One-year follow-up of dual diagnosis patients attending a 4-month integrated inpatient treatment

The purpose of this study was to assess a 4-month inpatient treatment program based on integrated models for patients with substance use and psychiatric disorders (dual diagnosis patients). On admission and at the 1-year follow-up, a consecutive sample of 118 dual diagnosis patients who entered the program were assessed by interview. Eighty-four patients (70.6%) completed the 1-year follow-up interview, reporting less frequent substance use, less severe psychiatric symptoms, a lower rehospitalization rate, and better housing conditions than on admission. Patients diagnosed with a comorbid personality disorder had a better improvement in the frequency of drinking and were less likely to be rehospitalized than patients with schizophrenia or depression. The results suggest that the integrated inpatient program may be a promising treatment approach for dual diagnosis patients. The results await replication in controlled studies that need to include an assessment of outpatient treatment following inpatient programs.     

Differing effects of antipsychotic medications on substance abuse treatment patients with co-occurring psychotic and substance abuse disorders

This retrospective study of patients treated in a ninety-day, inpatient, dual-diagnosis treatment program examined antipsychotic effectiveness in this population using length of stay in treatment and successful program completion as outcome measures. All patients with co-occurring substance dependence and schizophrenia or schizoaffective disorder treated with olanzapine, risperidone, ziprasidone, and typical depot neuroleptics from January 2001 to December 2003 (N = 55) are the subjects of this study. Patients stayed longer in treatment when taking risperidone (82 +/- 19 days) or ziprasidone (74 +/- 21 days) compared with olanzapine (44 +/- 30 days) or typicals (47 +/- 36 days). Eighty-eight percent of risperidone patients and 64% of ziprasidone patients successfully completed the program, while only 33% of olanzapine patients and 40% of patients on typicals successfully completed the program. Risperidone and ziprasidone were associated with significantly better program performance than olanzapine or depot typicals in this population. Possible reasons for this difference are discussed.     

Treatments for patients with dual diagnosis: a review

BACKGROUND: Comorbid substance use and mental illness is prevalent and often results in serious consequences. However, little is known about the efficacy of treatments for patients with dual diagnosis. METHODS: This paper reviews both the psychosocial and medication treatments for those diagnosed with a substance-related disorder and one of the following disorders: (a) depression, (b) anxiety disorder, (c) schizophrenia, (d) bipolar disorder, (e) severe mental illness, and (f) nonspecific mental illness. We made no restriction of study design to include all published studies, due to the dearth of studies on treatments of patients with dual diagnosis. RESULTS: Fifty-nine studies were identified (36 randomized-controlled trials; RCT). Limited number of studies, especially RCTs, have been conducted within each comorbid category. This review did not find treatments that had been replicated and consistently showed clear advantages over comparison condition for both substance-related and other psychiatric outcomes. CONCLUSIONS: Although no treatment was identified as efficacious for both psychiatric disorders and substance-related disorder, this review finds: (1) existing efficacious treatments for reducing psychiatric symptoms also tend to work in dual-diagnosis patients, (2) existing efficacious treatments for reducing substance use also decrease substance use in dually diagnosed patients, and (3) the efficacy of integrated treatment is still unclear. This review provides a critique of the current state of the literature, identifies the directions for future research on treatment of dual-diagnosis individuals, and calls for urgent attention by researchers and funding agencies to conduct more and more methodologically rigorous research in this area.     

A Prospective Study of Integrated Outpatient Treatment for Substance-Abusing Schizophrenic Patients

Forty-seven psychiatric inpatients with concurrent RDC-diagnosed schizophrenia and psychoactive substance use disorders were randomly assigned to one of two outpatient treatment programs: 1) integrated psychiatric and substance abuse treatment; or 2) non-integrated treatment. Patients abused cocaine, alcohol, and marijuana, with over two-thirds using all three drugs. At 4 months, 16 of 23 patients (69.6%) in integrated treatment remained in treatment vs. 9 of 24 (3 7.5%) in the nonintegrated treatment. Rehospitalization did not differ between groups, but treatment nonstarters had significantly more days in the hospital than those who began treatment. At 8 months, addiction and psychiatric severity decreased significantly for patients remaining in treatment. Engagement in integrated outpatient treatment may decrease rehospitalization, and lessen psychiatric and substance abuse severity.     

