Dual Diagnosis Treatment Research Articles

Training Changes Professionals’ Attitudes Towards Dual Diagnosis

Studies have shown that mental health professionals in many cases have counterproductive attitudes towards patients with mental illnesses and comorbid substance use disorders (dual diagnosis). This is problematic because professionals’ attitudes are important for both the therapeutic alliance and treatment outcome. This study tested whether providing training in dual diagnosis treatment to mental health professionals will affect their attitudes positively. Twenty-one professionals completed a questionnaire on attitudes towards working with dual diagnosis (Comorbidity Problems Perceptions Questionnaire, CMPPQ) pre-training and post-training. Results showed that there was a significant positive change in total CMPPQ scores and a positive change in all six subscales of the CMPPQ following training, indicating that the training resulted in more positive attitudes. The study suggests that training might be a promising way to improve mental health professionals’ attitudes. Future research is needed to confirm this finding in controlled studies with more participants and a longer follow-up.

Node-link mapping, an asset?

Purpose– The purpose of this paper is to evaluate the use of node-link mapping (NLM) on the effectiveness of a structured treatment for dual diagnosis for men living in a low-secure environment.Design/methodology/approach– In total, 15 participants were recruited and randomly allocated to one of two conditions. The control group, treatment as usual (TAU) or the treatment group, TAU with NLM. Outcome measures used were: a qualitative evaluation form, The Alcohol and Illegal Drugs Decisional Balance Scale and the Brief Situational Confidence Questionnaire.Findings– Results indicate no statistically significant difference for either group on the pre- and post-treatment outcome measures used. Qualitative data indicated that those using NLM reported the intervention as useful and instructive more often.Research limitations/implications– The results gained were only a snapshot of the intervention straight after treatment and did not take into account any long-term benefits of therapy such as substance use relapse rates. The outcome measures used may not have been properly understood by all respondents, or reflect practical change. The NLM tool may not have been used as confidently as TAU. The TAU condition needs to be reviewed to improve effectiveness, and NLM to be included to improve the accessibility. A study comparing other outcome tools needs to be completed. Training for staff using NLM may require coaching.Originality/value– This paper has a high/low originality. It highlights a number of advantages to NLM when comparing this to TAU.

Anxiety associated with substance abuse

Substance abuse and anxiety is a common comorbid dyad and an example of so-called dual diagnosis in psychiatry. Comorbidity of anxiety and addictive disorders may be due to interdependence of these states as well as common predisposing factors and pathogenic mechanisms. There are various medicines in the treatment of anxiety associated with substance abuse, including benzodiazepines, calcium channel modulators, non-benzodiazepine anxiolytics, antidepressants and antipsychotics. One of the best approaches to the treatment of chronic anxiety disorders in drug treatment clinic is a long course of treatment with antidepressants, primarily with selective serotonin reuptake inhibitors as first line preparations. Such medications as pregabalin, buspirone, etifoxine and alimemazine are also of interest for the treatment of dual diagnosis patients.

Patient attitudes toward technology-assisted treatment during hospital-based dual-diagnosis treatment

Patient attitudes toward technology-assisted treatment during hospital-based dual-diagnosis treatment

Atypical Antipsychotic Drugs in Dual Diagnosis Patients: A Review

Introduction: Dual Diagnosis (DD), defined as the co-occurrence of a Substance Use Disorder (SUD) and a Severe Mental Illness (SMI), is associated with several negative outcomes. Typical antipsychotics (TAP) are not of great value for patients with DD as they are associated with poorer responses and can worsen SUD. Atypical antipsychotics (AAP) offer several advantages compared to TAP. In DD, they have been found to be effective in treating both, psychiatric symptoms and substance use. The aim of this article is to review the use of AAP for treating DD patients. Methods: A search of MEDLINE, EMBASE and Pubmed was performed in order to identify publications that examined the use of AAP in the treatment of DD. Results: The largest number of studies focuse on clozapine, with consistently positive data. Data regarding aripiprazole are also consistent but less substantial. Olanzapine, risperidone and quetiapine have given inconclusive and inconsistent results. Finally, there is little use of amisulpride, ziprasidone, paliperidone and asenapine or it is has not been documented. Discussion: Today, there is a consensus on using AAT instead of TAP for treating patients with DD. Patients with DD show a poorer response to treatment with TAP, and TAP may even worsen the addictive behaviour. AAP are as effective as TAP in treating psychiatric symptoms, but they are more effective in reducing substance use in DD patients. Because with the exception of CLO none of the AAP have shown to be superior to the others, when choosing between the different AAP agents clinicians should take into account other variables such as medical comorbidity, possible pharmacological interactions of concomitant treatments and profile of side effects. Even though a growing body of evidence suggests the beneficial effects of AAP in DD patients, further randomized, blinded, controlled trials, with larger sample sizes and longer followups are needed.

