Co-occurring Substance Abuse Disorders Research Articles

Serious Mental Illness in Post-Acute and Long-Term Care:Building Knowledge, Sharing Care

Serious Mental Illness in Post-Acute and Long-Term Care:Building Knowledge, Sharing Care

Exposure to Kynurenic Acid during Adolescence Increases Sign-Tracking and Impairs Long-Term Potentiation in Adulthood.

Changes in brain reward systems are thought to contribute significantly to the cognitive and behavioral impairments of schizophrenia, as well as the propensity to develop co-occurring substance abuse disorders. Presently, there are few treatments for persons with a dual diagnosis and little is known about the neural substrates that underlie co-occurring schizophrenia and substance abuse. One goal of the present study was to determine if a change in the concentration of kynurenic acid (KYNA), a tryptophan metabolite that is increased in the brains of people with schizophrenia, affects reward-related behavior. KYNA is an endogenous antagonist of NMDA glutamate receptors and α7 nicotinic acetylcholine receptors, both of which are critically involved in neurodevelopment, plasticity, and behavior. In Experiment 1, rats were treated throughout adolescence with L-kynurenine (L-KYN), the precursor of KYNA. As adults, the rats were tested drug-free in an autoshaping procedure in which a lever was paired with food. Rats treated with L-KYN during adolescence exhibited increased sign-tracking behavior (lever pressing) when they were tested as adults. Sign-tracking is thought to reflect the lever acquiring incentive salience (motivational value) as a result of its pairing with reward. Thus, KYNA exposure may increase the incentive salience of cues associated with reward, perhaps contributing to an increase in sensitivity to drug-related cues in persons with schizophrenia. In Experiment 2, we tested the effects of exposure to KYNA during adolescence on hippocampal long-term potentiation (LTP). Rats treated with L-KYN exhibited no LTP after a burst of high-frequency stimulation that was sufficient to produce robust LTP in vehicle-treated rats. This finding represents the first demonstrated consequence of elevated KYNA concentration during development and provides insight into the basis for cognitive and behavioral deficits that result from exposure to KYNA during adolescence.

Factors associated with treatment attrition for Medicaid-enrolled youth with serious emotional disturbances

Premature discontinuation from treatment is a significant problem that undermines the delivery of effective mental health services and increases the risk for relapse and poor outcomes. However, factors associated with treatment attrition in children and adolescents are not well understood. This retrospective longitudinal cohort study examines factors associated with attrition for Medicaid-enrolled youth, aged 5 to 17 with “new episodes” of ICD-9-CM diagnosed serious emotional disturbance (N=43,122). Information on individual-level (demographic and clinical characteristics) and contextual-level variables (county socio-demographic, economic, and health care resources) were abstracted from Medicaid claim files and the Area Resource File. Multilevel modeling was used to assess the association between individual and contextual-level variables and attrition. Of the 43,122 youth in the study sample, 4056 (9.4%) discontinued treatment. The odds of treatment attrition were significantly higher for youth who were male (OR=1.16, p<0.001), black compared to white (OR=1.19, p<0.001), had a co-occurring substance abuse disorder (OR=1.35, p=0.01), and lived in a county with a larger percentage of minorities (OR=1.02, p=0.01). In contrast, youth diagnosed with bipolar and depressive disorders compared to ADHD (OR=0.78, p<0.001 and OR=0.87, p=0.01, respectively), with comorbid psychiatric (OR=0.74, p<0.001) and medical disorders (OR=0.82, p<0.001), and a prior history of two or more psychotropic medications compared to no medications (OR=0.76, p<0.001) had lower odds of attrition. Residence in a county with a larger number of pediatricians and psychologists also reduced the odds of attrition (OR=0.97, p=0.05 and OR=0.99, p=0.03 respectively). Overall, this study suggests that a combination of individual factors, demographic and clinical, and contextual factors impact attrition in children's mental health outpatient treatment.

