Severe Substance Use Research Articles

Subtypes of Clients With Serious Mental Illness and Co-occurring Disorders: Latent-Class Trajectory Analysis

This study identified and characterized groups of clients who have serious mental illness and co-occurring substance use disorders. Substance abuse recovery of 177 clients with co-occurring disorders was followed for ten years with multiperspective ratings every six months. Latent-class trajectory analysis was used to identify subgroups; profile analysis was used to examine baseline risk factors and treatment participation. Two ratings of substance abuse recovery-stage of treatment and abstinence-were highly concordant and identified the same four groups: early recovery, unstable recovery, late recovery, and no recovery. The early-recovery group was characterized by less severe substance use disorders at baseline and by use of clozapine. The unstable-recovery group was too small for statistical analyses. The late-recovery group was similar to the no-recovery group at baseline but participated more extensively in treatments, especially residential dual-diagnosis programs, during the first three years of follow-up. Latent-class trajectory analysis based on ten-year trajectories of substance abuse recovery identified clinically meaningful groups among clients with serious mental illness and co-occurring substance use disorders. Profiles of the three most common groups suggest differential clinical approaches for each.

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

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

Interferon-based hepatitis C treatment in patients with pre-existing severe mental illness and substance use disorders

Hepatitis C infection in patients with mental illness and drug addiction is highly prevalent and infrequently treated. Over the past 5 years, a wealth of studies specifically focused on these groups have demonstrated comparable rates of sustained virological response, compliance and adverse events. Optimization of psychotropic and opioid-replacement therapy with integrated psychiatric/addiction treatment prior to and during IFN-α initiation produces optimal results. Experience in treating these populations demonstrates clinical outcomes comparable with those without these comorbidities. Patients with mental illness and drug addiction should have routine screening and treatment for HCV infection to prevent associated morbidity and mortality.

Psychosocial Treatments for People with Co-occurring Severe Mental Illnesses and Substance Use Disorders (Dual Diagnosis): A Review of Empirical Evidence

Considerable research documents the health consequences of psychosis and co-occurring substance use disorders. Results of randomized controlled trials assessing the effectiveness of psychosocial interventions for persons with dual diagnoses are equivocal but encouraging. Many studies are hampered by small, heterogeneous samples, high attrition rates, short follow-up periods, and unclear description of treatment components. The treatments available for this group of patients (which can be tailored to individual needs) include motivational interviewing, cognitive-behavioral therapy, contingency management, relapse prevention, case management, and skills training. Regardless of whether services follow integrated or parallel models, they should be well coordinated, take a team approach, be multidisciplinary, have specialist-trained personnel (including 24-hour access), include a range of program types, and provide for long-term follow-up. Interventions for substance reduction may need to be further developed and adapted for people with serious mental illnesses. Further quality trials in this area will contribute to the growing body of data of effective interventions.

News and Notes

News and Notes

Use of health care services by patients with co-occurring severe mental illness and substance use disorders.

To better respond to the health care needs of people with co-occurring mental illness and substance use disorders, it is vital to understand their itinerary through the health care system. To describe the characteristics of service utilization among patients with co-occurring disorders in a large urban area. We used a sample (n = 5467) constituted from administrative and clinical databases. Those identified as having substance use disorders and psychoses were followed over 12 months with respect to their utilization of medical services. A descriptive analysis of the data and a two-step cluster analysis were undertaken. Our analyses revealed a relatively high utilization of emergency services, outpatient clinics, private practices and hospitalization among patients with co-occurring disorders of severe mental illness and substance use. The two-step cluster analysis produced four heterogeneous groups in terms of service utilization. This study demonstrates the need to develop strategies for organizing health care and services that are adapted to various sites of service utilization and to diverse profiles of patients with co-occurring mental illness and substance use disorders.

Experiences of alcohol and other drugs in individuals with severe mental illness and concomitant substance use disorders

Background: It is well known that severe mental illness (SMI) with concurrent substance use disorders (SUD) commonly occurs. This comorbidity has distressing social, psychological, psychiatric and somatic consequences. Aim: To gain greater understanding of how individuals with SMI and SUD experience the roles of alcohol and other drugs for their health and life situation. Method: Eight individuals were interviewed on two occasions. The semi-structured interviews, which were based on an interview guide, were transcribed verbatim and analysed thematically. Results: Alcohol and drug use influenced the individuals' own experiences of their health and life situation both in a positive and negative way. Substance use had meaning for their: ‘experience of themselves’ – well-being and discomfort, energy and lack of energy, meaningfulness and disorientation, identity and personality change; ‘experiences of relationships’ – affiliation and alienation; ‘experiences of mental health’ – decreased and increased symptom...