Enforced abstinence from tobacco during in-patient dual-diagnosis treatment improves substance abuse treatment outcomes in smokers.

Although the prevalence of tobacco use in those in substance abuse treatment is known to be quite high, most treatment programs do not address tobacco. The purpose of this study was to determine substance abuse recovery rates a year after treatment in a fully integrated, 90-day inpatient, dual diagnosis treatment program where patients are required to quit tobacco use in addition to drug and alcohol use for the duration of their 3 month stay. Tobacco is treated in the same way as other drugs and alcohol. One hundred fifty-four patients enrolled in a yearlong follow-up after treatment study consisting of monthly phone contact to assess recovery from substance abuse. One hundred forty (n=140) patients completed the year follow-up. At the time of entry into the program 120 (86%) were using tobacco daily. At the end of the year this decreased to 102 (73%). Patients who were using tobacco were more likely to relapse to other drugs or alcohol (p = .01). Patients who actively attempted to abstain from tobacco after treatment were significantly more likely to remain continuously abstinent throughout the year (p = .03). This study demonstrates that tobacco use is correlated with relapse and addressing tobacco in treatment as seriously as and in the same fashion as other drugs, improves outcomes. When provided with a tobacco free treatment environment for 90 days, patients with substance abuse and mental illness can and do make the decision to quit tobacco and stay quit, aiding their ability to remain sober.

Opiate-use patients attending residential treatment: characteristics, outcomes, and implications for practice

Background As opiate use has increased, there has been a corresponding increase in the number of opiate users presenting for treatment. Questions regarding the challenges of treating opiate users in residential treatment remain largely unanswered. This study seeks to determine what, if any, meaningful differences exist between opiate and non-opiate users, as well as within opiate users who enter voluntary, private, or residential dual-diagnosis treatment, and the impact of any differences relative to treatment motivation, length, and outcomes. Materials and methods Data for this study were drawn from 1972 individuals, utilizing the Addiction Severity Index, the Treatment Service Review, the University of Rhode Island Change Assessment, and a satisfaction measure. Interviews were conducted at program intake, and 1 and 6-month interviews post-discharge. Results The results suggest that although there are similarities there are also some important differences in characteristics, motivation, completion, engagement, retention, levels of satisfaction, and post-treatment service use. Additional analyses were conducted when significant within-group differences by age for opiate users were revealed.

Enforced abstinence from tobacco during in-patient dual-diagnosis treatment improves substance abuse treatment outcomes in smokers

Background and Objectives Although the prevalence of tobacco use in those in substance abuse treatment is known to be quite high, most treatment programs do not address tobacco. The purpose of this study was to determine substance abuse recovery rates a year after treatment in a fully integrated, 90-day inpatient, dual diagnosis treatment program where patients are required to quit tobacco use in addition to drug and alcohol use for the duration of their 3 month stay. Tobacco is treated in the same way as other drugs and alcohol. Methods One hundred fifty-four patients enrolled in a yearlong follow-up after treatment study consisting of monthly phone contact to assess recovery from substance abuse. Results One hundred forty (n=140) patients completed the year follow-up. At the time of entry into the program 120 (86%) were using tobacco daily. At the end of the year this decreased to 102 (73%). Patients who were using tobacco were more likely to relapse to other drugs or alcohol (p = .01). Patients who actively attempted to abstain from tobacco after treatment were significantly more likely to remain continuously abstinent throughout the year (p = .03). Conclusions This study demonstrates that tobacco use is correlated with relapse and addressing tobacco in treatment as seriously as and in the same fashion as other drugs, improves outcomes. Scientific Significance When provided with a tobacco free treatment environment for 90 days, patients with substance abuse and mental illness can and do make the decision to quit tobacco and stay quit, aiding their ability to remain sober. (Am J Addict 2015;24:252–257)

The impact of a sleep hygiene intervention on residents of a private residential facility for individuals with co-occurring mental health and substance use disorders: results of a pilot study.

