Treatment of dual diagnosis patients: A relapse prevention group approach

Treatment outcomes of an integrated residential programme for patients with schizophrenia and substance use disorder

BACKGROUND

About half of all schizophrenic patients have a co-occurring substance use disorder, leading to poorer social and functional outcomes than obtained in non-abusing patients. To improve outcomes, integrated treatments have been designed that address the two conditions simultaneously. Results are, however, conflicting because the available effect studies are hampered by various methodological issues, among which are heterogeneous patient samples.

METHODS

In this comparative study, two well-described patient samples diagnosed with schizophrenia and co-morbid substance abuse disorders either received an integrated treatment (IDDT) or treatment as usual (TAU).

RESULTS

Patients in the IDDT condition showed significant reductions in illicit drug and alcohol use, improvements on all psychiatric symptom domains, reported higher quality of life and improved on social and community functioning. In contrast, patients' improvements in the TAU group were moderate and limited to a few substance use and psychiatric outcomes. The TAU group had significantly higher dropout rates 6 and 12 months after baseline, suggesting that the IDDT programme was more successful in committing patients.

CONCLUSIONS

Our results suggest that an integrated approach to schizophrenic patients and co-morbid substance use disorders is superior to standard treatment and may be considered as the treatment of choice for this patient group.

Psychotherapy through the phases of bipolar disorder: Evidence for general efficacy and differential effects

The obstacle facing pharmacotherapy for bipolar disorder is that almost half of the patients do not achieve recovery over the duration of treatment. Although the reason for this disappointing clinical outcome remains unclear, structured psychotherapy has helped to fill these gaps in the treatment of bipolar disorder. Psychoeducation, family-focused therapy, interpersonal and social rhythm therapy, and cognitive behavior therapy have all received attention in the research literature. In this review, by assessing the outcomes from randomized control trials across the phases of bipolar disorder, we demonstrate that psychotherapy is an effective adjunctive treatment. We also show that the use of psychotherapy for bipolar disorder has differential results depending on when and under what conditions it is administered.

Mortality in a cohort of opiate and amphetamine users in Perth, Western Australia

AIMS

This study compares the hazard of death among opiate and amphetamine using clients who accessed drug treatment with individuals who had no specialist treatment contact between 1985 and 1998.

DESIGN, SETTING, PARTICIPANTS

This was a retrospective cohort study of 4280 drug-using individuals (2887 opiate users, 1393 amphetamine users) admitted to Perth metropolitan hospitals or Perth psychiatric institutions between 1985 and 1998. Of these, 1469 attended Next Step Specialist Drug and Alcohol Services (928 received methadone and 541 attended counselling or support groups) and 2811 had no contact with this service.

METHODS

Data from two drug treatment programmes were linked with hospital morbidity, psychiatric services and the mortality database using record linkage.

FINDINGS

The results show that people who were currently in drug treatment had a lower hazard of death compared with non-clients and those who had ceased treatment. Those who had ceased treatment more than 6 months ago had 7.0 times the hazard of all-cause death and 8.4 times the hazard of drug-cause death. Opiate users were at 1.4 times the hazard of all-cause death and 2.4 times the hazard of drug-cause death compared with amphetamine users. Males were at 1.79 times the hazard of all-cause death and, unexpectedly, were found to be at 2.69 times the hazard of drug-cause death compared with females.

CONCLUSIONS

Treatment protected clients from premature death compared with people who did not receive treatment and also those who ceased treatment. While amphetamine users had a lower risk of mortality compared with opiate users, the full extent of the relationship between amphetamine use and mortality needs to be examined further.

Anxiety and substance use comorbidity among inpatients with schizophrenia

OBJECTIVE

To determine the association between lifetime anxiety symptoms and anxiety disorders and substance use disorders among patients with schizophrenia.

METHOD

Participants were 184 inpatients with schizophrenia at the Schizophrenia Research Unit (SRU) at the New York State Psychiatric Institute (NYSPI). Multivariate logistic regression analyses were used to determine the relationship between specific anxiety symptoms and anxiety disorders and substance use disorders among inpatients with schizophrenia.

RESULTS

Anxiety symptoms and anxiety disorders were prevalent among 31.5% of the sample. Panic attacks were associated with a significantly increased odds (OR=7.4 (1.2, 47.1)) of comorbid alcohol or substance use disorders (lifetime). This association was specific to panic attacks and persisted after adjusting for differences in sociodemographic characteristics and comorbid anxiety symptoms and anxiety disorders.

CONCLUSIONS

These findings are consistent with and extend previous data by providing evidence of an association between panic attacks and increased likelihood of substance use disorders among inpatients with schizophrenia. Future studies that determine the nature of this relationship, the sequence of symptom onsets, and examine whether treatment of anxiety can influence the onset or outcome associated with substance use are needed.

