Treatment programmes for people with both severe mental illness and substance misuse

A contingency management intervention to reduce cannabis use and time to relapse in early psychosis: the CIRCLE RCT

BACKGROUND

Cannabis is the most prevalent illicit substance among people with psychosis, and its use is associated with poorer clinical and social outcomes. However, so far, there has been limited evidence that any treatment is effective for reducing use. Contingency management (CM) is an incentive-based intervention for substance misuse that has a substantial evidence base across a range of substances and cohorts. However, to date there have been no randomised controlled trials (RCTs) of CM as a treatment for cannabis use specifically in psychosis.

OBJECTIVE

To conduct a RCT investigating the clinical effectiveness and cost-effectiveness of CM in reducing cannabis use among Early Intervention in Psychosis (EIP) service users.

DESIGN

The CIRCLE (Contingency Intervention for Reduction of Cannabis in Early Psychosis) trial was a rater-blinded, multicentre RCT with two arms. Participants were randomised 1 : 1 to either an CM arm, in which participants received CM for cannabis use alongside an optimised treatment-as-usual programme including structured psychoeducation, or a control arm in which participants received the treatment as usual only.

SETTING

EIP services across the Midlands and the south-east of England.

PARTICIPANTS

The main eligibility criteria were EIP service users with a history of psychosis, aged 18-36 years, and having used cannabis at least once per week during 12 of the previous 24 weeks.

INTERVENTION

The CM intervention offered financial incentives (i.e. shopping vouchers) for cannabis abstinence over 12 once-weekly sessions, confirmed using urinalysis. The maximum value in vouchers that participants could receive was £240.

MAIN OUTCOME MEASURES

The main outcome was time to relapse, operationalised as admission to an acute mental health service or hospital. The primary outcome was assessed at 18 months post inclusion using electronic patient records. Secondary outcomes assessed the clinical effectiveness and cost-effectiveness of the intervention, for which data were collected at 3 and 18 months.

RESULTS

A total of 278 participants were randomised to the CM arm and 273 were randomised to the control arm. In total, 530 (96%) participants were followed up for the primary outcome. There was no significant difference in time to admission between trial arms by 18 months following consent (hazard ratio 1.03, 95% confidence interval 0.76 to 1.40). There were no statistically significant differences in most secondary outcomes, including cannabis use, at either follow-up assessment. There were 58 serious adverse events, comprising 52 inpatient episodes, five deaths and one arrest.

LIMITATIONS

Participant retention was low at 18 months, limiting the assessment of secondary outcomes. A different CM intervention design or reward level may have been effective.

CONCLUSIONS

The CM intervention did not appear to be effective in reducing cannabis use and acute relapse among people with early psychosis and problematic cannabis use.

FUTURE WORK

Cannabis use is still a significant clinical concern in this population. A pressing need remains to identify suitable treatments. A wider perspective on the social circumstances of young people with psychosis may be needed for a successful intervention to be found.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN33576045.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 45. See the NIHR Journals Library website for further project information.

Psychosocial interventions for people with both severe mental illness and substance misuse

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.

A randomised controlled trial of the clinical and cost-effectiveness of a contingency management intervention compared to treatment as usual for reduction of cannabis use and of relapse in early psychosis (CIRCLE): a study protocol for a randomised controlled trial

BACKGROUND

Around 35-45 % of people in contact with services for a first episode of psychosis are using cannabis. Cannabis use is associated with delays in remission, poorer clinical outcomes, significant increases in the risk of relapse, and lower engagement in work or education. While there is a clear need for effective interventions, so far only very limited benefits have been achieved from psychological interventions. Contingency management (CM) is a behavioural intervention in which specified desired behavioural change is reinforced through financial rewards. CM is now recognised to have a substantial evidence base in some contexts and its adoption in the UK is advocated by the National Institute for Health and Care Excellence (NICE) guidance as a treatment for substance or alcohol misuse. However, there is currently little published data testing its effectiveness for reducing cannabis use in early psychosis.

