How did the COVID-19 lockdown impact patients with dual diagnoses?

Schizophrenia and Co-Occurring Substance Use Disorder

The purpose of this study was to determine the extent of comorbid substance use disorders in patients referred for treatment of personality disorders. Two hundred inpatients and outpatients were assessed by semistructured interviews for substance use and personality disorders. Univariate odds ratios were calculated for groups of substance use disorders and each DSM-III-R axis II disorder; comorbidity among axis II disorders was controlled in multivariate models predicting current or lifetime substance use disorder groups. The impact of personality disorder on chronicity and overall impairment associated with substance use disorders was evaluated. Close to 60% of subjects with substance use disorders had personality disorders. Borderline personality disorder was significantly associated with current substance use disorders, excluding alcohol and cannabis, and with lifetime alcohol, stimulant, and other substance use disorders, excluding cannabis. Antisocial personality disorder was associated with lifetime substance use disorders other than alcohol, cannabis, and stimulants. These relationships remained significant after controlling for the presence of all other personality disorders. There was no evidence that personality disorders increased the chronicity of substance use disorders, but comorbid personality disorders were associated with greater global impairment. Borderline personality disorder may be associated with a wide variety of substance use disorders, especially among patients seeking treatment for personality problems.

This practice parameter describes the assessment and treatment of children and adolescents with substance use disorders and is based on scientific evidence and clinical consensus regarding diagnosis and effective treatment as well as on the current state of clinical practice. This parameter considers risk factors for substance use and related problems, normative use of substances by adolescents, the comorbidity of substance use disorders with other psychiatric disorders, and treatment settings and modalities. (Reprinted with permission from the Journal of the American Academy of Child and Adolescent Psychiatry 2005; 44(6):609–621)

The enduring challenge of antipsychotic non-adherence

Objective-This study identified ways that consumers of mental health services are active participants in psychiatric treatment.Methods-Self-reported activity in treatment and observations of audio recorded psychiatric visits were examined.Four providers (3 psychiatrists and one nurse practitioner) and 10 of their consumers with severe mental illness (40 total) were recruited.Consumers completed questionnaires on patient activation, illness self-management and medication attitudes on the day of a psychiatric visit.The visit was audiotaped, transcribed, and thematically analyzed.Providers reported diagnosis, substance abuse, and medication adherence.Results-Self-reported patient activation was positively related to illness self-management and negatively related to substance abuse.Consumers were active in partnership building, seeking and displaying competence, and directing treatment; however, there was little relationship between selfreported activation and observed behaviors.Conclusions-Consumers are active in a variety of ways; but, similar to other populations, the relationship to self-reported desire for involvement is not direct.Living successfully with chronic health conditions requires active collaboration in managing illness --consumer and health care provider working together to identify problem areas, set goals, learn self-management skills, and participate in follow-up (1).An active partnership is critical because the majority of time spent managing chronic illnesses takes place when the consumer is on his/her own in the community rather than in the provider's office.Further,

Objective-Patients with concomitant psychiatric and substance use disorders are commonly assigned representative payees or case managers to help manage their funds, but money management has not been conceptualized as a theory-based treatment.This randomized clinical trial was conducted to determine the effect of a money management-based therapy, advisor-teller money manager (ATM), on substance abuse or dependence.Methods-Ninety patients at a community mental health center who had a history of cocaine or alcohol abuse or dependence were assessed after random assignment to 36 weeks of ATM (N=47) or a control condition in which use of a financial workbook was reviewed (N=43).Patients assigned to ATM were encouraged to deposit their funds into a third-party account, plan weekly expenditures, and negotiate monthly budgets.Substance use calendars and urine toxicology tests were collected every other week for 36 weeks and again 52 weeks after randomization.Results-Patients assigned to ATM had significantly more negative toxicologies for cocaine metabolite over time than patients in the control group, and treating clinicians rated ATM patients as significantly more likely to be abstinent from illicit drugs.Self-reported abstinence from alcohol did not significantly differ between groups.Unexpectedly, patients assigned to ATM were more likely to be assigned a representative payee or a conservator than control participants during the follow-up period (ten of 47 versus two of 43).One patient in ATM assaulted the therapist when his check had not arrived.Conclusions-ATM is an efficacious therapy for the treatment of cocaine abuse or dependence among people with concomitant psychiatric illness but requires protection of patient autonomy and staff safety.People with severe psychiatric illnesses commonly use alcohol, cocaine, or both (1,2).Because of their substance use and disabling psychiatric illnesses, patients with co-occurring disorders are frequently poor and need to make the most of their limited income to avoid abject poverty.Unfortunately, high proportions of psychiatric patients report difficulty managing their money and have made poor financial decisions under the influence of drugs (3).Patients' desire to have money is a potentially powerful motivation to stop buying alcohol and cocaine, and people who are poor and mentally ill indicate a desire for help with concrete financial concerns (4).