An increasing number of Americans are experiencing sleep problems. There is evidence of a complex, bidirectional relationship between sleep disorders, substance abuse, and mental health symptoms. Institutional settings have been shown to elicit sleep problems as well. This pilot study was conducted with 28 patients in private, residential, dual-diagnosis treatment for addiction and mental health disorders. Upon admission, consenting patients were administered the Addiction Severity Index to assess pretreatment substance use and mental health symptoms. Patients followed a normal course of treatment as well as participated in a nightly sleep hygiene group that included relaxation suggestions. Evaluations with the Addiction Severity Index were completed again 30 days after discharge from treatment. Significant improvements in some substance use patterns as well as mental health symptoms were noted. Although results cannot be directly attributed to the use of a sleep hygiene group, this pilot study lays the foundation for future investigations of interventions supporting sleep in the dual-diagnosis population.

Translating Neurobiology to the Treatment of Dual Diagnosis: The Example of Nicotinic Receptors and Neurocognitive Endophenotypes in Schizophrenia

Endophenotypes are heritable traits associated with psychiatric illness. Certain endophenotypes associated with schizophrenia such as working memory and sensory gating may be linked to the high tobacco smoking prevalence in patients with schizophrenia. Evidence suggests a critical role for the nicotinic acetylcholine receptor system (nAChR) in the underlying pathophysiology of schizophrenia. Despite the negative consequences associated with tobacco use, patients with schizophrenia have a much more difficult time quitting smoking and remaining abstinent compared with their non-psychiatric counterparts. Deficits in nAChR function may contribute to the cognitive deficits that are seen with the illness, such as deficits in working memory and sensory gating, and to co-morbid tobacco use disorders. Accordingly, treatments for tobacco use disorder in this population should focus on remediation of the disease-related endophenotypes that restore neurocognitive function and reduce the risk of smoking relapse.

Prescription drug monitoring program inquiry in psychiatric assessment: detection of high rates of opioid prescribing to a dual diagnosis population.

An epidemic of prescription drug abuse is disproportionately impacting the mentally ill. We examined the utility of a state prescription drug monitoring database for assessing recent controlled substance prescribing to patients presenting for dual diagnosis treatment. In a community mental health center that provides integrated dual diagnosis care, we queried the Indiana Scheduled Prescription Electronic Collection and Tracking (INSPECT) system for all cases that were open as of August 2, 2011, and had been practitioner-diagnosed (per DSM-IV criteria) by January 2, 2012. INSPECT provided a record of controlled substance dispensations to each patient; diagnostic evaluation was conducted blind from prescription data compilation covering the prior 12 months. Demographic data, insurance status, and DSM-IV diagnoses were compiled from the clinic's electronic medical record. The sample (N = 201) was 51% female, 56% white, and two-thirds uninsured. Over 80% were dually diagnosed with substance use disorders and psychotic, mood, or anxiety disorders. Nicotine and alcohol disorders were identified in most, with about a third diagnosed with cannabis, cocaine, or opioid disorders. A majority of patients (n = 115) had been prescribed opioids in the prior year, with nearly 1 in 5 prescribed an opioid and benzodiazepine simultaneously. Patients were dispensed a mean of 4 opioid prescriptions and 213 opioid pills. More opioid prescriptions correlated with opioid dependence (OR = 1.08; 95% CI, 1.016-1.145), and more prescribers correlated with personality disorder diagnoses (OR = 1.112; 95% CI, 1.001-1.235). Higher rates and riskier patterns of controlled substance prescribing were identified in patients with Medicaid/Medicare insurance compared to uninsured patients. Prescription drug monitoring is a powerful tool for assessing addictions and high frequencies of patient exposures to prescribed opioids in a dual diagnosis clinic. Improved prevention and treatment strategies for addictions as facilitated by more research and clinical use of prescription drug monitoring in psychiatric care are warranted.