Gender differences in cocaine dependence

Aims: This study examined gender differences among treatment-seeking cocaine-dependent outpatients (e.g., on demographics, psychopathology, and substance abuse). Participants: Participants were 2376 adults with cocaine dependence entering a multisite randomized controlled trial of psychosocial therapies. Findings: Women, compared to men, had less severe lifetime substance use problems but a higher pattern of psychiatric, medical, social/family, and employment problems; they also had more positive expectations and opinions about treatment. Conclusions: Women may be willing to engage in treatment but may have challenging economic and psychosocial concerns over and above their addiction.

Bidirectional Partner Violence Among Homeless Young Adults

One of the most prevalent forms of violence in contemporary society is the victimization of intimate partners. Although it has been established that homeless young people experience high levels of victimization on the street, little is known about partner violence (PV) experiences among this group, especially bidirectional violence. As such, the purpose of this study is to examine the prevalence of PV and bidirectional violence and to investigate risk factors and outcomes of this form of violence using a sample of homeless young adults. Overall, 59% of the sample experienced bidirectional violence. Multivariate results reveal that sexual abuse and neglect are significant correlates of PV. In addition, being either a victim or perpetrator of PV is associated with more severe substance use and higher levels of posttraumatic stress disorder (PTSD). Finally, there is support for bidirectional violence among homeless young adults even after controlling for early histories of maltreatment.

Medical Clinic Characteristics and Access to Behavioral Health Services for Persons With HIV

Medical Clinic Characteristics and Access to Behavioral Health Services for Persons With HIV

Treatment issues with substance use disorder clients who have mood or anxiety disorders

Background: Co-occurring substance use and mental health disorders may complicate the impact of treatment. Oftentimes, substance treatment practitioners are not prepared to deal with both issues and may focus primarily on substance use disorders while the untreated mental health issues dilute treatment effectiveness. Research has yet to identify an effective treatment approach for clients with more severe substance use and less severe mental health problems. Aims: To review the treatment literature and uncover the evidence base for clients who have more severe substance use and less severe mental health problems. Method: The research literature was reviewed for studies that evaluated treatment or services for clients with substance use disorders and mood or anxiety disorders. The focus was on studies of clients with more severe substance use and less severe mental health problems. Results: We identified 45 studies that met our criteria for inclusion and reviewed them for common themes and variations. Conc...

A voxel-based morphometric MRI study in psychopathic traits

Event Abstract Back to Event A voxel-based morphometric MRI study in psychopathic traits Hiroki Fukui1*, R. Kawada1 and K. Yoshikawa1 1 National Institute of Mental Health, Japan Purpose: Psychopathy is characterized by a failure to experience emotions that are necessary for appropriate social behavior, such as empathy. These characters are considered to construct a latent dimension rather than a latent taxon. Non-clinical individuals are relatively free of potentially confounding variables (e.g., severe substance use, physical abuse history) that can often complicate the interpretation of brain-imaging deficits. Our aim was to examine whether a specific association exists between abnormalities of brain structures and psychopathic traits in community samples. Furthermore, we explored the correlation between the psychopathic trait- related structures and empathic abilities. Method: Twenty-two healthy subjects underwent structural magnetic resonance imaging and their psychopathic tendency was examined using the self-rating questionnaire Levenson Self-Report Psychopathy Scale (LSRP) and Psychopathic Personality Inventory-Revised (PPI-R). We applied voxel-based morphometry to investigate regional brain volume alternations. We employed the Empathic Concern (EC) Subscale of the Interpersonal Reactivity Index (IRI) to measure empathic abilities and assessed the correlation with the brain volume of psychopathy-associated areas. Results: An association between the LSRP total score and volume reductions in the right precuneus (Prc) was identified. Scores of LSRP primary psychopathy scores were correlated with the bilateral Prc, right orbitofrontal cortex (OFC), and right amygdala volume decrease. The scores of the EC Subscale of IRI scores were not associated with the structural abnormality of the amygdala or OFC, but were associated with the right Prc. Conclusion: Our findings support the view that psychopathy is a dimension in the brain structure level. We suggest that the precuneus may play an important role in the empathy of psychopathic people, by its third-person perspective-taking function. Conference: 10th International Conference on Cognitive Neuroscience, Bodrum, Turkey, 1 Sep - 5 Sep, 2008. Presentation Type: Poster Presentation Topic: Cerebral Asymmetry Citation: Fukui H, Kawada R and Yoshikawa K (2008). A voxel-based morphometric MRI study in psychopathic traits. Conference Abstract: 10th International Conference on Cognitive Neuroscience. doi: 10.3389/conf.neuro.09.2009.01.142 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 05 Dec 2008; Published Online: 05 Dec 2008. * Correspondence: Hiroki Fukui, National Institute of Mental Health, Tokyo, Japan, fukui@ncnp.go.jp Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Hiroki Fukui R. Kawada K. Yoshikawa Google Hiroki Fukui R. Kawada K. Yoshikawa Google Scholar Hiroki Fukui R. Kawada K. Yoshikawa PubMed Hiroki Fukui R. Kawada K. Yoshikawa Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Medicare Part D Prescription Drug Benefits and Administrative Burden in the Care of Dually Eligible Psychiatric Patients

