...
Introduction: Mental health interventions disseminated via, or accessed using, digital technologies are an innovative new treatment modality for managing co-morbid depression and substance use disorder. The present systematic review assessed the current state of this literature.
Methods: A search of the Cochrane Library, Embase, Pubmed, PsycINFO and Scopus databases identified six eligible studies (Nparticipants=862), utilising quasi-experimental or randomised controlled designs. Reporting quality was evaluated and Hedges' g effect sizes (with 95% confidence intervals and p-values) were calculated to determine treatment effectiveness. Process outcomes (e.g. treatment satisfaction, attrition rates) were also examined.
Results: Quality ratings demonstrated high internal validity, although external validity was low. Effect size data revealed medium to large and short-term improvements in severity of depression and substance use symptoms in addition to global improvement in social, occupational and psychological functioning. Longer-term treatment effectiveness could not be established, due to the limited available data. Preliminary findings suggest that there was high client satisfaction, therapeutic alliance and client engagement.
Discussion: Mobile phone devices and the Internet can help to increase access to care for those with mental health co-morbidity. Large-scale and longitudinal research is, however, needed before digital mental healthcare becomes standard practice. This includes establishing critical therapeutic factors including optimum levels of assistance from clinicians.
... Twenty-four articles were empirical articles, nine were theoretical/applied articles, two were review articles, and one article was a committee proceeding. A descriptive review by Barrowclough, Haddock, Fitzsimmons, and Johnson (2006) was included because it presented unpublished data from a randomized control treatment trial. A review by Sterling, Weisner, Hinman, and Parthasarathy (2010) was included because it presented unpublished findings from a National Institutes of Health (NIH) funded study, R01AA16204. ...
... Symptoms associated with concurrent mental illness and SUDs may exacerbate individual vulnerability and act as barriers to treatment access. For example, individuals with COD including psychosis are extremely vulnerable because their substance use often worsens mental health symptoms, creates psychosocial instability, lowers motivation, and decreases their ability to seek and access treatment (Barrowclough et al., 2006;Green, Drake, Brunette, & Noordsy, 2007). Individuals with co-occurring schizophrenia and SUDs may have impaired cognition, lack social interaction skills, and have low energy levels and low motivation (Bellack & DiClemente, 1999;Little, 2001). ...
The purpose of this integrative review is to examine and synthesize extant literature pertaining to barriers to substance abuse and mental health treatment for persons with co-occurring substance use and mental health disorders (COD). Electronic searches were conducted using ten scholarly databases. Thirty-six articles met inclusion criteria and were examined for this review. Narrative review of these articles resulted in the identification of two primary barriers to treatment access for individuals with COD: personal characteristics barriers and structural barriers. Clinical implications and directions for future research are discussed. In particular, additional studies on marginalized sub-populations are needed, specifically those that examine barriers to treatment access among older, non-White, non-heterosexual populations.
... A key factor underlying poor treatment outcomes among individuals with serious mental illness has been hypothesized to be low motivation (Barrowclough, Haddock, Fitzsimmons, & Johnson, 2006). Specifically, negative symptoms are the core features which reflect motivational deficits in schizophrenia. ...
... Motivation among individuals with serious mental illness appears to be a significant factor in accounting for substance use treatment engagement and outcome (Barrowclough et al., 2006). Therefore, Motivational Interviewing is frequently used in this population as a standalone or to augment other substance use treatment components and has demonstrated effectiveness in improving treatment outcomes. ...
... We also know that less than 10% of those with COD receive treatment for both illnesses [27], and individuals with COD have higher rates of relapse and lower rates of treatment completion than individuals with single disorders [12]. Their treatment requires more frequent contacts and longer duration [28]. That the final sample for the current study includes individuals who remained in PROS for at least one month, and for an average of 13 months, suggests that these individuals are engaged in treatment. ...
Though the recovery model has been implemented widely in outpatient mental health settings, there are no large sample evaluations of recovery oriented psychiatric rehabilitation programs that address both serious mental illness (SMI) and co-occurring disorders (COD) using a more comprehensive Medicaid reimbursable approach. This study examined preliminary hospitalization outcomes, for adults with SMI and COD enrolled in the NYS Personalized Recovery Oriented Services (PROS) program. McNemar’s chi-square test was used to examine changes in hospitalization rates from pre-PROS admission to post-PROS discharge in a sample of 12,006 adults discharged from PROS. Negative binomial regression models were used to calculate adjusted rates of hospitalizations and hospital days. Demographic, psychosocial, and diagnosis predictor variables were extracted from the OMH web-based Child and Adult Integrated Reporting System. Hospitalization data were extracted from the Mental Health Automated Recordkeeping System, and Medicaid. From pre-admission to post-discharge, psychiatric hospitalization rate decreased significantly, from 24% to 14%. Substance related hospitalizations also decreased significantly, from 5% to 3%. Average number of hospitalizations and number of days hospitalized decreased even after adjusting for sociodemographic factors. PROS serves a high number of COD patients, and the number of psychiatric and substance related hospitalizations decreased after an episode of PROS, as did the number of days hospitalized. Findings support the maintenance of psychiatric rehabilitation models that include recovery oriented components. Further analyses with control samples are proposed.
... The New Hampshire Dual Disorders study demonstrated that individuals with COD who were served on ACT teams had lower hospitalization, alcohol and drug use rates, and increased substance use disorder remission rates compared to individuals served in outpatient treatment for their COD (McHugo et al. 1999). Integrated care approaches, which treated both mental illnesses and substance use disorders with the same team, at the same time, by the same agency, began to be routinely used in the late 1990s as they were associated with improved outcomes (Barrowclough et al. 2006;Drake et al. 1998Drake et al. , 2008. ...
Individuals with co-occurring illnesses are at risk for poor outcomes related to criminal justice, hospitalization, housing, and employment. High fidelity evidence-based models, including integrated dual disorder treatment (IDDT), are associated with significant outcome improvements. A descriptive analysis of secondary datasets including the full sample of IDDT fidelity reviews completed from 2006 to 2012 in one state was completed. Total IDDT fidelity significantly improved from baseline fidelity review (68) to second review (40) [t(38) = 35.00, p < .001], and from second review to third review (13) [t(12) = 22.60, p < .001], with adequate inner-rater reliability by the second review. Individual items that were lower across reviews included practice penetration and family interventions, and higher individual items included multi-disciplinary team, integrated treatment specialist, and time-unlimited services, and treatment measures are higher than organizational measures in baseline and subsequent reviews. In this large state-wide sample, IDDT took time to implement, and improved fidelity occurred from baseline to third review, and variance between components of the practice was significant.
... Other outcome measures require service users to be discharged into the community. They include recording outpatient treatment adherence (Swanson et al, 1999), hospital re-admissions (Hulse & Tait, 2003), re-conviction rates (Chandler & Spicer, 2006), housing and subsistence (Moggi et al, 1999) and social functioning (Barrowclough et al, 2006). Challenges of using conventional outcome measures in medium secure units Many conventional outcome measures used to evaluate dual diagnosis interventions are difficult to employ in medium secure units due to the nature of the service. ...
This article outlines conventional dual diagnosis outcome measures and the challenges of using these measures to evaluate interventions in medium secure units. It suggests how these challenges can be overcome by using alternative outcome measures such as measures of motivation, stages of change, beliefs, knowledge, group satisfaction, therapeutic alliance or coping strategies.
... Follow-up was usually of short duration. Only post treatment results were reported by Bellack et al. [38] and Barrowclough et al. [44], three months post-intervention results were reported by James et al., [37] nine months post-intervention results were reported by Haddock [36] and 12-months post-intervention results were reported by Kavanagh et al. [34]. Certainly, results from four RCTs reporting outcomes in terms of cannabis use may be more informative and these are considered below here. ...
There is growing and converging evidence that cannabis may be a major risk factor in people with psychotic disorders and prodromal psychotic symptoms. The lack of available pharmacological treatments for cannabis use indicates that psychological interventions should be a high priority, especially among people with psychotic disorders. However, there have been few randomised controlled trials (RCTs) of psychological interventions among this group. In the present study we critically overview RCTs of psychological and pharmacologic interventions among people with psychotic disorders, giving particular attention to those studies which report cannabis use outcomes. We then review data regarding treatment preferences among this group. RCTs of interventions within "real world" mental health systems among adults with severe mental disorders suggest that cannabis use is amenable to treatment in real world settings among people with psychotic disorders. RCTs of manual guided interventions among cannabis users indicate that while brief interventions are associated with reductions in cannabis use, longer interventions may be more effective. Additionally, RCTs reviewed suggest treatment with antipsychotic medication is not associated with a worsening of cannabis cravings or use and may be beneficial. The development of cannabinoid agonist medication may be an effective strategy for cannabis dependence and suitable for people with psychotic disorders. The development of cannabis use interventions for people with psychotic disorders should also consider patients' treatment preferences. Initial results indicate face-to-face interventions focussed on cannabis use may be preferred. Further research investigating the treatment preferences of people with psychotic disorders using cannabis is needed.