METHODS

CIRCLE is a two-arm, rater-blinded randomised controlled trial (RCT) investigating the clinical and cost-effectiveness of a CM intervention for reducing cannabis use among young people receiving treatment from UK Early Intervention in Psychosis (EIP) services. EIP service users (n = 544) with a recent history of cannabis use will be recruited. The experimental group will receive 12 once-weekly CM sessions, and a voucher reward if urinalysis shows that they have not used cannabis in the previous week. Both the experimental and the control groups will be offered an Optimised Treatment as Usual (OTAU) psychoeducational package targeting cannabis use. Assessment interviews will be performed at consent, at 3 months, and at 18 months. The primary outcome is time to relapse, defined as admission to an acute mental health service. Secondary outcomes include proportion of cannabis-free urine samples during the intervention period, severity of positive psychotic symptoms, quality-adjusted life years, and engagement in work or education.

DISCUSSION

CIRCLE is a RCT of CM for cannabis use in young people with a recent history of psychosis (EIP service users) and recent cannabis use. It is designed to investigate whether the intervention is a clinically and cost-effective treatment for cannabis use. It is intended to inform future treatment delivery, particularly in EIP settings.

TRIAL REGISTRATION

ISRCTN33576045 : doi 10.1186/ISRCTN33576045 , registered on 28 November 2011.

Developing a dual diagnosis service in Cork, Ireland by way of participatory action research (PAR)

Purpose

– Developing a dual diagnosis service in Cork, Ireland by way of participatory action research (PAR) background: internationally there is a growing consensus regarding the ideal of integrated treatment. In Ireland, recommendations identified the need for multi-disciplinary team integration and client participation being central to service development. Such recommendations collectively fit most appropriately with PAR, the methodological and theoretical framework best suited to achieve the objectives of the inquiry. PAR's inclusive philosophy creates processes of negotiation, self-reflexivity and exploration of power issues with the lived experience of communities. Key elements of this approach facilitate the development of emancipatory and participatory democracy whilst highlighting identified social issues through research, learning and action. The paper aims to discuss these issues.

Design/methodology/approach

– Cyclical processes of planning, action, observation and reflection in cycle one have facilitated the introduction of PAR's methodological framework into the existing public health (Health Service Executive) system of primary care addiction and mental health services. Developing stakeholder relationships in decision making processes has been pivotal in cycle 1 as the process of collective engagement evolves. Stakeholders begin to experience their collective participation in the methods adopted and a collective sense of ownership and commitment to the iterative process begins to take shape. Stakeholders in cycle 1 have participated in multiple data generation methods including: informal interviews, planned discussion and focus groups, multidisciplinary team meetings, testimonials, observations and reflections.

Findings

– Cycle 1 of this PAR inquiry has engaged stakeholders (service users and their families, practitioners including; academic/practitioners, a consultant psychiatrist, psychologist, mental health nurses, an occupational therapist, psychotherapists, an acupuncturist, an addiction counsellor, an art therapist) in an integrated process of inquiry. PAR methods adopted in this cycle have facilitated particular dual diagnosis service developments and emerging initiatives (previously unidentified). Actions collaboratively planned for and illustrated in this paper include: the implementation of a psychotherapy group and implementing direct access to an acupuncture clinic.

Originality/value

– Stakeholders collaboratively experience PAR's methodological and theoretical approach which has facilitated service developments in cycle 1 of the inquiry. This sets the stage for the completion of actions already in motion and for further initiatives to continue to evolve as cycle 2 processes emerge.

The use of psychological therapies by mental health nurses in Australia

This paper reports on a research project which examines the feasibility of mental health nurses employing psychological therapies in the nursing care of people with severe mental illness. Attitudes towards current usage and factors influencing the adoption of psychological therapies are investigated. The paper addresses the gap in the Australian nursing literature regarding the therapeutic role of mental health nurses (MHN)s in relation to the use of evidence-based psychological therapies. This paper presents the findings from an online questionnaire survey of 528 practising MHNs in Australia. The findings demonstrate enthusiastic support among nurses towards employing psychological therapies, with 93% of respondents indicating they would like to use psychological therapies in their current practice. Correspondingly, there is strong demand for education and training in applying psychological therapies. A number of barriers to implementing psychological therapies are identified. It is noted that place of employment is a significant factor, with mental health nurses working in the public sector more likely to state institutional barriers are restricting their therapeutic potential and preventing them from implementing psychological therapies.

