Exploring the diversity of dual diagnosis: utility of cluster analysis for program planning

Profiles of Service Users with Severe Mental Disorders Based on Adequacy of Help

This study has for aims to develop a typology describing adequacy of help based on socio-demographic, clinical and service utilization variables for 204 service users with severe mental disorders treated in the community. Study participants were recruited in an urban area of Quebec (Canada). Adequacy of help was assessed with the Montreal Assessment of Needs Questionnaire. A cluster analysis identified five profiles of service users. Adequacy of help was mainly related to continuity of care, help given by services, seriousness of needs and, to some extent, quality of life (QOL). Adequacy of help was highest among Class 3 participants, described as older individuals with mood disorders, who lived in autonomous housing and enjoyed good QOL. They received substantial help from both relatives and services. Adequacy of help was lowest for Class 5, which included individuals affected by co-occurring mental disorders but who also lived autonomously. Health service utilization was more strongly related to adequacy of help for this sample than were the socio-demographic and clinical factors tested.

Typology of patients with mental health disorders and perceived continuity of care

Background: While multiple socio-demographic, clinical and service use variables have been associated with continuity of care (CoC) in patients diagnosed with mental health disorders (MHDs), little is known about how these variables may inform clinical practice and service planning.Aim: This article identified profiles of patients with MHDs to better understand their perceptions of CoC.Method: The sample for this cross-sectional study comprised 327 patients recruited by staff or self-referred from four local health networks in Quebec (Canada). Data were collected using standardized instruments, and patient medical records. A three-factor conceptual framework based on Andersen's Behavioral Model was used, integrating predisposing, needs and enabling factors.Results: Cluster analyses identified five patient profiles. Profiles that included relatively more patients with common MHDs reported less continuity than those with patients primarily affected by severe MHDs.Conclusions: Service planning and delivery should be better adapted to patient profiles in order to improve CoC, and increased access to services prioritized.

Comparing Perceived Adequacy of Help Received Among Different Classes of Individuals with Severe Mental Disorders at Five-Year Follow-Up: A Longitudinal Cluster Analysis

This study developed a typology describing change in the perceived adequacy of help received among 204 individuals with severe mental disorders, 5 years after transfer to the community following a major mental health reform in Quebec (Canada). Participant typologies were constructed using a two-step cluster analysis. There were significant differences between T0 and T2 for perceived adequacy of help received and other independent variables, including seriousness of needs, help from services or relatives, and care continuity. Five classes emerged from the analysis. Perceived adequacy of help received at T2 increased for Class 1, mainly comprised of older women with mood disorders. Overall, greater care continuity and levels of help from services and relatives related to higher perceived AHR. Changes in perceived adequacy of help received resulting from several combinations of associated variables indicate that MH service delivery should respond to specific profiles and determinants.

Typology of individuals with substance dependence based on a Montreal longitudinal catchment area study

This study sought to develop a typology of individuals with substance dependence (ISD) based on a longitudinal survey (n = 2,434) and 121 ISD. The latter were divided into three groups: newly abstinent individuals, chronic dependents and acute dependents. Individuals' typology was developed by cluster analysis. Newly abstinent individuals had fewer emotional problems and mental disorders in the previous 12 months. Four classes of ISD were identified, labelled respectively "chronic multi-substance consumption and mental disorders comorbidities," "multi-substance consumption," "alcohol and marijuana consumption" and "alcohol consumption only." Strategies adapted to each of these profiles could be promoted for more effective treatment.

Typology of people with first-episode psychosis

AIMS

The aim of the current study was to create a typology of patients with first-episode psychosis based on sociodemographic and clinical characteristics, service use and outcomes using cluster analysis.

METHODS

Data from all respondents who were accepted into the Early Psychosis Intervention Programme (EPIP), Singapore from 2007 to 2011 were analysed. A two-step clustering method was carried out to classify the patients into distinct clusters.

RESULTS

Two clusters were identified. Cluster 1 comprised largely of younger people with mean age of 25.5 (6.0) years at treatment contact, who were predominantly male (55.3%), single (98.3%) and living with parents (86.3%). Cluster 1 had a higher proportion of people diagnosed with the schizophrenia spectrum disorder (71.4%) and with a positive family history of psychiatric illness. Patients in cluster 2 were generally older with a mean age of 33.6 (4.7) years and the majority were women (74.2%). Cluster 1 had people with higher Positive and Negative Syndrome Scale (PANSS) scores at baseline as compared with cluster 2. After a 1-year follow up, their scores were still poorer than their counterparts in cluster 2, especially for PANSS negative score. The functioning level of people in cluster 1 showed less improvement than the people in cluster 2 after a year of treatment.