... Thus, there is a strong case for targeting people at an earlier stage of the illness when cannabis use is not so well established. Psychological treatments for substance misuse have been developed for people with psychosis (Barrowclough, Haddock, Fitzimmons, & Johnson, 2006; Cleary, Hunt, Matheson, Siegfried, & Walter, 2008), but only a few studies have specifically targeted people in first episode psychosis. Although the results are promising , small samples and lack of adequate control groups mean no firm conclusions can be drawn (Addington, 2003; Edwards et al., 2006; Kavanagh et al., 2003). ...
This qualitative study identifies factors influencing the use of substances in young people with recent onset psychosis. A purposive sample of 19 people aged between 16 and 35 years from an Early Intervention Service in the English National Health Service (NHS) was interviewed using a semi-structured guide. All had experienced a psychotic episode and were within 3 years of first contact with the service. All were either currently misusing substances or had been doing so in the 6 months prior to first contact with the service. All participants were/had been regular cannabis users and for 13(68%) cannabis was the primary drug of use. Thematic analysis identified four key themes in participants accounts of factors influencing their substance abuse: influence of perceived drug norms on behaviour; attributions for initial and ongoing drug-taking behaviour; changes in life goals affecting drug use; beliefs about the links between mental health and drug use. These findings have clear implications for interventions at a number of levels to support young people using substances in early psychosis including public health messages, education and psychological therapies.
... Auch die anderen genannten Programme schnitten schlechter ab, sei es, dass eine wesentlich längere Behandlungszeit notwendig war (Addington & Addington, 2001;Barrowclough et al., 2006) oder die Effekte für die Interventionsgruppe nie signifikant besser waren als die der ...
In epidemiologischen Studien wird ein Anstieg der Prävalenzrate von Cannabiskonsum - insbesondere bei Jugendlichen - seit vielen Jahren berichtet. Zu dieser Konsumentengruppe gehören auch Personen, die an einer Psychose erkrankt sind. Während die Komorbidität von Psychose und Cannabiskonsum (-missbrauch oder auch abhängigkeit) seit längerem bekannt ist, bleibt die Ätiologie weiterhin unklar. Verschiedene Behandlungsansätze für Patienten mit Doppeldiagnose wurden entwickelt, bisher mangelt es jedoch an Evaluationen derselben. Die vorliegende Dissertation hatte die Überprüfung der Anwendbarkeit einer adaptierten Version des Basistrainings aus dem Programm von Roberts et al. (1999) in einem stationären Setting sowie das Erfassen von kurz- und mittelfristigen Veränderungen der Symptomatik von Konsumverhalten und Psychopathologie zum Ziel. Dazu wurde eine randomisiert kontrollierte Studie an einer Patientengruppe mit schizophrener Erkrankung und komorbidem Cannabiskonsum (im Jahr vor dem stationären Aufenthalt) durchgeführt. Während die eine Patientengruppe (n = 31) das kognitiv-verhaltenstherapeutische Programm erhielt, besuchte die Kontrollgruppe (n = 27) ein Selbstsicherheitstraining, in dem Substanzkonsum nicht im Mittelpunkt stand. Beide Trainings umfassten acht Gruppensitzungen innerhalb eines Zeitraums von vier Wochen. Während der Cannabiskonsum objektiv über unter Sicht abgegebene Urinkontrollen wöchentlich erhoben wurde, erfolgte die Einschätzung der Psychopathologie vor Beginn und nach Abschluss der Trainings sowie zu einer Nachuntersuchung sechs Monate nach Trainingsbeginn. Zusätzlich wurden Maße für die Motivation, Selbstwirksamkeit und Suchtdruck erhoben sowie die Zusammenhänge mit dem Konsumverhalten überprüft. Es konnte festgehalten werden, dass sich das Training gut in das integrierte Behandlungsprogramm einfügen ließ. Bereits im stationären Rahmen waren positive Effekte durch den Einsatz des kognitiv-verhaltenstherapeutischen Manuals zu verzeichnen. Sowohl in der Interventionsgruppe als auch in der Kontrollgruppe verbesserte sich die Symptomatik bezüglich Psychopathologie und Konsumverhalten. Der Suchtdruck stand in engem Zusammenhang mit fortgesetztem Cannabiskonsum. Während die Motivation über den Erhebungszeitraum variierte, blieb die erlebte Selbstwirksamkeit überdauernd auf hohem Niveau. Hier konnten keine interventionsspezifischen Unterschiede festgestellt werden. Der von anderen Substanzen bekannte enge Zusammenhang zwischen Wirkungserwartung und Konsum einer Substanz konnte für Cannabis bestätigt werden. Die Schwere der Erkrankung hatte keinen Einfluss auf den klinischen Verlauf. Ob die geringen Unterschiede zwischen den Trainings auf den grundsätzlichen Genesungsverlauf zurückzuführen waren oder ob sie durch die minimale thematische Auseinandersetzung mit der Suchtproblematik in Form der wöchentlichen Erhebung von Urinstatus und Einschätzung von Suchtdruck, Motivation und Selbstwirksamkeit bedingt waren, blieb offen und muss in weiteren Untersuchungen ebenso überprüft werden wie eine mögliche weitere Verbesserung durch die Fortsetzung des Programms in ambulanten Gruppensitzungen. Epidemiological studies show an increase of the prevalence rate of cannabis consumption for the last few years especially in teenagers. The same is true for those dually diagnosed with psychosis and cannabis abuse. The concept of dual diagnosis is well known since a few years, but still the etiology is not finally solved. At the same time, different treatments were developed for this group of patients, but no evaluations were done. The aim of this dissertation was to implement an adapted version of a formerly developed treatment in an inpatient setting a specialized unit for young schizophrenic patients in a psychiatric hospital - and assess the changes (short- and middleterm) of symptoms as well concerning the consumerism of drugs as the psychopathology. The treatment approach based on the basic training of Roberts, L.J., Shaner, A. & Eckman, T.A. (Overcoming addictions: Skills training for people with schizophrenia. New York: W.W. Norton & Company, 1999). For this purpose a randomized controlled treatment trial was done on a group of dually diagnosed schizophrenic patients with cannabis abuse. 31 patients received the cognitive-behavioral training (CBT), the control group (n = 27) attended a training to increase social comeptence. Both trainings span eight sessions of 45 minutes during four weeks. Cannabis consumption was measured through objective controls of urinstatus weekly. Psychopathology was assessed before and after completion of the training as well as six months later at follow-up. Motivational status, self-efficacy and craving were assessed weekly as well during the time of the training and at follow-up. The results included the fact that the training was easily installed in the integrated treatment schedule in the inpatient setting. There was evidence that significant improvement occurred following implementation of the behavioral-cognitive training. The psychopathology improved in both intervention groups even though the increase was higher in the CBT group. Same effects were found for the consumption of cannabis. Craving was strongly associated with continuing drug use. Motivational status changed during the training, where as the self-efficacy remained at a high level. Concerning these aspects no treatment-related differences were found. The strong relationship between the effect expectancy and drug use (well know for use of alcohol, nicotine) was confirmed for cannabis. The severity of symptoms had no impact on the results of the training. It was not obvious if the differences weredue to the general course of the convalescence or if the cognitive examination of the topic following the weekly assessment of drug use, craving, self-efficacy and motivation provoked the change. This should be examined in further studies as well as the benefit of subsequent outpatient assistance and medical care.
... Consistent with Barrowclough , Haddock, Fitzsimmons, and Johnson (2006), it was generally felt that people with a serious mental illness may find it difficult to develop and maintain the motivation to change their substance use. This lack of motivation and concern about the adverse effects of substances may contribute to clinical inattention (Barrowclough et al., 2006; Drake, Essock, et al., 2001; Gregg et al., 2007), and consumer workers identified themselves as a potential resource for assisting clients to find meaningful social networks and programs. They did raise, however, the concern that clients may prefer to view themselves as a " drug user " than a " mentally ill client, " although both stereotypes are negatively stigmatized in the community (Gafoor & Rassool, 1998). ...
