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.     

Implementing dual diagnosis services for clients with severe mental illness

After 20 years of development and research, dual diagnosis services for clients with severe mental illness are emerging as an evidence-based practice. Effective dual diagnosis programs combine mental health and substance abuse interventions that are tailored for the complex needs of clients with comorbid disorders. The authors describe the critical components of effective programs, which include a comprehensive, long-term, staged approach to recovery; assertive outreach; motivational interventions; provision of help to clients in acquiring skills and supports to manage both illnesses and to pursue functional goals; and cultural sensitivity and competence. Many state mental health systems are implementing dual diagnosis services, but high-quality services are rare. The authors provide an overview of the numerous barriers to implementation and describe implementation strategies to overcome the barriers. Current approaches to implementing dual diagnosis programs involve organizational and financing changes at the policy level, clarity of program mission with structural changes to support dual diagnosis services, training and supervision for clinicians, and dissemination of accurate information to consumers and families to support understanding, demand, and advocacy.     

Treatment for Dual Diagnosis Patients in the Psychiatric and Substance Abuse Systems

The purpose of this study was to describe and compare the extent to which psychiatric and substance abuse programs treating dual diagnosis patients in the residential and outpatient modalities offered the components recommended for this client group. Surveys were completed by managers of 753 programs in the Department of Veterans Affairs that had a treatment regimen oriented to dual diagnosis patients. Programs within both the psychiatric and substance abuse systems had some of the key services of integrated treatment (e.g., assessment and diagnosis, crisis intervention, counseling targeted at psychiatric and at substance use problems, medications, patient education, HIV screening and counseling, family counseling and education). However, compared to psychiatric programs, substance abuse programs were more likely to offer some of these services and other critical components (e.g., a cognitive-behavioral treatment orientation, assignment of a single case manager to each patient). Outpatient psychiatric programs were particularly lacking on key management practices (e.g., use of clinical practice guidelines, performance monitoring of providers) and services (e.g., detoxification, 12-step meetings) of integrated treatment. Generally, differences between psychiatric and substance abuse programs appeared to involve difficulties in developing treatment that is fully oriented toward the co-occurring diagnosis. To improve the provision of high-quality dual-focused care, we recommend planners' use of cross-system teams and applications of recently produced tools designed to increase programs' ability to deliver integrated care to dually disordered individuals.     

Prevalence and consequences of dual diagnosis

The co-occurrence of a severe mental illness and a substance abuse or dependence disorder is common enough to be considered the expectation more than the exception. Substance use disorders can occur at any phase of mental illness. Causes of this comorbidity may include self-medication, genetic vulnerability, environment or lifestyle, underlying shared origins, and/or a common neural substrate. The consequences of dual diagnosis include poor medication compliance, physical comorbidities, poor health, poor self-care, increased risk of suicide or risky behavior, and even possible incarceration. All of these factors contribute to increased burden and reduced capacity of the health care system to adequately treat patients. Screening, assessment, and integrated treatment plans for dual diagnosis to address both the substance use disorder and the mental illness are strongly recommended.     

A Comparison of Treatment Outcomes for Individuals with Substance Use Disorder Alone and Individuals with Probable Dual Diagnosis

The co-occurrence of substance use and mental health problems, often referred to as dual diagnosis (DD), is increasingly recognised as commonplace within substance abuse treatment programs. Two-hundred and thirty-four individuals from 9 Australian Salvation Army drug and alcohol rehabilitation programs completed a 3-month post-discharge telephone follow-up. Using a cut-off score from the Psychiatric Subscale of the Addiction Severity Index (5^th ed.), 66.7% were classified as likely to have DD and 33.3% as substance use disorder only (SUD). Both groups reported comparable and decreased substance use levels at follow-up, yet DD individuals perceived less improvement in substance use problems. Comparable improvements were reported in the areas of: symptom distress and recovery from symptoms. This was despite greater scope for improvement in individuals with DD. Duration of treatment and access to post treatment services were also assessed. Understanding factors effecting treatment outcomes is imperative for the implementation of effective, evidence based treatment programs.     

