Follow-Up Contact Bias in Evaluation of Substance Abuse Treatment Programs

This study examined the problem of follow-up contact bias in evaluation of substance abuse treatment programs using administrative data sets. Completed discharges in Iowa were compared to clients contacted 6 months after treatment. The percent of clients reporting no substance use doubled between admission to treatment and follow-up. Unemployment, arrests, and number of days of work or school missed declined. However, clients included in the follow-up sample were significantly different in terms of risk factors for adverse outcomes. The authors conclude that improvements in social functioning 6 months after discharge cannot be generalized to the entire population of clients treated, since those not found have a different combination of risk factors.     

Substance abuse and personality disorders in homeless drop-in center clients: symptom severity and psychotherapy retention in a randomized clinical trial

This study evaluated the psychiatric symptoms, psychosocial problems, and treatment response of personality-disordered substance abusers receiving services within a homeless drop-in center. Fifty-two homeless clients were assessed after program admission and randomly assigned to receive either individual psychotherapy focused on personality disorder and substance abuse relapse prevention (dual-focus schema therapy [DFST]) or standard group substance abuse counseling (SAC). Client functioning was assessed using measures of personality disorder, psychiatric symptoms, early maladaptive schemas, interpersonal problems, and addiction-related psychosocial impairment. Therapy retention (total weeks in treatment) and utilization (number of weeks in which sessions were attended) were the primary outcomes. Although rates of cluster B personality disorders were comparable to other substance dependent samples, clusters A and C disorders were disproportionately more common. Clients reported significant psychiatric symptoms, criminality, and psychosocial impairment, yet made limited lifetime use of mental health services. Overall, there was greater utilization of individual DFST than group SAC. However, clients with more severe personality disorder symptoms demonstrated better utilization of SAC than DFST.     

Explaining lifetime criminal arrests among clients of a psychiatric probation and parole service.

This study examines the extent to which sociodemographic characteristics, clinical characteristics, substance abuse problems, and the array of lifetime criminal behavior may explain lifetime arrests among offenders supervised by the psychiatric probation and parole service. Three hundred twenty-five clients with new cases at a psychiatric probation and parole service in a large urban center were screened for major psychiatric disorders. They were also interviewed for socio-demographic characteristics, mental health treatment history, criminal behavior, and arrest history. Hierarchical block multiple regression analysis tested a model explaining lifetime arrests. After controlling for age and other demographic variables, the number of lifetime psychiatric hospitalizations and lifetime occurrences of mania diagnosis significantly explained lifetime arrests. The total model explained about 10 percent of the variance in lifetime arrests after controlling for opportunity variables, which explained 45 percent. The explanatory power of lifetime hospitalizations and mania support the contention that symptoms, rather than diagnosis, may be the most important clinical factor in explaining criminal arrest among persons with mental illness. Implications for psychiatric services include the development of effective jail diversion programs.     

Comorbidity training needs at a state psychiatric hospital

This study explored training issues relevant to work with comorbid clients (those with both psychiatric and substance abuse diagnoses) among members of a psychiatric hospital clinical staff (N=147). Respondents reported that they had received limited training for working with comorbid or substance abusing clients; they perceived comorbid clients as presenting with particular concerns, especially regarding referral to treatment services and management of acting-out behaviors; and they attached great importance to the need for training in comorbidity. With high proportions of clients at psychiatric hospitals being comorbid, it is imperative that staff members receive training to deal with substance abuse and comorbidity. These results suggest that such training has not been available, but it is needed and wanted.     

Prevalence of Primary Methamphetamine-Related Cases and Treatment-Centre Preparedness Among Youth Outpatient Substance Abuse Treatment Centres in British Columbia, Canada

Adolescent methamphetamine use is a prominent concern for Canadian media and government. Few empirical studies, however, have established the scope of adolescent methamphetamine use or associated outpatient substance abuse treatment utilization. The current study aimed to answer the following questions: (1) What was the overall proportion of primary methamphetamine-related cases seen at youth outpatient substance abuse treatment centres in British Columbia in 2005–2006?; (2) What kind of treatment programming did these treatment centres offer primary methamphetamine users?; and (3) How prepared were these treatment programs to provide services to primary methamphetamine users? We developed a comprehensive list of all sites offering outpatient substance-abuse treatment programs for youth in British Columbia. We asked the Executive Director (or designate) of each facility about the program’s annual caseload, proportion of primary methamphetamine-related cases, treatment approach, and preparedness to provide effective treatment for methamphetamine users. Responses were received from 68 of the 80 centres on our final master list. Approximately 11% (780/6,840) of all cases at the sites were due primarily to methamphetamine use. The proportion of primary methamphetamine-related cases varied widely across sites in B.C., with contacted centres reporting between 0–65% of their caseload in 2005–2006 as primarily methamphetamine-related. Almost all facilities integrated primary-methamphetamine users into treatment-as-usual, and few centres (12%) felt inadequately prepared to offer treatment for methamphetamine users. The current study found a substantial proportion of all cases seen at youth outpatient substance abuse treatment centres in British Columbia in 2005–2006 were primarily due to methamphetamine misuse. While most treatment sites integrated youth methamphetamine users into regular treatment programming and few treatment directors indicated that their programs were inadequately prepared to offer treatment services to methamphetamine-using clients, more evidence is needed to ascertain the most effective treatment strategies for methamphetamine users.     

