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A Comparative Evaluation of Substance Abuse Treatment IV. The Effect of Comorbid Psychiatric Diagnoses on Amount of Treatment, Continuing Care, and 1Year Outcomes
... Research has found that more attendance at 12-step groups during formal treatment is associated with better substance use and functioning outcomes at treatment discharge (Fiorentine and Hillhouse, 2000;Ouimette et al., 1998), but self-help participation during treatment may not be linked to postdischarge outcomes. The number of 12step meetings dual diagnosis patients attended during an acute phase of treatment had no association with outcomes at a 1-year follow-up (Ouimette et al., 1999). Patients who attend self-help meetings after discharge from formal treatment, however, are more likely than those who do not to maintain abstinence, and more attendance is associated with greater improvement in substance use and functioning outcomes (Christo and Franey, 1995;Fiorentine, 1999;Miller et al., 1997;Ouimette et al., 1999). ...
... The number of 12step meetings dual diagnosis patients attended during an acute phase of treatment had no association with outcomes at a 1-year follow-up (Ouimette et al., 1999). Patients who attend self-help meetings after discharge from formal treatment, however, are more likely than those who do not to maintain abstinence, and more attendance is associated with greater improvement in substance use and functioning outcomes (Christo and Franey, 1995;Fiorentine, 1999;Miller et al., 1997;Ouimette et al., 1999). ...
... Although the relationship of 12-step attendance to specific outcomes varied to some extent according to whether attendance was measured in amount, duration or frequency, the results are consistent in showing that more attendance during treatment is beneficial to patients' alcohol and psychiatric outcomes at discharge, and that more attendance following acute care also benefits patients' alcohol, drug and psychiatric problems at 1 year. Dual diagnosis patients clearly derive advantages from 12-step group involvement for both their substance use and mental health problems (Kurtz et al., 1995;Meissen et al., 1999;Ouimette et al., 1999;Rychtarik et al., 2000). Regarding the mechanisms by which attendance "works," one study found that consistent participation in a 12-step program by persons with dual diagnoses was related to better medication adherence, which in turn was related to a lower likelihood of severe mental illness symptoms and of psychiatric hospitalization during a 1-year follow-up period (Magura et al., 2002). ...
This study of dual diagnosis patients examined the associations of the intensity of acute care services and 12-step self-help group attendance with substance use and mental health outcomes.
Participants (n = 230; 96% men) received treatment in one of 14 residential programs and were evaluated with the Addiction Severity Index at discharge (98%) and at 1-year follow-up (80%).
High service intensity in acute treatment was associated with better substance use and family/social outcomes both at discharge and at 1 year when patients' intake status was controlled. More attendance at 12-step self-help groups was also associated with better patient substance use and psychiatric outcomes, both during and following treatment. The benefits of more 12-step group attendance, however, depended on whether acute treatment was of low or high service intensity. More 12-step group attendance during treatment was associated with better alcohol and drug outcomes at discharge only among patients treated in low-service-intensity programs; and more attendance postdischarge was associated with better psychiatric and family/social functioning at 1 year only among patients receiving low-service-intensity care.
We suggest potential means by which high-service-intensity acute care programs might better facilitate patients' postdischarge use of 12-step self-help groups to benefit outcomes.
... Indeed, 7.7 million adults in the U.S. have cooccurring mental health and SU disorders (Han, Compton, Blanco, & Colpe, 2017). Compared to single-disorder individuals, individuals with co-occurring SU and mental health conditions have a more complex and severe clinical presentation that is associated with poorer treatment outcome and a host of negative social, psychological, and health-related consequences (e.g., Ouimette, Gima, Moos, & Finney, 1999;Ouimette & Read, 2014;Santucci, 2012;Sheidow, McCart, Zajac, & Davis, 2012;Stewart et al., 2016;Todd et al., 2004). Moreover, individuals with comorbid SU and psychiatric conditions are more likely to report use of multiple substances, which can further complicate diagnosis and treatment (Agrawal, Lynskey, Madden, Bucholz, & Heath, 2007). ...
Introduction
Measures of motives for alcohol use provide an important avenue for understanding underlying psychological reasons that drive use and predict distinct patterns of use. The Modified Drinking Motives Questionnaire–Revised (MDMQ-R; Grant, Stewart, O'Connor, Blackwell, Conrod, 2007) measures five drinking motives: social, enhancement, conformity, coping-with-anxiety, and coping-with-depression. The MDMQ-R and its predecessors have previously been validated only in non-clinical normative samples.
Purpose
Therefore, the present study aimed to validate the factor structure and internal consistency of the MDMQ-R in a diverse psychiatric sample of substance-using young adults that presented with either exclusive alcohol use or polysubstance use.
Method
Participants were 255 substance-using young adults (18-26 years; M= 21.17) admitted to the young adult partial hospitalization treatment program at a private psychiatric hospital (62% female, 78% Caucasian, 43% students).
Results
A confirmatory factor analysis revealed that items loaded on their respective latent factors (ps<.01; loadings between .50-.90; reliabilities between .80-.94). However, goodness of fit statistics were not reflective of model fit found in Grant et al. (2007) in the overall sample, as well as in alcohol-only and polysubstance-using samples.
Discussion
Results suggest that the factor structure of the MDMQ-R did not replicate in the present sample. Potential explanations and future directions are discussed in light of the results, including generalizability and clinical utility.
... In Oumette et al.'s follow-up study, comorbid AD impaired engagement in SUD treatment, and comorbid AD-SUD patients had worse results in functioning and symptom measures when compared with patients with SUD alone. About 41.6% of patients with comorbid diagnosis reported significant distress [38]. Ford et al. reported that severity of PTSD symptoms is associated with poor contingency management, but not standard treatment [39]. ...
Substance use disorders is a worldwide public health problem that commonly ocur together with our psychiatric and medical disorders. Along with etiologic origins, prognosis of anxiety disorders intercepts with substance use disorders. Due to overlapping symptoms and complaints, it is always difficult for clinicians to recognise these disorders separately. In addition, selecting the best treatment approach is challenging because of the relative risk for developing anxiety disorders in substance use patients or vice versa. In this chapter, authors are focused on adding new aspects to the clinicians for evaluating, treating and following patients with comorbid substance use disorder and anxiety disorder.
... Clients with comorbid mental health disorders can present with complex psychological symptoms that have the potential to interfere with treatment for the substance use disorder, and the long term outcomes of substance use treatment [20][21][22][23]. Typically, clients with comorbid mental health and substance use conditions present with a more severe clinical profile compared to clients with a substance use disorder alone, including poorer physical health, more severe substance use, increased risk of homelessness, poorer social and occupational functioning and greater difficulties in interpersonal and family relationships [24,25]. ...
Issues:
The aim of this paper was to conduct a systematic review of the prevalence of comorbid mental health conditions in people accessing treatment for substance use in Australia.