IMPACT OF INITIAL HOSPITALIZATION ON 3-YEAR OUTCOME IN PATIENTS WITH FIRST EPISODE PSYCHOSIS IN HONG KONG

used to generate unbiased and efficient estimates, as well as proper standard errors. This modeling takes into account (a) the influence of different sample sizes across counties and (b) the dependence among individual outcomes clustered within the same county. Results: HLM showed both significant individual and contextual effects. Race (i.e. African American), homelessness, and comorbidity of a substance abuse significantly decreased the odds of conforming to standards of continuity of care. Co-morbidity of substance abuse provided the most substantial decrease in rates of conformance. There was very little consistency in odds of conformance rates for contextual level variables. Conformance to standards of quality continuity of care decreased if the community had higher rates of poverty, had fewer community mental health centers, and was classified as rural. Discussion: The overall findings show that basic standards of quality continuity of care are not being met for some adults with schizophrenia in parts of the USA. The results highlight substantial disparities in basic standards of quality continuity of care. Conformance rates are significantly lower for African Americans and the homeless. Particularly striking were the results for those with a cooccurring substance abuse disorder as they had the lowest conformance rate of any individual based factor. Contextual factors significantly associated with lower conformance rates were number of available mental health centers, level of poverty, and whether the community is rural. Such disparities leave certain individuals and communities vulnerable to a host of negative consumer outcomes. The results demonstrate a clear need for quality of care monitoring particularly for specific groups and communities. The results can serve as guidance for future research in disparities in quality of care.

Criminalization of the mentally ill

In the great world of “they sayers,” they say that the more things change, the more things stay the same. Over a decade ago, Peplau (1994), affectionately known as the mother of psychiatric nursing, observed that the first great psychiatric revolution, and the beginning of contemporary psychiatric nursing, occurred when patients were moved from jails to asylums, and from asylums to hospitals. Regrettably, for a variety of reasons and life circumstances, countless consumers of traditional mental health services increasingly find themselves seeking mental health care under the auspices of jails, prisons, and correctional facilities – a phenomenon frequently referred to as the criminalization of the mentally ill. The deinstitutionalization movement that began in the 1960s, reached its peak in the 1970s, and continues today in some jurisdictions has often been blamed for the criminalization of the mentally ill. And although the philosophical underpinnings of deinstitutionalization were admirable, critics have declared that the “deinstitutionalization of seriously mentally ill individuals has been the largest failed social experiment in twentieth century America” (Torrey, 1995, p. 1612). Unfortunately, the persistent lack of appropriate mental health policy for individuals with chronic mental illness, coupled with insufficient community-based services, resulting in a lack of timely access to assessment and treatment, has resulted in a fragmented mental healthcare system. Many individuals with mental illness are not able to access appropriate and timely treatment; many have co-occurring substance abuse disorders and engage in criminal activities to support their drug habits; whereas others have long histories of committing crimes of survival (Human Rights Watch [HRW], 2003). Regardless of the scenario, they find themselves being bounced between courts, jails, and prisons – a process known as transinstitutionalization (Slovenko, 2003). Sadly, correctional facilities have become “front-line mental health providers” (HRW, 2003, p. 16), representing the “mental health institutions of the 21st century” (White & Whiteford, 2006, p. 302). A recent study by the United States Department of Justice reported that 479,000 local jail inmates (64% of their total population), 705,000 state prisoners (56% of their total population), and 78,000 federal prisoners (representing 45% of their total population) present with symptoms of serious mental illness (i.e., schizophrenia, bipolar disorder, and depression) (James & Glaze, 2006). And although these numbers are particularly staggering, similar trends have been reported in Canada and the United Kingdom as well. Conventional wisdom would dictate that prisons were never designed to meet the needs of individuals requiring treatment for mental illness, and controversy exists regarding how well-equipped prisons are to deal with the complex needs of mentally ill offenders. All too often,

Women with Co-Occurring Substance Abuse Disorders and PTSD: How Women Understand their Illness

This article reports the findings of a qualitative study that explored women's understanding about their “illness” co-occurring substance use disorders (SUD), and post-traumatic stress disorder (PTSD). The findings are part of a larger study that investigated the effectiveness of “Seeking Safety Treatment” within a therapeutic community among women with SUD and PTSD co-morbidities. Seventy-eight women in treatment, who met the diagnostic criteria for Post Traumatic Stress Disorder, participated in the study. Typical study participants were Caucasian, heterosexual, single women between 25 and 38 years old, with 2 children, a high school level education, unemployed, and had annual incomes of less than $10,000. This study summarized responses to a questionnaire given to the women when they entered treatment. Responses are summarized according to question. The following represents a general summary:Drugs or addiction caused the illness that brought me to treatment, and it was largely the result of my family life. The illness numbs me. I hope that I can achieve sobriety through the treatment here. I have suffered multiple losses because of my illness, and I am most afraid that I will die because of it. The illness causes me to be very angry. I think my family should treat me lovingly. I have a bad, severe and lifelong illness.The findings of the study are intended to assist in developing effective treatment programs for women with multiple diagnoses accompanying their substance abuse disorders.