Physical health care monitoring for people with serious mental illness

BACKGROUND

Current guidance suggests that we should monitor the physical health of people with serious mental illness, and there has been a significant financial investment over recent years to provide this.

OBJECTIVES

To assess the effectiveness of physical health monitoring, compared with standard care for people with serious mental illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (October 2009, update in October 2012), which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO.

SELECTION CRITERIA

All randomised clinical trials focusing on physical health monitoring versus standard care, or comparing i) self monitoring versus monitoring by a healthcare professional; ii) simple versus complex monitoring; iii) specific versus non-specific checks; iv) once only versus regular checks; or v) different guidance materials.

DATA COLLECTION AND ANALYSIS

Initially, review authors (GT, AC, SM) independently screened the search results and identified three studies as possibly fulfilling the review's criteria. On examination, however, all three were subsequently excluded. Forty-two additional citations were identified in October 2012 and screened by two review authors (JX and MW), 11 of which underwent full screening.

MAIN RESULTS

No relevant randomised trials which assess the effectiveness of physical health monitoring in people with serious mental illness have been completed. We identified one ongoing study.

AUTHORS' CONCLUSIONS

There is still no evidence from randomised trials to support or refute current guidance and practice. Guidance and practice are based on expert consensus, clinical experience and good intentions rather than high quality evidence.

Psychosocial interventions for people with both severe mental illness and substance misuse

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

For this update (2013), the Trials Search Co-ordinator of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (July 2012), which is based on regular searches of major medical and scientific databases. The principal authors conducted two further searches (8 October 2012 and 15 January 2013) of the Cochrane Database of Systematic Reviews, MEDLINE and PsycINFO. A separate search for trials of contingency management was completed as this was an additional intervention category for this update.

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

We independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of relative risk (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. For all meta-analyses 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

We included 32 trials with a total of 3165 participants. Evaluation of long-term integrated care included four RCTs (n = 735). We found no significant differences on loss to treatment (n = 603, 3 RCTs, RR 1.09 CI 0.82 to 1.45, low quality of evidence), death by 3 years (n = 421, 2 RCTs, RR 1.18 CI 0.39 to 3.57, low quality of evidence), alcohol use (not in remission at 36 months) (n = 143, 1 RCT, RR 1.15 CI 0.84 to 1.56,low quality of evidence), substance use (n = 85, 1 RCT, RR 0.89 CI 0.63 to 1.25, low quality of evidence), global assessment of functioning (n = 171, 1 RCT, MD 0.7 CI 2.07 to 3.47, low quality of evidence), or general life satisfaction (n = 372, 2 RCTs, MD 0.02 higher CI 0.28 to 0.32, moderate quality of evidence).For evaluation of non-integrated intensive case management with usual treatment (4 RCTs, n = 163) we found no statistically significant difference for loss to treatment at 12 months (n = 134, 3 RCTs, RR 1.21 CI 0.73 to 1.99, very low quality of evidence).Motivational interviewing plus cognitive behavioural therapy compared to usual treatment (7 RCTs, total n = 878) did not reveal any advantage for retaining participants at 12 months (n = 327, 1 RCT, RR 0.99 CI 0.62 to 1.59, low quality of evidence) or for death (n = 493, 3 RCTs, RR 0.72 CI 0.22 to 2.41, low quality of evidence), and no benefit for reducing substance use (n = 119, 1 RCT, MD 0.19 CI -0.22 to 0.6, low quality of evidence), relapse (n = 36, 1 RCT, RR 0.5 CI 0.24 to 1.04, very low quality of evidence) or global functioning (n = 445, 4 RCTs, MD 1.24 CI 1.86 to 4.34, very low quality of evidence).Cognitive behavioural therapy alone compared with usual treatment (2 RCTs, n = 152) showed no significant difference for losses from treatment at 3 months (n = 152, 2 RCTs, RR 1.12 CI 0.44 to 2.86, low quality of evidence). No benefits were observed on measures of lessening cannabis use at 6 months (n = 47, 1 RCT, RR 1.30 CI 0.79 to 2.15, very low quality of evidence) or mental state (n = 105, 1 RCT, Brief Psychiatric Rating Scale MD 0.52 CI -0.78 to 1.82, low quality of evidence).We found no advantage for motivational interviewing alone compared with usual treatment (8 RCTs, n = 509) in reducing losses to treatment at 6 months (n = 62, 1 RCT, RR 1.71 CI 0.63 to 4.64, very low quality of evidence), although significantly more participants in the motivational interviewing group reported for their first aftercare appointment (n = 93, 1 RCT, RR 0.69 CI 0.53 to 0.9). Some differences, favouring treatment, were observed in abstaining from alcohol (n = 28, 1 RCT, RR 0.36 CI 0.17 to 0.75, very low quality of evidence) but not other substances (n = 89, 1 RCT, RR -0.07 CI -0.56 to 0.42, very low quality of evidence), and no differences were observed in mental state (n = 30, 1 RCT, MD 0.19 CI -0.59 to 0.21, very low quality of evidence).We found no significant differences for skills training in the numbers lost to treatment by 12 months (n = 94, 2 RCTs, RR 0.70 CI 0.44 to 1.1, very low quality of evidence).We found no differences for contingency management compared with usual treatment (2 RCTs, n = 206) in numbers lost to treatment at 3 months (n = 176, 1 RCT, RR 1.65 CI 1.18 to 2.31, low quality of evidence), number of stimulant positive urine tests at 6 months (n = 176, 1 RCT, RR 0.83 CI 0.65 to 1.06, low quality of evidence) or hospitalisations (n = 176, 1 RCT, RR 0.21 CI 0.05 to 0.93, low quality of evidence).We were unable to summarise all 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 due to high or unclear risks of bias because of poor trial methods, or poorly reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals.

