Dual Diagnosis Patients Research Articles

Flupenthixol in Relapse Prevention in Schizophrenics with Comorbid Alcoholism: Results from an Open Clinical Study

Substance use, especially alcoholism, has been recognized as a significant problem in schizophrenic patients, though only a few studies on the effects of pharmacotherapy in these patients have been conducted so far. The thioxanthene neuroleptic flupenthixol, which can be given intramuscularly (i.m.) for improving compliance, has been studied as a possible anti-craving drug both in animal models of alcoholism and some clinical studies. Pilot studies suggest that comorbid schizophrenics with substance use may benefit from treatment with flupenthixol. Efficacy of flupenthixol (10–60 mg i.m.) in reducing alcohol consumption of dual diagnosis patients was studied in an open 6-month clinical trial in 27 schizophrenics with comorbid alcoholism. Twenty-one patients entered the intention-to-treat analysis. Fourteen subjects were completers, 13 dropped out. Six patients completely abstained from alcohol during treatment. Alcohol consumption was significantly reduced compared to baseline (4 weeks before treatment as measured by timeline follow-back interview). In general, while patients showed a marked improvement concerning alcohol consumption, only a slight improvement in psychopathology was recorded. Overall tolerability was good. These data indicate a probable beneficial effect of flupenthixol in schizophrenic patients with comorbid alcoholism. Although the efficacy of flupenthixol as an anti-craving drug in dual diagnosis patients has to be explored in further studies, the drug may be considered a promising medication for these patients.

Comorbidity Common in Addicts, But Integrated Treatment Rare

Comorbidity Common in Addicts, But Integrated Treatment Rare

A Comparison Between Dually Diagnosed Inpatients with and without Axis II Comorbidity and the Relationship to Treatment Outcome

The presence of a personality disorder (PD) has been associated with certain types of poor treatment outcomes in patients with substance use disorders (SUDs). The purpose of this study was to determine the prevalence of comorbid PDs in psychiatrically hospitalized adults with both non-SUD Axis I disorders and SUDs, and to assess the relationship between Axis II psychopathology and degree of pretreatment addiction severity and treatment outcome. Method: One hundred consecutive inpatients admitted to a mixed dual diagnosis inpatient unit were assessed using semistructured interviews for SUDs, non-SUD Axis I disorders, and PDs. Pretreatment severity was assessed using a modified version of the Addiction Severity Index (ASI). Outcome measures were assessed both during hospitalization and at an initial follow-up appointment after discharge. Statistical analyses were performed comparing dually diagnosed patients with and without Axis II psychopathology. Results: A significant number (53%) of the patients met criteria for at least one personality disorder. Of the PDs, Cluster B PDs were the most prevalent, particularly borderline personality disorder (74%) and antisocial personality disorder (66%). Dually diagnosed patients without an Axis II diagnosis had less severe pretreatment severity measures. During hospitalization, patients with Axis II disorders had higher levels of psychopathology on the Brief Symptom Inventory (BSI) subscales of sensitivity and hostility. However, there was no difference in overall degree of global improvement during hospitalization. During follow-up, patients with Axis II disorders were significantly less likely to be compliant in attending their initial follow-up appointment. Conclusions: Dual diagnosis inpatients with PDs appear to improve as much as patients without PDs during their inpatient hospitalizations; however, they appear to be less likely to be compliant with attending their initial follow-up appointment.

Engaging Dual Diagnosis Patients into Treatment: The T.E.E.A.C.H. Program

This article outlines a model for engaging dually-diagnosed patients into treatment, particularly those patients in the precontemplation and contemplation phases of treatment. The model first focuses on the development of a positive therapeutic relationship with the patient. It then helps patients to realize both the positive and the negative aspects of their substance use. By acknowledging this central conflict and their ambivalence about using, and delivering hope that patients can learn other ways to obtain the benefits of their substance use without the negative consequences, patients can be engaged into treatment and helped to begin the process of change.

Psychopathology in dual-diagnosis and nonaddicted schizophrenics: are there differences?