Predicting Acceptance of Treatment in Male Dual-Diagnosis Outpatients

The authors studied a cohort of 128 male veterans undergoing preadmission screening for a specialized outpatient program for chronically mentally ill substance abusers. Demographic, substance abuse, and comorbid psychiatric variables were evaluated for their correlation with acceptance (44 patients) or rejection (84 patients) of the treatment offered. A later age at onset of both substance abuse and comorbid psychiatric illness significantly increased the likelihood of acceptance, as did the presence of a primary alcohol use disorder and the absence of current medical problems. A strong correlation was observed between the age at onset of substance abuse and comorbid psychiatric disorder, suggesting that in many dual-diagnosis patients the two disorders could be manifestations of a single process.     

Outpatient Alcohol and Drug Treatment for Adolescents with Co-Occurring Conduct Disorder

Conduct disorder (CD) commonly co-occurs among adolescents with substance use disorder (SUD) and complicates the clinical course of SUD. Although research has begun to investigate CD's impact on adolescent response to SUD treatment, comparatively little is known about the effects of outpatient SUD treatment on this population. This study examined how co-occurring CD influences SUD treatment response as well as longer-term outcomes. Adolescent outpatients (N = 126; M age = 16.7, 25% female) with (i.e., SUD-CD; n = 52), and without CD (SUD-only; n = 74), were compared at baseline. Multilevel mixed models tested group effects on percent days abstinent (PDA) and other clinical and continuing care variables during and following treatment at 6 and 12 months. At baseline, SUD-CD participants had significantly greater psychiatric symptoms, substance use consequences, problem severity, and comorbid internalizing disorders. Both groups changed similarly on measured variables during treatment; however, the sample overall showed increases in PDA and drops in psychiatric symptoms. Following treatment, there were no differences in PDA between groups (p = .44). Both groups showed lower rates of psychiatric symptoms and arrests in the year following treatment, though SUD-CD still reported more psychiatric symptoms (p = .01) and higher inpatient (p = .02) and outpatient treatment (p = .04) utilization than SUD-only. SUD-CD patients may require a more psychiatrically integrated treatment approach during outpatient SUD treatment and more assertive and aggressive continuing care to reduce psychiatric distress, decrease the risk of further hospitalizations, and increase quality of life.     

Substance Abuse and Psychiatric Illness: Psychosocial Correlates

The authors examined the psychosocial correlates of 1) having a history of any type of psychiatric treatment and 2) being staff-identified as a suitable candidate for treatment from an outpatient dual-diagnosis program. They reviewed 1,303 consecutive patients in a 16-month period who applied for substance abuse and/or dual-diagnosis treatment at a Veterans Administration hospital. The sample included 665 individuals describing a history of prior psychiatric treatment, 126 of whom were referred for outpatient dual-diagnosis treatment. Data were collected at the time of treatment application and included demographics, employment and treatment histories, and recent substance use. Even the broadest definition of dual diagnosis (having a history of any type of psychiatric treatment) was associated with higher rates of homelessness, disconnection from social support systems, unemployment and vocational disability, and treatment chronicity; a narrower definition selected for even greater impairment. Substance abuse programs should anticipate significant case management needs in addition to psychiatric support when treatment programs are expanded to include services to patients with comorbid psychiatric illness.     

Chemical dependency patients with cooccurring psychiatric diagnoses: service patterns and 1-year outcomes

