Violence Among Comorbid and Noncomorbid Severely Mentally Ill Adults: A Pilot Study

This pilot study examined the relationship between substance dependence and violence in a sample of severely mentally ill adults. Subjects were 42 psychiatric outpatients enrolled in a clinical case management program in San Francisco, California. Almost 40% of the participants reported perpetrating at least one violent act in the past 12 months. Comorbid participants were over 4 1/2 times more likely to commit a violent act in the past 12 months than noncomorbid participants. Substance dependence was also more frequently associated with perpetration of a violent act by female than by male participants and by Caucasian than by African American participants. Comorbid mentally ill participants appear more likely to perpetrate violent acts than those with mental illness alone. The dangers of substance dependence in terms of the perpetration of violence may not be in mental illness or substance dependence alone but in their co-occurrence. Further investigation is needed to assess risk factors for violence and victimization in multiple environmental and situational domains. It will be important to explore the moderating effects of gender and race on the co-occurrence of mental illness, substance dependence, and the perpetration of violent acts.     

Co-morbidity Across Levels of Hospital Security

This study explores the prevalence of co-morbid mental illness and substance abuse across three levels of hospital security (non-secure, medium and high secure). The medical records of 428 individuals with a mental illness were examined for evidence of a history of co-morbid substance abuse and criminal convictions. Abuse of solvents, hallucinogens, cocaine and poly-substance abuse were all found to be more likely in the high secure mentally ill population compared to the non-forensic (non-secure) mentally ill population. Therefore not only was the prevalence of co-morbidity greater at higher levels of security but the type of substances abused by high secure patients were also different from the types abused by non-forensic patients. There were some unexpected findings, most notably high secure patients were significantly less likely to abuse alcohol than non-forensic patients. The validity of these findings is discussed. Across the whole sample violent crime was particularly associated with abuse of cannabis, solvents, hallucinogens and poly-substance abuse. However even after controlling for violent crime, significantly higher levels of substance abuse were found at higher levels of hospital security.     

Factors associated with partner violence among female alcoholic patients and their male partners

OBJECTIVE: This study described the extent of partner violence victimization and perpetration among married or cohabiting female alcoholic patients and the factors associated with it. METHOD: Male-to-female and female-to-male physical partner violence were examined for 103 female alcoholic patients seeking couples-based outpatient alcoholism treatment. Partner violent (PV) and nonpartner violent (NPV) groups were compared on hypothesized risk factors. RESULTS: In the year before treatment, about two thirds of the women were victimized by their male partners, and a similar proportion engaged in violence toward their male partners. Severe violence also was high, with 22% victimization and 50% perpetration prevalence. Women committed more violent acts overall and were more likely to commit severely violent acts than the men in these couples. Risk factors for PV in both the victimization and perpetration models were as predicted: less education, lower income, greater relationship problems, stronger beliefs in the link between relationship problems and the female patient's drinking, greater cocaine use by the perpetrator of violence and greater emotional distress of the men. Greater alcohol and drug use and more severe alcohol problems also distinguished male perpetrators from their nonviolent counterparts in the female victimization model. Predictions that female patients in the PV group would report greater substance use and problems, childhood violence exposure and emotional distress than their female counterparts in the NPV group were not supported for either victimization or perpetration models. CONCLUSIONS: Partner violence is a serious problem for women in alcoholism treatment. More research is needed to increase understanding of risk factors and explanatory models for such violence.     

Predictors of violence following Emergency Department visit for cocaine-related chest pain

This study examined 1-year violence outcomes among non-injured patients treated in the Emergency Department (ED) for cocaine-related chest pain. An urban Level I ED required patients with chest pain (age 60 and younger) provide a urine sample for cocaine testing. Cocaine-positive consenting patients (n=219) were interviewed in the ED; 80% completed follow-up interviews over 12-months (n=174; 59% male, 79% African-American, mean age=38.8, standard deviation 9.06; range=19-60). Baseline rates of past year violent victimization and perpetration history were: 38% and 30%, respectively. During the 12-month follow-up, rates of victimization and perpetration outcomes were 35% and 30%, respectively. Predictors of violence outcomes (either victimization or perpetration) in the year post-ED visit based on characteristics were measured at baseline or during the follow-up period (i.e., gender, age, psychological distress, binge drinking days, cocaine use days, marijuana use days, substance abuse/dependence diagnosis, victimization/perpetration history). Victimization during the follow-up was related to younger age, more frequent binge drinking and marijuana use at baseline, and victimization history, and to substance abuse/dependence, more frequent binge drinking, and psychiatric distress at follow-up. Specifically, participants who reported victimization at baseline were approximately 3 times more likely to report victimization at 12-month follow-up. Perpetration during the follow-up was related to younger age and more frequent binge drinking at baseline, and to substance abuse/dependence, more frequent binge drinking, and psychiatric distress at follow-up. Overall, no significant gender differences were observed in violence; however, women were more likely than men to report injury during the most severe partner violence incident. Violence is a common problem among patients presenting to an inner-city ED for cocaine-related chest pain, with younger age and frequency of binge drinking being a consistent marker of continued violence involvement. Intervention approaches to link these not-in-treatment cocaine users to services and reduce cocaine use must take into account concomitant alcohol misuse and violence.     

