Psychosocial aspects of substance abuse by clients with severe mental illness

As the literature on co-occurring substance abuse in persons with severe mental illnesses has evolved, emphasis on biologic and pharmacologic factors has diverted attention from important psychosocial issues. The authors review recent research showing that a) psychosocial risk factors may explain consistently high rates of substance abuse by these persons, b) substance abuse is for most clients a socio-environmental phenomenon embedded in interpersonal activities, and c) both natural recovery processes and effective treatments rely on developing new relationships, activities, coping strategies, and identities. Thus, psychosocial issues are critical in our attempts to understand and address substance abuse in this population.     

Substance abuse relapse in a ten-year prospective follow-up of clients with mental and substance use disorders

OBJECTIVES: This study addressed the rate and predictors of substance abuse relapse among clients with severe mental illness who had attained full remission from substance abuse. METHODS: In a ten-year prospective follow-up study of clients with co-occurring severe mental and substance use disorders, 169 clients who had attained full remission, defined according to DSM-III-R as at least six months without evidence of abuse or dependence, were identified. The Kaplan-Meier survival curve was developed to show the pattern of relapse, and a discrete-time survival analysis was used to identify predictors of relapse. RESULTS: Approximately one-third of clients who were in full remission relapsed in the first year, and two-thirds relapsed over the full follow-up period. Predictors of relapse included male sex, less than a high school education, living independently, and lack of continued substance abuse treatment. CONCLUSIONS: After attaining full remission, clients with severe mental disorders continue to be at risk of substance abuse relapse for many years. Relapse prevention efforts should concentrate on helping clients to continue with substance abuse treatment as well as on developing housing programs that promote recovery.     

Effectiveness of cognitive-behavioral trauma treatment for incarcerated women with mental illnesses and substance abuse disorders

An open trial design was used to examine the implementation and effectiveness of a cognitive-behavioral intervention (Seeking Safety) for comorbid post-traumatic stress disorder (PTSD) and substance use disorder (SUD) for incarcerated women with Axis I mental disorders who self-referred for specialty trauma treatment. The study sample was female inmates aged 18 and old who were primarily minority, had experienced childhood-based trauma, committed violent crimes, had a serious mental illness, and resided in maximum, medium, and minimum compounds of a women's prison. A total of 74 women completed the group intervention, with the average attending 23 of the 28 sessions (82%). Implementation feasibility was demonstrated by the ability to recruit, screen, assign, and retain participation. Effectiveness was supported by changes pre-post intervention on the PTSD Checklist (ES=0.56) and Global Severity Index (ES=0.47). Of the 19 completers with PCL scores of 50 or higher pre-intervention, 16 (84%) had scores below 50, the "cut score" consistent with or supportive of a PTSD diagnosis. Three-quarters or more of participants reported that Seeking Safety was helpful in each of the following areas: overall, for traumatic stress symptoms, for substance use, to focus on safety, and to learn safe coping skills. Future directions include the need for larger scale randomized controlled trials in medium or maximum security prisons and fidelity evaluations of non-research dissemination efforts.     

Responding to the threat of HIV among persons with mental illness and substance abuse

PURPOSE OF REVIEW: This article discusses current knowledge regarding the threat of HIV among persons with mental illness and substance abuse, and strategies for reducing this threat. It contains a review of the prevalence and consequences of dual/triple diagnosis, HIV risk behaviour and current HIV risk-reduction interventions among persons with dual diagnosis and interventions for triply diagnosed individuals. RECENT FINDINGS: Many persons with dual diagnosis remain undetected and there is a high prevalence of sexual risk behaviours among persons with dual diagnosis. Case management and supportive housing programmes are feasible options for the delivery of HIV risk-reduction interventions among such patients, and the adaptation of integrated behavioural treatment interventions can improve behavioural and healthcare utilization outcomes. SUMMARY: The developing world continues to see an escalation in HIV incidence. A more complete understanding of mental health, substance use and HIV serostatus interactions is needed to serve vulnerable populations. Mental health status not only mediates HIV risk behaviours, but positive serostatus has various effects on mental health. Co-morbid substance abuse is common among HIV-positive individuals with mental illness, resulting in serious adverse effects. Separate services for individuals with co-occurring substance abuse are less effective than integrated treatment programmes.     

Future directions in substance dependence research

Substance dependence is a major health problem but increasing understanding of its neurobiology is likely to lead to improved prevention and treatment. Fundamental aspects of dependence include tolerance and withdrawal and the fact that the drug becomes the centre of the addict's world. Neuroimaging has been key in defining underlying neurobiological mechanisms. The activity in particular brain regions has been shown to be altered in addiction. These include the anterior cingulate which is involved in emotional salience and the orbitofrontal cortex, involved in impulse control. Dopamine is the key neurotransmitter since most abused drugs increase its levels, and many pharmacotherapies have targeted this system. The opiate system is also key in mediating the pleasurable effects of some drugs such as alcohol by increasing dopamine levels. The GABA and glutamate systems mediate many of the other effects of alcohol. As the neurobiology of different components of addiction become evident, pharmacological approaches involve exploiting our new understanding which will likely lead to improved treatments.     