Approach:
A systematic review identified studies meeting the following eligibility criteria: reporting original data published in English; sample presenting for substance use treatment in Australia; assessing the prevalence of mental health and substance use conditions and reporting the percentage of participants with co-occurring mental health and substance use conditions. A narrative analysis was conducted because of the heterogeneity of methods used to assess key outcome variables and small number of studies assessing particular mental health outcomes. The abstracts of 1173 records were screened, and 59 full articles were assessed for eligibility. Eighteen studies were included in the review.
Key findings:
Prevalence estimates of current mental disorders in substance use treatment clients varied (47 to 100%). Mood and anxiety disorders were particularly prevalent, with the prevalence of current depression ranging from 27 to 85% and current generalised anxiety disorder ranging from 1 to 75%.
Implications:
The high prevalence of mood and anxiety disorders in substance use treatment settings indicates a need for clinicians to screen and assess for these disorders as part of routine clinical care, and be familiar with evidence-based management and treatment strategies.
Conclusion:
Although further studies are required to determine the prevalence of the full range of mental health disorders in this population, these findings emphasise the high prevalence of comorbid mental disorders are among individuals accessing substance use treatment in Australia. [Kingston REF, Marel C, Mills KL. A systematic review of the prevalence of comorbid mental health disorders in people presenting for substance use treatment in Australia. Drug Alcohol Rev 2016;00:000-000].
... However, all of these studies have follow-ups that are three years or less. Other studies (again, with follow-ups less than three years) have not found significant relations between affective/anxiety disorders and risk for alcohol relapse (Bowen et al., 2000;Davidson and Blackburn, 1998;Marquenie et al., 2006;Ouimette et al., 1999;Powell et al., 1992;Sellman and Joyce, 1996), although some of these studies examined lifetime rather than current affective/anxiety diagnoses or included individuals who were receiving treatment for both their alcohol/affective anxiety problems. Overall, the current literature is unclear as to whether having an affective or anxiety disorder increases risk of relapse from an AUD in treatment samples, particularly in the long-term. ...
Objective: This study examined how effort to regulate alcohol use may interact with anxiety and affective disorders to influence long-term remission from alcohol dependence.
Method: Using participants (n = 96; 73% male; 66% children of alcoholics; 71% non-Hispanic Caucasian; 26% Hispanic) from a high-risk community study who showed evidence of recovered alcohol dependence at baseline, this study examined whether effort to regulate alcohol use at the baseline assessment significantly influenced the likelihood of maintaining remission from alcohol dependence for a period of five years or more. This study also examined whether having an anxiety or affective disorder interacted with effort to regulate alcohol use. All analyses controlled for treatment history, baseline alcohol use, parent alcoholism, age and gender.
Results: Results from logistic regressions showed that effort to regulate alcohol use had a significant unique main effect on long-term maintenance of remission from alcohol dependence. Having an affective and/or anxiety disorder did not have a significant main effect on the maintenance of remission. However, having an anxiety/affective disorder significantly moderated the influence of effort to regulate alcohol use such that the protective effect of effort to regulate use on remission from alcohol dependence was only significant for those without an affective or anxiety disorder.
Conclusions: Individuals who try harder to limit their drinking are more likely to maintain long-term remission from alcohol dependence. However, affective and anxiety disorders may undermine the protective effect of effort to regulate alcohol use on long-term remission.
... Wystêpowanie zaburzeñ psychicznych, np. depresyjnych, czy te¿ du¿e nasilenie ich objawów nie musi jednoznacznie wi¹zaae siê z niepowodzeniem terapii u pacjentów uzale¿nionych od alkoholu (42,54,56,117,139,140,142,143). W niektórych badaniach pacjenci ze wspó³istniej¹c¹ du¿¹ depresj¹ osi¹gali nawet d³u¿sze okresy abstynencji i mieli ni¿sze ryzyko nawrotu picia ni¿ pacjenci bez depresji. ...
ñ Among factors related to patient relapse, social and demographic variables such as gender, age, marital status, employment, social support resources as well as psychological and biological characteristics were reported. Psychological predictors include negative mood states, craving, self- efficacy, limited skills to cope with high-risk events, neurocognitive abnormalities, impulsiveness and other personality traits. Comorbid psychopathology has also received much attention as a sig- nificant predictor of poor treatment outcomes in alcoholic patients. Among psychiatric disorders ñ affective, anxiety, personality disorders such as borderline and antisocial personality are particularly associated with a high risk of relapse to heavy drinking. Comorbid depression has been considered as probably the strongest risk factor for failure in maintaining abstinence. In addition to psychiatric diagnosis, severity of psychopathology also has been found to be more pronounced among patients who relapsed, compared to abstainers. Several studies reported relationships between anxiety and alcoholism. Anxiety promotes drinking (self-medication), substance misuse and can lead to relapse. Among personality disorders, borderline, avoidant and antisocial personality disorders are the most strongly associated with the risk for relapse in alcohol dependence.
... Several meta-analyses have demonstrated that AA is beneficial for many people (Emrick et al, 1993;, and two large-scale studies have shown that 12-step therapy is equally effective as Cognitive behavioral therapy, and actually superior when total abstinence was the treatment goal (Project MATCH, 1997;1998;Ouimette, 1999). In this context, a series of studies have investigated how AA groups differ in social dynamics and, in turn, how such perceived dynamics influence the practicing of prescribed AA-related behaviors such as working the 12 steps (Montgomery et al., 1995;Horstmann & Tonigan 2000). ...
... In addition, we examined whether patients' improvement differed for patients with a comorbid personality disorder compared to patients with comorbid axis one diagnoses (e.g., schizophrenia, major depression). Patients with personality disorders were expected to show more improvement than patients with axis one diagnoses [28,33]. The ethics committee of the University Hospital of Psychiatry Berne approved the study in advance. ...
The purpose of this study was to assess a 4-month inpatient treatment program based on integrated models for patients with substance use and psychiatric disorders (dual diagnosis patients). On admission and at the 1-year follow-up, a consecutive sample of 118 dual diagnosis patients who entered the program were assessed by interview. Eighty-four patients (70.6%) completed the 1-year follow-up interview, reporting less frequent substance use, less severe psychiatric symptoms, a lower rehospitalization rate, and better housing conditions than on admission. Patients diagnosed with a comorbid personality disorder had a better improvement in the frequency of drinking and were less likely to be rehospitalized than patients with schizophrenia or depression. The results suggest that the integrated inpatient program may be a promising treatment approach for dual diagnosis patients. The results await replication in controlled studies that need to include an assessment of outpatient treatment following inpatient programs.
... 33 For example, patients with co-occurring psychiatric disorders may be less likely to continue substance use disorder care and to be abstinent. 34 However, just as data on PPM and outcome percentages at the facility level provide little information on the relationship between the PPM and outcomes for patients within facilities, facility-level data on potential confounders provide little information on the relationships among the PPM, outcomes, and confounders for patients within facilities. Thus, entering the proportion of substance use disorder patients at various facilities with comorbid psychiatric conditions as a covariate in a facility-level analysis would be unlikely to control for the confounding of psychiatric conditions with receipt of continuing care and outcomes at the patient level. ...