Analysis of 447 schizophrenic inpatients found a lifetime prevalence for substance use of 42.9% (3-month prevalence 29%). While the overall differences were small between schizophrenics using (dual diagnosis) and those not using substances, dual-diagnosis patients in general reported more positive symptoms, especially more intense hallucinations. These differences were observed in patients with current (3-month) substance use on admission but not on discharge, possibly as a result of substance use. The most marked differences were in previous suicide attempts and delinquency, which were more prevalent in dual-diagnosis schizophrenics. These findings indicate that patients with dual diagnosis are more disturbed than other schizophrenics. We discuss the implications for the self-medication hypothesis for substance use in schizophrenia and future research in this area are discussed.

Factors Related to Poor Contact of Discharged Dual Diagnosis Patients From a Psychiatric Emergency Room

Objectives Dual diagnosis patients are difficult to treat because of their noncompliance with follow-up care. The authors believed that the ability to contact these patients after acute psychiatric treatment may be an important first step toward engaging them into treatment. This study examined the factors that are associated with the ability to contact dual diagnosis patients by phone after discharge from a psychiatric emergency room. Methods The authors reviewed 6 months of psychiatric emergency room evaluations, collecting data on all dually diagnosed patients. Starting 2 weeks after discharge from their psychiatric emergency room, they called each patient by telephone. Results The authors found that male patients or those with a psychotic diagnosis were much harder to locate by telephone. Conclusions More intensive effort is required to be able to contact and engage this vulnerable population into treatment.

Dialectical Behavior Therapy of borderline patients with and without substance use problems: Implementation and long-term effects

Objective: The aim of this article is to examine whether standard Dialectical Behavior Therapy (DBT) (1) can be successfully implemented in a mixed population of borderline patients with or without comorbid substance abuse (SA), (2) is equally efficacious in reducing borderline symptomatology among those with and those without comorbid SA, and (3) is efficacious in reducing the severity of the substance use problems. Method: The implementation of DBT is examined qualitatively. The impact of comorbid SA on its efficacy, as well as on its efficacy in terms of reducing SA, is investigated in a randomized clinical trial comparing DBT with treatment-as-usual (TAU) in 58 female borderline patients with ( n=31) and without ( n=27) SA. Results: Standard DBT can be applied in a group of borderline patients with and without comorbid SA. Major implementation problems did not occur. DBT resulted in greater reductions of severe borderline symptoms than TAU, and this effect was not modified by the presence of comorbid SA. Standard DBT, as it was delivered in our study, however, had no effect on SA problems. Conclusions: Standard DBT can be effectively applied with borderline patients with comorbid SA problems, as well as those without. Standard DBT, however, is not more efficacious than TAU in reducing substance use problems. We propose that, rather than developing separate treatment programs for dual diagnosis patients, DBT should be “multitargeted.” This means that therapists ought to be trained in addressing a range of severe manifestations of personality pathology in the impulse control spectrum, including suicidal and self-damaging behaviors, binge eating, and SA.

