Perceived reasons for substance misuse among persons with a psychiatric disorder

The etiology of substance use among persons with severe mental illness remains unclear. This study investigates stated reasons for substance use among persons in recovery from co-occurring disorders of serious mental illness and substance abuse and dependence. The desire to fit in with peers played a key role in the initiation of substance use; boredom, loneliness, temptations to use, and stress were cited most as relapse triggers. The authors discuss the need for dually diagnosed persons to develop sobriety-supporting peer networks to help them learn adaptive strategies to deal with the stress of recovery; further, treatment programs should instill hope for recovery and provide opportunities for meaningful activities and relationships.     

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.     

Treatment for co-occurring mental and substance use disorders in five state Medicaid programs

OBJECTIVES: This study described the locations and patterns of psychiatric and substance abuse treatment for Medicaid beneficiaries with co-occurring mental and substance use disorders in five states. METHODS: Medicaid beneficiaries aged 21 to 65 with psychiatric or substance use disorders were identified with claims and encounter records. Groups were further divided into those with and those without a diagnosed substance use disorder. Adjusted odds of treatment in community-based settings, inpatient facilities, emergency departments, and hospital outpatient departments were calculated. RESULTS: A total of 92,355 persons had a psychiatric disorder, 34,158 had a substance use disorder, and 14,256 had co-occurring psychiatric and substance use disorders. In all five states, beneficiaries with severe mental illness (schizophrenia, bipolar disorder, or major depression) and a substance use disorder had higher odds of inpatient, emergency department, and hospital-based outpatient psychiatric treatment, compared with those with severe mental illness alone. In four of five states, both severe and less severe mental illness and a co-occurring substance use disorder were associated with lower odds of community-based treatment compared with those with the respective mental illness alone. Compared with those with less severe mental illness alone, individuals with less severe psychiatric disorders and a co-occurring substance use disorder had higher odds of inpatient treatment in all states and of emergency department use in three of five states. Odds of inpatient and outpatient hospital use and emergency department use for substance abuse treatment were higher for persons with severe mental illness and a co-occurring substance use disorder in most states, compared with odds for those with a substance use disorder alone. CONCLUSIONS: Heavy inpatient and emergency department use by Medicaid beneficiaries with co-occurring substance use disorders is a consistent cross-state problem. Co-occurring disorders may decrease the likelihood of community-based treatment for those with less severe mental disorders and for those with severe mental illness, suggesting that policies focusing only on these settings may miss a significant proportion of people with these co-occurring disorders.     

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.     

Supported employment for people with co-occurring disorders

Research shows that people with dual disorders (i.e., a co-occurring mental illness and substance use disorder) are successful in supported employment programs and that employment can be a crucial step in their recovery. Based on experience observing supported employment services for 15 years, we propose practice guidelines for people with dual disorders. Successful programs share several approaches: 1) encourage employment, 2) understand substance abuse as part of the vocational profile, 3) find a job that supports recovery, 4) help with money management, and 5) use a team approach to integrate mental health, substance abuse, and vocational services.     

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.     

Relapse of substance use disorder and its prevention among persons with co-occurring disorders

This article summarizes the scientific literature on the relapse process, describes the basic principles of relapse prevention treatment, highlights the major empirical studies, and offers suggestions for future research and application, especially in terms of ongoing care for persons with co-occurring disorders. Relapse prevention treatments have a well-established efficacy and effectiveness for persons with substance use disorders. Key ingredients include reducing exposure to substances, fostering motivation for abstinence, self-monitoring, recognizing and coping with cravings and negative affect, identifying thought processes with relapse potential, and deploying, if necessary, a crisis plan. Relapse prevention approaches may be best suited for persons in the action of maintenance stages of treatment or recovery. Further research is needed to examine relapse prevention therapies as a key component to continuing care for persons with co-occurring substance use and psychiatric disorders.     