Relationships between health care process performance measures (PPMs) and outcomes can differ in magnitude and even direction for patients versus higher level units (e.g., health care facilities). Such discrepancies can arise because facility-level relationships ignore PPM-outcome relationships for patients within facilities, may have different confounders than patient-level PPM-outcome relationships, and may reflect facility effect modification of patient PPM-outcome relationships. If a patient-level PPM is related to better patient outcomes, that care process should be encouraged. However, the finding in a multilevel analysis that the proportion of patients receiving PPM care across facilities nevertheless is linked to poor hospital outcomes would suggest that interventions targeting the health care facility also are needed.
... those with SUD-only (Chi, Satre, & Weisner, 2006). Following treatment, many of these individuals return to substance use, experience employment and social difficulties, and report significant distress and psychiatric symptoms (Ouimette, Gima, Moos, & Finney, 1999). Identifying factors associated with substance use may aid clinicians and providers in their efforts to better meet the needs of this population. ...
This longitudinal study examined the contribution of anxiety/depressive symptoms and lifetime and recent trauma exposure to substance use after residential substance abuse treatment among individuals with co-occurring disorders. Data were collected from adults at treatment entry and 6 and 12 months later. At treatment entry, nearly all participants reported lifetime trauma exposure, and over one third met criteria for posttraumatic stress disorder (PTSD). Over the follow-up, nearly one third of the participants were exposed to trauma. Lifetime trauma exposure and a diagnosis of PTSD at treatment entry were not associated with substance use over the follow-up. Trauma exposure and anxiety/depressive symptoms over the follow-up were associated with an increased likelihood of substance use. Gender did not moderate the association between trauma exposure and anxiety/depressive symptoms and substance use. These findings highlight the importance of monitoring for trauma exposure and symptoms of anxiety/depression to better target interventions and continuing care approaches to reduce the likelihood of posttreatment substance use in this population.
... The data for this study were drawn from a larger project on the outcome of SUD treatment (for details, see Ouimette, Finney, & Moos, 1997;Ouimette, Gima, Moos, & Finney, 1999). This study expands on this prior work by considering four questions: (a) Do DD patients perceive SUD residential treatment programs as positively as SUD patients and do they benefit as much during treatment, as shown by their proximal outcomes at discharge? ...
Few studies have investigated whether dually diagnosed patients with co-occurring substance use and psychiatric disorders (DD) respond as well to substance use disorder (SUD) treatments as patients with SUD do. Here we assessed whether male veteran DD and SUD patients with alcohol dependence diagnoses differed in the process and outcomes of residential SUD treatment. The main findings showed that (a) DD patients did not perceive SUD programs as positively as patients with SUD did and had worse proximal outcomes at discharge from treatment; (b) DD patients did as well as SUD patients on 1- and 5-year substance use outcomes but had worse psychiatric outcomes; and (c) patients who perceived treatment more positively and had better outcomes at discharge had better longer term outcomes. Thus, residential SUD programs are relatively effective in reducing DD patients' substance use problems; however, they are less successful in engaging DD patients in treatment and addressing their psychiatric problems.
... Those with psychopathology did equally well in TSF and CBT in Project MATCH, but depressed clients did better in CBT than in TSF in Maude-Griffin's study (Maude-Griffin et al., 1998). Many have expressed concern that AA may be inappropriate for those with psychiatric problems (American Psychiatric Association, 1995;Noordsy, Schwab, Fox, & Drake, 1996), but empirical evidence of AA's effectiveness has begun to paint a different picture (Morgenstern et al., 2003;Morgenstern, Kahler, & Epstein, 1998;Ouimette, Gima, Moos, & Finney, 1999). Given the high level of concurrent mental health disorders among treatment-seeking clients, MAAEZ is especially promising for those at the high end of the severity spectrum. ...
Most treatment programs recommend clients attend 12-step groups, but many drop out posttreatment. The effectiveness of Making Alcoholics Anonymous [AA] Easier (MAAEZ ), a manual-guided intervention designed to help clients connect with individuals encountered in AA, was tested using an "OFF/ON" design (n = 508). MAAEZ effectiveness was determined by comparing abstinence rates of participants recruited during ON and OFF conditions and by studying the effect of the number of MAAEZ sessions attended. At 12 months, more clients in the ON condition (vs. OFF) reported past 30-day abstinence from alcohol (p = .012), drugs (p = .009), and both alcohol and drugs (p = .045). In multivariate analyses, ON condition participants had significantly increased odds of abstinence from alcohol (odds ratio [OR] = 1.85) and from drugs (OR = 2.21); abstinence odds also increased significantly for each additional MAAEZ session received. MAAEZ appeared especially effective for those with more prior AA exposure, severe psychiatric problems, and atheists/agnostics. MAAEZ represents an evidence-based intervention that is easily implemented in existing treatment programs.
... For example, recovery from substance abuse was poorer when patients had comorbid anxiety or depressive disorders. 49 Comorbid patients had comparable substance abuse outcomes but fared worse on psychological symptoms and employment outcomes. Similarly, recovery from bulimia nervosa was poorer when there was comorbidity with depression. ...
A more complete understanding of the psychosocial and clinical predictors of response to pharmacotherapy would be of great value to both patients and physicians. Most demographic and clinical factors have not been found to be useful predictors of response. Although comorbid illness affects quality of life, there is confounding evidence about its importance when predicting response to antidepressant therapy. Some social support factors appear to be positive predictors of outcome in most trials. There is evidence to suggest that comorbid anxiety disorders and panic-agoraphobic spectrum symptoms are negative predictors of response to treatment. Substance abuse has been associated with a poorer response to antidepressant therapy, and recovery from substance abuse problems has been shown to be poorer among patients with comorbid depression. Assessment of personality dimensions may be a useful predictor of clinical course and outcome, but personality disorders present a complicated picture, with significant interaction among variables. A number of variables are significantly related to clinical course, but few factors have been clearly linked to treatment response. The challenge is to determine if any of these factors are indeed independent predictors of response and whether it is possible to match choice of antidepressant therapy and patient type.
... st have (a) abstained from all 13 drugs investigated, (b) had no problems related to drug or alcohol abuse and (c) consumed 3 ounces or less of alcohol per day on maximum drinking days in the past 3 months. Freedom from problems related to substance use was reflected by a response of 'never' to all items from the Problems From Substance Use scale (Ouimette et al . 1999b). Participants were coded '0' if they were not remitted at the time of follow-up. Our rationale for including non-problem drinkers in the remitted category was twofold. First, some patient did not have alcohol use disorders before treatment and may have continued to drink moderately without problems after treatment. Secondly, some patie ...