Young chronic patients and substance abuse

The prevalence of substance abuse was investigated in 100 young chronic patients consecutively admitted to a long-term private psychiatric hospital. Data were obtained from diagnostic research interviews with each subject at admission. Half of the subjects had concurrent diagnoses of psychiatric disorder and substance abuse. One-third of the dual-diagnosis patients began using substances before the onset of a diagnosable psychiatric disorder, and they more often had a diagnosis of schizophrenia. Half of the dual-diagnosis patients abused three or more drugs. Implications of the findings for treatment and community management of dual-diagnosis patients are discussed.     

Remission of psychiatric symptoms among drug misusers after drug dependence treatment

The study investigates changes in psychiatric symptoms after drug dependence treatment, and relationships between pretreatment problems, illicit drug use, treatment retention, and changes in psychiatric symptoms. The sample comprised 662 drug-dependent adults recruited at admission to treatment in residential rehabilitation programs (15 agencies) or outpatient methadone treatment (16 methadone maintenance programs and 15 methadone reduction programs). Using a longitudinal, prospective cohort design, data were collected by structured interviews at intake to treatment and at 1-month and 6-month follow-ups. Reductions were found in a range of psychiatric symptoms after admission to drug dependence treatment and among patients treated in outpatient and in residential programs. These reductions occurred rapidly (during the first month) and were maintained at subsequent follow-up. At intake to treatment, 39% of the residential sample met criteria for psychiatric caseness. This figure dropped to 3% at both 1-month and 6-month follow-up. Among methadone patients, 15% met criteria for psychiatric caseness at intake, and this dropped to 5% at 1 month and 3% at 6 months. Improvement in psychiatric symptoms was positively related to treatment retention. Some of the psychiatric symptoms presented by drug-dependent patients at admission to treatment are associated with drug misuse and show rapid remission after substance misuse treatment.     

Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study.

OBJECTIVE: The study examined the association between fidelity of programs to the assertive community treatment model and client outcomes in dual disorders programs. METHODS: Assertive community treatment programs in the New Hampshire dual disorders study were classified as low-fidelity programs (three programs) or high-fidelity programs (four programs) based on extensive longitudinal process data. The study included 87 clients with a dual diagnosis of severe mental illness and a comorbid substance use disorder. Sixty-one clients were in the high-fidelity programs, and 26 were in the low-fidelity programs. Client outcomes were examined in the domains of substance abuse, housing, psychiatric symptoms, functional status, and quality of life, based on interviews conducted every six months for three years. RESULTS: Clients in the high-fidelity assertive community treatment programs showed greater reductions in alcohol and drug use and attained higher rates of remission from substance use disorders than clients in the low-fidelity programs. Clients in high-fidelity programs had higher rates of retention in treatment and fewer hospital admissions than those in low-fidelity programs. No differences between groups were found in length of hospital stays and other residential measures, psychiatric symptoms, family and social relations, satisfaction with services, and overall life satisfaction. CONCLUSIONS: Faithful implementation of, and adherence to, the assertive community treatment model for persons with dual disorders was associated with superior outcomes in the substance use domain. The findings underscore the value of measures of model fidelity, and they suggest that local modifications of the assertive community treatment model or failure to comply with it may jeopardize program success.     

Predictors of retention in dual-focus self-help groups

Attendance at 12-step groups has been found useful in maintaining abstinence from substance use; many members disengage early, missing out on potential benefits. New 12-step based groups have emerged to address the recovery needs of the many substance users with psychiatric comorbidity. Little is known about factors associated with retention in 12-step, especially in this population. This study sought to identify predictors of retention over a one-year period among members of a dual-focus 12-Step fellowship (N = 276). Using multivariate analysis, the following baseline characteristics were associated with greater retention one year later: older age, more lifetime arrests, abstinence in the pre-baseline year, more psychiatric symptoms in the pre-baseline year, not taking psychiatric medication, being more troubled by substance abuse than by mental health, and greater level of self-efficacy for recovery; residing in supported housing and being enrolled in outpatient treatment at follow-up were also significantly associated with better retention. Clinical implications to enhance retention in specialized 12-step groups are discussed.     