AUTHORS' CONCLUSIONS

We included 32 RCTs and found no compelling evidence to support any one psychosocial treatment over another for people to remain in treatment or to reduce substance use or improve mental state in people with serious mental illnesses. 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.

Appraising evidence for intervention effectiveness in early psychosis: conceptual framework and review of evaluation approaches

The literature that is relevant to evaluation of treatment effectiveness is large, scattered and difficult to assemble for appraisal. This scoping review first develops a conceptual framework to help organize the field, and second, uses the framework to appraise early psychosis intervention (EPI) studies. Literature searches were used to identify representative study designs, which were then sorted according to evaluation approach. The groupings provided a conceptual framework upon which a map of the field could be drawn. Key words were cross-checked against definitions in dictionaries of scientific terms and the National Library of Medicine Medical Subject Headings (MeSH) browser. Using the final list of key words as search terms, the EPI evaluation literature was appraised. Experimental studies could be grouped into two classes: efficacy and effectiveness randomized controlled trials. Non-experimental studies could be subgrouped into at least four overlapping categories: clinical epidemiological; health service evaluations; quality assurance studies; and, quasi-experimental assessments of treatment effects. Applying this framework to appraise EPI studies indicated promising evidence for the effectiveness of EPI irrespective of study design type, and a clearer picture of where future evaluation efforts should be focused. Reliance on clinical trials alone will restrict the type of information that can inform clinical practice. There is convergent evidence for the benefits of specialized EPI service functions across a range of study designs. Greater investment in health services research and quality assurance approaches in evaluating EPI effectiveness should be made, which will involve scaling up of study sizes and development of an EPI programme fidelity rating template. The degree of complexity of the evaluation field suggests that greater focus on research methodology in the training of Australasian psychiatrists is urgently needed.

Cochrane Reviews of non-medication-based psychotherapeutic and other interventions for schizophrenia, psychosis, and bipolar disorder: A systematic literature review

Mental health-care professionals are striving to keep up to date with health interventions that are effective and beneficial to patients. The Cochrane Reviews make available a systematic and up-to-date review of a comprehensive range of health interventions. We identified a total of 28 interventions from a systematic search and review of the Cochrane Reviews for either schizophrenia, psychosis, schizoaffective, or bipolar disorder. These interventions have been graded into tables of: strong support that merits application, moderate support that warrants consideration of application, not supported, and data that is deemed inconclusive. The tables provide a comprehensive summary and classification of evidence-based practices. This information is presented in a way to enable nurses and other health-care professionals to analyze their own practices to improve mental health services and outcomes for patients. Of the 28 interventions identified in this review, four had strong support and five had moderate support meriting application. Limitations of this review are discussed.