Relationship between diabetes and mortality among persons with co-occurring psychotic and substance use disorders

OBJECTIVE: Individuals with diabetes and individuals with serious mental illness are more likely than the general population to die prematurely. The study examined the impact of diabetes on mortality among 197 individuals with co-occurring psychotic and substance use disorders who participated in a randomized controlled study of integrated mental health and substance abuse treatment. METHODS: The authors examined Medicaid claims for evidence of diabetes and applied survival analyses to examine whether time from study entry until death was different for individuals with and without evidence of diabetes. RESULTS: Of individuals with co-occurring psychotic and substance use disorders, 21% had evidence of diabetes. In a 12-year period, 41% of those with evidence of diabetes died compared with 10% of those without evidence of diabetes. CONCLUSIONS: Interventions targeted for diabetes prevention and diabetes management are critical for persons with serious mental illness, particularly among those who also abuse substances.     

Managing comorbid schizophrenia and substance abuse

Effective treatments for co-occurring schizophrenia and substance abuse have emerged over the past 15 years. They involve integration and melding of mental health and substance abuse treatments, helping people to acquire the skills and supports they need to manage both illnesses and to pursue functional goals, and a comprehensive, long-term approach to recovery. Further research is needed to refine specific interventions and to improve knowledge regarding implementing integrated treatment settings in routine mental health programs.     

Managing comorbid schizophrenia and substance abuse

Effective treatments for co-occurring schizophrenia and substance abuse have emerged over the past 15 years. They involve integration and melding of mental health and substance abuse treatments, helping people to acquire the skills and supports they need to manage both illnesses and to pursue functional goals, and a comprehensive, long-term approach to recovery. Further research is needed to refine specific interventions and to improve knowledge regarding implementing integrated treatment settings in routine mental health programs.     

A national survey of care for persons with co-occurring mental and substance use disorders

OBJECTIVE: The delivery of appropriate treatment to persons who have mental and substance use disorders is of increasing concern to clinicians, administrators, and policy makers. This study sought to describe use of appropriate mental health and comprehensive substance abuse care among adults in the United States with probable co-occurring disorders. METHODS: Data from the Healthcare for Communities survey, which is based on a national household sample studied in 1997 and 1998, were used to identify individuals who had probable co-occurring mental and substance use disorders. The sociodemographic and clinical characteristics of these individuals and their use of services were recorded. Logistic regression analysis was used to identify variables associated with receipt of mental health and substance abuse treatment and with receipt of appropriate treatment. RESULTS: Estimates for the U.S. adult population based on the weighted survey data indicated that 3 percent of the population had co-occurring disorders. Seventy-two percent did not receive any specialty mental health or substance abuse treatment in the previous 12 months; only 8 percent received both specialty mental health care and specialty substance abuse treatment. Only 23 percent received appropriate mental health care, and 9 percent received supplemental substance abuse treatment. Perceived need for treatment was strongly associated with receipt of any mental health care and with receipt of appropriate care. CONCLUSIONS: Despite the availability of effective treatments, most individuals who had co-occurring mental health and substance use problems were not receiving effective treatment. Efforts to improve the care provided to persons who have co-occurring disorders should focus on strategies that increase the delivery of effective treatment.     

Violent victimization of persons with co-occurring psychiatric and substance use disorders

OBJECTIVE: This study examined the frequency with which persons in the community with psychiatric disorders, substance use disorders, and both types of disorders are victims of violence. METHODS: The relationship between diagnosis, gender, and victimization over a one-year period was examined in two cross-sectional data sets, one drawn from a study of adaptation to community life of persons with severe mental illness in Connecticut (N=109) and the other drawn from assessments made by caseworkers in a Connecticut outreach project for persons with psychiatric and substance use disorders (N=197). Analysis of variance was used to evaluate the frequency of victimization across diagnostic categories in each data set. RESULTS: People with co-occurring psychiatric and substance use disorders had significantly more episodes of victimization than those with either a psychiatric or a substance use disorder only. Gender was not associated with victimization. Qualitative data from focus groups indicated that social isolation and cognitive deficits leading to poor judgment about whom to trust may leave people with serious mental illness vulnerable to drug dealers. CONCLUSIONS: Social environmental mechanisms, such as exploitation by drug dealers, may play an important role in maintaining victimization among persons with co-occurring disorders.     

