The role of substance use in families' attributions and affective reactions to their relative with severe mental illness

Substance Use in Relation to Mental Illness: A Study of Mexican-Origin Latinos with Schizophrenia and Their Family Members

Little is known about family context and substance use behaviors among Latinos with schizophrenia. Learning about patient and family caregiver perceptions of use is critical to our understanding of how best to support these vulnerable patients and family caregivers. This study explored perceptions of substance use in relation to mental illness among Latinos primarily of Mexican origin with schizophrenia and their family caregivers. Semistructured interviews were conducted with 34 participants (20 family caregivers; 14 patients) with direct and indirect substance use experience, in their preferred language. Data were analyzed using thematic analysis, which consisted of comparing codes across and within patient and family caregiver transcripts. Findings revealed that substance use affected well-being, particularly patient recovery and caregiver burden. Strategies to address well-being included limiting substance use, being vigilant about patient use, and communicating the negative impact of use. The environmental impact and stigma of substance use were major contextual challenges. Patients addressed these by limiting their socialization. Family social context was important to how substance use was perceived and managed by patients and caregivers. As such, treatment models should consider a holistic perspective that incorporates family context when addressing substance use among Latinos with schizophrenia.

Caregiving for Relatives with Psychiatric Disorders vs. Co-Occurring Psychiatric and Substance Use Disorders

Despite the high comorbidity of psychiatric and substance use disorders, extremely little research has examined the experience of caregiving for relatives with co-occurring psychiatric and substance use disorders (COD). The primary objective of the present article is to identify characteristics pertaining to care recipients, family caregivers, and the experience of providing caregiving associated with care recipients having COD vs. only having psychiatric disorders (PD). A U.S. community recruited sample of 1394 family caregivers of persons with COD or PD was employed. Chi-square and Mann-Whitney-Wilcoxon tests were conducted. Compared to caregivers of persons with only PD, caregivers of persons with COD provided slightly less caregiving but experienced significantly greater negative effects from providing care. Caregivers of persons with COD were also more likely to fear care recipients would engage in multiple problematic behaviors. Most significant differences found in providing care to recipients with COD vs. only PD persisted when examining care recipients with severe psychiatric disorders or more moderate psychiatric disorders. Additional findings and treatment implications are described.

Caregiver criticism, help-giving, and the burden of schizophrenia among Mexican American families

OBJECTIVES

This study tested an attribution model of help-giving in family caregivers of persons with schizophrenia as it relates to caregivers' reported burden. We hypothesized (a) that caregivers' attributions of their ill relatives' responsibility for their symptoms would be associated with more negative and less positive affective reactions, (b) that affective reactions would be related to perceptions of administered support, and (c) that support would in turn predict greater burden.

METHODS

We examined 60 family caregivers of Mexican origin living in Southern California. Mexican Americans were chosen because of their high degree of contact with their ill relative, thereby facilitating the examination of help-giving and burden. Contrary to past studies, caregivers' attributions and affective stance were assessed independently, the former based on self-report and the latter based on codes drawn from the Camberwell Family Interview. Caregiver burden was assessed at baseline and one year later.

RESULTS

Path analyses showed partial support for the attribution model of help-giving. Specifically, attributions of responsibility negatively predicted caregiver's warmth, which in turn predicted more administered support. Contrary to hypotheses, attributions were not associated with caregiver criticism, and criticism was positively related to administered support. In addition, caregiver support was not related to burden at either baseline or a year later. Criticism was a significant predictor of burden at follow-up through burden at baseline.

CONCLUSION

The emotional stance of caregivers predicts burden independent of the help they provide. Caregiver criticism not only predicts negative patient outcomes but can predict negative caregiver outcomes as well.

PRACTITIONER POINTS

Positive clinical implications In family treatment, it is important to address caregiver criticism not only because of its relationship to poor clinical outcomes of ill relatives but also because of its relationship to greater caregiver burden. Integrating a balanced rationale for family interventions - to improve ill relatives' and caregivers' outcomes - may promote further engagement of both parties as some caregivers may be additionally motivated to improve their own well-being, and some ill relatives may appreciate more equitably distributing the treatment focus. Limitations The caregiver sample was in general low in criticism; therefore, the findings may not be generalizable to families with a higher degree of criticism. There was a 35% sample attrition at the one-year follow-up.