Treatment approaches for dual diagnosis clients in England

INTRODUCTION

Dual diagnosis (DD, co-occurrence of substance use and mental health problems) prevalence data in England are limited to specific regions and reported rates vary widely. Reliable information on actual service provision for dual diagnosis clients has not been collated. Thus a national survey was carried out to estimate dual diagnosis prevalence in treatment populations and describe the service provision available for this client population in drug/alcohol (DAS) and mental health services (MHS).

DESIGN

A questionnaire was sent to managers of 706 DAS and 2374 MHS. Overall, 249 (39%) DAS and 493 (23%) MHS participated in the survey.

RESULTS

In both DAS and MHS, around 32% of clients were estimated to have dual diagnosis problems. However, fewer than 50% of services reported assessing clients for both problem areas. Regarding specific treatment approaches, most services (DAS: 88%, MHS: 87%) indicated working jointly with other agencies. Significantly fewer services used joint protocols (DAS: 55%, MHS: 48%) or shared care arrangements, including access to external drug/alcohol or mental health teams (DAS: 47%, MHS: 54%). Only 25% of DAS and 17% of MHS employed dual diagnosis specialists.

CONCLUSIONS

Dual diagnosis clients constitute a substantial proportion of clients in both DAS and MHS in England. Despite recent policy initiatives, joint working approaches tend to remain unstructured.

Addressing substance misuse in a medium secure unit

Individuals diagnosed with severe mental illness have higher rates of alcohol and substance misuse than the general population. This can present the client and the care team with a variety of issues around physical and psychological well‐being, as well as social and occupational functioning. In forensic psychiatry, the effect of comorbid substance misuse on offending behaviour is particularly pertinent. There have, however, been few studies examining the treatment of alcohol and substance misuse within this particular patient group.At a regional secure unit in North Wales, a group for inpatients was set up to provide education on alcohol and substance misuse over a course of six informal meetings, and to then evaluate participants' attitudes towards substance misuse. Of the six participants, five reported that their knowledge of substances had increased, and that they had no intention to use drugs again after discharge. Staff and client participants also suggested useful future topics for the group.

Organizational change to transfer knowledge and improve quality and outcomes of care for patients with severe mental illness: a systematic overview of reviews

OBJECTIVE

To provide a comprehensive overview of the research on organizational changes aimed at improving health care for patients with severe mental illness and to learn lessons for mental health practice from the results.

METHOD

We searched for systematic literature reviews published in English during 2000 to 2007 in PubMed, PsycINFO, CINAHL, EMBASE, and the Cochrane Central Register of Systematic Reviews. Three reviewers independently selected and assessed the studies' quality. Studies involving changes of who delivers health care, how care is organized, or where care is delivered were included. We categorized the studies using an existing taxonomy of 6 broad categories of strategies for organizational change.

RESULTS

A total of 21 reviews were included. Among these, 17 had reasonably good methodological quality, Almost all reviews included or intended to include randomized controlled trials (RCTs), 6 reviews did not identify studies that met eligibility criteria. Multidisciplinary teams and integrated care models had been reviewed most frequently (a total of 15 reviews). In most studies, these types of changes showed better outcomes in terms of symptom severity, functioning, employment, and housing, compared with conventional services. Different results were found on cost savings. Other types of organizational changes, such as changing professional roles or introducing quality management or knowledge management, were much less frequently reviewed. Very few reviews looked at effects of organizational changes on professional performance.

CONCLUSIONS

There is a fairly large body of evidence of the positive impact of multidisciplinary teams and integrated care changes on symptom severity, functioning, employment, and housing of people with severe mental illness, compared with conventional services. Other strategies, such as changes in professional roles, quality or knowledge management, have either not been the subject of systematic reviews or have not been evaluated in RCTs. There is still a lack of insight in the so-called black box of change processes and the impact of change on professional performance.

Outcomes of public concern in schizophrenia

BACKGROUND

Schizophrenia is known to be associated with a range of adverse outcomes, which have an impact atthe societal level and are therefore of public concern.