Response: The Neurobiological Model in Community Treatment Programs

Chris Farentinos: This is very important information for patients and counselors to have. Patients can understand their reactions in terms of, ‘By taking this drug I stimulated my brain so much I’ve kind of extinguished its ability to produce certain neurotransmitters, and once I stop taking the drug, dysphoria will arise and that creates a cycle of addiction.’ And the counselor can have more empathy for the client: It’s not that the clients are not trying to get better or that they are bad people, but they feel so bad after they stop using the drug that they have to go back. There is also a neurobiological connection to impulsivity and personality disorders, so the whole thing fits together. Doug Ziedonis: From a pragmatic point of view, this kind of article is useful for stigma-busting with legislatures, since they don’t want to pay for habits or choices. They want to pay only in cases of medical necessity. The recovery community agrees with the disease concept of addiction. Most of the recovery models people use when working with addicted patients use some type of bio-psycho-social-spiritual matrix. The biological part is considered most important in early stages of recovery, maybe during the first year, because the patient has to deal with acute withdrawal, dependence, and then protracted withdrawal. Where the recovery and medical communities often don’t see eye to eye is when the disease concept gets translated into a rationale for using medication, whether it is in the case of dual-diagnosis patients or even the use of naltrexone to treat opiate addiction. Naltrexone is a great medication; it can be very useful in treating impaired professionals. But if you survey average community treatment programs, hardly any patients are on naltrexone. Methadone is its own medical model system that doesn’t always link well with places that use the abstinence model. I have worked at abstinence programs and have worked at Yale as medical director of a methadone program. I favor the use of methadone as part of a treatment continuum. Tom Brewster: Therapeutic communities have long been the most resistant single group to the use of medications for opiate abuse treatment. I think there has been a movement among providers to utilize methadone more in our therapeutic communities. There certainly has been in my community. We actively maintain patients on the medication and have trained our counselors. Our recovering counselors are abstinence-oriented individuals: they don’t drink and they certainly aren’t using illicit substances. They generally challenge any form of medication, particularly analgesic medication, even when it should be legitimately used for pain reduction after surgery and so forth. But our program has embraced methadone despite this resistance, because of the biological connection described by Kosten and George. The information about biology and about medications is useful for patients who are asking to be taken off methadone. Patients come to me and say, ‘I want to detox. Methadone is not good. It is a weakness. My wife wants me off of it, my employer wants me off, society wants me off, my probation officer wants me off.’ Corrections workers press patients to feel guilty about taking a narcotic medicine. They don’t believe in it. We resist this pressure because we know better. The relapse rate of those who get off methadone maintenance is perilously high. We strongly discourage people from going off the medicine.

Comorbid Psychiatric and Alcohol Abuse/Dependence Disorders

Factors related to comorbid versus only substance disorders are essential to understanding and treating these complex problems. Medical records of sixty-nine inpatients at a private rehabilitation hospital in Southern California were reviewed to determine the associations between personal history factors and (1) comorbid psychiatric and substance abuse disorders and (2) participant's self-assessed progress in treatment. Results revealed significant differences between dual diagnosis patients (alcohol abuse/dependence and an affective disorder) and alcohol abuse/dependence only in regard to gender, previous diagnosis, length of illness, suicide attempts, psychotropic medication history, maternal emotional, physical and sexual abuse, paternal abuse, legal difficulties, and psychosocial Stressors. No significant differences between substance abusing patients and dually diagnosed patients were found in terms of self-assessment of progress in treatment. Significant correlations were found between self-assessed progress in treatment and major depression (versus bipolar disorder), use of psychotropic medication, and less abuse from mother or primary caretaker. Identification of these personal history factors may be useful in developing and implementing treatment plans.

Arkansas Partnership Program: An Innovative Continuum of Care Program for Dually Diagnosed Forensic Patients

Abstract A unique public-private partnership created a new continuum of care that would effectively bridge the gap between inpatient treatment and community after-care for insanity acquitees suffering from chronic mental illness and substance abuse disorders. Focusing specifically on the needs of dually-diagnosed patients, treatment is delivered in a secure, 42-bed residential facility using a carefully designed series of hierarchical stages that enable residents to gradually build and strengthen their coping and life skills. Following graduation from the residential program, patients receive “assertive community treatment,” which provides enhanced, enduring supports to prevent “revolving door” recidivism. Although the patients have severe chronic diagnoses and have been acquitted of extremely dangerous criminal behavior, eighteen discharged patients have made a successful transition to the community for an average of 508 days without a single relapse into criminal behavior or substance abuse. Only two have required brief temporary readmission for stabilization of mental illness, and one needed inpatient readmission.

One-Year Follow-Up of Dual Diagnosis Patients Attending a 4-Month Integrated Inpatient Treatment

The purpose of this study was to assess a 4-month inpatient treatment program based on integrated models for patients with substance use and psychiatric disorders (dual diagnosis patients). On admission and at the 1-year follow-up, a consecutive sample of 118 dual diagnosis patients who entered the program were assessed by interview. Eighty-four patients (70.6%) completed the 1-year follow-up interview, reporting less frequent substance use, less severe psychiatric symptoms, a lower rehospitalization rate, and better housing conditions than on admission. Patients diagnosed with a comorbid personality disorder had a better improvement in the frequency of drinking and were less likely to be rehospitalized than patients with schizophrenia or depression. The results suggest that the integrated inpatient program may be a promising treatment approach for dual diagnosis patients. The results await replication in controlled studies that need to include an assessment of outpatient treatment following inpatient programs.