With the development of peer support networks in the mental health system, formal training should be provided regarding the adverse effects of substance use. Four educational workshops were conducted with caregivers and consumer workers to increase their knowledge and confidence to support people with a dual diagnosis. Workshops were evaluated through presurvey and postsurvey. The workshops were well received, and postworkshop, participants reported fewer negative attitudes toward people with a dual diagnosis and increased understanding and knowledge regarding substance misuse. This study highlights the effectiveness of targeted workshops for caregivers and consumer workers and advocates that nurses take a more active role in educational projects involving stakeholders.
... There is a need for more research on how best to disseminate and implement evidence-based interventions into the different settings [28]. Although the evidence regarding interventions and treatment models is not conclusive, it does suggest that many people with a dual diagnosis are not engaged in treatment programs, and few are in remission or recovery [10,30,31]. There is no doubt that this group is difficult to engage and over two-thirds of respondents admitted that working with these clients was more difficult than working with those without a dual diagnosis. ...
Substance misuse by people with a serious mental illness may exacerbate psychiatric symptoms and contribute to relapse. The aim of the study was to ascertain the views of a wide range of Australian mental health service providers on staff education and training, client contact and management, assessment, and treatment effectiveness and service delivery.
A survey was sent to a sample of 171 mental health stakeholders in Australia identified through internet searches, state and territory mental health departments and professional organisations.
Of the 66 respondents (39% response rate), the substances identified to be most problematic were alcohol and cannabis. Integrated service models of treatment were identified as the most preferable and effective. Barriers to treatment included client motivation to reduce substance use, poor communication and coordination between treatment services, and lack of specific services for dual diagnosis clients. Almost all indicated a need for further training in the area of dual diagnosis.
Dual diagnosis is common and the reality is that this vulnerable clientele will continue to challenge service providers and treatment approaches into the foreseeable future. Issues include the organization and delivery of treatment services, education and training, resource allocation, collaboration between treatment agencies and clinically relevant research evaluating the effectiveness of practice. It is thus surprising that with so much investment in this area the majority of stakeholders are still dissatisfied with access to and the level of care for dual diagnosis clients.
... Engaging and treating patients who use substances are known to be challenging (Barrowclough et al., 2005;Drake et al., 2004;Donald et al., 2005;Lowe & Abou-Saleh, 2004;Mueser et al., 2005). It is suggested that patients with a substance use disorder have a tendency toward a continuing reduction in lifestyle quality driven by a lack of motivation to change their level of substance use (Mueser, 2004). ...
The influence of substance use on patient's needs and caregiving consequences has received insufficient research attention. We sought to determine whether patients with comorbid substance use have higher levels of need, anxiety, depression, and caregiving consequences than those of patients who do not use substances. A total of 520 patients participated, and those who used substances (n = 216) reported higher levels of unmet needs, anxiety, and caregiving consequences than did patients who did not use substances. Carers of patients who used substances also reported higher anxiety and more caregiving consequences. Very few patients were actively involved in treatment programs to reduce their substance use.
Our study examined co-occurring substance use and major depressive disorders among justice-involved adolescents to inform behavioral health services planning within U.S. criminal justice systems. We used data from the 2015–2017 administrations of the National Survey on Drug Use and Health (NSDUH), an annual survey of non-institutionalized U.S. individuals aged 12 and older, to yield a national sample of 41,579 adolescents. Rates of co-occurring disorders were 4.5 times higher among justice-involved adolescents than non-justice-involved adolescents, with 6.3% of justice-involved adolescents meeting criteria for co-occurring disorders in the past year compared to 1.2% of non-justice-involved adolescents. Justice involvement was associated with greater substance use treatment but not mental health treatment. High rates of co-occurring disorders among justice-involved adolescents suggest the criminal justice system to be a unique opportunity for treatment engagement. The integrated mental health and substance use treatment needs of justice-involved adolescents with co-occurring disorders should be prioritized.
Background
The dual diagnosis of cannabis use disorder (CUD) and severe mental disorder (SMD) results in clinically complex individuals. Cannabis use is known to have negative consequences on psychiatric symptoms, medication compliance, and disease prognosis. Moreover, the effectiveness of currently available psychotherapeutic treatments is limited in this population. In this context, our research team developed avatar intervention, an approach using virtual reality as a therapeutic tool to treat CUD in individuals with SMD.
Objective
This pilot clinical trial aimed to evaluate, until the 1-year follow-up, the efficacy of avatar intervention for CUD among 32 participants with a dual diagnosis of SMD and CUD.
Methods
Over the course of the 8 intervention sessions, participants were given the opportunity to enter a dialogue in virtual reality with an avatar representing a person with a significant role in their consumption, who was animated in real time by a therapist. The primary outcomes were the quantity of cannabis consumed and the frequency of use. Secondary outcomes included severity of problematic cannabis use, motivation for change, protective strategies for cannabis use, consequences of cannabis use, psychiatric symptoms, and quality of life. Changes in reported outcomes during the assessment periods before the intervention; postintervention; and 3, 6, and 12 months after the end of the intervention were assessed using a linear mixed-effects model.
Results
Significant reductions were observed in the quantity of cannabis consumed, and these were maintained until the 12-month follow-up visit ( d =0.804; P <.001; confirmed by urine quantification). Frequency of cannabis use showed a small significant reduction at the 3-month follow-up ( d =0.384; P =.03). Moreover, improvements were observed in the severity of CUD, cannabis-related negative consequences, the motivation to change cannabis use, and the strategies used to mitigate harms related to cannabis use. Finally, moderate benefits were observed for quality of life and psychiatric symptoms.
Conclusions
Overall, this unique intervention shows promising results that seem to be maintained up to 12 months after the end of the intervention. With the aim of overcoming the methodological limitations of a pilot study, a single-blind randomized controlled trial is currently underway to compare the avatar intervention for CUD with a conventional addiction intervention.
Little is known about family context and substance use behaviors among Latinos with schizophrenia. Learning about patient and family caregiver perceptions of use is critical to our understanding of how best to support these vulnerable patients and family caregivers. This study explored perceptions of substance use in relation to mental illness among Latinos primarily of Mexican origin with schizophrenia and their family caregivers. Semistructured interviews were conducted with 34 participants (20 family caregivers; 14 patients) with direct and indirect substance use experience, in their preferred language. Data were analyzed using thematic analysis, which consisted of comparing codes across and within patient and family caregiver transcripts. Findings revealed that substance use affected well-being, particularly patient recovery and caregiver burden. Strategies to address well-being included limiting substance use, being vigilant about patient use, and communicating the negative impact of use. The environmental impact and stigma of substance use were major contextual challenges. Patients addressed these by limiting their socialization. Family social context was important to how substance use was perceived and managed by patients and caregivers. As such, treatment models should consider a holistic perspective that incorporates family context when addressing substance use among Latinos with schizophrenia.
Background:
Even low levels of substance misuse by people with a severe mental illness can have detrimental effects.
Objectives:
To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care.
Search methods:
The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases.
Selection criteria:
We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness.
Data collection and analysis:
Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison.
Main results:
Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence).
Authors' conclusions:
We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.
Individuals with substance use and concurrent mental disorders or co-occurring disorders (CODs) present numerous risks and treatment challenges. CODs are particularly pronounced within criminal justice settings. Offenders with CODs have higher risk for recidivism and have unique problems including criminal thinking and antisocial behaviours, commonly referred to as “criminogenic needs”. Two important frameworks for treating CODs with offender populations are the Risk-Need-Responsivity Model (RNR) and the Social Learning Model (SLM). These help to guide the application of integrated evidence-based treatments (EBTs) including Cognitive Behavioural Therapy (CBT), Motivational Interviewing (MI), behavioural modification, behavioural social skills training and family therapy. Programmatic adaptions include comprehensive screening/assessment, specialised tracks for dual diagnoses, intensive and phased treatment, ancillary services (e.g. peer support, relapse prevention), cross-training of staff, interdisciplinary treatment teams, specialised caseloads, and linkage with community mental health and social services. EBTs and programmatic adaptations have been successfully applied in community, jail and prison settings, and research indicates that integrated and structured treatment approaches significantly reduce reoffending and recidivism. Aftercare or reentry services can improve successful transition back into the community and improve offender outcomes. Risk assessment and structured assessment can be used to match offenders to the appropriate level of care and intensity of services. Future research should include controlled trials that examine the effectiveness of integrated offender treatment programmes and their components on key outcomes that include recidivism, substance use, utilisation of behavioural health services and psychosocial functioning.