The availability of psychiatric programs in private substance abuse treatment centers, 1995 to 2001

OBJECTIVE: The high rate of co-occurrence of substance abuse and mental disorders renders the availability of psychiatric programs, or integrated service delivery, a vital quality-of-care issue for substance abuse clients. This article describes the availability of psychiatric programs and integrated care for clients with severe mental illness in the private substance abuse treatment sector and examines these patterns of service delivery by profit status and hospital status. METHOD:S: Survey data from the National Treatment Center Study, which is based on a nationally representative sample of privately funded substance abuse treatment centers, were used to identify the proportion of centers that offered psychiatric programs in 1995-1996, 1997-1998, and 2000-2001. Centers reported whether they treated clients with severe mental illness on-site or referred them to external providers. Repeated-measures general linear models were used to test for significant changes over time and to assess mean differences in service availability by profit status and hospital status. RESULTS: About 59 percent of private centers offered a psychiatric program, and this proportion did not significantly change over time. The proportion of centers that referred clients with severe mental illness to external providers increased significantly from 57 percent to 67 percent. For-profit centers and hospital-based centers were significantly more likely to offer psychiatric programs and were less likely to refer severe cases to other providers. CONCLUSION:S: Although the importance of integrated care for clients with dual diagnoses is widely accepted, data from the private substance abuse treatment sector suggest that this pattern of service delivery is becoming less available.     

Severely mentally ill substance abusers: an 18-month follow-up study

  Background: The aims of this study were to investigate initial characteristics and improvement after 18 months in patients with comorbidity of severe mental illness and substance dependence. These patients took part in a multicentre study aimed at improving co-operation between psychiatric health care units and social services. Methods: A total of 358 patients, 66% men, were included. There were four diagnostic subgroups: psychosis 29%, depression 17%, borderline personality disorder 23%, and other diagnoses of equal severity 31%. Initially and at follow-up the following measurements were used: global functioning axis V DSM-III-R (GAF), seven areas of Addiction Severity Index (ASI) and psychological symptoms (SCL-90). The outcome of substance use during the past 6 months was estimated by the Clinical Rating Scale (CRS). Results: Most patients were single (77%) and few (10%) had income from employment. Many (61%) had made suicide attempts, and 52% had somatic diseases before entering this project. After 18 months, 14 patients (3.9%) had died, and 288 patients (84%) could be interviewed. There were significant improvements in all but one ASI area (employment), in psychological symptoms and in global functioning. There was a positive correlation between the reductions in severity of alcohol abuse, drug abuse, psychiatric symptoms, relationships (ASI) and psychological symptoms. Forty-eight percent of patients with mainly alcohol-related problems, and 57% of those with mainly drug-related problems were either “abstinent” or using drugs “without impairment” (CRS) after 18 months. Improvement did not differ between psychiatric subgroups. Conclusion: These patients have weak social integration. Alcohol dependence was the most common substance use disorder. In most areas investigated, patients had improved. No substance abuse was found in half of the patients at follow-up. Accepted: 24 October 2000     

The rise in methamphetamine use among American Indians in Los Angeles County

A preliminary review of substance abuse treatment admission data from 2001-2005 was conducted to explore the use of methamphetamine among American Indians in treatment programs funded by Los Angeles County. Comparisons were made between primary methamphetamine users and users whose primary drug was a substance other than methamphetamine. In that period, the number of American Indians reporting methamphetamine as their primary drug in Los Angeles County significantly increased, particularly among females.     

Correlates and antecedents of hospital admission for attempted suicide: a nationwide survey in Italy

The present study examined data on symptom patterns in the week prior to admission for suicide attempt, in a nationwide representative sample of patients. Socio-demographic, clinical, and treatment data was gathered for 1,547 patients admitted over a 12-day index period during the year 2004 to 130 public and 36 private psychiatric facilities in Italy. Patients were evaluated in terms of whether they had been admitted for having attempted suicide or not. A detailed checklist was used to assess symptom pattern at admission; diagnoses were based on ICD-10 categories. Two-hundred thirty patients (14.8%) in the sample had been admitted for suicide attempt. Patients with depression or with personality disorders were more frequently observed among suicide attempters. First-contact patients were significantly more likely to have been admitted after a suicide attempt, the only exception being individuals with bipolar disorder, manic phase. No diagnosis was statistically related to admission after suicide attempt, once symptoms pattern at admission had been accounted for. Disordered eating behavior, depressive symptoms, substance abuse, and non-prescribed medication abuse were positively related to attempted suicide, as were any traumatic events in the week prior to admission; symptoms of psychosis (hallucinations/delusions) and lack of self-care were negatively associated with suicide attempt admission. Greater attention to symptoms immediately preceding or concomitant with admission after a suicide attempt can be a key factor in establishing the best treatment plan and discharge strategy, the most effective community-service referral, and targeted intervention programmes for patients hospitalized for a suicide attempt.     