BACKGROUND: Improving services and treatment outcomes for individuals with cooccurring alcohol and drug use disorders and psychiatric conditions has been a critical challenge to clinicians and policy makers. This study examined 1-year outcomes for individuals entering chemical dependency (CD) treatment with and without cooccurring psychiatric diagnoses targeted by California parity legislation. Among those with cooccurring conditions (i.e., dual-diagnosis patients), we examined a model including individual characteristics, treatment services, and extratreatment characteristics to understand CD outcome predictors in this population. We hypothesized that longer CD treatment duration and receiving psychiatric services would predict higher abstinence levels. In particular,patterns of psychiatric services (amount of services, receiving a critical dose, or receiving services concurrently with CD treatment) were assessed in relation to outcome. METHODS: We examined abstinence rates 1 year after intake for 747 adults with and without cooccurring conditions. Among dual-diagnosis patients, logistic regression was used to examine predictors of abstinence. RESULTS: At baseline, dual-diagnosis patients (N=104) had higher levels of medical, family, and employment problems than others. They had similar CD retention and received more psychiatric services during the year after intake and had comparable CD outcomes at 1 year. Length of stay in CD treatment, hours of psychiatric services, number of months with concurrent CD and psychiatric services, and number of 12-step meetings attended were independent predictors of abstinence for dual diagnosis patients. CONCLUSIONS: Chemical dependency outcomes in patients with cooccurring psychiatric conditions were positively associated with the number and patterning of services. Receiving psychiatric services concurrently with CD treatment may be beneficial for dual-diagnosis patients. Future studies should examine how best to integrate services to optimize treatment outcomes.     

Recent suicide attempt and the effectiveness of inpatient and outpatient substance use disorder treatment

BACKGROUND: The present study investigated whether or not the effect of treatment setting (inpatient or outpatient) on 6-mo follow-up substance use varied for suicidal and non-suicidal patients. In particular, the study tested the hypothesis that treatment setting would have no differing effect for non-suicidal participants, but for suicidal participants, inpatient setting would be more closely associated with positive outcomes than the outpatient setting. METHODS: A national sample of patients presenting for treatment of substance use disorders in the Veterans Administration health care system was selected to participate in the study. A total of 1,289 participants provided complete data on psychiatric and substance-related problems at baseline and 6-mo follow-up. RESULTS: At baseline, 4% (n=53) of the sample reported having made a suicide attempt within the past 30 days. Those who reported a suicide attempt were no more likely to have been treated in an inpatient setting than in an outpatient setting. A significant interaction between baseline suicide attempt and treatment setting was found, such that non-suicidal patients reported similar patterns of substance use when treated in inpatient or outpatient settings, but suicidal patients were significantly more likely to have better substance-related outcomes at 6-mo follow-up if they were treated in inpatient compared with outpatient settings. CONCLUSIONS: Suicidal patients displayed substantial improvement after substance use disorders treatment and seem particularly responsive to treatment in inpatient settings.     

Medical comorbidity in women and men with schizophrenia

BACKGROUND: Persons with persistent mental illness are at risk for failure to receive medical services. In order to deliver appropriate preventive and primary care for this population, it is important to determine which chronic medical conditions are most common. OBJECTIVE: We examined chronic medical comorbidity in persons with schizophrenia using validated methodologies. DESIGN: Retrospective analysis of longitudinal administrative claims data from Wellmark Blue Cross/Blue Shield of Iowa. PARTICIPANTS: Subjects with schizophrenia or schizoaffective disorder (N=1,074), and controls (N=726,262) who filed at least 1 claim for medical services, 1996 to 2001. MEASUREMENTS: Case subjects had schizophrenia as the most clinically predominant psychotic disorder, based on psychiatric hospitalization, psychiatrist diagnoses, and outpatient care. Controls had no claims for any psychiatric comorbidity. Using a modified version of the Elixhauser Comorbidity Index, inpatient and outpatient claims were used to determine the prevalence of 46 common medical conditions. Odds ratios (ORs) were adjusted for age, gender, residence, and nonmental health care utilization using logistic regression. RESULTS: Subjects with schizophrenia were significantly more likely to have 1 or more chronic conditions compared with controls. Adjusted OR (95% confidence interval [CI]) were 2.62 (2.09 to 3.28) for hypothyroidism, 1.88 (1.51 to 2.32) for chronic obstructive pulmonary disease, 2.11 (1.36 to 3.28) for diabetes with complications, 7.54 (3.55 to 15.99) for hepatitis C, 4.21 (3.25 to 5.44) for fluid/electrolyte disorders, and 2.77 (2.23 to 3.44) for nicotine abuse/dependence. CONCLUSIONS: Schizophrenia is associated with substantial chronic medical burden. Familiarity with conditions affecting persons with schizophrenia may assist programs aimed at providing medical care for the mentally ill.     