Many patients treated for substance use disorders (SUDs) who become involved in 12-Step self-help groups have improved treatment outcomes. However, due to high rates of psychiatric comorbidity and major depressive disorder (MDD), among SUD patients in particular, concerns have been raised over whether these benefits extend to dual diagnosis patients. This study examined the influence of comorbid MDD among patients with SUDs on 12-Step self-help group involvement and its relation to treatment outcome.
A quasi-experimental, prospective, intact group design was used with assessments completed during treatment, and 1 and 2 years postdischarge.
A total of 2161 male patients recruited during in-patient SUD treatment, of whom 110 had a comorbid MDD diagnosis (SUD-MDD) and 2051 were without psychiatric comorbidity (SUD-only).
SUD-MDD patients were initially less socially involved in and derived progressively less benefit from 12-Step groups over time compared to the SUD-only group. However, substance use outcomes did not differ by diagnostic cohort. In contrast, despite using substantially more professional out-patient services, the SUD-MDD cohort continued to suffer significant levels of depression.
Treatment providers should allocate more resources to targeting depressive symptoms in SUD-MDD patients. Furthermore, SUD-MDD patients may not assimilate as readily into, nor benefit as much from, traditional 12-Step self-help groups such as Alcoholics Anonymous, as psychiatrically non-comorbid patients. Newer, dual-diagnosis-specific, self-help groups may be a better fit for these patients, but await further study.
... In order to be categorized as remitted (coded ''1''), a patient must have (a) abstained from all 13 drugs investigated in the current study, (b) had no problems related to drug or alcohol abuse, and (c) consumed 3 ounces or less of alcohol per day on maximum drinking days in the past 3 months. Freedom from problems related to substance use was reflected by a response of ''never'' to all items from the Problems From Substance Use scale (Ouimette, Gima, et al., 1999). Partic- ipants were coded ''0'' if they were not remitted at the time of followup. ...
Attendance at 12-step self-help groups is frequently recommended as an adjunct to professional substance use disorder (SUD) treatment, yet patient dropout from these groups is common. This study assessed the prevalence, predictors, and treatment-related factors affecting dropout in the first year following treatment for 2,778 male patients. Of these, 91% (2,518) were identified as having attended 12-step groups either in the 90 days prior to, or during, treatment. At 1-year followup 40% had dropped out. A number of baseline factors predicted dropout. Importantly, patients who initiated 12-step behaviors during treatment were less likely to drop out. Further findings suggest patients at highest risk for dropout may be at lower risk if treated in a more supportive environment. Clinicians may decrease the likelihood of dropout directly, by screening for risk factors and focusing facilitation efforts accordingly, and indirectly, by increasing the supportiveness of the treatment environment, and facilitating 12-step involvement during treatment.
... Moreover, depression should be re-assessed following stabilization or abstinence (see Husband et al., 1996; Strain, Stitzer, & Bigelow, 1991), as self-reports may overestimate depressive disorders, particularly early in treatment episodes when patients may be experiencing withdrawal. Diagnosing personality disorders in substance users is challenging (see Ball, Rounsaville, Tennen, & Kranzler, 2001), but accurate identification of personality disorders may be important in treatment planning (Ball & Cecero, 2001) because personality disorders are common in drug users and generally confer poorer prognosis (Marlowe, Kirby, Festinger, Husband, & Platt, 1997; Ouimette, Gima, Moos, & Finney, 1999; Rounsaville et al., 1998). In addition, comorbid personality disorder among drug users has also been associated with greater severity of substance dependence, particularly in the case of antisocial personality disorder (Brooner, King, Kidorf, Schmidt, & Bigelow, 1997; Galen, Brower, Gillespie, & Zucker, 2000). ...
Although there are a wealth of clinically useful, brief, and low-cost assessment instruments available for use with drug-dependent populations, relatively few are broadly used in clinical practice. With an emphasis on: (1). the multidimensional nature of drug users' problems; and (2). assessments that can be integrated into empirically validated treatments, clinically useful assessments in four general categories (evaluation and diagnosis of drug dependence, identifying concurrent disorders and problems, treatment planning, and evaluation of treatment outcome) are briefly summarized. Progress in the field of drug abuse treatment has been significantly hampered by the failure to adopt, across research and clinical settings, a common set of assessments.
... In line with the study results of Dixon et al . (1998) and Ouimette et al . (1999) based on treated subjects, we can assume that comorbidity does not lead to worse outcomes on alcohol measures, although lower levels of psychological functioning can be found even in remitted alcohol-dependent subjects with a life-time history of comorbidity. Data suggest that processes of remission from non-substance use diagnosis seem ...
It is well known that only a minority of alcohol-dependent subjects seek help and that the majority of alcohol-dependent individuals recover without utilization of formal help. Psychiatric comorbidity is highly prevalent among alcohol-dependent individuals. However, no data are available on the impact of psychiatric comorbidity on natural recovery.
To analyse the impact of non-psychotic psychiatric comorbid Axis I disorders on remission rate and utilization of formal help in alcohol-dependent individuals drawn from a representative general population sample in northern Germany (response rate: 70.2%, n = 4075). Psychiatric diagnoses and utilization of help were assessed in a personal interview using standardized instruments. One hundred and fifty-three life-time alcohol-dependent individuals were assessed, among whom 98 fulfilled the criteria for sustained long-term remission according to the Diagnostic and Statistical Manual version II (DSM-IV) criteria. Any coincidence of DSM-IV non-psychotic Axis I disorders with alcohol dependence was counted as comorbidity. Comorbidity rate in the whole sample was 36.1%.
The rate of individuals who remitted from alcohol dependence without formal help was 36.9% in the non-comorbid and 42.6% in the comorbid group. Utilization of formal help was unrelated to comorbidity. Dually diagnosed subjects without a history of help-seeking showed minor differences concerning reasons for not seeking help. Seeking help was not related to schooling, severity of dependence and gender.
Data reveal that remission without formal help is equally prevalent among non-comorbid as among comorbid alcohol-dependent individuals. Axis I comorbidity is not related directly to utilization of alcohol-related help. Negative prognoses for untreated comorbid alcohol-dependent individuals are not justified from an epidemiological point of view.
... Abstinence was most highly correlated with post-discharge out-patient treatment and with 12-Step program participation, such as with AA, during the year after discharge. The researchers did not evaluate outcomes for clients with psychotic disorders separately in this report, but in another analysis of the same data outcomes for clients with severe mental illnesses were the same as those with milder mental illnesses [37]. ...
Substance use disorder is the most common and clinically significant co-morbidity among clients with severe mental illnesses, associated with poor treatment response, homelessness and other adverse outcomes. Residential programs for clients with dual disorders integrate mental health treatment, substance abuse interventions, housing and other supports. Ten controlled studies suggest that greater levels of integration of substance abuse and mental health services are more effective than less integration. Because the research is limited by methodological problems, further research is needed to establish the effectiveness of residential programs, to characterize important program elements, to establish methods to improve engagement into and retention in residential programs and to clarify which clients benefit from this type of service.