Mental health status and community adjustment after treatment in a residential treatment program for homeless veterans.

OBJECTIVE: An uncontrolled outcome study was conducted to examine clinical improvement and the relationship of psychiatric and substance abuse problems, community adjustment, and housing status among homeless veterans who participated in a multisite residential treatment program. METHOD: The study was performed at three U.S. Department of Veterans Affairs medical centers in Florida, Ohio, and California. Baseline, discharge, and 3-month postdischarge follow-up data were collected for 255 veterans admitted to the Domiciliary Care for Homeless Veterans Program. Multiple dimensions of outcome were examined, including psychiatric symptoms, alcohol abuse, drug abuse, social contacts, income, employment, and housing. RESULTS: Program participation was found to be associated with improvement in all areas of mental health and community adjustment. Improvement in psychiatric symptoms was associated with superior housing outcomes and improvement in community adjustment. When correlates of improvement in alcohol and drug abuse were examined, only one of eight possible relationships was found to be significant: improvement in alcohol problems was positively associated with improvement in employment. CONCLUSIONS: Homeless mentally ill veterans derive clear benefits from participation in a multidimensional residential treatment program. Improvement in mental health problems, however, is weakly linked to improvement in other areas, suggesting that treatment programs may have to attend separately to multiple domains of life adjustment.     

Clinicians' and clients' perspectives on the impact of assertive community treatment.

OBJECTIVE: Clients in an assertive community treatment program and their clinicians were asked to rate clients' current difficulties in 13 quality-of-life areas to determine whether improvement in any area predicted reductions in hospitalization and incarceration. METHODS: A peer counselor interviewed 45 clients about psychiatric symptoms, substance use and abuse, medical issues, medication compliance, primary supports, social supports, vocational and occupational issues, housing, daily living skills, economic issues and entitlements, legal involvement, behavioral issues, and treatment involvement. The clients' clinicians rated the clients in these same areas. Ratings of clients' difficulties in these areas at program entry were based on combined ratings made at intake and after a review of clients' charts. Data on hospitalization and incarceration were obtained from medical and police records. Logistic regression analyses were used to seek predictors of declines in admissions to hospitals and jails (referred to as institutional admissions). RESULTS: Institutional admissions decreased after program entry; decreases were larger among clients admitted in recent years. Clients improved significantly in all 13 quality-of-life areas based on comparisons of both clinicians' and clients' ratings and baseline ratings; however, clients rated themselves as having less difficulty than their clinicians thought they had in the areas of substance abuse, medication compliance, primary supports, social supports, daily living skills, and treatment involvement. Based on clinicians' ratings, improvement in substance abuse issues predicted declines in institutionalized admissions. Based on clients' ratings, improvement in social support and economic issues predicted declines. CONCLUSIONS: These findings emphasize the importance of clients' perspectives in treatment planning and suggest that clinicians may overlook the smaller incremental steps toward improvement that are valued by clients.     

Crack/cocaine abusers in the general hospital: assessment and initiation of care.

OBJECTIVE: Cocaine, either smoked (as "crack") or taken intranasally, is now a common cause of psychiatric illness. This study was designed to assess the impact of cocaine abuse on a general psychiatric service and an obstetrics service in an urban general hospital and to evaluate a program for engaging affected patients in addiction treatment. METHOD: The charts of 300 general psychiatric patients (not admitted for addiction treatment) and 60 cocaine-abusing prenatal or postpartum patients were reviewed. A treatment referral program based on professionally directed peer leadership was established for patients with cocaine abuse. Results of evaluation and referral of 100 other cocaine-abusing psychiatric patients and the 60 prenatal or postpartum patients were then determined. RESULTS: Fully 64% (N = 191) of the 300 psychiatric patients were diagnosed as substance abusers; 38% (N = 113) of them abused cocaine. Almost one-third of these cocaine abusers had no axis I diagnosis other than substance abuse/dependence, and the majority were homeless. Urine samples were positive for cocaine in a majority of the obstetric patients studied. A majority of the psychiatric patients who were referred through the peer-led program enrolled in outpatient cocaine treatment--three times as many as in the chart review group. Most of the obstetric patients suitable for referral enrolled for treatment as well. CONCLUSIONS: Cocaine abuse may be responsible for a large portion of psychiatric admissions in urban public general hospitals. Cocaine abusers in psychiatric and obstetrics services are apparently responsive to a peer-oriented mode of referral into treatment.     