Recognizing the need for a more comprehensive approach to preventing child homicides that result from family violence, the authors applied Haddon's three methods of injury prevention to the context of family violence: modification of the agent of injury; identification of control strategies to intervene in the process of injury; and application of the comprehensive Haddon matrix to explore pre-event, event, and post-event strategies addressing the child, parent, and the environment. Examples of evidence-based strategies were identified to support this approach, and innovative strategies were suggested which build on existing approaches applied to other contexts. Recommendations and implications for research and practice are discussed.
Clinical experience suggests that people with psychosis generally show a diverging substance use pattern compared with other people with ‘dual disorders’. The aim of this study was to describe substance use patterns in individuals with psychosis and relate these to substance use patterns in persons with other kinds of psychiatric disorders in combination with substance abuse. A wider aim was to contribute to a deeper understanding of interactions between mental illness and substance use. Two groups were recruited, one with persons diagnosed with psychotic disorders and one with people with other (mainly anxiety- and affective-) disorders. All participants also had substance-related problems. The participants completed the questionnaires Alcohol Use Disorders Identification Test and Drug Use Disorders Identification Test, and information about socio-demographic and care-related characteristics was collected. Group differences were calculated. The participants with psychosis scored significantly lower on most questions concerning affective/cognitive aspects of drug use, such as longing, guilt and experience of failing in relation to alcohol and drugs. They also showed fewer indications of alcohol dependence. A possible interpretation is that the findings reflect group differences in mentalization and affect-regulation relevant to both substance use and psychiatric illness. This may have implications for theoretical understanding of dual disorders as well as for psychotherapeutic treatment.
Over 50% of people with a severe mental illness also use illicit drugs and/or alcohol at hazardous levels. This review is
based on the findings of 32 randomized controlled trials which assessed the effectiveness of psychosocial interventions, offered
either as one-off treatments or as an integrated or nonintegrated program, to reduce substance use by people with a severe
mental illness. The findings showed that there was no consistent evidence to support any one psychosocial treatment over another.
Differences across trials with regard to outcome measures, sample characteristics, type of mental illness and substance used,
settings, levels of adherence to treatment guidelines, and standard care all made pooling results difficult. More quality
trials are required that adhere to proper randomization methods; use clinically valuable, reliable, and validated measurement
scales; and clearly report data, including retention in treatment, relapse, and abstinence rates. Future trials of this quality
will allow a more thorough assessment of the efficacy of psychosocial interventions for reducing substance use in this challenging
population.
Dual-diagnosis strategies are developing in medium secure services in response to both government policies and clinical need and there has been a move towards integrated services for this patient group. Substance use that has been a feature of the index offence must be taken into account as much as psychosis or the offending behaviour. Treatment of dual diagnosis relies heavily on cognitive-behavioural therapies. Relapse in either psychosis or substance use increases risk and re-admission rates to medium security. This paper reviews the literature on family interventions in dual diagnosis and its applicability to forensic mental health inpatient services. As there appeared to be limited direct evidence, various domains were examined and extrapolated to a forensic setting as appropriate. The review indicates the potential for positive outcomes for families following family interventions in dual diagnosis, which may be beneficial in a forensic setting in lowering risk.
This paper presents the outcomes of a small qualitative study investigating the experience of mental health practitioners working with dual diagnosis in an early intervention in psychosis (EIP) team with a focus on the use of a specifically developed screening tool. Interviews were conducted with mental health professionals who were employed as care co-ordinators within an EIP team. Grounded theory was adopted as a method for making sense of the data obtained. Six themes that emerged from the data are described: the importance of the cycle of change in treatment planning; service accountability and responsibility; the nature of psychotic illness; assumptions about substance use; confidence; and using the tool as part of the recovery process. These themes were discussed in relation to research surrounding psychosis, substance use and screening methods.Despite identifying the importance of a more integrated method of working with this complex service user group, gaps remain in practice. Modifications to the screening tool are recommended and a need for substance-use-specific interventions training for practitioners working within EIP services is identified.
Background. The co-occurrence of substance use and mental illness (dual diagnosis) is a common clinical problem and one that is often not adequately addressed therapeutically.Aims. To review the literature on psychological treatments for dual diagnosis, and make recommendations for clinicians regarding to deployment of such interventions tailored to the age and developmental stage of the individual.Method. Selective literature review.Results. Despite significant methodological problems in conducting research into treatments for dual diagnosis, a number of specific approaches have an emerging evidence base in this patient population. These include motivational interviewing, cognitive behavioural therapy, contingency management, social skills training, problem solving, psychosocial education, case management and family/carer support. A few studies have attempted to integrate some or most of these elements into a comprehensive intervention.Conclusions. Existing psychological treatments for dual diagnosis can be effective and are best deployed as part of an integrated service model. However, much remains to be learnt regarding the optimal care of individuals with dual problems of substance use and a mental illness.
To review the literature on pharmacological and psychosocial treatment approaches for people with schizophrenia and comorbid substance use disorder(s) (SUD). Method: Selective literature review.
Despite the high prevalence of comorbid SUD among people with schizophrenia, there is a considerable paucity of rigorously conducted randomized controlled treatment trials. While there is some evidence for clozapine, and for the adjunctive use of agents such as naltrexone for comorbid alcohol dependence, the available literature largely comprises case studies, case series, open label studies and retrospective surveys. In terms of psychosocial approaches, there is reasonable consensus that integrated approaches are most appropriate. Regarding specific aspects of care, motivational interviewing, cognitive behavioural therapy and contingency management have an emerging supportive literature, as do family interventions. However, there is no 'one size fits all', and a flexible approach with the ability to apply specific components of care to particular individuals, is required. Group-based therapies and longer-term residential services have an important role for some patients, but further research is required to delineate more clearly which patients will benefit from these strategies.
While there is growing (albeit limited) evidence that integrated and well articulated interventions that encompass pharmacological and psychosocial parameters can be beneficial for people with schizophrenia and comorbid SUD, there remains a considerable gap in the literature available to inform evidence-based practice.
This qualitative study identifies factors influencing the use of substances in young people with recent onset psychosis. A purposive sample of 19 people aged between 16 and 35 years from an Early Intervention Service in the English National Health Service (NHS) was interviewed using a semi-structured guide. All had experienced a psychotic episode and were within 3 years of first contact with the service. All were either currently misusing substances or had been doing so in the 6 months prior to first contact with the service. All participants were/had been regular cannabis users and for 13(68%) cannabis was the primary drug of use. Thematic analysis identified four key themes in participants accounts of factors influencing their substance abuse: influence of perceived drug norms on behaviour; attributions for initial and ongoing drug-taking behaviour; changes in life goals affecting drug use; beliefs about the links between mental health and drug use. These findings have clear implications for interventions at a number of levels to support young people using substances in early psychosis including public health messages, education and psychological therapies.
This study is a report of a systematic review to assess current evidence for the efficacy of psychosocial interventions for reducing substance use, as well as improving mental state and encouraging treatment retention, among people with dual diagnosis.
Substance misuse by people with a severe mental illness is common and of concern because of its many adverse consequences and lack of evidence for effective psychosocial interventions.
Several electronic databases were searched to identify studies published between January 1990 and February 2008. Additional searches were conducted by means of reference lists and contact with authors.
Results from studies using meta-analysis, randomized and non-randomized trials assessing any psychosocial intervention for people with a severe mental illness and substance misuse were included.
Fifty-four studies were included: one systematic review with meta-analysis, 30 randomized controlled trials and 23 non-experimental studies. Although some inconsistencies were apparent, results showed that motivational interviewing had the most quality evidence for reducing substance use over the short term and, when combined with cognitive behavioural therapy, improvements in mental state were also apparent. Cognitive behavioural therapy alone showed little consistent support. Support was found for long-term integrated residential programmes; however, the evidence is of lesser quality. Contingency management shows promise, but there were few studies assessing this intervention.
These results indicate the importance of motivational interviewing in psychiatric settings for the reduction of substance use, at least in the short term. Further quality research should target particular diagnoses and substance use, as some interventions may work better for some subgroups.