Substance use disorders in hospitalized psychiatric patients: the experience of one psychiatric emergency service in Turin

In the present study we sought: 1) to estimate the frequency of substance use disorders (SUD), and 2) to investigate whether there is a mere association between diagnosis and SUD in a large cohort of patients with severe psychiatric disorders representative of the usual setting and modality of care of a psychiatric emergency service in a geographically well-defined catchment area in Italy, independent of sociodemographic features, anamnestic data and clinical status. The study was conducted between January 2007 and December 2008. The following rating scales were performed: the Clinical Global Impression-Severity (CGI-S), the Global Assessment of Functioning scale (GAF) and the Brief Psychiatric Rating Scale (BPRS). Factors found to be associated (p<0.05) with SUD[+] in the univariate analyses were subjected to multilevel logistic regression model with a backward stepwise procedure. Among 848 inpatients of our sample 29.1% had a SUD codiagnosis. Eleven factors accounted for 30.6% of the variability in SUD[+]: [a] a Personality Disorder diagnosis, [b] a Depressive Disorder diagnosis, [c] male gender, [d] previous outpatient contacts, [e] single marital status, [f] no previous psychiatric treatments, [g] younger age, [h] lower scores for BPRS Anxiety-depression and [i] BPRS Thought Disturbance, [l] higher scores for BPRS Activation and [m] BPRS Hostile-suspiciousness. The findings are important in identifying (1) the complexity of the clinical presentation of SUD in a inpatients sample, (2) the need for collaboration among health care workers, and (3) the need to develop and apply treatment programs that are targeted at particular risk groups.

A randomized controlled trial of family intervention for co-occurring substance use and severe psychiatric disorders

Substance use disorders have a profound impact on the course of severe mental illnesses and on the family, but little research has evaluated the impact of family intervention for this population. To address this question, a randomized controlled trial was conducted comparing a brief (2-3 mo) Family Education (ED) program with a longer-term (9-18 mo) program that combined education with teaching communication and problem-solving skills, Family Intervention for Dual Disorders (FIDD). A total of 108 clients (77% schizophrenia-spectrum) and a key relative were randomized to either ED or FIDD and assessed at baseline and every 6 months for 3 years. Rates of retention of families in both programs were moderate. Intent-to-treat analyses indicated that clients in both programs improved in psychiatric, substance abuse, and functional outcomes, as did key relatives in knowledge of co-occurring disorders, burden, and mental health functioning. Clients in FIDD had significantly less severe overall psychiatric symptoms and psychotic symptoms and tended to improve more in functioning. Relatives in FIDD improved more in mental health functioning and knowledge of co-occurring disorders. There were no consistent differences between the programs in substance abuse severity or family burden. The findings support the utility of family intervention for co-occurring disorders, and the added benefits of communication and problem-solving training, but also suggest the need to modify these programs to retain more families in treatment in order to provide them with the information and skills they need to overcome the effects of these disorders.

Maladaptive Coping as a Mediator of Family Stress

Family members of women substance users may be at risk for stress-related problems. Family coping responses may affect outcomes for both families and women in treatment. Eighty-two women in treatment for substance use disorders (56 with comorbid psychiatric conditions) and 82 family members were interviewed. Stressors related to women's disorders were significantly related to increased family member burden. Women's behavioral problems predicted greater family member Worry, Displeasure, and Impact. Extent of women's drug or alcohol use predicted greater family member Stigma and Impact. Family member maladaptive coping partially mediated relationships between family member stressors and family member Displeasure and Impact. Family member maladaptive coping also functioned as a moderator between the stressors and Impact.

Criminal Justice Involvement and Service Need among Men on Methadone who Have Perpetrated Intimate Partner Violence

Perpetrators of male-to-female intimate partner violence (IPV) may be likely to have multiple service needs, the extent of which may vary with respect to criminal justice involvement. The salience of the criminal justice system and the potential impact on service needs due to arrest and incarceration is underscored given the association between substance use and IPV. This study utilized a sample of men in methadone treatment who perpetrated male-to-female IPV in order to examine associations between criminal justice involvement and perceived additional service need(s). Results indicate that the likelihood of having a service need(s) significantly increased as time since most recent arrest or incarceration decreased. These findings highlight the need and potential benefit that can be derived from greater coordination amongst the criminal justice, IPV prevention, and drug treatment systems and service providers.

Family intervention for co-occurring substance use and severe psychiatric disorders: participant characteristics and correlates of initial engagement and more extended exposure in a randomized controlled trial

Clients with severe mental illness and substance use disorder (i.e., dual disorders) frequently have contact with family members, who may provide valuable emotional and material support, but have limited skills and knowledge to promote recovery. Furthermore, high levels of family conflict and stress are related to higher rates of relapse. The present study was a two-site randomized controlled trial comparing a comprehensive, behaviorally-based family intervention for dual disorders program (FIDD) to a shorter-term family psychoeducational program (FPE). The modal family was a single male son in his early 30s diagnosed with both alcohol and drug problems and a schizophrenia-spectrum disorder participating with his middle-aged mother, with whom he lived. Initial engagement rates following consent to participate in the study and the family intervention programs were moderately high for both programs (88% and 84%, respectively), but rates of longer term retention and exposure to the core elements of each treatment model were lower (61% and 55%, respectively). Characteristics of the relatives were the strongest predictors of successful initial engagement in the family programs with the most important predictor being relatives who reported higher levels of benefit related to the relationship with the client. Subsequent successful exposure to the family treatment models was more strongly associated with client factors, including less severity of drug abuse and male client gender. The results suggest that attention to issues of motivating relatives to participate in family intervention, and more focused efforts to address the disruptive effects of drug abuse on the family could improve rates of engagement and retention in family programs for dual disorders.