Social Justice, Respect, and Meaning-Making: Keys to Working with the Homeless Elderly Population

I don't look you in the eye, I'm ashamed, but I see you. Do you know that I am more than I appear? For God's sake, see the real me. Fuhr, 1996, p. 2 In U.S. culture, people do not like to believe that their grandparents, great uncles and aunts, and aging parents might suffer from severe mental illness, much less that they may be substance abusers or alcoholics. Consequently, we often deny that elderly people with mental illness and addictions exist, or if they do, we consider them to be anomalies. Substance abuse programs designed for the special of older adults are rare in the United States, and traditional mental health providers are often reluctant to work with the population, thus making difficult for the older adults to receive mental health services (Ladner, cited in Rosenheck, Bassuk, & Saloman, 1998). As a society, we have been slow to accept the growing need for age-specific treatment services for elderly people, especially elderly individuals. It is easy to distance ourselves from the problem of homelessness, telling ourselves could never happen to any seniors I know, but in fact, it is increasingly happening to elderly people. LITERATURE REVIEW In recent years, the number of individuals who are older than 50 has grown, and the numbers are expected to increase as the problem and elderly population escalates. At the same time that the aging population is growing, the amount of affordable housing is decreasing, thus making the marginally housed individuals even more vulnerable (Rosenheck et al., 1998). Estimates of the aging population vary considerably, ranging from 6 percent to 27 percent of the total population (Kutza & Keigher, 1991), but the numbers alone do not tell the story of this population. Elderly people need special attention as their age makes them especially defenseless; their options for reintegrating into society are few; and their physical ability to withstand the hardships of being or living in shelters is limited. They often lack a network of relatives and friends, and their impaired judgment may lead to financial mismanagement and exploitation. Complications of aging can also affect the treatment process: The decline in hearing and vision may create a lack of trust and hypervigilance among elderly people; they may reluctantly choose to remain on the streets because they are often targets in shelters; and they often fear that their independence will be limited, or worse, that they will be institutionalized (Cohen & Sullivan, 1990; Keigher, Ahrens, & Lumpkin, 1987; Kutza & Keigher, 1991; Rosenheck et al., 1998). There is general agreement that approximately one-third of the single adult population suffers from a severe mental illness, and the percentage of mental illness among people is significantly higher than that of the domiciled population (Wells, Williams, & Dennis, 2003). In addition, approximately 50 percent of people with a serious mental illness have a co-occurring substance abuse disorder (Fischer & Breakey, 1991). The symptoms of mental illness or substance abuse disorders may render individuals more vulnerable to homelessness or marginal housing, and given this susceptibility, has been estimated that as many as two-thirds of the people with a serious mental illness have been or at risk of becoming (Tessler & Dennis, cited in Wells et al., 2003). With regard to treating this population, the Federal Task Force on Homelessness and Severe Mental Illness (1992) noted that homeless persons with severe mental illness will partake of services, if the service system can break out of the mold of traditional service provision and becomes responsive to their needs (p. 360). The task force recommended safe-haven programs, namely, small and supportive environments with linkages to more specialized services to serve the hardest-to-reach portion of the mentally ill population. …

A brief community linkage intervention for veterans with a persistent mental illness and a co-occurring substance abuse disorder

Objective: Individuals with co-occurring psychiatric and substance abuse problems often exhibit poor outpatient treatment engagement and re-hospitalization following discharge from acute psychiatric services. Although case management can improve treatment engagement and reduce attrition, these services are often delivered indefinitely, limiting the availability of treatment slots. In an effort to reduce re-hospitalization rates and improve outcomes during the transition from inpatient to outpatient treatment, we developed and evaluated Time-Limited Case Management (TLC), an eight-week integrated mental health and substance abuse augmentation intervention. Method: Sixty-five dually diagnosed veterans admitted to inpatient psychiatric treatment were included in the program evaluation, 32 who received the TLC service in addition to Treatment as Usual (TAU) that began during inpatient treatment and continued after the transition to outpatient services, and a comparison group of 33 who received only TAU without transitional support provided through the TLC augmentation service. Results: The TLC group had fewer days and episodes of hospitalization at two and six month post-study entry. Furthermore, the TLC group exhibited greater improvements on the Global Assessment of Functioning from baseline to the six-month follow-up. Conclusion: TLC appears to be an effective transitional augmentation service with benefits that persist beyond the eight weeks of the program. Future research should include a larger and more rigorously controlled trial to confirm the efficacy and unique contributions of the intervention