Community psychiatric nurse aftercare for alcoholics: a five-year follow-up study

The aim of this study was to determine if community psychiatric nurse (CPN) aftercare for 1 year improved the 5-year outcome in patients following inpatient treatment for alcohol dependence. A 5-year follow-up study, observer blind, with non-random allocation of subjects to aftercare by CPN for 1 year or standard outpatient care, was used. Subjects had all received inpatient treatment for 6 weeks in a rural alcohol treatment unit. Subjects were traced and assessed in the community 5 years after the index admission. The participants consisted of 127 white male alcoholics. All were first admissions, who had been selected for inpatient treatment and who completed a 6-week inpatient stay. Seventy-three subjects received intensive aftercare by CPN for 1 year, 54 subjects received standard outpatient appointments not due to random allocation but because no CPN was available. Data were collected by semi-structured interview at entry to the trial, namely background epidemiological information, details of drinking history, previous hospital admission, educational, employment and criminal information. At 5-year follow-up, data on drinking status, use of other drugs, hospital admissions, criminal behaviour and gambling, attendance at self-help groups, relationships and employment were collected. Thirty-six per cent of the CPN aftercare group was completely abstinent during the 5 years after treatment compared to 6% of the standard aftercare group (p 0.001). Subjects receiving CPN aftercare were less likely to report blackouts (p 0.05) or gambling (p 0.05). They were more likely to attend hospital meetings (p 0.0001). CPN aftercare is an effective way of maximizing the effects of inpatient treatment. The effects endured for 5 years after treatment.     

Inpatient hospitalization for substance use disorders one year after residential rehabilitation: predictors among US veterans

ABSTRACT

Background: The Veterans Health Administration (VHA) is among the principal providers of the full range of substance use disorders (SUD) treatment in the US. Relatively little, however, is known about patient outcomes after residential rehabilitation. Objective: To identify predictors of SUD inpatient hospitalization (primarily medically managed detoxification) in the year after SUD residential rehabilitation among US veterans. Methods: Medical records of 64 veterans admitted to one of two residential rehabilitation programs in the Northeast during the first quarter of FY 2012 were abstracted. Data included demographic, clinical, and treatment (inpatient and outpatient) information for the year before and after residential rehabilitation. Annual rates of treatment utilization were compared. Results: The veterans (mean age, 48.2 years) used substances for a mean of 27.6 years. Alcohol was the primary drug of choice (69%). More than half had SUD inpatient hospitalizations in the year before (79%) and after (53%) residential rehabilitation; SUD inpatient admission occurred an average of 64 days after discharge. According to the multivariate Cox regression model, the estimated risk of SUD inpatient hospitalization increased by 25% for each past year SUD inpatient hospitalization, decreased by 74% if there was no opiate use disorder diagnosis, and decreased by 2% for each day increase in residential rehabilitation length of stay when extent of service connected disability, marital status, and days since last SUD inpatient admission are taken into account. Conclusions: Risk factors for SUD inpatient hospitalization after residential rehabilitation have been identified and, if confirmed, may represent opportunities for targeted program change.     

Matching Adolescents Who Abuse Drugs to Treatment

This “matching” study attempts to determine characteristics of adolescent drug abuse patients that may determine whether an inpatient or an outpatient treatment setting will be more effective or more suitable for meeting the needs of the patient. Compared to short-term inpatient treatment, long-term outpatient treatment was shown to have significantly greater effect in reducing substance use/abuse for patients who had relatively more severe social lifestyle problems, family problems, and employment problems. Outpatient treatment even showed a trend toward a significantly better outcome for patients with more severe psychiatric problems.     