Symptom severity, amount of treatment, and 1-year outcomes among dual diagnosis patients.

This study reports on associations among symptom severity, amount of treatment, and 1-year outcomes in a national sample of 8,622 dual diagnosis patients, who were classified at treatment entry into low-, moderate-, and high-severity groups. Patients with more severe symptoms at intake had poorer 1-year outcomes. Higher severity patients did not receive adequate "doses" of care: Compared with low-severity patients, they had a shorter duration of care, although a longer duration was associated with improved outcomes; they also were less likely to receive outpatient substance abuse treatment, although more intensive treatment was associated with better drug outcomes. High-severity patients improved more on drug and legal outcomes, but less on psychiatric and family/social outcomes, than low-severity patients did when treatment was of longer duration or higher intensity. Dual diagnosis patients with highly severe symptoms would likely benefit from a longer episode of care that includes substance abuse and psychiatric outpatient treatment.

Mental illness, substance abuse, demographics and offending: dual diagnosis in the suburbs

High rates of offending and violence have been found in patients with co-morbid severe mental illness and substance misuse (dual diagnosis), although research has focused upon inner-city populations. This study compares offending and violence rates in patients with dual diagnosis (DD) and patients with psychosis only, drawing on a more demographically representative population. Forty patients with severe mental disorders were interviewed in a geographically defined catchment area in Croydon, Surrey. Cases of alcohol or drug misuse were identified, and measures of lifetime history of offending (including violence) and recent violence were obtained. DD patients were more likely to report a lifetime history of both offending and violence than patients with psychosis only (although gender may play a greater role than substance misuse). Few instances of recent violence were found, and no between-group differences were detected. The medical caserecords of DD patients were significantly more likely to contain a lifetime history of non-substance misuse-related offending, but not violence. However, the extent to which substance misuse contributes to violence and offending independently of contextual variables requires further investigation.

Correlates of substance misuse in patients with first-episode schizophrenia and schizoaffective disorder.

To identify factors associated with substance misuse in first-episode patients with schizophrenia or schizoaffective disorder. Twenty-seven patients with a past or current history of substance misuse were compared with 91 patients with no history of misuse on demographic and psychopathological measures before being treated for their first episode of psychosis, and on cognitive measures after 6 months of treatment. There were no statistically significant differences between groups for sex, schizophrenia subtype, marital status, education, family history of schizophrenia, course of illness, age of onset, baseline symptoms, time to treatment response, medication side effects, attention span, memory and executive functioning. However, dual diagnosis patients were found to have a higher parental social class, better premorbid cognitive functioning, higher IQ and better language skills. First-episode patients with a history of substance misuse have higher intellectual functioning, which may be associated with higher premorbid socioeconomic status and cognitive functioning.

Correlates of substance misuse in patients with first‐episode schizophrenia and schizoaffective disorder

Objective: To identify factors associated with substance misuse in first‐episode patients with schizophrenia or schizoaffective disorder. Method: Twenty‐seven patients with a past or current history of substance misuse were compared with 91 patients with no history of misuse on demographic and psychopathological measures before being treated for their first episode of psychosis, and on cognitive measures after 6 months of treatment. Results: There were no statistically significant differences between groups for sex, schizophrenia subtype, marital status, education, family history of schizophrenia, course of illness, age of onset, baseline symptoms, time to treatment response, medication side effects, attention span, memory and executive functioning. However, dual diagnosis patients were found to have a higher parental social class, better premorbid cognitive functioning, higher IQ and better language skills. Conclusion: First‐episode patients with a history of substance misuse have higher intellectual functioning, which may be associated with higher premorbid socioeconomic status and cognitive functioning.

Schizophrenia and substance misuse problems: a comparison between patients with and without significant carer contact.