A comorbidity of mental health and substance misuse problems has been associated with deleterious outcomes. In the United Kingdom it has been acknowledged that people with comorbidity have often received poor care, with gaps in service provision suggesting ambivalence towards this issue. Previous reviewing authors have concluded that health professionals hold stereotypical views towards people that misuse substances, but these findings may not be directly comparable to those who work within mental health services. There is however a growing body of evidence concerning this context. The author has reviewed the literature from 1996 to 2006 to ascertain mental health professionals and allied workers attitudes and perceptions towards comorbidity, perceptions on the effectiveness of service systems, and perceptions of personal knowledge and skill in providing effective interventions. The evidence presented mainly pertains to mental health nurses, which reflects their status as the largest discipline within the mental health workforce. Overall attitudes towards comorbidity are mixed, possibly being related to contextual issues of practice and are not necessarily negative. However, there is an almost universal negative perception of deficiencies in service provision and the adequacy of training. Implications for research, development and practice are explored.
The prevalence of comorbid alcohol, other drug, and mental disorders in the US total community and institutional population was determined from 20,291 persons interviewed in the National Institute of Mental Health Epidemiologic Catchment Area Program. Estimated US population lifetime prevalence rates were 22.5% for any non-substance abuse mental disorder, 13.5% for alcohol dependence-abuse, and 6.1% for other drug dependence-abuse. Among those with a mental disorder, the odds ratio of having some addictive disorder was 2.7, with a lifetime prevalence of about 29% (including an overlapping 22% with an alcohol and 15% with another drug disorder). For those with either an alcohol or other drug disorder, the odds of having the other addictive disorder were seven times greater than in the rest of the population. Among those with an alcohol disorder, 37% had a comorbid mental disorder. The highest mental-addictive disorder comorbidity rate was found for those with drug (other than alcohol) disorders, among whom more than half (53%) were found to have a mental disorder with an odds ratio of 4.5. Individuals treated in specialty mental health and addictive disorder clinical settings have significantly higher odds of having comorbid disorders. Among the institutional settings, comorbidity of addictive and severe mental disorders was highest in the prison population, most notably with antisocial personality, schizophrenia, and bipolar disorders.
The article discusses various reports published within the issue, including one by William Fals-Stewart and colleagues on behavior couples therapy and another by Patricia J. Conrod and Sherry H. Stewart on the dual diagnosis treatment approaches that employ cognitive-behavioral techniques.
Several large-scale studies examining outcome predictors across various substance use treatments indicate a need to focus on psychiatric comorbidity as a very important predictor of poorer SUD treatment involvement and outcome. We have previously argued that current cognitive-behavioral treatments (CBT) approaches to SUD treatment do not focus on the necessary content in treatment in order to effectively address specific forms of psychiatric comorbidity, and thus only provide clients with generic coping strategies for managing psychiatric illness (as would be achieved in other SUD treatment approaches; Conrod et al., 2000). Furthermore, following our review of the literature on dual-focused CBT treatment programs for concurrent disorders in this article, we argue that combining CBT-oriented SUD treatments with specific CBT treatments for psychiatric disorders is not as straightforward as one would think. Rather, it requires very careful consideration of the functional relationship between specific disorders, patient reactions to specific treatment components, and certain barriers to treatment in order to achieve an integrated dual-diagnosis focus in treatment that is meaningful and to which clients can adhere.
Homeless adults with both a serious mental illness and substance dependence (N = 276) were randomly assigned to: (1) a social model residential program providing integrated mental health and substance abuse treatment; (2) a community-based nonresidential program using the same social model approach; or (3) a control group receiving no intervention but free to access other community services. Interventions were designed to provide 3 months of intensive treatment, followed by 3 months of nonresidential maintenance. Subjects completed baseline interviews prior to randomization and reinterviews with 3,6, and 9 months later. Results showed that, while substance use, mental health, and housing outcomes improved from baseline, subjects assigned to treatment conditions differed little from control subjects. Examination of the relationship between length of treatment exposure and outcomes suggested that residential treatment had positive effects on outcomes at 3 months, but that these effects were eroded by 6 months.
Alcohol is the most commonly used drug among people with mental disorders; however, few studies have addressed subjective reasons for drinking among the mentally ill. The purpose of this study was to evaluate the relationship between drinking motives and drinking patterns in 67 psychiatric outpatients. Results indicated that both positive and negative reinforcement motives differentiated drinkers from nondrinkers, with both types of motives correlated significantly with maximum quantity consumed in the last year. Enhanced negative (but not positive) reinforcement motives were associated with a history of treatment for alcohol or drug abuse. This study, which yielded findings similar to those found in previous research with nonclinical participants, represents the first psychometric investigation of motives underlying alcohol use among people with mental disorders. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Compared the effectiveness of an integrated mental health and substance abuse treatment within an assertive community treatment (ACT) approach with a standard case management approach for 203 patients (mean age 34 yrs) with dual disorders of severe mental illness and substance use disorders over 3 yrs. It was hypothesized that ACT Ss would increase their days in stable community housing by decreasing hospital, jail, and homeless days. It was also hypothesized that ACT Ss would experience greater symptom reductions and improvements in quality of life. ACT Ss showed greater improvements on some measures of substance abuse and quality of life, but the groups were equivalent on most measures, including stable community days, hospital days, psychiatric symptoms, and remission of substance use disorder.
The prevalence of comorbid alcohol, other drug, and mental disorders in the US total community and institutional population was determined from 20,291 persons interviewed in the National Institute of Mental Health Epidemiologic Catchment Area Program. Estimated US population lifetime prevalence rates were 22.5% for any non-substance abuse mental disorder, 13.5% for alcohol dependence-abuse, and 6.1% for other drug dependence-abuse. Among those with a mental disorder, the odds ratio of having some addictive disorder was 2.7, with a lifetime prevalence of about 29% (including an overlapping 22% with an alcohol and 15% with another drug disorder). For those with either an alcohol or other drug disorder, the odds of having the other addictive disorder were seven times greater than in the rest of the population. Among those with an alcohol disorder, 37% had a comorbid mental disorder. The highest mental-addictive disorder comorbidity rate was found for those with drug (other than alcohol) disorders, among whom more than half (53%) were found to have a mental disorder with an odds ratio of 4.5. Individuals treated in specialty mental health and addictive disorder clinical settings have significantly higher odds of having comorbid disorders. Among the institutional settings, comorbidity of addictive and severe mental disorders was highest in the prison population, most notably with antisocial personality, schizophrenia, and bipolar disorders.
Social functioning as an outcome variable in family interventions with schizophrenic patients has been a relatively neglected area. The requirements of a scale of social functioning to measure the efficacy of family interventions include: the measurement of skill/behaviour relevant to the impairments and the demography of this group; the ability to yield considerable information with an economy of clinical time; and the establishment of 'comparative' need through comparison between subscales and with appropriate reference groups. Results from three samples show that the Social Functioning Scale is reliable, valid, sensitive and responsive to change.
This study examined the effects of integrating mental health, substance abuse, and housing interventions for homeless persons with co-occurring severe mental illness and substance use disorder. With the use of a quasi-experimental design, integrated treatment was compared with standard treatment for 217 homeless, dually diagnosed adults over an 18-month period. The integrated treatment group had fewer institutional days and more days in stable housing, made more progress toward recovery from substance abuse, and showed greater improvement of alcohol use disorders than the standard treatment group. Abuse of drugs other than alcohol (primarily cocaine) improved similarly for both groups. Secondary outcomes, such as psychiatric symptoms, functional status, and quality of life, also improved for both groups, with minimal group differences favoring integrated treatment.
Patients with severe mental disorders such as schizophrenia and co-occurring substance use disorders traditionally received treatments for their two disorders from two different sets of clinicians in parallel treatment systems. Dissatisfaction with this clinical tradition led to the development of integrated treatment models in which the same clinicians or teams of clinicians provide substance abuse treatment and mental health treatment in a coordinated fashion. We reviewed 36 research studies on the effectiveness of integrated treatment for dually diagnosed patients. Studies of adding dual-disorders groups to traditional services, studies of intensive integrated treatments in controlled settings, and studies of demonstration projects have thus far yielded disappointing results. On the other hand, 10 recent studies of comprehensive, integrated outpatient treatment programs provide encouraging evidence of the programs' potential to engage dually diagnosed patients in services and to help them reduce substance abuse and attain remission. Outcomes related to hospital use, psychiatric symptoms, and other domains are less consistent. Several program features appear to be associated with effectiveness: assertive outreach, case management, and a longitudinal, stage-wise, motivational approach to substance abuse treatment. Given the magnitude and severity of the problem of dual disorders, more controlled research on integrated treatment is needed.