Perpetration of partner violence: effects of cocaine and alcohol dependence and posttraumatic stress disorder

The present study examined the effects of substance dependence and posttraumatic stress disorder (PTSD) on perpetration of partner violence. Participants were 72 men and 124 women diagnosed with and/or without PTSD and cocaine or alcohol dependence. Participants were interviewed with the Structured Clinical Interview for the DSM-IV (SCID-IV) and completed the Conflict Tactics Scale-2 (CTS-2). Analyses indicated that participants with comorbid cocaine dependence and PTSD reported the highest frequency of partner violence relative to all other groups. Main effects were also detected for drug dependence and PTSD. Results suggest that substance dependence and PTSD alone are associated with increased violence in couples, and most importantly, the presence of PTSD serves to further potentiate the perpetration of partner violence among cocaine-dependent individuals.     

The Association Between Phencyclidine Use and Partner Violence: An Initial Examination

The association between phencyclidine (PCP) use and violent behavior is unclear. The current investigation evaluated the association between PCP addiction and intimate partner violence, a specific violent behavior, using the substance abuse evaluations of 109 PCP, 81 cannabis, and 97 polysubstance (alcohol and cannabis) abusing offenders. Relative to both comparison groups, PCP users were more likely to receive inpatient referrals, have a significant legal history, and have perpetrated past-year general and intimate partner violence. Data suggest that PCP use may be associated with greater violence perpetration than cannabis use alone or in conjunction with problematic alcohol use.     

Methods of changing patterns of substance use among individuals with co-occurring schizophrenia and substance use disorder.

Individuals with a severe mental illness and substance use disorder tend to have medical and social problems and to make slower progress in treatment than those who have either disorder alone. Nevertheless, little attention has been paid to the discovery of effective methods of modifying substance use in the severely mentally ill (SMI). The purpose of this study was to collect qualitative data as a way to help identify techniques that might help to change patterns of substance use in the SMI. The participants were 21 men and women who were psychiatric clinic outpatients and who had a current schizophrenia spectrum diagnosis. A total of 18 participants had a lifetime diagnosis of alcohol abuse or dependence, and 21 lifetime other drug diagnoses were recorded for the sample. These individuals participated in focus group discussions about topics related to substance use and people's experiences with trying to quit. The results showed that participants identified several therapeutic and extratherapeutic factors that helped them to initiate and maintain changes in their substance use, as well as factors that hindered change. The findings are related to knowledge about the effectiveness of substance use disorder treatment techniques in general, and implications of the data are discussed for the conduct of integrated treatment of individuals with severe mental illness and a substance use disorder.     

Associations between substance use,post-traumatic stress disorder and the perpetration of violence: A longitudinal investigation

Aim

Substance use disorder (SUD) and post-traumatic stress disorder (PTSD) commonly co-occur. This is of significant concern, given the increased risk for violence perpetration among individuals with this comorbidity. Limited research, however, has examined relationships between SUD, PTSD and violence among individuals longitudinally. Such an investigation is warranted given that substance use and PTSD symptoms can fluctuate over time. This study therefore aims to examine how changes in substance use and PTSD symptom severity are associated with the perpetration of violent crime over time among individuals with comorbid SUD and PTSD.

Method

One-hundred and two men and women who met criteria for SUD and PTSD were interviewed four times over a 9-month period. These interviews included measures of past-month violent crime perpetration, substance use and dependence, PTSD symptom severity, and depression and state anxiety symptoms. Generalised estimating equations (GEE) modelled associations between substance use, PTSD and violence.

Results

Increased substance use, more severe substance dependence and more severe PTSD symptomology were consistently associated with violent crime over time. Multivariate GEE analyses, however, revealed that the PTSD hyperarousal symptoms, specifically, were independently associated with violence over time.