Many researchers and clinicians in the mental health field have given much attention over the last few years to patients with co-morbid problems of schizophrenia and substance use. This population is becoming a focus of attention for all service providers owing to the suggested increase in numbers of patients with these dual diagnoses and the observed negative effects on patients and costs to services. The advantages for providing family interventions in schizophrenia are now well established and increasingly these interventions are being evaluated for families of dual diagnosis patients. Many dually diagnosed patients do not, however, have a great deal of contact with a carer/relative. This paper looks at whether differences exist between patients with a dual diagnosis that have carer contact and those who do not have carer contact in terms of their illness history and type of substance use. For the purpose of this article 'carer' refers to an individual who is an informal carer or relative with whom the client has weekly contact of 10 h. Many of these carers provide the client with emotional, physical and material support. The identification process for both'carer contact' and 'no carer contact' patients was conducted through the screening of the hospital's care programme approach (CPA) lists and through contact with care coordinators and consultants. Case notes of all patients identified were screened and information on demographic data, duration of illness, admissions and substance use was collected. Results indicated that the 'no carer contact' group was older and had significantly more days in hospital at last admission. It is possible that as patients get older their contact with significant others decreases, i. e. loss of contact with key relatives is due to age rather than severity of substance use. Furthermore, patients' reduced contact results in them having longer stays in hospital possibly because they will not receive additional support when discharged.

Psychopathology in dual diagnosis and non-addicted schizophrenics - are there differences?

In a previous publication we reported lifetime and 3-month prevalence estimates for substance use in two large samples of schizophrenic inpatients (Soyka et al. 1993). A subsequent analysis of psychopathological findings assessed by means of the AMDP Manual (Guy and Ban 1982) in schizophrenic in-patients of the Haar Mental State Hospital (N=447), in whom a lifetime prevalence for substance use of 42.9% (3-month prevalence 29%) had been reported, was performed. While the overall differences between substance using (dual diagnosis) and nonusing schizophrenics were small, dual diagnosis patients in general reported more positive symptoms, especially more intense hallucinations. These differences could basically be demonstrated in patients with current (3-month) substance use on admission but not on discharge possibly as a result of substance use. Most marked and highly significant results were found with respect to previous suicide attempts and delinquency which were more prevalent in dual diagnosis schizophrenics. Results of this study indicate that dual diagnosis patients compared to other schizophrenics represent a more disturbed patient group. Implications for the self-medication hypothesis for substance use in schizophrenia and future research in this area are discussed.

Program components of a comprehensive integrated care system for seriously mentally ill patients with substance disorders

Using an integrated theoretical framework, a continuous and comprehensive model system of care for dual diagnosis patients can be designed.

Fluoxetine treatment of cocaine-dependent patients with major depressive disorder

Sixty-eight male and female individuals with both DSM-IV diagnoses of cocaine dependence and major depressive disorder were randomly assigned to one of two medication conditions (placebo vs. 40 mg per day) as part of a double-blind, placebo-controlled clinical efficacy trial of fluoxetine for the treatment of this dual diagnosis. During the 12-week outpatient treatment phase all participants also received individual cognitive-behavioral psychotherapy targeting both cocaine use and depression. Depressive symptoms remitted as a function of time in treatment, with no significant medication effects found. Fewer cocaine positive urines were found during the first 6 weeks of treatment in the placebo group compared with the 40-mg group. Cocaine use and depressive symptoms during treatment were significantly correlated. The findings fail to support the role of fluoxetine for treatment of cocaine use and depression in dually-diagnosed patients.

12-Step Participation and Attitudes Toward 12-Step Meetings in Dual Diagnosis Patients

This study examined participation in 12-step programs and attitudes toward 12-step meetings in an outpatient sample of 81 severely mentally ill patients with comorbid substance use disorders. The study found that dual diagnosis patients attended 12-step programs at rates comparable to those reported for patients in primary addiction treatment settings. Diagnosis and attitudes toward 12-step meetings each had independent effects on 12-step participation. The difficulties that some dual diagnosis patients report experiencing at 12-step meetings may need to be addressed to maximize 12-step attendance and potential to benefit from 12-step programs.