Health care utilization in dementia patients with psychiatric comorbidity

PURPOSE: The purpose of this research was to determine if differences in service use exist between dementia patients with and without psychiatric comorbidity. DESIGN AND METHODS: A retrospective cohort study was conducted on all Veterans Affairs (VA) beneficiaries seen at the Houston Veterans Affairs Medical Center with a VA Outpatient Clinic File diagnosis of dementia in 1997. The primary dependent measure was amount of Houston VA health service use from study entry until the end of fiscal year 1999 or until death. RESULTS: Of the 864 dementia patients in the identified cohort, two thirds had a comorbid psychiatric diagnosis. Examination of 2-year health service use revealed that, after adjusting for demographic and medical comorbidity differences, dementia patients with psychiatric comorbidity had increased medical and psychiatric inpatient days of care and more psychiatric outpatient visits compared with patients without psychiatric comorbidity. IMPLICATIONS: Further understanding of the current health service use of dementia patients with psychiatric comorbidity may help to establish a framework for considering change in the current system of care. A coordinated system of care with interdisciplinary teamwork may provide both cost-effective and optimal treatment for dementia patients.     

A Public Dual-Diagnosis Detoxification Unit: Part III: Short-Term Efficacy of Treatment

Despite the frequency of alcohol and drug dependence in mentally ill people, data are not readily available on the detoxification and acute stabilization of psychiatric symptoms in this group. The authors have previously reported on a public dual-diagnosis treatment model for homeless or homeless-prone patients. They now report on a pilot prospective study investigating the efficacy of this short-term treatment in stabilizing psychiatric symptoms. The Brief Psychiatric Rating Scale (BPRS) and Clinicians' Global Improvement (CGI) and Severity Scale (CGS) were used to assess treatment stabilization in alcohol-dependent subjects referred with (n = 12) or without psychiatric disorders (n = 12). The psychiatrically referred group had significantly more psychiatric impairment and symptoms at admission than control subjects, but both groups showed similar progressive improvement in symptoms on hospitalization Days 2, 4, and 6 as assessed by both the BPRS and CGI (23% reduction by Day 6, all Ps < 0.001). These findings indicate that a public dual-diagnosis detoxification unit appears effective in stabilizing psychiatric symptoms in this group of psychiatrically referred, alcohol-dependent patients.     

Psychiatric illness among drug court probationers

The purpose of this study was to identify the level of psychiatric symptoms reported by probationers involved with a drug court in Hennepin County, Minnesota. Sixty probationers completed a brief demographic interview, the Beck Depression and Anxiety Inventories (BDI and BAI) and a measure of medical quality of life. Fifteen participants completed a structured interview for psychiatric diagnosis (SCID-I). The sample was predominantly male, African American, and unemployed. Over 40% had received treatment for psychiatric problems, including 20% who reported a history of inpatient psychiatric admission and 15% currently taking a psychotropic medication. More than 1/3 of BDI and BAI scores were moderate to severe. The mean Short Form (SF)-36 scores were significantly lower than in the general population. Trends suggested more distress associated with: Caucasian race, female gender, less education, unemployment, and less previous legal involvement. Of 15 participants that completed a SCID-I, 13 participants met lifetime diagnostic criteria for at least one psychiatric disorder. The most common diagnoses were major depressive disorder and posttraumatic stress disorder (PTSD). Three participants met diagnostic criteria for current psychotic disorder. Half of participants who currently met criteria for a disorder reported that they had never received psychiatric treatment. Results indicate participants currently were experiencing high rates of emotional symptoms. Serious mental illness was common. Many of these individuals had not been identified previously as needing psychiatric treatment. More frequent and thorough screening for psychiatric illness in drug court settings is necessary to identify serious psychiatric illnesses.     

Psychiatric Illness Among Drug Court Probationers

The purpose of this study was to identify the level of psychiatric symptoms reported by probationers involved with a drug court in Hennepin County, Minnesota. Sixty probationers completed a brief demographic interview, the Beck Depression and Anxiety Inventories (BDI and BAI) and a measure of medical quality of life. Fifteen participants completed a structured interview for psychiatric diagnosis (SCID‐I). The sample was predominantly male, African American, and unemployed. Over 40% had received treatment for psychiatric problems, including 20% who reported a history of inpatient psychiatric admission and 15% currently taking a psychotropic medication. More than 1/3 of BDI and BAI scores were moderate to severe. The mean Short Form (SF)‐36 scores were significantly lower than in the general population. Trends suggested more distress associated with: Caucasian race, female gender, less education, unemployment, and less previous legal involvement. Of 15 participants that completed a SCID‐I, 13 participants met lifetime diagnostic criteria for at least one psychiatric disorder. The most common diagnoses were major depressive disorder and posttraumatic stress disorder (PTSD). Three participants met diagnostic criteria for current psychotic disorder. Half of participants who currently met criteria for a disorder reported that they had never received psychiatric treatment. Results indicate participants currently were experiencing high rates of emotional symptoms. Serious mental illness was common. Many of these individuals had not been identified previously as needing psychiatric treatment. More frequent and thorough screening for psychiatric illness in drug court settings is necessary to identify serious psychiatric illnesses.     