CONCLUSIONS

There is a compelling need to develop new therapies and intensively treat young people presenting with psychosis as this group tends to have poorer outcomes even after 1 year of treatment.

Predictive typology of subjective quality of life among participants with severe mental disorders after a five-year follow-up: a longitudinal two-step cluster analysis

BACKGROUND

This study aims to create a predictive typology of quality of life at five-year follow-up of 204 individuals with severe mental disorders, according to clinical, socio-demographic, and health service use variables.

METHODS

Participant typology was carried out by means of two-step cluster analysis. Independent variables were measured at T0 and subjective quality of life (SQOL) at T2.

RESULTS

Analysis yielded four classes. SQOL at T2 was higher than the mean in Class 4 ("Older, poorly educated single men living in supervised housing, with psychotic disorders but with few serious needs, receiving substantial help from services") and lower than the mean in Class 2 ("Young females with serious needs and co-occurring mental and addiction disorders living in independent apartments").

CONCLUSION

Given that predictive SQOL varies in relation to combinations of associated variables, it would be useful for treatments or service programs to target specific predictors to the different profiles.

Typology of persons with severe mental disorders

BACKGROUND

Persons with severe mental disorders (PSMD) form a highly heterogeneous group. Identifying subgroups sharing similar PSMD profiles may help to develop treatment plans and appropriate services for their needs. This study seeks to establish a PSMD typology by looking at individual characteristics and the amount and adequacy of help received.

METHODS

The study recruited a sample of 352 persons located in south-western Montreal (Quebec, Canada). Cluster analysis was used to create a PSMD typology.

RESULTS

Analysis yielded five clusters: 1. highly functional older women with mood disorders, receiving little help from services; 2. middle-aged men with diverse mental disorders and alcohol abuse, receiving insufficient and inadequate help; 3. middle-aged women with serious needs, mood and personality disorders and suicidal tendencies, living in autonomous apartments, and receiving ample but inadequate help; 4. highly educated younger men with schizophrenia, living in autonomous apartments, and receiving adequate help; and 5. older poorly educated men with schizophrenia, living in supervised apartments, with ample help perceived as adequate. Marked differences were found between men and women, between users diagnosed with schizophrenia and others, and between persons living in supervised or autonomous apartments.

CONCLUSION

Our study highlights the existence of parallel subgroups among PSMD related to their socio-demographic status, clinical needs and service-use profiles, which could be used to focus more appropriate interventions. For mental health service planning, it demonstrates the relevance of focusing on individuals showing critical needs who are affected by multiple mental disorders (especially when associated with alcohol abuse), and often find help received as less adequate.

Typology of adults diagnosed with mental disorders based on socio-demographics and clinical and service use characteristics

BACKGROUND

Mental disorder is a leading cause of morbidity worldwide. Its cost and negative impact on productivity are substantial. Consequently, improving mental health-care system efficiency - especially service utilisation - is a priority. Few studies have explored the use of services by specific subgroups of persons with mental disorder; a better understanding of these individuals is key to improving service planning. This study develops a typology of individuals, diagnosed with mental disorder in a 12-month period, based on their individual characteristics and use of services within a Canadian urban catchment area of 258,000 persons served by a psychiatric hospital.

METHODS

From among the 2,443 people who took part in the survey, 406 (17%) experienced at least one episode of mental disorder (as per the Composite International Diagnostic Interview (CIDI)) in the 12 months pre-interview. These individuals were selected for cluster analysis.

RESULTS

Analysis yielded four user clusters: people who experienced mainly anxiety disorder; depressive disorder; alcohol and/or drug disorder; and multiple mental and dependence disorder. Two clusters were more closely associated with females and anxiety or depressive disorders. In the two other clusters, males were over-represented compared with the sample as a whole, namely, substance abuses with or without concomitant mental disorder. Clusters with the greatest number of mental disorders per subject used a greater number of mental health-care services. Conversely, clusters associated exclusively with dependence disorders used few services.

CONCLUSION

The study found considerable heterogeneity among socio-demographic characteristics, number of disorders, and number of health-care services used by individuals with mental or dependence disorders. Cluster analysis revealed important differences in service use with regard to gender and age. It reinforces the relevance of developing targeted programs for subgroups of individuals with mental and/or dependence disorders. Strategies aimed at changing low service users' attitude (youths and males) or instituting specialised programs for that particular clientele should be promoted. Finally, as concomitant disorders are frequent among individuals with mental disorder, psychological services and/or addiction programs must be prioritised as components of integrated services when planning treatment.