... Substance-related problems. Participants also completed the Problems From Substance Use scale (Ouimette, Gima, Moos, & Finney, 1999). This assesses the negative consequences of alcohol and drug use, including domains such as health, legal, monetary, occupational, residential, and interpersonal. ...
To better understand the relationship between abstinence self-efficacy and treatment outcomes in substance use disorder patients, experts in the field need more information about the levels of abstinence self-efficacy most predictive of treatment outcomes. Participants (N = 2,967) from 15 residential substance use disorder treatment programs were assessed at treatment entry, discharge, and 1-year follow-up. A signal detection analysis compared the ability of different measures of self-efficacy to predict 1-year abstinence and identified the optimal cutoffs for significant predictors. The maximal level of abstinence self-efficacy (i.e., 100% confident) measured at discharge was the strongest predictor of 1-year abstinence. Treatment providers should focus on obtaining high levels of abstinence self-efficacy during treatment with the goal of achieving 100% confidence in abstinence.
Objective: To determine mental health service utilization patterns among women treated for substance use disorders (SUD) and identify factors associated with patterns of high mental health service use.
Methods: Data were provided by 4,447 women treated for SUD in California during 2000-2002 for whom mental health services utilization records were acquired. A latent class model was fitted to women’s high use of services (>6 services/year over 8 years). Multinomial logistic regression was used to identify predisposing, enabling, and need factors associated with utilization patterns.
Results: In 8 years after initiating SUD treatment, 50% of women utilized mental health services. High use probability was consistently low for most women (76.9%); for others, however, it decreased immediately following SUD treatment and then increased over time (9.3%), increased immediately following SUD treatment and then decreased (8.7%), or remained consistently high (5.1%). Consistently high services use was negatively associated with marriage (OR 0.60, p<0.05) and employment (OR 0.53, p<0.05) and positively associated with older age (OR 1.04, p<0.001), homelessness (OR 1.68, p<0.05), public assistance (OR 1.76, p<0.01), outpatient SUD treatment (OR 3.69, p<0.01), longer SUD treatment retention (OR 1.00, p<0.01), treatment desire (ORs 1.46, p<0.001), and co-occurring disorder diagnosis (ORs 2.89-44.93, p<0.001). Up to 29% of women with co-occurring mental health disorders at SUD treatment entry did not receive any mental health treatment in the subsequent 8 years.
Conclusions: Mental health services utilization patterns among women treated for SUD are hetereogeneous and dynamic. Understanding factors related to women’s utilization patterns may aid efforts to optimize care and ensure appropriate use of mental health services.
Full text is online at http://authors.elsevier.com/a/1RwE~2eOOLi8XV
There are few clinical trials of 12-step treatments for individuals with serious mental illness and alcohol or drug dependence. This randomized trial assessed the effects of adding a 12-session 12-step facilitation therapy (TSF), adapted from that used in Project MATCH, to treatment as usual in an outpatient dual diagnosis program. Participants were 121 individuals dually diagnosed with alcohol dependence and a serious mental disorder, followed during 12 weeks of treatment and 36 weeks post-treatment. Participants receiving TSF had greater participation in 12-step programs, but did not demonstrate greater improvement in alcohol and drug use. However, considered dimensionally, greater participation in TSF was associated with greater improvement in substance use, and greater 12-step participation predicted decreases in frequency and intensity of drinking. Findings suggest that future work with TSF in this population should focus on maximizing exposure to TSF, and maximizing the effect of TSF on 12-step participation.
This investigation involved a first-attempt at modeling long-term treatment and work trajectories in a large, urban sample of individuals in publicly funded substance abuse treatment: (a) determining the demographic factors that predicted work patterns and (b) examining the longitudinal relationship between work status and continued treatment, persistent drug use, and psychological problems investigated work status across three years. Mixed-effects regression models revealed that significantly more participants were working and looking for work at each follow-up. Gains in labor force participation were greatest at six months while gains in employment were greatest at 24 months. Several demographic variables predicted later work status including age, gender, living arrangement, occupational skills, and having children in foster care. Participants who continued treatment, continued to use drugs, or reported psychological problems were most likely to be out of the labor force. By far, the greatest barrier to long-term employment was continued drug use.
Objective: The purpose of this study, which is part of a larger clinical trial, was to examine the cost-effectiveness of case management for individuals treated for substance abuse in a residential setting. Method: Clients who agreed to participate were randomly assigned to one of four study groups. Two groups received face-to-face case management and one telecommunication case management, and the fourth was the control group. Results: Using a ratio of cost to days free from substance abuse, the case management groups were less cost-effective than the control group at 3 months, 6 months, and 12 months. The telecommunication case management was least cost-effective of the three case management conditions. Conclusion: Results from the analysis revealed case management is not cost-effective as a supplement to traditional drug treatment over a 12-month follow-up period.
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.
The concept of personality in addiction research has traditionally been subject to controversies about its measurement and role in aetiology and treatment. Early studies (1950-1980) typically sought but failed to identify a single pre-addictive personality, suggesting either clinical heterogeneity or the unimportance of personality as an aetiological factor. This review summarizes recent evidence for the notion that distinct personality traits do play an important role in several pathways to addictive behaviours. Furthermore, it will be argued that recent studies strongly indicate the clinical relevance of the routine assessment of (maladaptive) personality traits in individuals admitted for substance abuse treatment.
The purpose of this study was to explore the prevalence rates of co-occurring mental health problems among 70 flight attendants
in substance abuse treatment. Results indicated that flight attendants in treatment were more likely to experience alcohol
dependency than drug dependency. A high proportion of participants reported clinical levels of anxiety, major depressive disorder,
dysthymia, and dependent personality disorder. Quality of life indicators suggested that the flight attendants were slightly
above average in life satisfaction for a treatment population. Implications for clinical practice with this population were
also discussed.
KeywordsFirst responders–Flight attendants–Substance abuse–Mental health
Anxiety disorders commonly occur among those with substance use disorders. This article reviews the literature describing the prevalence and patterns of this comorbidity in epidemiological and clinical samples and theoretical models explaining this comorbidity, and reviews the effects of anxiety disorders on substance use outcomes and data from clinical trials that target comorbid anxiety disorders to examine the effects of treating anxiety disorders on substance use outcomes. Next, this review outlines evidence-based pharmacological and psychological treatments for anxiety disorders and provides treatment recommendations for those treating this comorbid population. Finally, a discussion of treatment-delivery issues is presented to address the important issues that arise when treating anxiety disorders in typical addictions-treatment settings.