Patients Benefit From CMHC, Medical School Partnership

Patients Benefit From CMHC, Medical School Partnership

Preliminary Outcomes from a Community Linkage Intervention for Individuals with Co-Occurring Substance Abuse and Serious Mental Illness

Objective: Few interventions assist individuals with a mental illness and a co-occurring substance abuse disorder in the transition from hospitalization to outpatient treatment. This change in care is often abrupt, resulting in fragmented treatment that jeopardizes recovery. This article reports on the preliminary outcomes from a new eight-week linkage intervention entitled “Time-Limited Case Management (TLC)” that integrates intensive outreach, Dual Recovery Therapy (DRT), and peer support to facilitate outpatient treatment engagement following discharge from Acute Psychiatry. Method: This eight-week naturalistic feasibility study included 59 recently hospitalized subjects with a mental illness and substance abuse disorder who were offered the new service. The individuals who agreed to receive TLC (n = 26) formed the treatment group and those who refused (n = 33) made up the comparison group. Results: The TLC service was successfully implemented into the system and improved the transition from inpatient to outpatient care. The individuals who received the TLC intervention had a higher show rate at the Day Treatment Center intake appointment, attended more days of treatment at the Day Center, had greater pharmacy refill compliance, and were less likely to be lost to follow-up at eight weeks than the comparison group. Conclusion: TLC represents a promising new approach to maintaining continuity in care following psychiatric hospitalization that may be easily implemented in other systems. We are currently in the process of developing an implementation manual and doing a large randomized controlled trial to determine whether the intervention improves substance abuse and psychiatric outcomes in addition to facilitating treatment engagement.

Anticonvulsant May Benefit Bipolar, Alcoholic Patients

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessAnticonvulsant May Benefit Bipolar, Alcoholic PatientsJim RosackJim RosackSearch for more papers by this authorPublished Online:4 Feb 2005https://doi.org/10.1176/pn.40.3.00400036Valproate (Depakote) appears to be effective not only in treating mood symptoms associated with bipolar disorder, but also in reducing drinking in those patients with co-occurring alcoholism.Data from a small, randomized, double-blind, controlled trial indicate that dual effectiveness is the result of independent effects on the two different disorders. The data provide support for the use of valproate to treat the more than half of all patients with bipolar disorder who have co-occurring substance abuse disorders. Among those with co-occurring substance abuse, alcoholism is the most frequent.“This has really been a population that has been previously neglected in research,” noted Ihsan Salloum, M.D., M.P.H., an associate professor of psychiatry at the University of Pittsburgh School of Medicine. “Most clinical trials involving patients with bipolar disorder have used `pure' patients; they have excluded those with co-occurring disorders, and conversely, those studies with patients who have substance abuse disorders have commonly excluded any patients who have any co-occurring psychiatric disorder.”The result, Salloum told Psychiatric News, is a void in the evidence base. Yet physicians dealing with a patient with bipolar disorder know that “they are dealing with a patient who most likely also has a substance abuse disorder. The degree of difficulty in treating the patient is much worse; there simply are no clear guidelines that address these comorbid problems.”Salloum and his colleagues had been encouraged by recent reports of small trials studying the use of several anticonvulsant mood stabilizers, including valproate and topiramate, in patients with alcoholism. Valproate, Salloum noted, had already been granted an indication for bipolar disorder, so he and his team set out to look at the effects of the drug in patients with both bipolar and alcoholism.They enrolled 59 patients with bipolar I disorder and alcoholism in a 24-week, double-blind, placebo-controlled, randomized parallel group trial. Recognizing that it would be unethical to have patients in a trial for 24 weeks on placebo only, Salloum and his colleagues added lithium to the protocol. All patients in the trial received “treatment as usual”—which included lithium plus a psychosocial intervention that included individual psychotherapy focused on the patients dealing with both disorders as well as taking medication. In addition, patients were then randomly assigned to have either valproate or placebo added to their treatment as usual.The group receiving valproate was found to have a significantly lower proportion of heavy drinking days and a trend toward fewer drinks per drinking day compared with those who received placebo.“When we added medication adherence as a variable, both findings became statistically significant,” Salloum noted. “That is, those patients who had higher serum levels of valproate had significantly better alcohol use outcomes overall—in reduced proportion of heavy drinking days and in fewer drinks per heavy drinking day, as well as fewer drinks per day throughout the study.”Valproate therapy also significantly prolonged the time to relapse to sustained heavy drinking, to an average of 93 days, compared with an average of 62 days for those on placebo.Salloum and his colleagues also monitored mood symptoms but saw no statistically significant differences between the two groups.“The study was relatively small,” Salloum noted. “Perhaps if we had had more patients, we may have had more power to detect a difference. But all patients were receiving lithium for their bipolar symptoms, so the addition of valproate may not have made a noticeable difference.”Nonetheless, Salloum added, “I think this is an encouraging study. It is really the first to be done in this dually diagnosed adult population using a double-blind, placebo-controlled paradigm.”Salloum's hope is that the trial will be replicated with larger numbers of patients and in multiple clinical sites.An abstract of “Efficacy of Valproate Maintenance in Patients With Bipolar Disorder and Alcoholism” is posted online at<http://archpsyc.ama-assn.org/cgi/content/abstract/62/1/37>.▪ Arch Gen Psychiatry 2005 62 37 ISSUES NewArchived