Comparison of offenders with mental illness only and offenders with dual diagnoses

OBJECTIVE: The study compared offenders who had severe mental illness only and offenders who had severe mental illness and substance abuse problems-dual diagnoses-to determine whether these groups differed. Offenders with dual diagnoses who were involved with the criminal justice system at different levels were compared to explore their profiles and experiences after release. METHODS: Secondary data collected on offenders who had diagnoses of severe mental illness and of substance abuse in Massachusetts were used to examine sociodemographic, clinical characteristics, and criminal justice characteristics, service needs, and community reentry experiences in the first three months postrelease of 265 offenders with major mental illness and 436 with dual diagnoses. RESULTS: Offenders with dual diagnoses were more likely to be female and to have a history of being on probation and of using mental health services. On release from correctional custody, they had more immediate service needs than offenders with mental illness alone, including a need for housing and sex offender treatment, and they were more likely to require an assessment for dangerousness. They were also more likely to return to correctional custody. CONCLUSIONS: The data do not suggest that offenders with dual diagnoses have a distinct clinical background, but rather that substance abuse is an important feature that affects their real or perceived level of functioning, engagement with the criminal justice system, and dependence on social service institutions in the community.     

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.     

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.     

Private sector coverage of people with dual diagnoses

In general, people with dual diagnoses account for a significant proportion of both the mental health and substance abuse populations. Most published information on dual diagnosis comes from research on selected treatment programs that are largely funded from public sources. This analysis uses private health insurance claims and eligibility files for 1989 to 1991 for three large firms to identify individuals with both substance abuse and mental health claims and to examine their characteristics, charges, and utilization. More than half of people with dual diagnoses incurred significant charges over three years in both mental health and substance abuse. These individuals with high mental health charges were more likely to be male than were patients with mental health claims alone; they were less likely to be male than were patients with claims for substance abuse and no mental health services. They were also significantly younger than were patients with substance abuse or mental health utilization only for two of the firms. The average charges for people with dual diagnoses were higher than those for patients with substance abuse or mental health claims only.     

The associations between substance use disorders, schizophrenia-spectrum disorders, and Axis IV psychosocial problems

Background Substance abuse among individuals with schizophrenia-spectrum disorders (SSDs) is associated with a range of adverse psychosocial outcomes in the areas of occupational functioning, housing stability, economic independence, access to health care, and involvement with the legal system. The aim of this study was to estimate the effects of substance use disorders (SUDs), SSDS, and dual diagnosis with both disorders on the risk for six important Axis IV psychosocial problems. This was accomplished using a large dataset of patients who are representative of individuals in routine US psychiatric practice. Method Weighted data from the 1999 Study of Psychiatric Patients and Treatments from a practice-based research network of the American Psychiatric Institute for Research and Education were analyzed. Some 615 US psychiatrists provided detailed clinical, psychosocial, and health services information on 1,843 patients, including 285 patients with one or more SUDs without an SSD, 180 patients with a diagnosis of an SSD without substance abuse comorbidity, and 68 dually diagnosed patients. Logistic regression models were used to determine effect estimates (adjusted odds ratios), and corresponding 95% confidence intervals were calculated. Results After adjusting for sociodemographic variables and for SSD diagnosis, SUD diagnosis was independently associated with increased risk for five of the Axis IV psychosocial problems of interest (occupational problems, housing problems, economic problems, problems with access to health care services, and problems related to interaction with the legal system/crime) when compared to all other psychiatric patients (n=1,310). After adjusting for the sociodemographic variables and for SUD diagnosis, SSD diagnosis (compared to all other psychiatric diagnoses) was associated with Axis IV economic problems, but not with the other five psychosocial problems of interest. The presence of both an SUD and an SSD diagnosis (dual diagnosis) was associated with a greater risk for four of the six Axis IV psychosocial problems studied, compared to the risks associated with either diagnosis alone. Limiting the substance of abuse to alcohol resulted in similar findings. Conclusions Although SUDs are associated with increased risk for poor social adjustment, the comorbidity of SUDs and SSDs is associated with greatly compounded psychosocial burdens. These findings, from a large sample of representative US psychiatric patients, demonstrate the ongoing need for improved services and policies for those specially burdened patients with the dual diagnosis of both an SSD and substance abuse or dependence.     

Behavioral interventions for dual-diagnosis patients.