This study critically examined associations among past year alcohol use, self-rated mental health and HIV risk-related behaviors for men and their partners, i.e., two or more partners and/or perpetration of partner violence. Data are reported from a population sample of 1,137 men aged 16-49 in Karnataka. Overall, 9.5% of all men reported HIV risk-related behaviors, 38.1% consumed alcohol, and about half (54.5%) of all current drinkers met criteria for hazardous alcohol use. Hazardous alcohol use and poorer mental health remained significantly associated with HIV-risk related behaviors after controlling for socio-demographics and psychosocial risk factors. More severe alcohol misuse, specifically alcohol dependence, and co-morbid hazardous alcohol use and poorer mental health, was associated with over two- and five-fold increases, respectively, in men's HIV risk-related behaviors. Implications of findings for HIV prevention and intervention programs for men and their partners and directions for future research are discussed.
We compared outpatients (regional facility) with substance use and psychiatric (N = 199) or only substance use (N = 146) disorders on baseline and one-year symptoms (93% follow-up), and treatment and 12-step group participation over the year (2005). We examined whether diagnostic status moderated associations between participation and outcomes (Addiction Severity Index) with regressions. At follow-up, dual diagnosis patients had more severe symptoms, despite comparable treatment. The groups were comparable on 12-step participation, which was associated with better outcomes. However, associations of participation with better outcomes were weaker for dual diagnosis patients. Study (VA HSR&D-funded) implications and limitations are noted and research suggested.
Cross-cultural comparisons may increase our understanding of different models of substance use treatment and help identify consistent associations between patients' characteristics, treatment conditions, and outcomes.
The aim of the study was to compare matched samples of substance use disorder (SUD) patients with personality disorders (PD) in Swiss and the United States (U.S.) residential SUD treatment programs and examine the relationship of program characteristics to 1-year outcomes.
A prospective, naturalistic design was used to compare 132 demographically matched Swiss and U.S. male patients drawn from a sample of 10 Swiss and 15 U.S. public treatment programs. Patients completed comparable inventories at admission, discharge, and 1-year follow-up.
Compared to Swiss SUD-PD patients, U.S. SUD-PD patients had more severe substance use and psychosocial problems at admission and follow-up. More intensive treatment and a stronger emphasis on patients' involvement were related to better outcomes for both Swiss and U.S. SUD-PD patients. Conclusion: There may be some cross-cultural consistency in the associations between treatment characteristics and SUD-PD patients' outcomes.
Treatment evaluation findings from representative programs in one country may apply elsewhere and contribute to our overall knowledge about how to improve SUD-PD patients' outcomes.
Studies measuring the effectiveness of 12-step self-help group attendance have yielded mixed results but none of the prior studies have accounted for the potential impact of interim abstinence status.
Participants were 1683 patients with substance use disorders (SUD) from 88 community residential facilities. Self-report data were collected at baseline and 1- and 4-year follow-ups, and included measures of SUD severity, social resources, coping, and 12-step self-help group attendance. We tested the hypothesis that 12-step self-help group attendance is more effective for non-abstinent patients than for abstinent patients. We also controlled for self-selection effects by using propensity score analyses and we cross-validated our results in a second sample of patients (N=2173).
Sample 1. Patients abstinent at 1-year post-treatment who attended 12-step self-help group meetings were no more likely to be abstinent at 4 years than abstinent patients who did not attend. However, for patients not abstinent at 1 year, a significant improvement in abstinence rates at 4 years emerged for those who attended 12-step self-help groups compared to those who did not (42% vs. 28.9%). A similar pattern emerged for SUD problems. There were no benefits from 12-step self-help group attendance for patients abstinent at 1 year, but non-abstinent patients who attended 12-step self-help groups had significantly fewer problems at 4 years. Sample 2. The cross-validation yielded consistent results as 12-step self-help group attendance led to higher abstinence rates and fewer SUD problems only among patients non-abstinent at interim assessment.
Individual's abstinence status should be considered when evaluating the potential influence of 12-step self-help group attendance on SUD outcomes. In addition, increased clinical resources should focus on assessing patients after discharge and on improving linkage of non-abstinent patients to self-help groups.
We examined the association between relapse-to-drinking and depressive symptomatology measured during inpatient treatment for alcohol disorder and 3 months posttreatment. Data were obtained from 298 veterans who completed 21-day inpatient treatment. Follow-up interviews were conducted at 3, 6, 9, and 12 months posttreatment. We used multiple logistic regression to assess the association between relapse and baseline/3-month posttreatment measures of depression (Beck Depression Inventory; BDI), controlling for important covariates. Our results showed that (a) the mild-to-moderately symptomatic participants (BDI = 14-19) at 3 months posttreatment were on average 2.9 times more likely than the nondepressed to have relapsed across follow-ups, and (b) the severely symptomatic participants (BDI = 20+) at 3 months posttreatment were on average 4.9 times more likely to have relapsed across follow-ups. Other analyses revealed that those with persistent depressive symptomatology reported at both baseline and 3 months posttreatment did not experience worse outcomes that those who reported symptomatology at 3 months posttreatment alone.
Over 3,000 patients from 15 VA inpatient, substance abuse treatment programs showed considerable improvement from intake to
a one-year follow-up. Patients in 12-step programs, as opposed to cognitive-behavioral (CB) or eclectic programs, and those
with more extended continuing outpatient mental health care and 12-step self-help group involvement, were more likely to be
abstinent and free of substance use problems at follow-up. Consistent with their better one-year outcomes, patients in 12-step
programs improved more between intake and discharge than CB patients on proximal outcomes assumed to be specific to 12-step
treatment (e.g., disease model beliefs) and as much or more on CB proximal outcomes. Proximal outcomes assessed at treatment
discharge and follow-up were, at best, modestly related to one-year substance use and other outcomes. No evidence was found
that CB or 12-step treatment is more beneficial for certain types of patients.
This study asked whether men and women who enrolled in substance use treatment reported similar changes in income from work, public assistance, and crime over time. Income data were analyzed for 261 substance users (77 women, 184 men) who entered day or residential treatment, and completed Addiction Severity Index measures at treatment entry and up to 18 months later. Over time, respondents reported increases in employment income. People whose main source of income at baseline had been crime or public assistance showed significant decreases respectively in income from crime or public assistance. Men made greater gains in work income than women did. Across time, men were more likely to be employed than women were. Findings show the economic value of substance use treatment, but less improvement in employment outcomes for women than men.
Anxiety sensitivity (AS) has been linked to both pathological anxiety and substance use problems. We evaluated relations between AS and substance use situations among individuals with substance use disorders (SUDs) and concurrent DSM-IV anxiety disorders. We predicted that AS would be most strongly associated with substance use in situations involving negative emotions and interpersonal conflict in substance abusers with anxiety disorders. This group was compared to substance abusers with concurrent mood disorders and substance abusers without other disorders (N=88). AS was positively related to negative emotion situations substance use for substance abusers with anxiety disorders and for substance abusers without other disorders. Contrary to predictions, significant differences between these groups were not found. The relationship between AS and negative emotion situations substance use remained after controlling trait anxiety in a combined group (anxiety disorders and substance abuse only groups). AS did not predict substance use for participants with concurrent mood disorders. Identification of factors that place anxious patients at risk for substance use problems will have implications for treatment and for the prevention of this form of maladaptive coping.