Precipitation and determination of the onset and course of schizophrenia by substance abuse--a retrospective and prospective study of 232 population-based first illness episodes

Onset and lifetime prevalence of substance abuse were assessed retrospectively using the IRAOS interview in a population-based, controlled sample of 232 first episodes of schizophrenia (ABC sample). Subjects with schizophrenia were twice as likely as controls to have a lifetime history of substance abuse at the age of first admission (alcohol abuse: 23.7 versus 12.3%; drug abuse: 14.2 versus 7.0%). 88% of the patients with drug abuse took cannabis. The sequence of substance abuse and schizophrenia was studied on the timing of abuse onset and illness onset, the latter as based on various definitions: first sign of the disorder, first psychotic symptom and first admission. 62% of the patients with drug abuse and 51% of those with alcohol abuse began the habit before illness onset (=first sign of the disorder). Abuse onset and illness onset occurred highly significantly within the same month (drug abuse in 34.6%, alcohol abuse in 18.2%). Unexpectedly, no temporal correlation was found between abuse onset and the onset of the first psychotic episode. We concluded that a small proportion of schizophrenias might have been precipitated by substance--mainly cannabis--abuse. Long-term effects of early substance abuse were studied prospectively at six cross-sections over five years from first admission on in a subsample of 115 first episodes of schizophrenia. Abusers showed significantly more positive symptoms and a decrease in affective flattening compared with controls. Five-year outcome as based on treatment compliance, utilization of rehabilitative measures and rate of employment was also poorer for patients with than without early substance abuse.     

Effects of psychiatric symptomatology on treatment outcome for adolescent male drug abusers

There is evidence that adult substance abusers tend to have high rates of psychiatric symptomatology and diagnosable psychiatric disorders and that those with more severe psychiatric problems show lower levels of improvement. This paper examines whether these same two findings also hold for adolescent substance abusers. The outcome of treatment, in a day treatment center in a private vocational high school setting, for 130 court-referred substance-abusing delinquent boys aged 14 to 18 years was studied in relation to their psychic symptomatology at admission, as measured by the Brief Symptom Inventory and the Emotional Reaction Inventory. The unexpected finding, although not conclusive, shows that there is a slight tendency among these young clients for those who report more psychiatric symptoms to improve more, rather than less, with treatment. For example, a greater score on the borderline psychotic subscale of the Emotional Reaction Scale predicted to more improvement as measured by reduction in drug use. A response set explanation was postulated for this finding: those clients who were more self-evaluative and more open and self-revealing about their disturbing inner thoughts and feelings might have been more trusting, more ready, and better motivated for counseling. The following are some possible explanations for the fact that the findings are different from those of some studies reported for adult substance abusers: adolescent drug abusers have, or are aware of having, or report, less psychiatric symptomatology, than adult abusers or addicts; our study sample included only court-referred delinquents; and there are differences in research methodology, specifically in the types of instruments and measures used.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of managed care on access to mental health services among Medicaid enrollees receiving substance treatment

OBJECTIVE: Mental health services are important to treatment retention and positive outcomes for many clients of substance abuse treatment programs. For these clients the implementation of managed care should provide for continued or increased access to mental health treatment, rather than decreased access because of short-term, cost-reduction objectives. This study assessed whether converting Medicaid from a fee-for-service program to a capitated, prepaid managed care program affected access to mental health services among clients who were treated for substance abuse. METHODS: Medicaid enrollees who were being treated for substance abuse in Oregon were interviewed before beginning treatment and after six months of service. One cohort (N=53) was interviewed one to six months before the implementation of managed care, a second (N=66) was interviewed two years after the implementation, and a third (N=49) was interviewed three to four years after the implementation. Logistic regression analyses were used to identify whether the implementation of managed care, the psychiatric need of the client, and other client characteristics affected the receipt of mental health services during the first six months of substance abuse treatment. RESULTS: Clients in all three cohorts had similar characteristics. The implementation of managed care did not affect whether clients received mental health services. A baseline interview score that was derived from items in the Addiction Severity Index psychiatric section was the only client characteristic that predicted receipt of mental health services. CONCLUSIONS: Although this study was a naturalistic experiment with many methodologic flaws, it provided a unique opportunity to observe whether the introduction of managed care changed access to mental health services among Medicaid enrollees who were being treated for substance abuse.