Dual diagnosis patients come to treatment with a variety of deficits,talents, and motivations. A biopsychosocial treatment plan involves multiple interventions, including medications, medical treatment, psychotherapy, family therapy, housing, and vocational rehabilitation. Treatment must be individualized and integrated, and this requires collaboration among a variety of health caregivers. There is empirical evidence that dual-diagnosis patients can be helped to stabilize, to remain in the community,and even to enter the workforce. Behavioral interventions are key ingredients to integrated and comprehensive treatment planning. There is no single model for dual disorders that explains why substance use and psychiatric illness co-occur so frequently. Mueser et al described four theoretical models accounting for the increased rates of comorbidity between psychiatric disorders and substance use disorders. They suggested that there could be a common factor that accounts for both, primary psychiatric disorder causing secondary substance abuse, primary substance abuse causing secondary psychiatric disorder, or a bidirectional problem, where each contributes to the other. There is evidence for each, although some are more compelling than others, and none is so compelling that it stands alone. Although family studies and genetic research could explain the common factor, no common gene has appeared. Antisocial personality disorder has been associated with very high rates of substance use disorders and mental illness; however, its prevalence is too low to explain most of the co-occurring phenomena. Common neurobiology, specifically the dopamine-releasing neurons in the mesolimbic system, also may be involved in mental illness, but this is not compelling at the moment. The Self-medication model is very appealing to mental health professionals, as an explanation for the secondary substance abuse model. Mueser et al suggest that three lines of evidence would be present to support this explanation: (1) patients would report beneficial effects of substance use on their symptoms; (2) epidemiology would report that a specific substance would be used by specific psychiatric disorders, and (3) psychiatric patients with severe symptoms would be more likely to abuse substances than those with mild symptoms. Unfortunately the research data do not support these. The primary substance abuse causing secondary psychiatric disorder model could be explained by neuronal kindling from substance-induced disorders. Patients who develop the psychiatric disorder after the substance use disorder do have a course of illness similar to those with a psychiatric disorder, but without substance use disorder. The bidirectional model is consistent with the tendency of disturbed teenagers to socialize with youth using alcohol and drugs; however, this model has not been tested rigorously in research studies. With such a disparate set of models, behavior interventions are conceptualized best as a multi-component program, a treatment plan that generates a problem list and devises an intervention to respond to each member of the list. This requires a talented, multi-disciplinary team or network that can assess carefully and package the interventions creatively, and dose the treatment components empathically to fit the patient's tolerance, motivation, and abilities.     

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.     

Evidence-based treatment of schizophrenia

People with schizophrenia can be helped greatly with pharmacologic and psychosocial interventions that are known to be effective. Several interventions are now supported by research: use of medications following specific guidelines, training in illness self-management, case management based on principles of assertive community treatment, family psychoeducation, supported employment, and integrated substance abuse treatment. However, few patients actually receive these evidence-based interventions because they are not provided in routine mental health settings. Therefore, implementing effective treatments in mental health treatment programs is a critical challenge for the field. We review the six areas of evidence-based treatment of schizophrenia, as well as knowledge regarding implementation of mental health programs in routine practice settings.     

The challenge of implementing and sustaining integrated dual disorders treatment programs

Integrated dual disorders treatment programs for people with severe mental illness and co-occurring substance use disorder have been implemented in a variety of community mental health center sites across the U.S. and in several other countries over the past 15 years. Consumers who receive services from programs that offer integrated dual diagnosis treatments that are faithful to evidence-based principles achieve significant improvements in their outcomes. Unfortunately, not all programs that attempt implementation are successful, and the quality of high-fidelity programs sometimes erodes over time. This article outlines implementation strategies that have been used by successful programs. As a general rule, success is achieved by involving all major participants (consumers, family members, clinicians, program leaders, and state or county mental health authorities) in the process and attending to the three phases of change: motivating, enacting, and sustaining implementation.     

Is Substance Abuse an Issue? Perceptions of Male and Female Community-Based Mental Health System Consumer-Survivors

Despite our increasing knowledge of the complexity of concurrent disorders the majority of research has involved either institutionalized or specific clinical populations and there have been limited opportunities to directly examine issues at the community level particularly if any differences exist between women and men. Using four standardized instruments, 150 male and 150 female community-based consumer-survivors in the London, Ontario area were interviewed. Eight focus group sessions including 65 individuals were also conducted. Differences between male and female respondents included primary diagnosis, history of family mental illness, family substance abuse, social supports and problematic parental substance abuse. While the overall level of functioning was similar for both sexes, men reported more problems with substance use while women reported a greater overall problem severity. Surprising was the lack of importance of substance abuse issues in respondents’ lives, particularly among focus group members as only four comments regarding substance abuse were made in over 10 h of dialogue. The findings support the belief that specific services by sex are required for this population though the likelihood of attending such programs would be increased if rudimentary income, housing and transportation needs were addressed.     

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.     