AIMS

To examine the epidemiology and methods for measuring six adverse outcomes in schizophrenia: violence, victimisation, suicide/self-harm, substance use, homelessness and unemployment.

METHOD

A review ofthe literature was carried out for each adverse outcome, with attention to critical appraisal of existing measurement tools.

RESULTS

Schizophrenia is associated strongly with all six outcomes, although research has mainly focused on violence. Each outcome acts as a risk factor for at least some of the other outcomes. There are few standardised or validated measures for these 'hard' outcomes. Each measure has inherent biases but a growing trend is for these to be minimised by using multiple measures.

CONCLUSIONS

A single instrument which systematically measures multiple societal outcomes of schizophrenia would be extremely useful for both clinical and research purposes.

Cannabis use and the risk of developing a psychotic disorder

WE BRIEFLY REVIEW THE EVIDENCE THAT CANNABIS USE IN ADOLESCENCE AND YOUNG ADULTHOOD IS A CONTRIBUTORY CAUSE OF SCHIZOPHRENIFORM PSYCHOSES, BY SUMMARISING LONGITUDINAL STUDIES THAT: a) have examined relationships between cannabis use and the risk of psychosis or psychotic symptoms; and b) have controlled for potential confounders, such as other forms of drug use and personal characteristics that predict an increased risk of psychosis. There is now reasonable evidence from longitudinal studies that regular cannabis use predicts an increased risk of schizophrenia and of reporting psychotic symptoms. These relationships have persisted after controlling for confounding variables such as personal characteristics and other drug use. The relationships did not seem to be explained by cannabis being used to self-medicate symptoms of psychosis. A contributory causal relationship is biologically plausible because psychotic disorders involve disturbances in the dopamine neurotransmitter system with which the cannabinoid system interacts, as has been shown by animal studies and a human provocation study. We briefly explore the clinical and public health implications of the most plausible hypothesis, that cannabis use precipitates schizophrenia in persons who are vulnerable because of a personal or family history of schizophrenia.

How reliable is the current evidence looking at the efficacy of harm reduction and motivational interviewing interventions in the treatment of patients with a dual diagnosis?

Current policy from the Department of Health advocates for an integrated approach to treating patients with a dual diagnosis. However, pragmatic and clinically effective brief interventions that can be delivered by nurses across mental health settings remain underdeveloped. Motivational interviewing has had some successful exposure in the field of dual diagnosis; however, harm reduction remains unexplored both conceptually and in terms of clinical intervention. This literature review examines the notion of harm reduction as a method of identifying and reducing the harm associated with the misuse of drugs and alcohol in relation to mental health problems. Currently there is a paucity of good quality evidence for integrated interventions in the treatment of dually diagnosed patients. Therefore, the papers are analysed in respect of their methodological quality and contribution to the evidence base to inform both future research and mental health nursing practice.

Motivational interviewing among psychiatric in-patients with substance use disorders

OBJECTIVE

There were three aims of the present study: 1) to document patterns of substance misuse among psychiatric in-patients with comorbid alcohol and other drug (AOD) use; 2) to examine associations among psychiatric and substance use diagnoses and readiness to change; and 3) to evaluate the effectiveness of an opportunistic motivational interview on engagement in a Specialist Substance Misuse Service (SSMS).

METHOD

One hundred and sixty subjects were randomly assigned to receive either a motivational interview or no intervention.

RESULTS

Overall, 66.3% of subjects met intervention threshold for cannabis, 60.6% for alcohol and 22.5% for amphetamines. There was a bimodal distribution of stage of change for cannabis use which was associated with age, with precontemplation being associated with older age and less frequent use. Attendance at the SSMS was low and unrelated to intervention status.

CONCLUSION

A different approach to treatment is recommended, including early intervention among cannabis users.

Managing comorbid schizophrenia and substance abuse

Effective treatments for co-occurring schizophrenia and substance abuse have emerged over the past 15 years. They involve integration and melding of mental health and substance abuse treatments, helping people to acquire the skills and supports they need to manage both illnesses and to pursue functional goals, and a comprehensive, long-term approach to recovery. Further research is needed to refine specific interventions and to improve knowledge regarding implementing integrated treatment settings in routine mental health programs.