A review of treatments for people with severe mental illnesses and co-occurring substance use disorders

Several interventions for people with co-occurring severe mental illnesses and substance use disorders have emerged since the early 1980s. This paper reviews 26 controlled studies of psychosocial interventions published or reported in the last 10 years (1994-2003). Though most studies have methodological weaknesses, the cumulative evidence from experimental and quasi-experimental research supports integrating outpatient mental health and substance abuse treatments into a single, cohesive package. Effective treatments are also individualized to address personal factors and stage of motivation, e.g., engaging people in services, helping them to develop motivation, and helping them to develop skills and supports for recovery. Accumulating evidence from quasi-experimental studies also suggests that integrated residential treatment, especially long-term (one year or more) treatment, is helpful for individuals who do not respond to outpatient dual disorders interventions. Current research aims to refine and test individual components and combinations of integrated treatments.     

Administrative challenges to working with HIV-positive clients: experiences of mental health and substance abuse program directors in Florida.

Administrators of publicly-funded mental health and substance abuse programs described their agencies' activities, policy development, the administrative impediments, and training needs related to caring for HIV-infected clients. Almost all have served HIV-infected clients and admit clients to their programs regardless of HIV status. The administrators reported little staff opposition to working with this clientele. Liability and confidentiality concerning testing and client/staff safety were major concerns. The difficulty of providing needed medical care and the expense of treating such clients were also viewed as major impediments to service delivery. The most critical training needs were for mental health interventions related to death and dying, grief counseling, and neuropsychological complications, as well as for policy and procedure development concerning legal and ethical issues.     

Qualitative interviews on substance abuse relapse and prevention among female trauma survivors

OBJECTIVE: Complex relationships among trauma, substance abuse, and mental disorders raise significant questions for the study of long-term recovery. The purpose of this qualitative study was to examine key themes in sustaining recovery among women with co-occurring disorders who had survived trauma. METHODS: In semistructured interviews conducted at one of the nine sites of the Women, Co-occurring Disorders, and Violence Study, 27 female trauma survivors described the influences they considered most important in sustaining and hindering their recovery, with an emphasis on recovery from substance abuse. Recurring themes in the interviews were identified. RESULTS: Seven themes emerged from this analysis. Four of these themes supported recovery: connection, self-awareness, a sense of purpose and meaning, and spirituality. Three others served as obstacles to recovery: battles with depression and despair, destructive habits and patterns, and lack of personal control. The women in this study reported that, although caring relationships provided important supports for sustained recovery, some of these same relationships increased emotional stress and conflict and thus may impede recovery. CONCLUSIONS: It is important for women and clinicians to place a high priority on the development of boundary management and other relationship skills. In addition, clinicians need to attend to negative feelings such as boredom and loneliness and to help women develop a range of meaningful activities that are consistent with a strong sense of identity. Individual relapse prevention skills by themselves seem insufficient to sustained abstinence.     

Medicaid eligibility and access to mental health services among adolescents in substance abuse treatment

OBJECTIVE: The co-occurrence of a mental disorder is common among adolescents who present for substance abuse treatment. This study was conducted to determine whether Medicaid eligibility was associated with greater use of mental health services. METHODS: The study used administrative data for 25,813 adolescents in Oregon. Propensity score analysis was used to assess the likelihood that the adolescents would use mental health services, with group differences and mental health need controlled for. RESULTS: Medicaid-eligible youths were nearly five times as likely to receive mental health services in the year they entered substance abuse treatment compared with non-Medicaid-eligible youths. In both groups, there was evidence of racial disparities as well as factors such as foster care that may facilitate access. CONCLUSIONS: The fact that Medicaid-eligible youths have greater access to mental health services should be considered in both state policies and research design. States considering ways to better serve adolescents with co-occurring disorders would do well to examine ways to promote Medicaid enrollment or expand eligibility.     

New directions for treatment research on sequelae of sexual abuse in persons with severe mental illness

Sexual abuse in childhood is increasingly recognized as an important etiologic component in a number of psychiatric disorders. One-quarter to one-third of all female children suffer sexual abuse before their eighteenth birthday, and at least one half of women with severe mental illness acknowledge such events. An even higher percentage of a particularly vulnerable group, dually diagnosed homeless women, appear to have a premorbid history of childhood victimization. In this paper, we review the emergent literature on childhood abuse, its sequelae and treatment; and discuss the implications of these data for the development of new approaches to trauma recovery in people with severe mental illness.Preparation of this article was supported in part by National institute of Mental Health Grant MH00839 to Robert Drake.     