Conclusions

This longitudinal study found that PTSD hyperarousal symptoms were consistently associated with the perpetration of violent crime, further highlighting the potentiating role of PTSD hyperarousal in relation to violence among individuals with SUD. These findings indicate that interventions addressing hyperarousal symptoms have the potential to reduce the susceptibility for violence among individuals with this common comorbidity.     

Hurt people who hurt people: violence amongst individuals with comorbid substance use disorder and post traumatic stress disorder

Aims

The association between substance use disorder (SUD) and the perpetration of violence has been well documented. There is some evidence to suggest that the co-occurrence of post traumatic stress disorder (PTSD) may increase the risk for violence. This study aims to determine the prevalence of violence perpetration and examine factors related to violence amongst individuals with comorbid SUD and PTSD.

Design and participants

Data was collected via interview from 102 participants recruited to a randomised controlled trial of an integrated treatment for comorbid SUD and PTSD.

Measurements

The interview addressed demographics, perpetration of violent crime, mental health including aggression, substance use, PTSD, depression, anxiety and borderline personality disorder.

Findings

Over half of participants reported committing violence in their lifetime and 16% had committed violence in the past month. Bivariate associations were found between violence perpetration and trait aggression, higher levels of alcohol and cannabis use, lower levels of other opiate use, and experiencing more severe PTSD symptoms, particularly in relation to hyperarousal. When entered into a backward stepwise logistic regression however, only higher levels of physical aggression and more severe PTSD hyperarousal symptoms remained as independent predictors of violence perpetration.

Conclusions

These findings highlight the importance of assessing for PTSD amongst those with SUD particularly in forensic settings. They also indicate that it is the hyperarousal symptoms of PTSD specifically that need to be targeted by interventions aimed at reducing violence amongst individuals with SUD and PTSD.     

Contingent reinforcement of marijuana abstinence among individuals with serious mental illness: a feasibility study

The feasibility of using monetary incentives to promote abstinence from marijuana use among individuals with serious mental illness was examined by using a within-subjects experimental design. Participants were 18 adults with schizophrenia or other serious mental illness who reported regular marijuana use. During 2 baseline conditions, participants received payment for submitting urine specimens independent of urinalysis results. During 3 incentive conditions, participants received varying amounts of money if urinalysis results were negative for recent marijuana use. The number of marijuana-negative specimens obtained was significantly greater during incentive than baseline conditions. These results provide evidence that marijuana use among at least some mentally ill individuals is sensitive to contingent reinforcement and support the potential feasibility of using contingency-management interventions to reduce substance abuse among the mentally ill.     

Substance Use and Violence Among Youth: A Daily Calendar Analysis

Background: While researchers have identified factors that contribute to youth violence, less is known about the details of violent incidents. In addition, substance use has been linked to youth violence; however, little is known about actual substance use on days in which violence occurs. Objective: This study examined reasons for peer violence and the association between substance use and violence using daily calendar-based analyses among at-risk urban youth. Methods: Data were collected from Emergency Department (ED) patients (ages 14–24; n = 599; 59% male, 65% African American) who screened positive for substance use in the past 6 months. Daily data regarding past 30-day substance use and violence and reasons for violent incidents were obtained via semi-structured interviews. Multi-level multinomial regression models were conducted to test the associations between substance use and peer violence incidents (i.e., none, moderate and severe). Results: Conflict over ‘personal belongings’ was a common reason for violence among males; ‘jealousy’/‘rumors’ were common reasons among females. Moderate victimization was more likely to be reported on days in which participants reported alcohol and cocaine use. Severe victimization was more likely to be reported on days in which participants reported alcohol use. Moderate or severe aggression was more likely to be reported on days in which participants reported alcohol and non-medical sedative use. Conclusions: Results suggest that youth violence prevention that addresses differential reasons for violence among males and females as well as substance use would be beneficial.     

Comorbid substance use diagnoses and partner violence among offenders receiving pharmacotherapy for opioid dependence

While previous studies find mixed evidence of an association between opioid use and intimate partner violence perpetration among community samples, initial evidence has detected increased rates of partner violence among individuals receiving pharmacological intervention for opioid dependence. The current study evaluated the role of current comorbid substance use diagnoses, a robust risk factor for violent behavior, on the likelihood of perpetrating partner violence among a high risk sample of offenders receiving pharmacological intervention for opioid dependence. The authors analyzed self-report data provided by 81 (55 male) opioid dependent offenders during a court-ordered substance use interview. Approximately one-third of the sample evidenced the recent use of intimate partner violence. Findings indicated that cocaine and benzodiazepine use were independently associated with an increased likelihood of reporting physical partner violence. Alcohol and cannabis use were not associated with partner violence. The current results offer further support for the ongoing need to conduct routine partner violence screenings among substance involved offenders and highlight the importance of developing individualized treatment plans that address comorbid substance use and partner-violent behaviors among individuals in treatment for opioid dependence.     