Medicare Part D Prescription Drug Benefits and Administrative Burden in the Care of Dually Eligible Psychiatric Patients

Collaborative Mental Health Care for the Homeless: The Role of Psychiatry in Positive Housing and Mental Health Outcomes

Factors associated with positive outcomes for homeless men referred to a shelter-based collaborative mental health care team were examined. A chart review of 73 clients referred over 12 months was completed. Two outcome measures were examined, clinical status and housing status, 6 months after their referral to the program. Among the referred clients, the prevalence of severe and persistent mental illness and substance use disorders was 76.5% and 48.5%, respectively. At 6 months, 24 clients (35.3%) had improved clinically, and 33 (48.5%) were housed. Logistic regression identified 2 factors associated with clinical improvement: the number of visits with a psychiatrist and treatment adherence. The same 2 factors were associated with higher odds of housing, and presence of substance use disorder was associated with lower odds of housing at 6-month follow-up. Care by a mental health specialist is positively associated with improved outcomes. Strategies to improve treatment adherence, access to mental health specialists, and innovative approaches to treatment of substance use disorders should be considered for this population. Having a psychiatrist as a member of a shelter-based collaborative care team is one possible way of addressing the complex physical and mental health needs of homeless individuals.

High expressed emotion: precipitating relapse in substance misuse disorders

There is a considerable body of evidence on the effect of high expressed emotion on individuals suffering severe mental illnesses; there is also considerable work on those people suffering the dual diagnosis of severe mental illness and substance use disorders. However, in the latter, the majority of studies appear to concentrate on the mental illness aspect of the condition. Literature searches identified that there were few scholarly articles on how expressed emotion affects relapse in those people with a substance use disorder, and yet there is a great deal of evidence regarding the disruption substance use can have on a family and on the individual. This article intends to provide an evaluation on the reasons why high expressed emotion should be addressed in substance use disorder and suggests that, if the benefits of reducing high expressed emotion in these disorders are as significant as in severe mental illness, then there is a sound basis for the increased use of family interventions in substance use disorders.

High expressed emotion, severe mental illness and substance use disorder

This article discusses the behavioural attitudes of high expressed emotion as a major contributor to relapse in patients dually diagnosed with severe mental illness and substance use disorder. There are a number of research studies and authoritative texts on this particular problem and discussions identify the role expressed emotion plays in this condition. However, the majority of literature concentrates on how high expressed emotion affects the person's mental illness causing relapse rather than any effect on their substance misuse. This article outlines severe mental illness and substance use disorder; identifies the components of expressed emotion and how this may contribute to relapse; management and care in this condition; the treatment and avoidance of expressed emotion by the family and the professional; and issues of nurse education, training and support.