Geriatric psychiatry home treatment (GHT): a pilot study on outcomes following hospital discharge for depressive and delusional patients

Elderly people with mental health problems receive much worse outpatient care than younger people. Although the health-promoting factors are known, there are hardly any studies on effective biopsychosocial care models. A 1-year longitudinal study examined the effectiveness of the GHT presented below. For this purpose, 12 depressive and delusional patients discharged from inpatient gerontopsychiatric care received mental and social treatment and care at home for 1 year. Functionality was surveyed by means of the Global Assessment of Functioning Scale (GAF) and psychiatric symptoms by means of the Brief Psychiatric Rating Scale (BPRS). Subjective quality of life (QoL) was surveyed by means of the WHOQOL-BREF self-report questionnaire. The main findings were as follows: (1) no patient had to receive inpatient psychiatric care or be admitted to a nursing home during the study period; (2) mental QoL had improved significantly after 1 year; (3) functionality remained stable; (4) the BPRS scores did not deteriorate. We see this as confirmation that GHT is an effective instrument for extramural care of elderly people with psychiatric disorders. The limitations of the pilot study necessitate further studies to back up the findings.     

Managing Disability Benefits as Part of Treatment for Persons With Severe Mental Illness and Comorbid Drug/Alcohol Disorders

The objective of this pilot study is to describe the use of a Social Security representative payee program as a clinical intervention integrated into long-term, dual-disorder treatment of severely mentally ill outpatients with comorbid drug/alcohol disorders. Compared with non-payees, patients selected to be payee participants were more likely to be male, have a diagnosis of schizophrenia, have a history of high inpatient utilization, and have higher current ratings of psychiatric symptoms, substance use, and functional disability. Despite these higher severity ratings, which usually predict poor outpatient compliance and higher rate of adverse outcomes, the payee participants attended about twice the number of outpatient service sessions as non-payees and were no more likely to be currently homeless, hospitalized, or incarcerated. The payee intervention is described, and ethical and research issues are discussed.     

Psychiatric comorbidity and greater hospitalization risk, longer length of stay, and higher hospitalization costs in older adults with heart failure

OBJECTIVES: To explore associations between psychiatric comorbidity and rehospitalization risk, length of hospitalization, and costs. DESIGN: Cross-sectional study of 1-year hospital administrative data. SETTING: Claims-based study of older adults hospitalized in the United States. PARTICIPANTS: Twenty-one thousand four hundred twenty-nine patients from a 5% national random sample of U.S. Medicare beneficiaries aged 65 and older, with at least one acute care hospitalization in 1999 with a Diagnostic-Related Group of congestive heart failure. MEASUREMENTS: The number of hospitalizations, mean length of hospital stay, and total hospitalization costs in calendar year 1999. RESULTS: Overall, 15.8% of patients hospitalized for heart failure (HF) had a coded psychiatric comorbidity; the most commonly coded comorbid psychiatric disorder was depression (8.5% of the sample). Most forms of psychiatric comorbidity were associated with greater inpatient utilization, including risk of additional hospitalizations, days of stay, and hospitalization charges. Additional hospitalization costs associated with psychiatric comorbidity ranged up to $7,763, and additional days length of stay ranged up to 1.4 days. CONCLUSION: Psychiatric comorbidity appears in a significant minority of patients hospitalized for HF and may affect their clinical and economic outcomes. The associations between psychiatric comorbidity and use of inpatient care are likely to be an underestimate, because psychiatric illness is known to be underdetected in older adults and in hospitalized medical patients.