The influence of treatment attendance on subsequent aggression among severely mentally ill substance abusers

The interrelationships between severe mental illness, substance use, and aggression are of longstanding importance with implications for community treatment programs, treatment research and public policy. Through the analysis of longitudinal data collected from 278 patients over a 6-month period following admission to an outpatient dual diagnosis treatment program, this study examined the association between dual diagnosis treatment attendance and subsequent aggression among individuals diagnosed with both a severe mental illness and a substance use disorder. We also tested substance use and psychiatric symptoms as mediators of this treatment–aggression relationship. The results of structural equation modeling analyses indicated that dual diagnosis treatment was associated with lower levels of subsequent aggression. Mediational analyses indicated that greater treatment involvement was associated with reduced substance use, which was associated with lower levels of aggression; thus, substance use was found to mediate the relationship between dual diagnosis treatment and aggression. Surprisingly, severity of psychiatric symptoms did not predict later aggression. These findings suggest that targeting substance use reduction in treatment may have the additional benefit of reducing the risk of later aggression among dual diagnosis patients.

Factors That Affect Treatment Initiation Among Individuals With Serious Mental Illness and Substance Abuse Disorder

Introduction: Studies have shown that approximately half of individuals with mental health disorders have a comorbid drug and alcohol diagnosis. Enrolling dually diagnosed patients in outpatient treatment programs has been a unique challenge for decades. Research identifying factors associated with patient treatment initiation has been limited. Clinicians have suspected that certain drugs, such as methamphetamine, may be a deterrent to treatment initiation. We wanted to identify factors that might be associated with the initiation of dually diagnosed patients in our outpatient dual diagnosis treatment program. Materials and Methods: Data for this study were obtained by retrospective review of 165 consecutive patient charts located in the Harbor-UCLA Dual Diagnosis Treatment Program during the fall of 2011. The factors we examined were age, sex, ethnicity, marital status, education, number of dependents, living situation, employment status, number of hospitalizations, substance abuse/psychiatric treatment background, previous suicide attempts, current medication, diagnosis, specific drug use history and legal history. The dependent variable in this study was treatment initiation. Results: On the basis of our chart review, we found 102 (62%) intake patients subsequently initiated treatment. After backward selection, 2 variables remained as independent predictors in the multivariate model: previous substance abuse treatment and history of methamphetamine use. Discussion: We found that previous substance abuse treatment and previous methamphetamine use were 2 significant predictor variables for initiation into our treatment program. Other possible factors such as sedative/hypnotic use in last 6 months, and alcohol use may also be significant factors in treatment initiation.

Capabilities for Handling Complex Substance abuse Problems and its Relationship to the Treatment System: Using the DDCAT Instrument to Explore Local Treatment Systems in Finland

Background Mental health problems in Finland have been the responsibility of the health care, and substance abuse problems have been handled within social care. In 2009, a national reform aiming at integrating mental health and substance abuse treatment systems (SATS) was launched. The critics of integration were concerned that it implies a medicalization and a narrowing of the social care goals. Aim This article analyses to what extent integration of mental health and SATS affect the capability to treat co-occurring substance abuse and mental health problems. A secondary aim is to assess the utility of the DDCAT (Dual Diagnosis Capability in Addiction Treatment) instrument in a Finnish context. Data The study is based on group interviews, using DDCAT, in six Finnish municipalities, three with integrated and three with separate mental health care and SATS. The assessment pertains to the main outpatient unit in the city. Results The dual diagnosis treatment capability did not depend on the system-level integration. Two municipalities where SATS was administratively separate from mental health care were able to achieve high dual diagnosis capability ratings while in one municipality with system level integration this capability was not very high. The DDCAT instrument puts an emphasis on medical staff and competence. Conclusions Strong, separate local SATS may adapt to the integration demands or needs by strengthening their psychiatric competence. This solution can result in treatment that is equally competent in treating mental health and substance abuse problems as integrated systems. The DDCAT instrument can be useful in a Finnish context to measure medical competence to handle dual diagnoses, irrespective of system solutions. For a balanced measurement, the instrument should be complemented with a section mapping competence to handle co-occurring social problems.