Does a History of Violence Influence Treatment,Self-Help,and 1-Year Outcomes in Substance Use Disorder Patients?

ABSTRACT

Rates of violence perpetration are high among patients with substance use disorder, but the impact of violence on substance use disorder treatment outcomes has received little attention. Patients with (n = 155) or without (n = 190) a history of difficulty controlling violent behavior were interviewed at entry to substance use disorder treatment and 1 year later. Substance use disorder severity, amount of treatment, and extent of participation in 12-step self-help groups were assessed to examine potential differences in treatment outcomes between violent and non-violent patients. After adjusting for baseline differences, no differences in substance use disorder severity were found at 1 year. However, over the year, violent patients received more treatment and participated more in 12-step groups compared to non-violent patients. In addition, violent patients benefited more from 12-step group participation than non-violent patients did. Referral to 12-step self-help groups may enhance the likelihood of recovery from a substance use disorder for patients with a history of violence.     

Coping and violence perpetration in a residential substance use disorder treatment sample

Background: Individuals in substance use disorder treatment report high rates of violence against partners and non-partners. There is growing interest in integrated coping-oriented treatment approaches for violence and substance use concerns, yet little is known about the relationship between specific coping responses and perpetration of partner and non-partner violence. Objective: This cross-sectional study evaluated relationships between coping responses and partner and non-partner physical assault perpetration in a substance use disorder treatment sample. Methods: Participants included 343 men (76%) and women (24%) who completed self-report survey measures of coping responses, violence perpetration, and substance use as part of screening for a randomized trial. Negative binomial regression was used to examine relationships between coping strategies and partner and non-partner violence perpetration, when accounting for substance use and demographic factors. Results: About one-third of participants reported partner violence perpetration (30%) and non-partner violence perpetration (34%). Frequency of partner violence and non-partner violence were both associated with more use of avoidant and emotion-focused strategies and less use of problem-focused coping in adjusted models. Discussion: Continued research is warranted to determine whether coping-oriented interventions decrease violence among people in substance use disorder treatment.     

Sex differences amongst dependent heroin users: Histories,clinical characteristics and predictors of other substance dependence

Introduction and aimsTo examine differences in the characteristics and histories of male and female dependent heroin users, and in the clinical characteristics associated with multiple substance dependence diagnoses.Design and methods1513 heroin dependent participants underwent an interview covering substance use and dependence, psychiatric history, child maltreatment, family background, adult violence and criminal history. Family background, demographic and clinical characteristics were analysed by sex. Ordinal regression was used to test for a relationship between number of substance dependence diagnoses and other clinical variables.ResultsWomen were more likely to experience most forms of child maltreatment, to first use heroin with a boyfriend or partner, to experience ongoing adult violence at the hands of a partner, and to have a poorer psychiatric history than men. Males had more prevalent lifetime substance dependence diagnoses and criminal histories and were more likely to meet the criteria for ASPD. Predictors of multiple substance dependence diagnoses for both sexes were mental health variables, antisocial behaviour, childhood sexual abuse, victim of adult violence, younger age at first cannabis use and overdose. As the number of dependence diagnoses increased, clinical and behavioural problems increased. Childhood emotional neglect was related to increasing dependence diagnoses for females but not males, whereas PTSD was a significant predictor for males but not females.Discussion and conclusionsMental health problems, other substance dependence, childhood and adult trauma were common in this sample, with sex differences indicating different treatment needs and possible different pathways to heroin dependence for men and women.     

Treatment of co-occurring alcohol dependence and perpetration of intimate partner violence: The role of anger expression

The purpose of the current study was to examine the role of high self-reported anger on violence and substance use across treatment. Seventy-three, alcohol-dependent males, with a domestic violence arrest within the past year, completed baseline anger measures and engaged in a 12 week cognitive behavioral therapy or 12 step facilitation group. Monthly assessments of substance use and violence were completed. At baseline, participants high on anger expression reported more physical violence in the prior month and more violent arrests. Participants high on anger expression had a greater proportion of positive breathalyzers across treatment, higher frequency of reported drug use across treatment, and higher reported frequency of verbal violence at discharge. These findings suggests that participants who are high on anger expression may need longer-term or more intensive treatments to maintain gains made during treatment because of the increased risk of relapse to both substance use and violence.     