The authors examined whether continuing outpatient mental health care, the orientation of the treatment program (12-step, cognitive-behavioral, or eclectic), and involvement in self-help groups were linked to substance abuse patients' remission status two years after discharge.
The data were from a cohort of 2,805 male patients who were treated through one of 15 Department of Veterans Affairs substance abuse programs. Remission was defined as abstinence from illicit drug use and abstinence from or nonproblem use of alcohol during the previous three months. The relationships of the three variables to remission were tested with regression models that controlled for baseline characteristics.
About a quarter of the study participants (28 percent) were in remission two years after discharge. Intake characteristics that predicted remission at two years included less severe substance use and psychiatric problems, lower expected disadvantages and costs of discontinuing substance use, and having abstinence as a treatment goal. No significant relationship emerged between treatment orientation and remission status two years later. Involvement in outpatient mental health care during the first follow-up year and participation in self-help groups during the last three months of that year were associated with a greater likelihood of remission at the two-year follow-up.
The results extend previously published one-year outcome findings showing that cognitive-behavioral and 12-step treatment programs result in similar remission rates. Patients who enter intensive substance abuse treatment with polysubstance use, psychiatric symptoms, or significant emotional distress have more difficulty achieving remission. Routinely engaging patients in continuing outpatient care is likely to yield better outcomes. The duration of such care is probably more important than the number of sessions.
The authors compared the changes in health care utilization and costs between a group of patients with schizophrenia who started treatment with risperidone and a group that started treatment with olanzapine.
A retrospective analysis was conducted of patients with schizophrenia who were given an initial prescription for risperidone or for olanzapine between March 1997 and March 1999. The change in utilization and cost of inpatient hospitalizations, outpatient clinic visits, medications, and total health care services from one year before to one year after initiation of treatment for the two groups was compared.
The risperidone and olanzapine groups comprised 325 and 285 patients, respectively. Total health care costs declined by 4,217 on average for patients in the olanzapine group after initiation of treatment. The difference was statistically significant, and it was largely due to drug and hospitalization costs. Drug costs for patients in the risperidone group underwent a smaller increase than those for patients in the olanzapine group (1,861). Hospitalization costs decreased by 1,423 for those in the olanzapine group.
Total health care costs declined for patients taking risperidone and increased for patients taking olanzapine after treatment was initiated.
The authors studied long-term patterns and predictors of use of mental health services by older surviving patients with substance use disorders in the Veterans Affairs (VA) health care system.
In this prospective longitudinal study, patient treatment records were used to determine long-term (ten-year) patterns and predictors of use of VA mental health services in a nationwide cohort of 10,678 surviving patients with a substance use disorder who were 55 years of age or older. The patients were categorized into three groups based on diagnosis during the index episode: patients with alcohol or drug abuse or dependence, patients with alcohol or drug psychosis, and patients with both a substance use and a psychiatric disorder. Most of the patients had alcohol use disorders.
Over the ten-year period, successively fewer patients obtained outpatient and inpatient mental health care. Among patients who did obtain such care, the intensity of service use increased. Medical care did not substitute for mental health treatment. Younger age, being unmarried, and having a more severe disorder were associated with a greater likelihood of mental health service use over the ten-year period. Patients with a dual diagnosis were significantly more likely to obtain outpatient mental health care. Treatment on a residential care unit and longer initial hospital stay were associated with a lower rate of mental health readmissions.
Of the substantial number of patients with substance use disorders who survive into old age, those with more long-standing substance use problems and with dual diagnoses have the greatest need for long-term mental health treatment.
In a cohort of 2,595 male patients in VA intensive treatment programs for substance use disorders (SUD), we tested whether psychiatric comorbidity, outpatient care and mutual help group attendance during the first two follow-up years predicted remission status at Year 5, controlling for covariates.
Logistic regression modeling of longitudinal data was used to test the hypotheses.
Dual diagnosis patients were less likely to be in remission at Year 5 than SUD-only patients. Outpatient care was at best only weakly related to Year 5 remission status. By contrast, mutual help involvement substantially improved the chances of substance use remission at Year 5 for both SUD-only and dual diagnosis patients. Mutual help involvement did not, however, offset the poorer prognosis for dual diagnosis patients.
Because mutual help groups specifically targeted to individuals with comorbid substance use and psychiatric disorders are currently rare, further research is recommended to investigate whether they are more effective than standard SUD mutual help groups in facilitating the recovery of persons with dual diagnoses.
This study reports on associations among symptom severity, amount of treatment, and 1-year outcomes in a national sample of 8,622 dual diagnosis patients, who were classified at treatment entry into low-, moderate-, and high-severity groups. Patients with more severe symptoms at intake had poorer 1-year outcomes. Higher severity patients did not receive adequate "doses" of care: Compared with low-severity patients, they had a shorter duration of care, although a longer duration was associated with improved outcomes; they also were less likely to receive outpatient substance abuse treatment, although more intensive treatment was associated with better drug outcomes. High-severity patients improved more on drug and legal outcomes, but less on psychiatric and family/social outcomes, than low-severity patients did when treatment was of longer duration or higher intensity. Dual diagnosis patients with highly severe symptoms would likely benefit from a longer episode of care that includes substance abuse and psychiatric outpatient treatment.
This study compared psychiatric and substance abuse acute care programs, within both inpatient and residential modalities of care, on organization and staffing, clinical management practices and policies, and services and activities. A total of 412 (95% of those eligible) Department of Veterans Affairs' programs were surveyed nationwide. Some 40% to 50% of patients in psychiatric and substance abuse programs, in both inpatient and residential venues of care, had dual diagnoses. Even though psychiatric programs had a sicker patient population, they provided fewer services, including basic components of integrated programs, than substance abuse programs did. Findings also showed that there is a strong emphasis on the use of clinical practice guidelines, performance monitoring, and obtaining client satisfaction and outcome data in mental health programs. The author's suggest how psychiatric programs might better meet the needs of acutely ill and dually diagnosed patients (e.g., by incorporating former patients as role models and mutual help groups, as substance abuse programs do; and by having policies that balance patient choice with program demand).
The purpose of this study was to compare the effectiveness of 12-step and cognitive-behavioral (Self-Management and Recovery Training [SMART]) approaches for persons with a dual diagnosis of serious mental illness and substance use disorder in an intensive outpatient/partial hospitalization setting. Participants (n = 112) were alternately assigned to the two treatment conditions, with 50 participants completing the 6-month treatment program. Assessments occurred at baseline, 3 months, and 6 months during treatment, and at 3- and 12-month follow-ups. Analyses were conducted on participants who had completed 3 months of treatment (n = 70). The 12-step intervention was more effective in decreasing alcohol use and increasing social interactions. However, a worsening of medical problems, health status, employment status, and psychiatric hospitalization were associated with the 12-step intervention. SMART was more effective in improving health and employment status, but marijuana use was greater for SMART participants. Improvements in alcohol use and life satisfaction occurred in both approaches. Covariates associated with treatment outcome were identified, with greater attendance being positively related to outcome. Involvement with the criminal justice system was positively related to treatment completion but negatively associated with medical problems. Less alcohol use, fewer medical problems, and better financial well-being at baseline were associated with better attendance.