Substance abuse and the transmission of hepatitis C among persons with severe mental illness

OBJECTIVES: The authors sought to better understand the relationship of substance abuse to higher rates of transmission of hepatitis C among persons with severe mental illness. METHOD:S: The authors assessed 668 persons with severe mental illness for HIV, hepatitis B, and hepatitis C infection through venipuncture. Demographic characteristics, substance abuse, and risk behaviors for blood-borne infections were assessed through interviews and collection of clinical data. RESULTS: Eighty-two percent of the assessed persons were not infected, and 18 percent had hepatitis C. Among those with hepatitis C infection, 546 (82 percent) tested negative for all viruses. Of the 122 (18 percent) who had hepatitis C, 53 (8 percent) had only hepatitis C, 56 (8 percent) had both hepatitis C and hepatitis B, three (1 percent) had hepatitis C and HIV, and ten (2 percent) had all three infections. More than 20 percent of the sample reported lifetime intravenous drug use, and 14 percent reported lifetime needle sharing. Fifty-seven percent had sniffed of snorted cocaine, and 39 percent had smoked crack. A stepwise regression model was used to identify interaction effects of these behaviors and risk of hepatitis C infection among persons with severe mental illness. Use of needles and of crack cocaine were associated with a large increase in the likelihood of hepatitis C infection. CONCLUSION:S: The high rates of co-occurring substance use disorders among persons with severe mental illness, coupled with the role of substance abuse as the primary vector for hepatitis C transmission, warrants special consideration.     

Mixing Oil and Water: Integrating Mental Health and Addiction Services to Treat People with a Co-occurring Disorder

Treatments for people with the co-occurring disorders of mental illness and substance use (abuse or dependence) have been evolving and improving since the mid 1980s. During this period substance abuse treatment programs reported between 50 and 75% of the people they served also had a mental health problem. At the same time, mental health programs reported between 20 and 50% of the people they served had a co-occurring problem of substance use or abuse. The proposed solution is to integrate the two treatment systems so as to treat both disorders at the same time. During the 1990s integrated treatment was proposed and several models of integrated care were evaluated. The fallacy of these conceptualizations is that the authors of these models presume that the numerous treatment interventions from both treatment traditions are compatible. This is a critical assumption. What if the two are not compatible? Rather than integrate the two systems of mental health and addiction treatment in whole, I would argue, a model is needed that selects the best interventions from each field and discard the rest. Suggestions are presented here for a beginning inventory of best practice interventions that could be the foundation for effectively treating people with co-occurring disorders.     

Integrating Cognitive Neuroscience Research and Cognitive Behavioral Treatment with Neurofeedback Therapy in Drug Addiction Comorbid with Posttraumatic Stress Disorder: A Conceptual Review

ABSTRACT

Persons with co-occurring mental and substance use disorders have a more persistent and refractory illness course than those without dual diagnosis. However, few studies have assessed the effects of cognitive-behavioral and biobehavioral treatments on brain function and behavioral indices in people with comorbid drug abuse and posttraumatic stress disorder (PTSD). In this conceptual review, we propose an integrated approach to assessment and treatment utilizing cognitive neuroscience methods, conventional psychotherapeutic treatment and neurofeedback therapy to assess the recovery of cognitive and emotional functions affected by chronic psychostimulant drug abuse co-occurring with PTSD. We review cognitive and motivational factors (e.g., craving, hypersensitivity to drug- and threat-related cues, deficient executive top-down control etc.) involved in addiction and PTSD, and discuss reasons for their persistence and high vulnerability to relapse in cocaine and methamphetamine users with co-morbid PTSD undergoing behavioral treatment. Incorporating neuroscience assessment methods to assess the effects of psychotherapy and neurofeedback interventions for comorbid disorders may provide significant potential for identifying side-by-side psychophysiological with clinical markers of treatment progress, and may also provide useful information for planning interventions.     

A SAMHSA research initiative assessing the effectiveness of jail diversion programs for mentally ill persons

For nearly 30 years jail diversion programs have had wide support as a way to prevent people with mental illnesses and substance use disorders from unnecessarily entering the criminal justice system by providing more appropriate community-based treatment. Although these programs have had wide support, very few systematic outcomes studies have examined their effectiveness. This paper discusses findings on rates of incarceration of persons with serious mental illness and co-occurring substance use disorders in U.S. jails, summarizes recently completed research on jail diversion programs, and describes a three-year research initiative begun in 1997 by the Substance Abuse and Mental Health Services Administration that uses a standardized protocol to examine the characteristics and outcomes of various types of jail diversion programs in nine sites throughout the U.S.     