Dr. Wilens Replies

Back to table of contents Previous article Next article Letters to the EditorFull AccessDr. Wilens RepliesTIMOTHY E. WILENS M.D.,TIMOTHY E. WILENS M.D.Search for more papers by this author,Published Online:1 Jun 2007AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To The Editor: The authors comment on the validity of the case presented for meeting criteria for ADHD in light of substance abuse in general and marijuana abuse in particular. For teaching purposes, the case purposely left some areas vague, since it is illustrative of a typical presentation of ADHD in a young adult with marijuana use disorder. While in a perfect world, it would be nice to have adults present with an established childhood diagnosis with evidentiary documentation and completed full-structured interviews on their first-degree relatives, such data are not available in clinical practice. Epidemiological evidence clearly indicates that most adults with ADHD are neither diagnosed nor treated for their condition and that ADHD is not a trivial disorder with substantial impairment (1) . Hence, practitioners must evaluate the presence of symptoms and not make a formal diagnosis of ADHD in the parents of individuals being assessed indirectly for the disorder, which is often the case for substance use disorders. The idea that not all inattention is ADHD is obvious; however, if you can elicit a history of a longitudinal track of a cluster of attentional- and/or hyperactive/impulsive-based symptoms in childhood that are associated with impairment and exist at times when there is no substance abuse, a multiplicity of studies have demonstrated the validity of the retrospective diagnosis of ADHD in adults (2 , 3) , even in the presence of substance use disorders (4) . In the illustrative case that I presented, the ADHD symptoms can be tracked well into junior high school—a time when neither marijuana nor other psychiatric comorbidity was present—establishing a long history of ADHD symptoms and associated dysfunction (4) . The authors’ single-survey study of stimulant abusers does not settle the issue of whether concurrent marijuana use is the causative agent in all attentional-based dysfunction and all psychostimulant abuse. For instance, it has been reported that approximately 20% of adults with substance use disorders and 40% of cannabis abusing adolescents have an ADHD diagnosis after detoxification from marijuana (5 , 6) (www. CSAT.gov). The authors lack data to support their contention that a diagnosis of ADHD can only be made with confidence after prolonged abstinence from nonmedical drug use. Unlike other comorbid disorders that are difficult to disentangle from substance use disorders, ADHD, by definition, predates substance use (onset ≤7 years old) and is a chronic disorder; there are no “attacks” of ADHD. Further, adults with ADHD who have been diagnosed with past and current substance use disorders compared with those diagnosed with no substance use have been shown to have similar characteristics, such as a family history of ADHD, neuropsychological disturbance, and functional impairments associated with ADHD symptoms (4) . Moreover, inspection of treatment studies of substance use disorders and ADHD shows a stable persistence in the symptoms of ADHD independent of the fluctuation of substance use throughout the trial (7 – 10) . In terms of the treatment of substance use disorders, while abstinence is of course preferred, a number of studies that the authors do not mention show that ADHD is not benign when comorbid with substance use. The idea that only absolute abstinence is acceptable prior to initiating other treatment is ideologically based and does not appreciate that ADHD predicts earlier-onset substance use, more severe substance use, a longer course and less remission from substance use, and lower retention rates in the treatment of substance use (11 – 14) . A number of innovative initiatives in this area that have led to newer guideline recommendations to treat ADHD in substance use disorders, after remission or stabilization of the substance use, have been established (14 , 15) . This practice of treating ADHD in context with “stabilized” substance use has been recently shown to have a positive impact on improving the outcomes of substance use disorders (10) and is being evaluated currently in a large multisite National Institute on Drug Abuse study of adolescents with ADHD and substance use disorders. In this regard, there are a number of new options that could be used to accomplish these goals at different stages of substance use recovery, including effective nonstimulants. Boston, Mass.Dr. Wilens’s disclosure accompanies his original article.