Comorbid Psychiatric in Drug Users: Integrative Review on Dual Diagnosis

Despite the high prevalence of dual diagnosis in the world and the importance to treatment patients, very little is known about complexity of this phenomenon and the factors associates in this population. Aim: Of delineating the themes to related dual diagnosis. Methods: Integrative review, two investigators independently reviewed the articles. Pubmed, Scopus, CINAHL and LILACS using combinations of the keywords "dual diagnosis" and "drug users". Results: Our search identified 15 papers, showed about two emphases, one on the drug users and other on the professional of mental health. The themes related patients were: psychiatric comorbidity in injecting drug users; reasons for the drug consume; substance use disorders and not substance use disorders in patients with mental illness; dual diagnosis in VIH patients. Other themes were: necessity to train the team of professional mental health; necessity to supervision of professional mental health during their job with the patients with dual diagnosis; necessity to do scientific gap to this patients; need to identify early dual diagnosis in drug users; to work with expanded clinical in the treatment of dual diagnosis in drug users; necessity to beware professionals mental health. Limitations: the search strategy did not rescue any intervention article in dual diagnosis. Conclusion: Given the high prevalence of dual diagnosis, the relative paucity of clinical guidance, and the potential impact that occurrence of dual diagnosis can have on the course of treatment. Implications for nursing and health policy: Nurses care directly from these patients need to know the disease for taking better care of their clients. For public policy contributes to the exhortation need for changes in the operation of mental health services, because they realized that there is dichotomy between mental health policy and alcohol and other drugs that do not include the care of a patient with dual diagnosis.

Alcohol craving in patients diagnosed with a severe mental illness and alcohol use disorder: Bidirectional relationships between approach and avoidance inclinations and drinking.

The current study was undertaken to better understand the craving-drinking relationship among individuals dually diagnosed with a severe mental illness (SMI) and an alcohol use disorder (AUD). Using an ambivalence conceptualization of craving (Breiner, Stritzke, & Lang, 1999), we investigated the bidirectional relationships between desires and behavioral intentions to use (approach inclinations) and not use (avoidance inclinations) alcohol and drinking outcomes in patients diagnosed with an SMI-AUD. Patients (N = 278) seeking outpatient dual diagnosis treatment from a community mental health center were followed longitudinally over the course of 6 months. Assessments at baseline, 2-month, 4-month, and 6-month intervals included approach and avoidance inclinations, alcohol urges, readiness to change, and drinking outcomes. Time-lagged multilevel growth curve modeling found that avoidance inclinations moderated the effect of approach inclinations on subsequent drinking outcomes differentially over time. Specifically, avoidance inclinations attenuated the effect of approach on subsequent heavier drinking levels, and high avoidance/low approach demonstrated significant decreases on levels of drinking over time. Results also indicated that number of drinks consumed and heavy drinking days predicted subsequent approach inclinations differentially over time, such that lower levels of drinking predicted decreases in approach inclinations. Decreases in drinking also predicted higher subsequent avoidance inclinations, which were maintained over time. These findings highlight the complexity of subjective craving responses and the importance of measuring both approach and avoidance inclinations. Among those diagnosed with SMI-AUDs, treatment strategies that increase avoidance inclinations may increase abstinence rates in this difficult-to-treat population.