Family support and substance use outcomes for persons with mental illness and substance use disorders

This paper explores the relationship between direct support from family members and friends and substance use outcomes for people with co-occurring severe mental illness and substance use disorders. Data are from a 3-year randomized trial of 203 patients in treatment for dual disorders. Informal (family) caregivers for 174 participants were asked about economic assistance and direct care that they provided to participants. Associations between family support and substance use outcomes were examined with bivariate comparisons of abstainers and nonabstainers and with regression models using change in substance use and cumulative substance use as dependent measures. Family economic support was associated with substance abuse recovery in bivariate and regression analyses. Caregiving hours were significantly associated with substance use reduction but not with cumulative substance use. Informal support was not associated with changes in psychiatric symptoms. The findings suggest that direct family support may help people with dual disorders to reduce or eliminate their substance use. Further research is needed to confirm this connection and to establish the mechanisms by which support is useful.     

Cigarette smoking and overweight/obesity among individuals with serious mental illnesses: a preventive perspective

BACKGROUND: Cigarette smoking and lifestyle factors underlying overweight/obesity (such as unhealthy diet and physical inactivity) appear to play a major role in the excess medical morbidity and mortality among persons with serious mental illnesses. The literature on the prevalence, etiology, prevention, and treatment of these two risk factors, in the context of serious mental illnesses, are reviewed following a preventive approach. METHODS: The review relied upon searches of the MEDLINE database, from 1996 through April 2006, restricted to the English language. Original research, review articles, and clinical guidelines relevant to the topics of cigarette smoking, unhealthy diet, physical inactivity, and overweight/obesity among individuals with serious mental illnesses were identified. RESULTS: Compared to those without a mental illness, individuals with a current mental illness are more than twice as likely to smoke cigarettes and more than 50% more likely to be overweight/obese, presumably the product of unhealthy diet and physical inactivity. Various biological, iatrogenic, and social factors place psychiatric patients at risk for these and other adverse health behaviors. Studies suggest that many of the same preventive approaches developed for general medical populations are likely to be effective in persons with serious mental disorders, though specialized approaches also are needed. Domains of prevention include primary prevention (population-based strategies to reduce the incidence of these adverse health behaviors), secondary prevention (early detection and treatment), and tertiary prevention (pharmacological and psychosocial treatments to reduce the burden of illness among those with the behaviors in question). However, mental health clinicians commonly lack the training or expertise to provide these services. CONCLUSIONS: The high prevalence, adverse effects, and efficaciousness of treatments for smoking and obesity in persons with serious mental illnesses suggest the importance of addressing these problems in this population. Both further research and dissemination efforts are needed to ensure that patients with serious mental illnesses receive the appropriate preventive and clinical services for these two adverse health conditions.     

Risk reconsidered: targets of violence in the social networks of people with serious psychiatric disorders

Risk Reconsidered: Targets of violence in the Social Networks of People with Serious Mental illness. This exploratory analysis addresses the questions: 1) Who among the members of the social network of a person diagnosed with a major psychiatric disorder is likely to become a target of violence?; 2) What kind of relationships do targets have with respondents in terms of the quality and quantity of interactions?, and 3) What are the risk factors that contribute to being a target of violence for people who are in the social networks of persons with serious mental disorders? The samples of 169 people with serious mental disorders were followed for 30 months. A logistic regression model of the risk for being a target of violence among the members of the cohort's social network reveals that both target and respondent characteristics are salient, and that mothers who live with adult children who have schizophrenia and co-occurring substance abuse bear a substantially elevated risk of becoming a target of violence, compared to other social network members. Other factors that elevate the risk for being a target of violence are being an immediate family members of the respondent, more time in residence with the respondent, and whether the respondent is financially dependent on the family. Respondents with the most mental health center visits had lower odds of committing an act or threat of violence against a social network member.