It is commonly held that substance use comorbidity in schizophrenia represents self-medication, an attempt by patients to alleviate adverse positive and negative symptoms, cognitive impairment, or medication side effects. However, recent advances suggest that increased vulnerability to addictive behavior may reflect the impact of the neuropathology of schizophrenia on the neural circuitry mediating drug reward and reinforcement. We hypothesize that abnormalities in the hippocampal formation and frontal cortex facilitate the positive reinforcing effects of drug reward and reduce inhibitory control over drug-seeking behavior. In this model, disturbances in drug reward are mediated, in part, by dysregulated neural integration of dopamine and glutamate signaling in the nucleus accumbens resulting form frontal cortical and hippocampal dysfunction. Altered integration of these signals would produce neural and motivational changes similar to long-term substance abuse but without the necessity of prior drug exposure. Thus, schizophrenic patients may have a predilection for addictive behavior as a primary disease symptom in parallel to, and in many, cases independent from, their other symptoms.
Comorbidity of substance abuse disorders with schizophrenia is associated with a greater risk for serious illness complications and poorer outcome. Methodologically sound studies investigating treatment approaches for patients with these disorders are rare, although recommendations for integrated and comprehensive treatment programs abound. This study investigates the relative benefit of adding an integrated psychological and psychosocial treatment program to routine psychiatric care for patients with schizophrenia and substance use disorders.
The authors conducted a randomized, single-blind controlled comparison of routine care with a program of routine care integrated with motivational interviewing, cognitive behavior therapy, and family or caregiver intervention.
The integrated treatment program resulted in significantly greater improvement in patients' general functioning than routine care alone at the end of treatment and 12 months after the beginning of the study. Other benefits of the program included a reduction in positive symptoms and in symptom exacerbations and an increase in the percent of days of abstinence from drugs or alcohol over the 12-month period from baseline to follow-up.
These findings demonstrate the effectiveness of a program of routine care integrated with motivational interviewing, cognitive behavior therapy, and family intervention over routine psychiatric care alone for patients with comorbid schizophrenia and alcohol or drug abuse or dependence.
While there is a growing body of evidence on the efficacy of psychological interventions for schizophrenia, this meta-analysis improves upon previous systematic and meta-analytical reviews by including a wider range of randomized controlled trials and providing comparisons against both standard care and other active interventions.
Literature searches identified randomized controlled trials of four types of psychological interventions: family intervention, cognitive behavioural therapy (CBT), social skills training and cognitive remediation. These were then subjected to meta-analysis on a variety of outcome measures. This paper presents results relating to the first two.
Family therapy, in particular single family therapy, had clear preventative effects on the outcomes of psychotic relapse and readmission, in addition to benefits in medication compliance. CBT produced higher rates of 'important improvement' in mental state and demonstrated positive effects on continuous measures of mental state at follow-up. CBT also seems to be associated with low drop-out rates.
Family intervention should be offered to people with schizophrenia who are in contact with carers. CBT may be useful for those with treatment resistant symptoms. Both treatments, in particular CBT, should be further investigated in large trials across a variety of patients, in various settings. The factors mediating treatment success in these interventions should be researched.
Epidemiological findings suggest that cannabis use is a risk factor for the emergence of psychosis, and that the induction of psychotic symptoms in the context of cannabis use may be associated with a pre-existing vulnerability for psychosis. This study investigated in a non-clinical population the interaction between cannabis use and psychosis vulnerability in their effects on psychotic experiences in daily life.
Subjects (N = 79) with high or low levels of cannabis use were selected among a sample of 685 undergraduate university students. Experience sampling method (ESM) was used to collect information on substance use and psychotic experiences in daily life. Vulnerability to develop psychosis was measured using a clinical interview assessing the level of psychotic symptoms. Statistical analyses were performed using multilevel linear random regression models.
The acute effects of cannabis are modified by the subject's level of vulnerability for psychosis. Subjects with high vulnerability for psychosis are more likely to report unusual perceptions as well as feelings of thought influence than subjects with low vulnerability for psychosis, and they are less likely to experience enhanced feelings of pleasure associated with cannabis. There is no evidence that use of cannabis is increased following occurrence of psychotic experiences as would be expected by the self-medication model.
Cannabis use interacts with psychosis vulnerability in their effects on experience of psychosis in daily life. The public health impact of the widespread use of cannabis may be considerable.
Participants with schizophrenia (N = 59) were assessed on self-evaluation, symptomatology, and positive and negative affect (expressed emotion) from significant others. An interview-based measure of self-evaluation was used and two independent dimensions of self-esteem were derived: negative and positive evaluation of self. As predicted, negative self-evaluation was strongly associated with positive symptoms, a more critical attitude from family members was associated with greater negative self-evaluation, and analyses supported a model whereby the impact of criticism on patients' positive symptoms was mediated by its association with negative self-evaluation. The interview-based method of self-esteem assessment was found to be superior to the questionnaire because its predictive effects remained after depressed mood was accounted for.
Thirty subjects with comorbid schizophrenia and alcohol use disorders were randomly assigned to receive either a Motivational Interviewing (MI) or Educational Treatment (ET) intervention with treatment goals of abstinence and/or decreased alcohol use. Subjects were followed up at 4, 8 and 24-weeks upon completion of the interventions. Outcome measures included number of drinking days, abstinence rates, average blood alcohol concentration and standard ethanol content per drinking day. Subjects randomized to the MI intervention had a significant reduction in drinking days and an increase in abstinence rates when compared to subjects receiving ET. Motivational Interviewing may be a useful treatment intervention for individuals with schizophrenia and alcoholism.
Improved management of mental illness and substance misuse comorbidity is a National Health Service priority, but little is known about its prevalence and current management.
To measure the prevalence of comorbidity among patients of community mental health teams (CMHTs) and substance misuse services, and to assess the potential for joint management.
Cross-sectional prevalence survey in four urban UK centres.
Of CMHT patients, 44% (95% CI 38.1-49.9) reported past-year problem drug use and/or harmful alcohol use; 75% (95% CI 68.2-80.2) of drug service and 85% of alcohol service patients (95% CI 74.2-93.1) had a past-year psychiatric disorder. Most comorbidity patients appear ineligible for cross-referral between services. Large proportions are not identified by services and receive no specialist intervention.
Comorbidity is highly prevalent in CMHT, drug and alcohol treatment populations, but may be difficult to manage by cross-referral psychiatric and substance misuse services as currently configured and resourced.
Alcohol is the most commonly used drug among people with mental disorders; however, few studies have addressed subjective reasons for drinking among the mentally ill. The purpose of this study was to evaluate the relationship between drinking motives and drinking patterns in 67 psychiatric outpatients. Results indicated that both positive and negative reinforcement motives differentiated drinkers from nondrinkers, with both types of motives correlated significantly with maximum quantity consumed in the last year. Enhanced negative (but not positive) reinforcement motives were associated with a history of treatment for alcohol or drug abuse. This study, which yielded findings similar to those found in previous research with nonclinical participants, represents the first psychometric investigation of motives underlying alcohol use among people with mental disorders.
The authors examined patterns of alcohol use among 115 DSM-III schizophrenics discharged from the state hospital and participating in an urban aftercare program. According to ratings by mobile outreach clinicians, 45% of the patients used alcohol, and 22% were clearly abusing alcohol. Alcohol use was associated with younger age, male sex, street drug use, medication noncompliance, lack of psychosocial supports, increased symptomatology, chronic medical problems, and a higher rate of rehospitalization. Even minimal drinking, not considered alcohol abuse by clinicians, predicted rehospitalization during 1-year prospective follow-up.
A growing body of research supports the effectiveness of integrated treatment for people with co-occurring severe mental illness and substance use disorders (dual disorders), but the effects of specific interventions are less clear. This review focuses on the effects of specific psychosocial interventions for dual disorders, including individual, group, and family modalities, as well as structural (e.g., case management model), procedural (e.g., contingency management), residential, and rehabilitation (e.g., vocational) interventions, with an emphasis on randomized controlled trials. Controlled research on specific individual interventions has focused mainly on motivation enhancement approaches for clients in the earlier stages of treatment, and has reported improved retention in treatment and substance abuse outcomes. Group interventions have been most extensively studied, with findings indicating that a variety of different treatment approaches specifically designed for dual disorder clients (e.g., emphasizing education, motivational enhancement, cognitive-behavioral counseling) are more effective at improving substance abuse outcomes than no group treatment or standard 12-Step approaches. Structural studies suggest that increasing the intensity of integrated dual disorder treatment produces only modest benefits. Residential dual disorder programs show great promise, especially for clients who are homeless and without psychosocial supports. Research on family therapy, procedural interventions, or rehabilitation is too premature at this time to draw any conclusions, although promising results have emerged in each area. Future avenues for research on specific interventions for dual disorders are considered.