Patients with concomitant psychiatric and substance use disorders are commonly assigned representative payees or case managers to help manage their funds, but money management has not been conceptualized as a theory-based treatment. This randomized clinical trial was conducted to determine the effect of a money management-based therapy, advisor-teller money manager (ATM), on substance abuse or dependence. Ninety patients at a community mental health center who had a history of cocaine or alcohol abuse or dependence were assessed after random assignment to 36 weeks of ATM (N=47) or a control condition in which use of a financial workbook was reviewed (N=43). Patients assigned to ATM were encouraged to deposit their funds into a third-party account, plan weekly expenditures, and negotiate monthly budgets. Substance use calendars and urine toxicology tests were collected every other week for 36 weeks and again 52 weeks after randomization. Patients assigned to ATM had significantly more negative toxicologies for cocaine metabolite over time than patients in the control group, and treating clinicians rated ATM patients as significantly more likely to be abstinent from illicit drugs. Self-reported abstinence from alcohol did not significantly differ between groups. Unexpectedly, patients assigned to ATM were more likely to be assigned a representative payee or a conservator than control participants during the follow-up period (ten of 47 versus two of 43). One patient in ATM assaulted the therapist when his check had not arrived. ATM is an efficacious therapy for the treatment of cocaine abuse or dependence among people with concomitant psychiatric illness but requires protection of patient autonomy and staff safety.

Patients with both mental illness and substance abuse pose a major clinical challenge to mental health and substance abuse clinicians. The literature seems to support the hypothesis that mental illness and substance abuse occur together more frequently than chance would predict. Assessment and classification of these patients should be guided by clinicians' needs to make meaningful therapeutic judgments and to communicate effectively with each other in coordinating treatment. Different phases of treatment require different approaches to assessment and classification. In initial classification, the clinician should recognize the problem of dual diagnosis and resist premature assumptions about which diagnosis is primary. Long-term treatment and rehabilitation may require systematic evaluation of alternative clinical by potbeses about why a patient exhibits both disorders. This approach eventually may lead to better ways to assess, classify, and treat these difficult patients.

Substance Abuse-Related Mortality Among Middle-Aged Male VA Psychiatric Patients

The purpose of this study is to demonstrate the effectiveness of a freestanding intensive outpatient program (IOP) in a private practice setting for the treatment of dual diagnosis substance-abusing patients. Pre- and post-treatment Symptom Checklist 90–Revised, Global Assessment of Functioning, and patient functional rating scales were analyzed. Reliable change indices and clinically significant change measures were utilized. Trajectories of change for depression and number of days substances were used were analyzed, based on weekly Brief Symptom Inventory and substance use data reported by patients. Client satisfaction was also assessed at the end of treatment. Although patients started treatment with psychiatric symptoms comparable to those found in inpatient settings and 56% presented with suicidal or homicidal ideation, all symptom scales, functional impairments, and number of days used were significantly reduced by the end of treatment. Effect size statistics, reliable change indices, and statistically significant results indicated that 56% to 74% of patients treated in this program may be expected to improve, depending on the stringency of the criteria utilized. It is clear that dual diagnosis substance-abusing patients can be safely and effectively treated in a private practice IOP setting.

This study examined the reliability and convergent, discriminant, and predictive validity of the Mental Illness Research, Education, and Clinical Center (MIRECC) version of the Global Assessment of Functioning (GAF) scale. The MIRECC GAF measures occupational functioning, social functioning, and symptom severity on three subscales. MIRECC GAF ratings were obtained for 398 individuals with schizophrenia or schizoaffective disorder who were receiving treatment at three Veterans Affairs mental health clinics. Assessments were completed by using the Positive and Negative Syndrome Scale and the Quality of Life Interview at baseline and nine months later. All three MIRECC GAF subscales exhibited very high levels of reliability. The occupational and symptom subscales showed good convergent and discriminant validity. The social subscale was related to measures of social functioning and, to a greater degree, symptom severity. The occupational and social subscales significantly predicted their respective domains at the nine-month follow-up. The symptom subscale predicted negative symptoms at follow-up; however, it did not predict positive symptoms or cognitive disorientation. Instead, the social subscale was predictive of cognitive disorientation at follow-up. When the standard GAF was routinely administered by clinicians, scores demonstrated little validity. The three MIRECC GAF subscales can be scored reliably, and they have good concurrent and predictive validity. Further work is needed on brief measures of patient functioning, especially measures of social functioning.