A classification of substance-dependent men on temperament and severity variables

This study examined the validity of classifying substance abusers based on temperament and dependence severity, and expanded the scope of typology differences to proximal determinants of use (e.g., expectancies, motives). Patients were interviewed about substance use, depression, and family history of alcohol and drug abuse. Self-report instruments measuring temperament, expectancies, and motives were completed. Participants were 147 male veterans admitted to inpatient substance abuse treatment at a U.S. Department of Veterans Affairs medical center. Cluster analysis identified four types of users with two high substance problem severity and two low substance problem severity groups. Two, high problem severity, early onset groups differed only on the cluster variable of negative affectivity (NA), but showed differences on antisocial personality characteristics, hypochondriasis, and coping motives for alcohol. The two low problem severity groups were distinguished by age of onset and positive affectivity (PA). The late onset, low PA group had a higher incidence of depression, a greater tendency to use substances in solitary contexts, and lower enhancement motives for alcohol compared to the early onset, high PA cluster. The four-cluster solution yielded more distinctions on external criteria than the two-cluster solution. Such temperament variation within both high and low severity substance abusers may be important for treatment planning.

Assessing the diversity of personal beliefs about addiction: development of the addiction belief inventory

Previous work in the field of substance use/misuse has suggested that client beliefs about addiction are quite diverse, and may influence the effectiveness of various treatment approaches. This paper presents an Addiction Belief Inventory (ABI) that was developed and evaluated to assess personal beliefs about addiction and substance use problems. The ABI is a 40-item instrument developed using two clinical samples: an alcohol user treatment group (N = 134) and a dual diagnosis treatment group (N = 536). Confirmatory factor analysis revealed seven stable subscales: inability to control, chronic disease, reliance on experts, responsibility for actions, responsibility for recovery, genetic basis, and coping. Multivariate analyses provided preliminary reliability and validational support. The utility of the ABI for clinical and research purposes is discussed, along with suggestions for future research and improvements to the instrument.

Longitudinal effects of integrated treatment on alcohol use for persons with serious mental illness and substance use disorders

A randomized experimental design was used to assign participants to an integrated mental health and substance use treatment program or to standard hospital treatment. A multilevel, nonlinear model was used to estimate hospital treatment effects on days of alcohol use for persons with serious mental illness and substance use disorders over 18 months. The integrated treatment program had a significant effect on the rate of alcohol use at 2 months postdischarge, reducing the rate of use by 54%. Motivation for sobriety at hospital discharge, posttreatment self-help attendance, and social support for sobriety were also found to reduce the rate of use during the follow-up period. Implications for mental health treatment and aftercare support are discussed.

Characteristics of dual diagnosis patients admitted to an urban, public psychiatric hospital: an examination of individual, social, and community domains

The study provides descriptive data on a large, diverse sample of dually diagnosed patients from an urban psychiatric inpatient setting, utilizing a comprehensive array of clinical, social and community functioning measures. The intent is to provide more useful and reliable information, particularly concerning African-Americans with a dual diagnosis in the public sector. Over a one year period, all persons admitted to a public psychiatric hospital with a DSM-III-R psychiatric diagnosis and a positive screen for substance abuse problems using clinical and structured measures (n = 486) were interviewed on the Addiction Severity Index (ASI) and other measures to assess community and social functioning, alcohol and drug use, psychiatric problems, and service histories. The majority of participants were found to have serious economic and employment problems, undesirable living arrangements, limited or conflictive family or social relationships, and some record of arrest. The ASI problem areas most to least in need of treatment were: psychiatric, alcohol and drug abuse, employment, family/social, legal, and medical. Substances most often currently abused were alcohol, cocaine, and cannabis; there was a high rate of polydrug abuse. Participants had experienced a median of 3.0 previous psychiatric hospitalizations, fewer outpatient substance abuse treatments, and limited community mental health contact. Some subgroup differences based on gender, age, and race were found which have implications for community treatment planning. The study results document the extreme heterogeneity in the dually diagnosed as well as their multiple treatment needs. To better inform treatment planning, future research on dual diagnosis should attempt to establish meaningful subgroups relevant to service needs and should utilize diverse clinical and functioning measures.