Motivational Interviewing (MI) is a brief treatment approach for helping patients develop intrinsic motivation to change addictive behaviors. While initially developed to target primary substance using populations, professionals are increasingly recognizing the promise this approach has for addressing the motivational dilemmas faced by patients who have co-occurring psychiatric and psychoactive substance use disorders. Unfortunately, this recognition has not lead to a clear explication of how MI might be adopted for specific diagnostic populations of dually diagnosed patients. In this article we describe how we have applied the principles and practices of MI to patients who have psychotic disorders and co-occurring drug or alcohol use problems. Specifically, we provide two supplemental guidelines to augment basic MI principles (adopting an integrated dual diagnosis approach, accommodating cognitive impairments and disordered thinking). We present recommended modifications to primary MI skill sets (simplifying open-ended questions, refining reflective listening skills, heightening emphasis on affirmations, integrating psychiatric issues into personalized feedback and decisional balance matrices). Finally, we highlight other clinical considerations (handling psychotic exacerbation and crisis events, recommended professional qualifications) when using MI with psychotic disordered dually diagnosed patients.
[review] information on the epidemiology of substance abuse in patients with severe mental illness / [discuss] methodological issues in epidemiological research on substance abuse in psychiatric patients / data on the prevalence of comorbid substance abuse disorders in psychiatric patients is reviewed, as well as the diagnostic and demographic correlates of abuse in this population / consider different [models] that may account for the high rate of substance abuse in persons with severe mental illness
models linking mental illness and substance abuse [secondary substance abuse model, secondary psychiatric disorder model, common factor model, bidirectional model] (PsycINFO Database Record (c) 2012 APA, all rights reserved)
more than two decades ago, the timeline was developed as a procedure to aid recall of past drinking / that method, first referred to as the gathering of daily drinking disposition data and later labeled as the timeline follow-back (TLFB) method, is the focus of this chapter / TLFB appears to provide a relatively accurate portrayal of drinking and has both clinical and research utility
administration of the TLFB technique / psychometric properties / test–retest reliability / subject-collateral comparisons / concurrent validity (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Client ambivalence is a key stumbling block to therapeutic efforts toward constructive change. Motivational interviewing—a nonauthoritative approach to helping people to free up their own motivations and resources—is a powerful technique for overcoming ambivalence and helping clients to get "unstuck." The first full presentation of this powerful technique for practitioners, this volume is written by the psychologists who introduced and have been developing motivational interviewing since the early 1980s.
In Part I, the authors review the conceptual and research background from which motivational interviewing was derived. The concept of ambivalence, or dilemma of change, is examined and the critical conditions necessary for change are delineated. Other features include concise summaries of research on successful strategies for motivating change and on the impact of brief but well-executed interventions for addictive behaviors.
Part II constitutes a practical introduction to the what, why, and how of motivational interviewing. . . . Chapters define the guiding principles of motivational interviewing and examine specific strategies for building motivation and strengthening commitment for change.
Rounding out the volume, Part III brings together contributions from international experts describing their work with motivational interviewing in a broad range of populations from general medical patients, couples, and young people, to heroin addicts, alcoholics, sex offenders, and people at risk for HIV [human immunodeficiency virus] infection. Their programs span the spectrum from community prevention to the treatment of chronic dependence.
All professionals whose work involves therapeutic engagement with such individuals—psychologists, addictions counselors, social workers, probations officers, physicians, and nurses—will find both enlightenment and proven strategies for effecting therapeutic change. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Previous work posits that severity of substance abuse and severity of schizophrenic symptoms should be linked by either or both of two mechanisms: self-regulation of symptoms and drug-induced exacerbation of symptoms. Research on these relationships has yielded mixed results. We examined the interrelationships of schizophrenic symptoms and substance abuse in 172 patients with co-occurring disorders. Relationships were weak or nonexistent, without any consistent pattern. Our findings do not support the view that substances are used to self-regulate symptoms. In addition, our results suggest that substance abuse may lead to higher rates of institutionalization through mechanisms other than by exacerbating symptoms.
Evaluation of Evaluative ResearchCochrane ReviewMethod
Outcome Measures and Data ExtractionWhat About Non-Rct Evidence?Away Forward for Outcome ResearchAcknowledgementsReferences
The Service Context: Northern Birmingham Mental Health ServicesContextual Factors Influencing the Compass Programme's Model of Service DeliveryDefining the ProblemTHE COMPASS PROGRAMME: an INTEGRATED “SHARED-CARE” TREATMENT APPROACHStaff: The Compass Programme TeamInterventionsWorking with the Assertive Outreach TeamsConsultation-LiaisonFuture DirectionsAcknowledgementsReferences
IntroductionThe Calgary Early Psychosis Treatment and Prevention ProgramAddressing Substance Use Through the Different Components of the Early Psychosis ProgramConclusions
References
This chapter contains section titled:
This chapter contains section titled:
Start Over and Survive! (Sos)Current PracticeCase ExamplesOutcome Studies on the ApproachConclusion
References
Over 1,700 psychiatric emergency room visits of schizophrenic and schizoaffective patients between 1984 and 1996 were reviewed, and urine drug screens (UDS) were recorded. Illicit drug use increased significantly over the 12-year period, with a large increase for cocaine (0% to 73% of positive UDS), a decline for amphetamines (60% to 0%), and a small increase for marijuana (0% to 27%). Opiate and sedative use remained unchanged. The results support the impression that cocaine use increased dramatically among urban schizophrenic patients beginning in 1988 and continuing to the present. Furthermore, cocaine seems to have replaced amphetamines as the preferred drug of abuse among schizophrenic persons following the crack epidemic.
Objective: This study reports the prevalence and correlates of ICD-10 alcohol- and drug-use disorders in the National Survey of Mental Health and Wellbeing (NSMHWB) and discusses their implications for treatment.Method: The NSMHWB was a nationally representative household survey of 10 641 Australian adults that assessed participants for symptoms of the most prevalent ICD-10 and DSM-IV mental disorders, including alcohol- and drug-use disorders.Results: In the past 12 months 6.5% of Australian adults met criteria for an ICD-10 alcohol-use disorder and 2.2% had another ICD-10 drug-use disorder. Men were at higher risk than women of developing alcohol- and drug-use disorders and the prevalence of both disorders decreased with increasing age. There were high rates of comorbidity between alcohol- and other drug-use disorders and mental disorders and low rates of treatment seeking.Conclusions: Alcohol-use disorders are a major mental health and public health issue in Australia. Drug-use disorders are less common than alcohol-use disorders, but still affect a substantial minority of Australian adults. Treatment seeking among persons with alcohol- and other drug-use disorders is low. A range of public health strategies (including improved specialist treatment services) are needed to reduce the prevalence of these disorders.
DefinitionsPrevalence of Substance Use ProblemsCorrelates of Substance UseConclusion
References
Substance use disorders occur in approximately 40 to 50% of individuals with schizophrenia. Clinically, substance use disorders are associated with a variety of negative outcomes in schizophrenia, including incarceration, homelessness, violence, and suicide. An understanding of the reasons for such high rates of substance use disorders may yield insights into the treatment of this comorbidity in schizophrenia. This review summarizes methodological and conceptual issues concerning the study of substance use disorders in schizophrenia and provides a review of the prevalence of this co-occurrence. Prevailing theories regarding the co-occurrence of schizophrenia and substance use disorders are reviewed. Little empirical support is found for models suggesting that schizophrenic symptoms lead to substance use (self-medication), that substance use leads to schizophrenia, or that there is a genetic relationship between schizophrenia and substance use. An integrative affect-regulation model incorporating individual differences in traits and responses to stress is proposed for future study.
The authors examined patterns of alcohol use among 115 DSM-III schizophrenics discharged from the state hospital and participating in an urban aftercare program. According to ratings by mobile outreach clinicians, 45% of the patients used alcohol, and 22% were clearly abusing alcohol. Alcohol use was associated with younger age, male sex, street drug use, medication noncompliance, lack of psychosocial supports, increased symptomatology, chronic medical problems, and a higher rate of rehospitalization. Even minimal drinking, not considered alcohol abuse by clinicians, predicted rehospitalization during 1-year prospective follow-up.