This study evaluated a patient-treatment matching strategy intended to improve the effectiveness of hospital-inpatient and community-residential treatment for dual diagnosis patients. Matching variables were the severity of patient disorders and the program's service intensity. Each of three high-intensity hospital programs was paired with a nearby high-intensity community program; there were also four low-intensity pairs. Patients (N=230) were randomly assigned to hospital or community care at intake, and followed at discharge (96%) and at 4 months (90%). Support was found for the matching strategy at discharge in that severely ill patients treated in high-intensity programs improved more on substance abuse outcomes, and moderately ill patients treated in low-intensity programs improved more on psychiatric outcomes. The benefits of matching held at 4 months in that high-severity patients had better alcohol outcomes when they were treated in high-rather than low-intensity programs. High-and moderate-severity patients did not show differential outcomes in hospital-based or community-based programs. Dual diagnosis patients should be matched by symptom severity with program service intensity, but matching with hospital or community care may not enhance treatment outcomes.
It is far from clear how comorbidity changes during alcoholism treatment. This study investigates: (1) the course of comorbid Axis I disorders in chronic alcoholics over 2 years of controlled abstinence in the outpatient long-term intensive therapy for alcoholics (OLITA) and (2) the effect of comorbid Axis I and II disorders in this group of patients on subsequent drinking outcome over a four-year follow-up. This prospective treatment study evaluates psychiatric variables of 89 severely affected chronic alcohol dependent patients on admission (t(1)), month 6 (t(2)), 12 (t(3)) and 24 (t(4)). Drinking outcomes have been analyzed from 1998 to 2002. On admission, 61.8% of the patients met criteria for a comorbid Axis I disorder, 63.2% for a comorbid personality disorder. Axis I disorders remit from t(1) (59.0% ill), t(2) (38.5%), t(3) (28.2%) to t(4) (12.8%) (p < 0.0001). Anxiety disorders remit more slowly from t(1) (43.6%) to t(3) (20.5%, p = 0.0086), whereas mood disorders remit early between t(1) (23.1%) and t(2) (5.1%, p = 0.0387) with a slight transient increase at t(3) (10.3%). During the four-year follow-up, the cumulative probability of not having relapsed amounts to 0.59. Two predictors have a strong negative impact on abstinence probability: number of inpatient detoxifications (p = 0.0013) and personality disorders (p = 0.0106). The present study demonstrates a striking remission of comorbid Axis I disorders upon abstinence during comprehensive long-term outpatient alcoholism treatment. The presence of an Axis II rather than an Axis I disorder on admission strongly predicts drinking outcome over a four-year follow-up.
This study examines the impact of comorbid Diagnostic and Statistical Manual version IV (DSM-IV) anxiety and/or depression on out-patient treatment for alcohol problems.
A prospective correlational design.
Seventy-one clients seeking alcohol out-patient treatment at two treatment sites were interviewed at commencement of a treatment episode for alcohol problems and reinterviewed using the same measures 3 months later. Comorbid DSM-IV anxiety and/or depression were measured by the Composite International Diagnostic Interview (CIDI), a comprehensive interview developed by the World Health Organization to assess current and life-time prevalence of mental disorders. Outcome measures included standardized measures of disability [the short form (SF)-12 Mental Health Summary Score and the number of days taken out of role] and the average amount of alcohol consumed. Clients were also asked to rate their satisfaction with the services received.
Participants with comorbid DSM-IV anxiety and/or depressive disorders were more disabled and drank more heavily than those without these comorbid disorders at entry to treatment. At 3-month follow-up both groups of participants (i.e. those with and without DSM-IV comorbid anxiety and/or depression) were significantly less disabled and also drank significantly less alcohol on an average drinking occasion than at baseline. Despite this, the comorbid group remained more disabled and drank more heavily than the non-comorbid group at follow-up.
Further research is needed to determine the most appropriate model of care for alcohol treatment seekers with comorbid DSM-IV anxiety and/or depression.
The role of 12-step programs and 12-step-oriented treatments for dually diagnosed individuals (DDI) remains unclear. Here are presented the results of a pilot study in which 10 seriously mentally ill patients received a modified 12-step facilitation (TSF) therapy emphasizing engagement of DDI in a specialized 12-step program for DDI. Participants significantly increased their 12-step attendance and decreased their substance use during the 12 weeks of treatment. Larger and longer-term studies are needed to assess the efficacy of modified TSF for DDI relative to other treatments, and to determine what forms of TSF are most effective in this population.
The authors review the literature on substance use disorders among persons with severe mental illnesses, including the other papers in this special section on relapse prevention, and suggest future directions. Although prevention of relapse to substance abuse has a well-developed theoretical and empirical base, this perspective has rarely been applied to persons with co-occurring severe mental illness. Research indicates that clients with co-occurring disorders are highly prone to relapse to substance abuse, even after they have attained full remission. Their risk factors include exacerbations of mental illness, social pressures within drug-using networks, lack of meaningful activities and social supports for recovery, independent housing in high-risk neighborhoods, and lack of substance abuse or dual diagnosis treatments. The evidence in hand suggests several steps: developing healthy and protective environments that are experienced as nurturing of recovery; helping people make fundamental changes in their lives, such as finding satisfying jobs, abstinent friends, networks of people who are in the process of recovery, and a sense of meaning; providing specific and individualized treatments for mental illnesses, substance use disorders, and other co-occurring problems; and developing longitudinal research on understanding and preventing relapse that addresses social context as well as biological vulnerabilities and cognitive strategies.
This study examined characteristics of substance use disorder (SUD) outpatients at intake to treatment (N=345) that were associated with more 12-step group attendance and involvement, Steps worked, and acceptance of 12-step philosophy at a 6-month follow-up (N=281, 81.4%). Patient characteristics covered the domains of sociodemographics, SUD severity, personal functioning, and previous help received. Distinguishing baseline characteristics of patients who attended more 12-step group meetings during follow-up were being less-educated, more engaged in religious practices, and more extroverted and interpersonally competent, and having had more previous 12-step group exposure. These patient characteristics were generally similar to those associated with more 12-step meeting involvement and philosophy acceptance. More 12-step meeting attendance and involvement were related to abstinence at 6 months. Associations of attendance with abstinence were stronger among patients who were younger, white, less-educated, unstably employed, less religious, and less interpersonally skilled. These patients may have had fewer available social resources and so benefitted more from the fellowship and support for abstinence that 12-step group members often provide. We suggest methods by which treatment providers may encourage 12-step group affiliation among patients likely to benefit from it on substance use outcomes.
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