Improving employment outcomes for persons with severe mental illnesses

BACKGROUND: Unemployment remains a major consequence of schizophrenia and other severe mental illnesses. This study assesses the effectiveness of the Individual Placement and Support model of supportive employment relative to usual psychosocial rehabilitation services for improving employment among inner-city patients with these disorders. METHODS: Two hundred nineteen outpatients with severe mental illnesses, 75% with chronic psychoses, from an inner-city catchment area were randomly assigned to either the Individual Placement and Support program or a comparison psychosocial rehabilitation program. Participants completed a battery of assessments at study enrollment and every 6 months for 2 years. Employment data, including details about each job, were collected weekly. RESULTS: Individual Placement and Support program participants were more likely than the comparison patients to work (42% vs 11%; P<.001; odds ratio, 5.58) and to be employed competitively (27% vs 7%; P<.001; odds ratio, 5.58). Employment effects were associated with significant differences in cumulative hours worked (t(211) = -5.0, P =.00000003) and wages earned (t = -5.5, P =.00000003). Among those who achieved employment, however, there were no group differences in time to first job or in number or length of jobs held. Also, both groups experienced difficulties with job retention. CONCLUSIONS: As hypothesized, the Individual Placement and Support program was more effective than the psychosocial rehabilitation program in helping patients achieve employment goals. Achieving job retention remains a challenge with both interventions.     

A clinical trial comparing interviewer and computer-assisted assessment among clients with severe mental illness

OBJECTIVE: Demographic, behavioral, and diagnostic information should routinely be collected from clients with severe mental illness, and data gathering should employ the most efficient techniques available. Surveys are increasingly conducted via Web-based computer-assisted interviewing (CAI), but this technique is not well validated for patients with severe mental illness. A randomized clinical trial of 245 clients was carried out to compare face-to face and computer-assisted interviewing (233 clients completed two surveys). METHODS: Self-report data were collected on demographic characteristics, substance abuse, risk behaviors for blood-borne diseases, trauma history, and posttraumatic stress disorder. Each client was assessed twice and randomly assigned to one of the four possible combinations of interviewer and computer (computer and computer, N=53; computer and interviewer, N=56; interviewer and computer, N=59; and interviewer and interviewer, N=65). The two formats were compared on feasibility, client preference, cost, reliability, convergent validity, and criterion validity. RESULTS: This study demonstrated the feasibility of CAI across a variety of inpatient and outpatient settings. All participants who began the CAI process completed the interview and responded to over 95% of the survey items. Participants liked using the computers as well as they liked face-to-face interviews, and they completed the CAI as quickly. CAI produced data as reliable and valid as face-to-face interviews produced and was less expensive, and results were available more quickly. The two formats were similar in criterion validity. CONCLUSIONS: CAI appears to be a viable technology for gathering clinical data from the population with severe mental illness and for transforming such information into a useful, quickly accessible form to aid in clinical decision making.     

Implementing evidence-based practices for persons with severe mental illnesses

Extensive empirical research, summarized in several reviews and codified in practice guidelines, recommendations, and algorithms, demonstrates that several pharmacological and psychosocial interventions are effective in improving the lives of persons with severe mental illnesses. Yet the practices validated by research are not widely offered in routine mental health practice settings. As part of an effort to promote the implementation of evidence-based practice, the authors summarize perspectives on how best to change and sustain effective practice from the research literature and from the experiences of administrators, clinicians, family advocates, and services researchers. They describe an implementation plan for evidence-based practices based on the use of toolkits to promote the consistent delivery of such practices. The toolkits will include integrated written material, Web-based resources, training experiences, and consultation opportunities. Special materials will address the concerns of mental health authorities (funders), administrators of provider organizations, clinicians, and consumers and their families.     

Vocational rehabilitation for subjects with severe mental illnesses in Germany

Objective  To assess the longitudinal effectiveness of a comprehensive vocational rehabilitation program in Germany. Methods  In a non-randomized open study, 106 participants of two comprehensive rehabilitation programs were prospectively and multidimensionally compared to a control group (n = 75) at program termination and at a 9 months follow-up. Primary outcome was employment status at 9 months follow-up, secondary outcome parameters were changes in symptoms (Positive and Negative Syndrome Scale), subjective well-being (WHOQOL-Bref), and level of functioning (Level of Functioning Scale) during the study. Results  Regarding the primary outcome measure, there was significant more day structuring employment (mainly sheltered) in the rehabilitation group than in the comparison group (39.7 vs. 18.7%) at 9 months follow-up. Regarding secondary outcomes, rehabilitation participants showed a better course in general symptoms, subjective well-being and level of functioning. Conclusion  Vocational services proved to be effective to find day structuring employment for subjects with severe mental illness. Furthermore it had positive effects on functioning and psychological well-being during a 9-months follow-up period.