Medicaid managed care, substance abuse treatment, and people with disabilities: review of the literature.

Most states enroll individuals with disabilities who receive Supplemental Security Income (SSI) in Medicaid managed care plans. The impact of managed care on these individuals, especially those with substance abuse disorders, is not well understood. A review of the literature related to substance abuse, disability, and Medicaid managed care suggests that substance abuse is a serious issue for individuals with disabilities. More research is needed to determine how the substance abuse treatment needs of individuals with disabilities can be met through Medicaid managed care. The authors identified topics for a research agenda on the needs of individuals with disabilities who also experience co-occurring substance abuse disorders. Implications for social work policy and practice are discussed.

Literature on integrated HIV care: a review

With a significant proportion of HIV-infected patients now presenting with co-occurring substance abuse disorders and mental disorders, interest in integrated HIV care is growing. However, no review of integrated HIV care has been conducted. Using relevant key word searches of the Medline and Psychlit databases, the authors identified about 450 publications. The few evaluations of integrated models tended to focus on measurements of engagement and retention in medical care, and their findings indicated an association between integrated HIV care and increased service utilization. No random assignment controlled studies were identified, except in the peripheral area of integrated care (without HIV primary care) for persons with co-occurring substance abuse disorders and mental disorders. The majority of reviewed articles described integrated models operating in the field and various aspects of implementation and sustainability. Overall, they supported use of a wide range of primary and ancillary services delivered by a multidisciplinary team that employs a ‘biopsychosocial’ approach. Despite the lack of scientific knowledge regarding the effects of integrated HIV care, those wanting to optimize treatment for patients with multiple interacting disorders can gain useful and practical knowledge from this literature.

Successful program maintenance when federal demonstration dollars stop: the ACCESS program for homeless mentally ill persons.

A major issue that has long dogged federal human services demonstration programs is the perception that when federal dollars end, the programs end-regardless of any proven successes. Access to Community Care and Effective Services and Supports (ACCESS) was a 5-year federal demonstration project to foster partnerships between service providers for homeless people with serious mental illness and co-occurring substance abuse disorders; and to identify effective, replicable systems integration strategies. After federal funding ended, research teams visited the ACCESS sites to determine which project elements remained and which strategies were used by the sites to continue ACCESS. This article describes ACCESS services and systems integration activities retained by the sites, new funding streams, and strategies used to obtain continued funding.

Emerging issues with mentally ill offenders: causes and social consequences.

Persons with mental illness and co-occurring substance abuse disorders are incarcerated at disproportionately high rates in comparison to the general population. Reasons may include high standards for involuntary commitment, an overall increase in substance abuse and the policy of deinstitutionalization. However, one significant reason may be that psychiatric institutions serve a social control function, which has not been appreciated by policymakers and program developers since deinstitutionalization. This paper presents provider views of the population and issues of concern for clients, families, and the agencies. Discussion includes service-provider response to the population, new program models, and implications for policymakers.

Analysis of three interventions for substance abuse treatment of severely mentally ill people.

Severely mentally ill people with co-occurring substance abuse disorders are difficult to treat and the course of their psychiatric treatment is worsened by substance abuse. Despite increased attention to the problem, few studies of specialized treatment are reported in the literature and most lack detail about the specialized interventions employed. Qualitative data, gathered as part of a larger study of the cost-effectiveness of three substance abuse interventions for severely mentally ill people, are presented which describe the interventions, their implementation in four community mental health centers over 18 months of the study, and their relationship to the quantitative outcomes. Illustrated is the difficulty of implementing innovative programs and the need for vigilance concerning program fidelity.