Co-occurring severe mental illness and substance use disorders: a review of recent research.

OBJECTIVE: Understanding the complex diagnostic and treatment issues posed by the co-occurrence of severe mental illness and substance use disorders has become a necessary exercise in current psychiatric practice. The authors reviewed research studies from the past six years that have contributed to our knowledge about effective assessment, diagnosis, course of illness, and treatment approaches. Research on special populations, including women, persons infected with HIV, and violent patients, is highlighted. METHODS: PsycINFO, Silver Platter, and MEDLINE were used to search for English-language studies published in the United States and other countries. To augment the search, selected bibliographies were reviewed with a focus on clinical standards. Information was sought on epidemiology, screening and assessment strategies, course of illness, models of treatment delivery, and cost of care. RESULTS AND CONCLUSIONS: Although estimates of the prevalence of substance use disorders vary by population, a higher prevalence among persons with severe mental illness has been confirmed. Routine screening for and assessment of substance use disorders among persons with severe mental illness has become the accepted standard of care. The course of severe mental illness is negatively influenced by a substance use disorder, and an integrated approach to the treatment of both disorders is generally accepted to be the most promising treatment strategy. Components of this strategy include harm reduction, treatment in stages, motivational interviewing, cognitive-behavioral interventions, and modified 12-step self-help groups.     

Assessment and classification of patients with psychiatric and substance abuse syndromes

Patients with both mental illness and substance abuse pose a major clinical challenge to mental health and substance abuse clinicians. The literature seems to support the hypothesis that mental illness and substance abuse occur together more frequently than chance would predict. Assessment and classification of these patients should be guided by clinicians' needs to make meaningful therapeutic judgments and to communicate effectively with each other in coordinating treatment. Different phases of treatment require different approaches to assessment and classification. In initial classification, the clinician should recognize the problem of dual diagnosis and resist premature assumptions about which diagnosis is primary. Long-term treatment and rehabilitation may require systematic evaluation of alternative clinical hypotheses about why a patient exhibits both disorders. This approach eventually may lead to better ways to assess, classify, and treat these difficult patients.     

Program development and integrated treatment across systems for dual diagnosis: mental illness, drug addiction, and alcoholism (MIDAA)

Numerous bureaus of mental health, drug addiction, and alcoholism are designated to provide service to persons who have discrete singular disorders of mental illness, drug addiction, or alcoholism. Mental health and substance abuse programs (nationally and internationally) have evolved with this singular limited-service capacity. Contrasting incompatible philosophies and treatment methods across the systems have resulted in minimal services for persons with dual diagnoses. The project the authors have outlined is an example of the development of a dual/multiple-disorder program that integrates these diverse systems and provides comprehensive services within each of the programs of each delivery system. These programs are cost-effective, use existing facilities, train and cross-train existing staff, correct the issues of incompatible treatment interventions, and end the dilemma of gaps in services systems and limited referral resources. As a result, the availability and quality of care for persons with dual diagnoses is greatly improved.     

Childhood trauma among individuals with co-morbid substance use and post traumatic stress disorder

BACKGROUND: Little is known about the impact of childhood trauma (CT) on the clinical profile of individuals with co-occurring substance use disorder (SUD) and post traumatic stress disorder (PTSD). AIMS: To compare the clinical characteristics of individuals with SUD+PTSD who have a history of CT with SUD+PTSD individuals who have experienced trauma during adulthood only. METHOD: Data were collected on 103 individuals as part of a randomised controlled trial examining the efficacy of an integrated psychosocial treatment for SUD+PTSD. Participants were recruited from substance use treatment services, community referrals and advertising. Data were collected on demographic characteristics, substance use and treatment histories, lifetime trauma exposure, and current physical and mental health functioning. RESULTS: The vast majority (77%) of the sample had experienced at least one trauma before the age of 16, with 55% of those endorsing childhood sexual abuse. As expected individuals with a CT history, as compared to without, evidenced significantly longer duration of PTSD. Those with a CT history also had more extensive lifetime trauma exposure, an earlier age of first intoxication, and reported more severe substance use (e.g., a greater number of drug classes used in their lifetime, higher severity of dependence scores and greater number of drug treatment episodes). CONCLUSION: Individuals with co-morbid SUD+PTSD who have experienced CT present with a more severe and chronic clinical profile in relation to a number of trauma and substance use characteristics, when compared to individuals with adulthood only trauma histories. It is therefore important for SUD+PTSD treatment planning that CT be carefully assessed.