Correlates of Intimate Partner Violence Among Men and Women in an Inner City Emergency Department

ABSTRACT

The current study surveyed medical or injured patients (men and women) in an inner city emergency department to examine the rates and correlates of intimate partner violence, including substance use patterns. Over a 2-year period, participants (n = 10,744) self-administered a computerized health survey during their emergency department visit that included screening items regarding past year history of intimate partner violence (including victimization and aggression). Overall, rates of any intimate partner violence involvement in past year were 8.7% (7.3% victimization and 4.4% aggression); however, women were more likely than men to report intimate partner violence. When examining participants' substance use patterns, participants who reported using both alcohol and cocaine were most likely to report intimate partner violence. Predictors of partner aggression and victimization were remarkably similar. This article provides unique data regarding correlates of past year intimate partner violence history among a comprehensive sample of male and female emergency department patients presenting for medical complaints or injury.     

Use of specialty substance abuse and mental health services in adults with substance use disorders in the community

AIMS: To examine the patterns and correlates of use of specialty substance abuse and mental health services among adults with alcohol or non-alcohol drug abuse or dependence in the community. METHODS: Analyses focused on 5,568 participants with alcohol or non-alcohol drug abuse or dependence drawn from a large representative cross-sectional survey of the US general population-the 2002 US National Survey on Drug Use and Health (NSDUH). RESULTS: Only 9.7% of adults with substance use disorders used specialty substance abuse services in the past year; 22.4% used mental health services. Severity of substance use disorder and less education were associated with using substance abuse services. Whereas psychological distress and impairment in role functioning due to psychological problems were associated with mental health service use. Male gender, black race/ethnicity, and lack of health insurance acted as barriers to using mental health services but not specialty substance abuse services. Past year use of substance abuse services, but not mental health services, was associated with lower likelihood of continued use of substances in the past month. CONCLUSIONS: Individuals with substance use disorders are more likely to use mental health services than specialty substance abuse services. However, only people who use specialty substance abuse services have a lower risk of continued use of substances. Findings highlight the need for integration of substance abuse treatments in the mental health care system and attention to different barriers to the two types of services.     

‘The great unmentionable’: Exploring the pleasures and benefits of ecstasy from the perspectives of drug users

There is limited evidence about the prevalence of mental illness and substance misuse comorbidity (comorbidity) and its current management. This hampers service development in the UK. We measured the prevalence of comorbidity in community mental health teams (CMHTs) and drug and alcohol services in four urban UK centres. We also described the patterns of comorbidity, assessed the health and social care needs of patients and described current management.

Among CMHT patients, 44% report past year problem drug use and/or harmful alcohol use. The majority of drug (74.5%) and alcohol patients (80.6%) had a past year psychiatric disorder. In each population most comorbid patients exhibit multiple disorders and have greater community care needs than non-comorbid patients. Comorbid status did not restrict access to interventions provided through the patient's allocated service, but joint management between services was uncommon.

Resources need to be deployed to enable substance misuse services to provide evidence-based interventions to a higher proportion of comorbid patients. The treatment need of comorbid CMHT patients are likely to be best met by mainstream mental health services. However, CMHTs need to develop these competencies through staff training and research into the effectiveness of novel interventions tailored to UK service contexts.     

What are the implications for clinical management and service development of prevalent comorbidity in UK mental health and substance misuse treatment populations?

There is limited evidence about the prevalence of mental illness and substance misuse comorbidity (comorbidity) and its current management. This hampers service development in the UK. We measured the prevalence of comorbidity in community mental health teams (CMHTs) and drug and alcohol services in four urban UK centres. We also described the patterns of comorbidity, assessed the health and social care needs of patients and described current management.

Among CMHT patients, 44% report past year problem drug use and/or harmful alcohol use. The majority of drug (74.5%) and alcohol patients (80.6%) had a past year psychiatric disorder. In each population most comorbid patients exhibit multiple disorders and have greater community care needs than non-comorbid patients. Comorbid status did not restrict access to interventions provided through the patient's allocated service, but joint management between services was uncommon.

Resources need to be deployed to enable substance misuse services to provide evidence-based interventions to a higher proportion of comorbid patients. The treatment need of comorbid CMHT patients are likely to be best met by mainstream mental health services. However, CMHTs need to develop these competencies through staff training and research into the effectiveness of novel interventions tailored to UK service contexts.