Dr. Wilens Replies

Back to table of contents Previous article Next article Letters to the EditorFull AccessDr. Wilens RepliesTIMOTHY E. WILENS M.D.,TIMOTHY E. WILENS M.D.Search for more papers by this author,Published Online:1 Jun 2007AboutSectionsView articleView PDFView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View article To The Editor: The authors comment on the validity of the case presented for meeting criteria for ADHD in light of substance abuse in general and marijuana abuse in particular. For teaching purposes, the case purposely left some areas vague, since it is illustrative of a typical presentation of ADHD in a young adult with marijuana use disorder. While in a perfect world, it would be nice to have adults present with an established childhood diagnosis with evidentiary documentation and completed full-structured interviews on their first-degree relatives, such data are not available in clinical practice. Epidemiological evidence clearly indicates that most adults with ADHD are neither diagnosed nor treated for their condition and that ADHD is not a trivial disorder with substantial impairment (1) . Hence, practitioners must evaluate the presence of symptoms and not make a formal diagnosis of ADHD in the parents of individuals being assessed indirectly for the disorder, which is often the case for substance use disorders. The idea that not all inattention is ADHD is obvious; however, if you can elicit a history of a longitudinal track of a cluster of attentional- and/or hyperactive/impulsive-based symptoms in childhood that are associated with impairment and exist at times when there is no substance abuse, a multiplicity of studies have demonstrated the validity of the retrospective diagnosis of ADHD in adults (2 , 3) , even in the presence of substance use disorders (4) . In the illustrative case that I presented, the ADHD symptoms can be tracked well into junior high school—a time when neither marijuana nor other psychiatric comorbidity was present—establishing a long history of ADHD symptoms and associated dysfunction (4) . The authors’ single-survey study of stimulant abusers does not settle the issue of whether concurrent marijuana use is the causative agent in all attentional-based dysfunction and all psychostimulant abuse. For instance, it has been reported that approximately 20% of adults with substance use disorders and 40% of cannabis abusing adolescents have an ADHD diagnosis after detoxification from marijuana (5 , 6) (www. CSAT.gov). The authors lack data to support their contention that a diagnosis of ADHD can only be made with confidence after prolonged abstinence from nonmedical drug use. Unlike other comorbid disorders that are difficult to disentangle from substance use disorders, ADHD, by definition, predates substance use (onset ≤7 years old) and is a chronic disorder; there are no “attacks” of ADHD. Further, adults with ADHD who have been diagnosed with past and current substance use disorders compared with those diagnosed with no substance use have been shown to have similar characteristics, such as a family history of ADHD, neuropsychological disturbance, and functional impairments associated with ADHD symptoms (4) . Moreover, inspection of treatment studies of substance use disorders and ADHD shows a stable persistence in the symptoms of ADHD independent of the fluctuation of substance use throughout the trial (7 – 10) . In terms of the treatment of substance use disorders, while abstinence is of course preferred, a number of studies that the authors do not mention show that ADHD is not benign when comorbid with substance use. The idea that only absolute abstinence is acceptable prior to initiating other treatment is ideologically based and does not appreciate that ADHD predicts earlier-onset substance use, more severe substance use, a longer course and less remission from substance use, and lower retention rates in the treatment of substance use (11 – 14) . A number of innovative initiatives in this area that have led to newer guideline recommendations to treat ADHD in substance use disorders, after remission or stabilization of the substance use, have been established (14 , 15) . This practice of treating ADHD in context with “stabilized” substance use has been recently shown to have a positive impact on improving the outcomes of substance use disorders (10) and is being evaluated currently in a large multisite National Institute on Drug Abuse study of adolescents with ADHD and substance use disorders. In this regard, there are a number of new options that could be used to accomplish these goals at different stages of substance use recovery, including effective nonstimulants. Boston, Mass.Dr. Wilens’s disclosure accompanies his original article.

Alcohol and Drug Abuse Prevention

<p>Substance use disorders cause meaningful disability for a substantial portion of the American population. A comorbid diagnosis occurs in 60% to 90% of those affected by substance-related disorders. Additionally, adolescents with severe substance use disorders are even more likely to have other psychiatric disorders than adults with substance use disorders. Aside from formal substance use disorder diagnoses, misuse of a substance may lead to impaired judgment and serious accidents. The effects of substance abuse are far-reaching and involve the patient, his or her family, other people involved with the patient, the medical community, society, the work force, and so on. The practicing psychiatrist is confronted daily with the consequences of alcohol and drug use and alcohol and drug use disorders.</p><h4>ABOUT THE AUTHOR</h4><p>Rebecca A. Powers, MD, MPH, is Adjunct Clinical Assistant Professor of Psychiatry, Stanford University School of Medicine.</p><p>Address correspondence to: Rebecca A. Powers, MD, MPH, 14651 S. Bascom Avenue, Suite 225, Los Gatos, CA 95032; fax 408-356-3484; or email: <a href="mailto:whoakmed@aol.com">whoakmed@aol.com</a>.</p><p>The author disclosed no relevant financial relationships.</p> <h4>EDUCATIONAL OBJECTIVES</h4> <ol> <li>Discuss the signifi cance of alcohol and drug abuse as public health problems.</li> <li>Explain why population-based prevention programs are important help control these problems.</li> <li>Describe prevention-minded approaches relevant to the practicing psychiatrist.</li> </ol>

Comorbidity: What have we learned and where are we going?

Substantial progress has been made in recent years in the recognition and treatment of comorbid mental, substance abuse, and health disorders. In this article, we summarize this progress and consider next steps by addressing the following three questions, with a focus on persons with severe mental illness and substance use disorders: (a) What have we learned about comorbidity? (b) What are the advantages of focusing on comorbidity, and what are the costs? and (c) What are the future directions for research and treatment of comorbid disorders?