S24 * NEW DEVELOPMENTS IN THE TREATMENT OF ALCOHOL USE DISORDERS

S24 * NEW DEVELOPMENTS IN THE TREATMENT OF ALCOHOL USE DISORDERS

Six-months outcomes of a randomised trial of supportive text messaging for depression and comorbid alcohol use disorder

Background and objectivesWe have previously reported that supportive text messages delivered twice daily for three months have the potential to provide personalised support for patients with depression and co-morbid Alcohol Use Disorder (AUD). In this study we report the six months outcomes. MethodsParticipants (n=54) with a DSM IV diagnosis of unipolar depression and AUD who completed an in-patient dual diagnosis treatment programme were randomised to receive daily twice supportive text messages (n=26) or a fortnightly thank you text message (n=28) for three months. Primary outcome measures at six months were Beck's Depression Inventory (BDI-II) scores and Cumulative Abstinence Duration (CAD). Trial registration: NCT0137868. ResultsUnlike at three months, there was no statistically significant difference in six months BDI-II scores between the intervention (n=24) and control (n=24) groups; 13.28 (SD=8.7) vs. 15.08 (SD=11.37) respectively after adjusting for the baseline scores, F (1, 45)=0.192, p=0.66. There was also no significant difference in CAD between the text message group and the control group: 84.14 days (9.20) vs. 74.73 days (28.97), t=1.422, df=41, p=0.16. However, patients in the intervention group had significantly higher days to first drink compared to those in the control group: 119.9 (47.7) vs. 62.4 (44.9), t=2.99, df=22, p=0.01. LimitationsLimitations of the study include the small sample size and the potential for loss of rater blinding. ConclusionThe effects of supportive text message intervention were not sustained beyond the period that the patients were receiving the intervention.

Drug use and treatment success among gang and non-gang members in El Salvador: a prospective cohort study

BackgroundThis article focuses on examining drug abuse treatment (DAT) in El Salvador highlighting gang vs. non-gang membership differences in drug use and treatment outcomes.MethodsCross-sectional and prospective cohort designs were employed to examine the study aims. The 19 centers that met the study’s inclusion criteria of one year or less in planned treatment offered varying treatment services: individual, group, family, and vocational therapy, dual diagnosis treatment, psychological testing, 12-step program, and outreach and re-entry aftercare. Most directors describe their treatment approach as “spiritual.” Data were collected from 625 patients, directors, and staff from the 19 centers at baseline, of which 34 patients were former gang members. Seventy-two percent (72%) of the former patients (448) were re-interviewed six-months after leaving treatment and 48% were randomly tested for drug use.ResultsEighty-nine percent (89%) of the DAT patients at baseline were classified as heavy alcohol users and 40% were using illegal drugs, i.e., crack, marijuana, cocaine, tranquilizers, opiates, and amphetamines. There were large decreases after treatment in heavy alcohol and illegal drug use, crime, and gang related risk activities. Gang members reported illegal drug use, crime, and gang related risk activity more than non-gang members, yet only 5% of the study participants were gang members; further, positive change in treatment outcomes among gang members were the same or larger as compared to non-gang members.ConclusionsAlcohol use is the drug of choice among DAT patients in El Salvador with gang member patients having used illegal drugs more than non-gang members. The study shows that DAT centers successfully reduced the use of illegal drugs and alcohol among gang and non-gang members. Although our study could not include a control group, we believe that the DAT treatment centers in El Salvador contributed to producing this treatment success among former patients. These efforts should be continued and complemented by funding support from the Salvadoran government for DAT centers that obtain certification. In addition, tailored/alternative treatment modalities are needed for gang members in treatment for heavy drinking.

Needs assessment of dual diagnosis: A cross-sectional survey using routine clinical data

Aims: Department of Health guidance on dual diagnosis (DD) recommends that services measure local need, and use this to inform service planning. This study aimed to use routine clinical data to estimate the prevalence of DD and unmet treatment need in a community drug and alcohol service, and to appraise the feasibility of using routine data for such purposes.Methods: First, a screening checklist was developed to determine whether a particular service-user met DD caseness criteria. Second, the electronic care records of 227 service-users were screened for DD caseness, as well as for documentation of current and/or previous receipt of mental health treatment.Findings: Seventy-two percent screened positive for having DD. Of these, around half were not receiving current treatment for their mental health, while 37% had never received mental health treatment. Higher rates of DD were found amongst women and those in treatment for alcohol dependence.Conclusions: The findings corroborate previous research showing high prevalences of DD and unmet treatment need within drug and alcohol services in general, and amongst certain high-risk subgroups in particular. The study demonstrates that using routine data to estimate unmet treatment need is feasible within the limited resources available to frontline services.