Objective-This retrospective cohort study examined the association between co-occurring serious mental illness and substance use disorders and parole revocation among inmates from the Texas Department of Criminal Justice, the nation's largest state prison system. Methods-The study population included all 8,149 inmates who were released under parole supervision between September 1, 2006, and November 31, 2006.An electronic database was used to identify inmates whose parole was revoked within 12 months of their release.The independent risk of parole revocation attributable to psychiatric disorders, substance use disorders, and other covariates was assessed with logistic regression analysis.Results-Parolees with a dual diagnosis of a major psychiatric disorder (major depressive disorder, bipolar disorder, schizophrenia, or other psychotic disorder) and a substance use disorder had a substantially increased risk of having their parole revoked because of either a technical violation (adjusted odds ratio [OR]=1.7,95% confidence interval [CI]=1.4-2.4) or commission of a new criminal offense (OR=2.8,95% CI=1.7-4.5) in the 12 months after their release.However, parolees with a diagnosis of either a major psychiatric disorder alone or a substance use disorder alone demonstrated no such increased risk.Conclusions-These findings highlight the need for future investigations of specific social, behavioral, and other factors that underlie higher rates of parole revocation among individuals with co-occurring serious mental illness and substance use disorders.Over the past four decades the widespread deinstitutionalization of persons with serious mental illness (1-3), the increase in drug-related arrests (4,5), and the reduction of community-based mental health care (1,2) have resulted in a substantial overrepresentation of persons with serious mental illness in the U.S. correctional system (1,2,6).Approximately 10% to 20% of U.S. prison inmates are estimated to have an axis I major mental disorder of thought or mood, such as major depressive disorder, bipolar disorder, or schizophrenia (7-12).Moreover, a majority of inmates with serious mental illness have a comorbid substance use disorder (7,(12)(13)(14)(15).A number of investigations have examined predictors of recidivism among released inmates (16)(17)(18)(19).Although results of these studies-conducted throughout a variety of criminal justice

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Continuing Care After Inpatient Psychiatric Treatment for Patients With Psychiatric and Substance Use Disorders

This study described the locations and patterns of psychiatric and substance abuse treatment for Medicaid beneficiaries with co-occurring mental and substance use disorders in five states. Medicaid beneficiaries aged 21 to 65 with psychiatric or substance use disorders were identified with claims and encounter records. Groups were further divided into those with and those without a diagnosed substance use disorder. Adjusted odds of treatment in community-based settings, inpatient facilities, emergency departments, and hospital outpatient departments were calculated. A total of 92,355 persons had a psychiatric disorder, 34,158 had a substance use disorder, and 14,256 had co-occurring psychiatric and substance use disorders. In all five states, beneficiaries with severe mental illness (schizophrenia, bipolar disorder, or major depression) and a substance use disorder had higher odds of inpatient, emergency department, and hospital-based outpatient psychiatric treatment, compared with those with severe mental illness alone. In four of five states, both severe and less severe mental illness and a co-occurring substance use disorder were associated with lower odds of community-based treatment compared with those with the respective mental illness alone. Compared with those with less severe mental illness alone, individuals with less severe psychiatric disorders and a co-occurring substance use disorder had higher odds of inpatient treatment in all states and of emergency department use in three of five states. Odds of inpatient and outpatient hospital use and emergency department use for substance abuse treatment were higher for persons with severe mental illness and a co-occurring substance use disorder in most states, compared with odds for those with a substance use disorder alone. Heavy inpatient and emergency department use by Medicaid beneficiaries with co-occurring substance use disorders is a consistent cross-state problem. Co-occurring disorders may decrease the likelihood of community-based treatment for those with less severe mental disorders and for those with severe mental illness, suggesting that policies focusing only on these settings may miss a significant proportion of people with these co-occurring disorders.