Trends in acute mental health care: comparing psychiatric and substance abuse treatment programs

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 relationship between anxiety and substance use disorders among individuals with severe affective disorders

We sought to determine the association between anxiety disorders and substance use disorders among patients with severe affective disorders in a community-based outpatient treatment program. Two hundred sixty participants in a supported socialization program were assessed using the Structured Clinical Interview for DSM-III-R (SCID). Multivariate logistic regression analyses were used to determine the relationship between anxiety disorders and alcohol and substance use disorders among patients with severe and persistent affective disorders (i.e., major depression and bipolar disorder). Among patients with severe and persistent affective disorders, cocaine (odds ratio [OR] = 5.9 [1.4, 24.6]), stimulant (OR = 5.1 [1.2, 20.9]), sedative (OR = 5.4 [1.2, 24.7]), and opioid use disorders (OR = 13.9 [1.4, 138.7]) were significantly more common among those with, compared with those without, anxiety disorders. This association persisted after adjusting for differences in sociodemographic characteristics and comorbid psychotic disorders. Significant associations between panic attacks, social phobia, specific phobia, and obsessive-compulsive disorder (OCD) and specific substance use disorders were also evident. These findings are consistent with and extend previous results by documenting an association between anxiety disorders and substance use disorders, independent of comorbid psychotic disorders among patients in a outpatient psychiatric rehabilitation program. These data highlight the prevalence of comorbid anxiety disorders, a potentially undetected and therefore undertreated problem, among patients with severe affective disorders and substance use comorbidity. Future work is needed to determine the nature of this association and to determine whether treatment of one prevents onset of the other.

Cost-effectiveness of mental health services for persons with a dual diagnosis: a literature review and the CCMHCP. The Cost-Effectiveness of Community Mental Health Care for Single and Dually Diagnosed Project

People suffering from comorbid mental illness and substance abuse disorders (the dually diagnosed) are thought to constitute large portions of clients treated as outpatients by public-sector community-based mental health providers. These providers dispense units of ambulatory mental health services and treatments incrementally to maintain clients in the community and out of psychiatric hospitals. Community maintenance is one step, albeit critical, toward quitting drugs and eventual abstinence. Thus, there is a need for information that compares the effectiveness and cost of such services on dually diagnosed clients to identify appropriate low-cost high-yield treatment and service options and packages. This article provides a review of the literature on the effectiveness of ambulatory mental health services and recent emergent reports of cost-effectiveness of programs for the dually diagnosed, paying special attention to the gray areas and gaps. This article also describes a new project; an inexpensive add-on to an existing community mental health center. The project will be examining over 4 years of data to compare influence and cost of different ambulatory mental health services and treatments delivered to a matched pair group of clients with dual disorders and those with only mental illness. The intention of this project is not only to address gray areas and gaps in the literature, but also to inform a more rational deployment of mental health services.

Achieving effective treatment of patients with chronic psychotic illness and comorbid substance dependence

OBJECTIVE

The changing effectiveness of a treatment program for dual-diagnosis patients was evaluated over a 2-year period with the use of a sequential study group design.

METHOD

The treatment outcome of 179 consecutively enrolled patients with chronic psychotic illness and comorbid substance dependence who entered a specialized day hospital dual-diagnosis treatment program from Sept. 1, 1994, to Aug. 31, 1996, was evaluated. The 24 months were divided into four successive 6-month periods for comparing the evolving effectiveness of the program for groups of patients entering the day hospital during these four periods. Treatment attendance, hospital utilization, and twice weekly urine toxicology analyses were used as outcome measures.

RESULTS

The initial treatment engagement rate, defined as at least 2 days of attendance in the first month, increased significantly from group 1 to group 4, more than doubling. Thirty-day and 90-day treatment retention rates also substantially increased from group 1 to group 4. More patients had no hospitalization in the 6 months after entering the day hospital program than in the 6 months before entering the day hospital program. Urine toxicology monitoring indicated that the patients in group 4 were more likely than those in group 1 to remain abstinent at follow-up.

CONCLUSIONS

The evolving clinical effectiveness of a developing program can be quantified by using a sequential group comparison design. The sequential outcome improvements may be related to the incremental contributions of assertive case management and skills training for relapse prevention.

Substance abuse treatment for people with schizophrenia

Substance abuse by people with schizophrenia is a serious public health problem that is associated with poor treatment compliance, increased rates of relapse, and disruption of role functioning. There is widespread agreement on the need to integrate psychiatric and substance abuse treatment for this dual disorder, but to date there are no specific treatments with solid empirical support. We first review the primary consequences of substance abuse by people with schizophrenia and then examine what is currently known about their treatment needs. We then describe the special problems faced by this population that interfere with their ability to reduce substance use, with or without treatment. The remainder of the paper focuses on description of a new behavioral treatment we have developed to compensate for the cognitive and motivational deficits that characterize the illness. We describe the development process and present some process data that demonstrate that the intervention is safe and acceptable for people with schizophrenia, and that we are able to train therapists to administer the procedures in a consistent and effective manner. Future studies will examine the effectiveness of the intervention.

Treatment models for clients with co-occurring addictive and mental disorders

Recent epidemiologic studies conducted by the National Comorbidity Survey have indicated that up to 51% of individuals with a serious mental illness are also dependent on or addicted to illicit drugs. However, only 50% of these clients with cooccurring addictive and mental disorders receive treatment that addresses both issues. The author provides a historical overview of treatment philosophies and approaches, describes current treatment models, and reports on outcome data that describe the efficacy of current treatment. Recommendations are made for nurses to incorporate effective treatment models into nursing practice.