We reviewed studies measuring unsupervised use of psychoactive substances in schizophrenic and control populations and organized the results by substance class. Despite much variation in their methodologies, these studies broadly agreed that schizophrenic groups' use of amphetamines and cocaine, cannabis, hallucinogens, inhalants, caffeine, and tobacco was significantly greater than or equal to use by control groups consisting of other psychiatric patients or normal subjects. Schizophrenic groups' use of alcohol, opiates, and sedative-hypnotics was significantly less than or equal to use by control groups. We discuss the implications of this nonrandom pattern of drug choice for the hypothesis of substance abuse as a form of self-medication in schizophrenia.
The variable results of positive-negative research with schizophrenics underscore the importance of well-characterized, standardized
measurement techniques. We report on the development and initial standardization of the Positive and Negative Syndrome Scale
(PANSS) for typological and dimensional assessment. Based on two established psychiatric rating systems, the 30-item PANSS
was conceived as an operationalized, drug-sensitive instrument that provides balanced representation of positive and negative
symptoms and gauges their relationship to one another and to global psychopathology. It thus constitutes four scales measuring
positive and negative syndromes, their differential, and general severity of illness. Study of 101 schizophrenics found the
four scales to be normally distributed and supported their reliability and stability. Positive and negative scores were inversely
correlated once their common association with general psychopathology was extracted, suggesting that they represent mutually
exclusive constructs. Review of five studies involving the PANSS provided evidence of its criterion-related validity with
antecedent, genealogical, and concurrent measures, its predictive validity, its drug sensitivity, and its utility for both
typological and dimensional assessment.
This study examined the internal reliability of standardized measures of substance use expectancies and motives in a schizophrenia
population (n = 70) and the relationship of these expectancies and motives to alcohol and drug use disorders. Internal reliabilities were
uniformly high for the subscales of the expectancy and motive measures. Analyses of the relationship between substance use
disorders and expectancies revealed strong substance-specific expectations. Alcohol expectancies were related to alcohol disorders
but not to drug disorders; cocaine expectancies were related to drug but not to alcohol disorders; and marijuana expectancies
were more strongly related to drug than to alcohol use disorders. In contrast, motives were related to substance use disorders,
and self-reported substance use problems were related to expectancies and motives in a nonspecific manner. These results suggest
that expectancy and motive questionnaires developed for the primary substance abuse population may be valid for psychiatric
populations. Research on motives and expectancies may help to clarify the functions of substance abuse in persons with schizophrenia.
Expressed emotion (EE) is a measure of the family environment that has been demonstrated to be a reliable psychosocial predictor of relapse in schizophrenia. However, in recent years some prominent nonreplications of the EE-relapse relationship have been published. To more fully address the question of the predictive validity of EE, we conducted a meta-analysis of all available EE and outcome studies in schizophrenia. We also examined the predictive validity of the EE construct for mood disorders and eating disorders.
An extensive literature search revealed 27 studies of the EE-outcome relationship in schizophrenia. Using meta-analytic procedures, we combined the findings of these investigations to provide an estimate of the effect size associated with the EE-relapse relationship. We also used meta-analysis to provide estimates of the effect sizes associated with EE for mood and eating disorders.
The results confirmed that EE is a significant and robust predictor of relapse in schizophrenia. Additional analyses demonstrated that the EE-relapse relationship was strongest for patients with more chronic schizophrenic illness. Interestingly, although the EE construct is most closely associated with research in schizophrenia, the mean effect sizes for EE for both mood disorders and eating disorders were significantly higher than the mean effect size for schizophrenia.
These findings highlight the importance of EE in the understanding and prevention of relapse in a broad range of psychopathological conditions.
Over 1,700 psychiatric emergency room visits of schizophrenic and schizoaffective patients between 1984 and 1996 were reviewed, and urine drug screens (UDS) were recorded. Illicit drug use increased significantly over the 12-year period, with a large increase for cocaine (0% to 73% of positive UDS), a decline for amphetamines (60% to 0%), and a small increase for marijuana (0% to 27%). Opiate and sedative use remained unchanged. The results support the impression that cocaine use increased dramatically among urban schizophrenic patients beginning in 1988 and continuing to the present. Furthermore, cocaine seems to have replaced amphetamines as the preferred drug of abuse among schizophrenic persons following the crack epidemic.
The effect of motivational interviewing on outpatient treatment adherence among psychiatric and dually diagnosed inpatients was investigated. Subjects were 121 psychiatric inpatients, 93 (77%) of whom had concomitant substance abuse/dependence disorders, who were randomly assigned to: a) standard treatment (ST), including pharmacotherapy, individual and group psychotherapy, activities therapy, milieu treatment, and discharge planning; or b) ST plus motivational interviewing (ST+MI), which involved 15 minutes of feedback on the results of a motivational assessment early in the hospitalization, and a 1-hour motivational interview just before discharge. Interviewers utilized motivational techniques described in Miller and Rollnick (1991), such as reflective listening, discussion of treatment obstacles, and elicitation of motivational statements. Results indicated that the proportion of patients who attended their first outpatient appointment was significantly higher for the ST+MI group (47%) than for the ST group (21%; chi2 = 8.87, df = 1, p<.01) overall, and for dually diagnosed patients (42% for ST+MI vs. 16% for ST only; chi2 = 7.68, df = 1, p<.01). Therefore, brief motivational interventions show promise in improving outpatient treatment adherence among psychiatric and dually diagnosed patients.
There is great concern in the UK, and other countries, about the clinical management of psychosis and substance misuse co-morbidity. However, relatively little is known about the UK prevalence and management of co-morbidity.
We implemented a screening survey of patients who were in treatment with an inner London adult mental health service and measured the prevalence of substance misuse amongst 851 psychotic patients. Caseworkers reported substance misuse and assessed clinical management arrangements.
Current prevalence of substance misuse was 24.4% (95% CI: 21.3-27.1). Rates of co-morbidity were higher in males (31% vs 16%, chi2 1df=26.0, P < 0.001) and patients over 51 (chi2 3df=50.1, P < 0.001). Adjusted odds of co-morbidity in patients under 51 were 0.19 (95% CI: 0.10-0.34) and 0.47 for females (95% CI: 0.32-0.69). Substance misuse interventions were provided to 20% of co-morbid patients--Only 5% were compliant.
The findings suggest substance misuse may be highly prevalent amongst psychotic patients. Most co-morbid patients do not receive appropriate treatment. The development of evidence-based interventions should be a priority.
To assess the effectiveness of a motivational interview among hospitalized psychiatric patients with comorbid substance use disorder in reducing alcohol and other drug (AOD) use.
Subjects were assigned randomly to receive an individual motivational interview (n=79) or a self-help booklet (control condition; n=81).
Subjects were volunteers recruited from a major public psychiatric hospital.
Subjects met abuse or dependence criteria on the structured clinical interview for diagnosis (SCID) for alcohol, cannabis or amphetamine or they reported hazardous use during the last month of one or more of these drug types on the opiate treatment index (OTI).
Either one 30-45-minute motivational interview or brief advice.
The SCID and OTI were the main measures.
There was a modest short-term effect of the motivational interview on an aggregate index of alcohol and other drug use (polydrug use on the OTI). Cannabis use remained high among the sample over the 12-month follow-up period.
Although motivational interviewing appears feasible among in-patients in psychiatric hospital with comorbid substance use disorders, more extensive interventions are recommended, continuing on an out-patient basis, particularly for cannabis use.
Motivational Interviewing (MI) is a brief treatment approach for helping patients develop intrinsic motivation to change addictive behaviors. While initially developed to target primary substance using populations, professionals are increasingly recognizing the promise this approach has for addressing the motivational dilemmas faced by patients who have co-occurring psychiatric and psychoactive substance use disorders. Unfortunately, this recognition has not lead to a clear explication of how MI might be adopted for specific diagnostic populations of dually diagnosed patients. In this article we describe how we have applied the principles and practices of MI to patients who have psychotic disorders and co-occurring drug or alcohol use problems. Specifically, we provide two supplemental guidelines to augment basic MI principles (adopting an integrated dual diagnosis approach, accommodating cognitive impairments and disordered thinking). We present recommended modifications to primary MI skill sets (simplifying open-ended questions, refining reflective listening skills, heightening emphasis on affirmation, integrating psychiatric issues into personalized feedback and decisional balance matrices). Finally, we highlight other clinical considerations (handling psychotic exacerbation and crisis events, recommended professional qualifications) when using MI with psychotic disordered dually diagnosed patients.