Legal system involvement and costs for persons in treatment for severe mental illness and substance use disorders.

OBJECTIVE: Persons with co-occurring severe mental illness and substance use disorders were followed for three years to better understand how they are involved with the legal system and to identify factors associated with different kinds of involvement. METHODS: Data came from a three-year study of 203 persons enrolled in specialized treatment for dual disorders. Cost and utilization data were collected from multiple data sources, including police, sheriffs and deputies, officers of the court, public defenders, prosecutors, private attorneys, local and county jails, state prisons, and paid legal guardians. RESULTS: Over three years 169 participants (83 percent) had contact with the legal system, and 90 (44 percent) were arrested at least once. Participants were four times more likely to have encounters with the legal system that did not result in arrest than they were to be arrested. Costs associated with nonarrest encounters were significantly less than costs associated with arrests. Mean costs per person associated with an arrest were $2,295, and mean costs associated with a nonarrest encounter were $385. Combined three-year costs averaged $2,680 per person. Arrests and incarcerations declined over time. Continued substance use and unstable housing were associated with a greater likelihood of arrest. Poor treatment engagement was associated with multiple arrests. Men were more likely to be arrested, and women were more likely to be the victims of crime. CONCLUSIONS: Effective treatment of substance use among persons with mental illness appears to reduce arrests and incarcerations but not the frequency of nonarrest encounters. Stable housing may also reduce the likelihood and number of arrests.     

Areas of skill training for persons with mental illness and substance use disorders: Building skills for successful community living

Conclusions The skills described in this article are by no means an exhaustive list. They do represent an organized set of behavioral, affective and cognitive skills which may serve a variety of purposes. Rehabilitation programs may use them to more clearly define their goals and shape their approaches to persons with dual disorders. Case managers may use them as a basis for building rehabilitation plans. Consumers can use this list to get their bearings regarding their own participation in treatment. Self-help groups may find these skills areas useful in developing their own unique perspectives on services to their recovering peers. Finally, vitally needed research efforts could find such a listing of skill areas useful in more systematically analyzing the black box of dual diagnosis programming for the purpose of measuring baselines and outcomes. Wouldn't it be nice if consumers and professionals spoke the same language and pursued similar results?     

The role of self-help programs in the rehabilitation of persons with severe mental illness and substance use disorders

Substance abuse treatment programs in the United States frequently incorporate self-help approaches, but little is known about the use of self-help groups by individuals with dual disorders. This paper brings together several current studies on the role of self-help programs in treating substance use disorders among individuals with severe mental illness. These studies indicate that only a minority of individuals with dual disorders become closely linked to self-help. Psychiatric diagnosis and possibly social skills are correlates of participation. Dually disordered consumers often experience the use of 12-step philosophy and jargon by mental health professionals as alienating and unempathic. The authors propose suggestions for incorporating self-help approaches into the comprehensive community care of individuals with dual disorders.Douglas L. Noordsy, M.D., is Assistant Professor of Psychiatry at Dartmouth Medical School and Research Associate at New Hampshire-Dartmouth Psychiatric Research Center. Brenda Schwab, Ph.D., is Research Associate at New Hampshire-Dartmouth Psychiatric Research Center and Research Assistant Professor of Community and Family Medicine, Dartmouth Medical School. Lindy Fox, M.A., is Clinical Interviewer and Trainer at New Hampshire-Dartmouth Psychiatric Research Center. Robert E. Drake, M.D., Ph.D., is Director of New Hampshire-Dartmouth Psychiatric Research Center and Andrew Thomson Professor of Psychiatry and Community and Family Medicine at Dartmouth Medical School.     

Medical morbidity,mental illness,and substance use disorders

OBJECTIVE: Previous research on the prevalence of medical disorders among adults with mental illness has been inconclusive. In general, studies have found higher rates among persons with mental illness, but these studies did not account for comorbid substance use disorders. The authors examined whether certain medical disorders are more prevalent among adults with severe mental illness and whether a comorbid substance use disorder increases prevalence beyond the effect of severe mental illness alone. METHODS: Administrative data from the Massachusetts Division of Medical Assistance were used in a cross-sectional observational study design. The sample consisted of 26,332 Medicaid beneficiaries 18 to 64 years of age. Of these, 11,185 had been treated for severe mental illness. Twelve-month prevalence rates were computed, and logistic regression was used to estimate the effect of a substance use disorder or another mental illness on the risk of having a medical disorder. RESULTS: Compared with Medicaid beneficiaries who were not treated for severe mental illness, those with severe mental illness had a significantly higher age- and gender-adjusted risk of the medical disorders considered in the study. Those with a comorbid substance use disorder had the highest risk for five of the disorders. CONCLUSIONS: The higher treated prevalence of certain medical disorders among adults with severe mental illness has three implications: substance use disorder is an important risk factor and requires early detection; integration of the treatment of medical disorders and severe mental illness should receive higher priority; and efforts should be made to develop specialized disease self-management techniques.     

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.     

Drug treatment outcomes for adolescents with comorbid mental and substance use disorders.

This study compared the pretreatment characteristics and posttreatment outcomes of substance-abusing adolescents with and without comorbid mental disorders in the Drug Abuse Treatment Outcome Studies for Adolescents. Subjects (N = 992) were sampled from 23 adolescent drug treatment programs across three modalities (residential, short-term inpatient, outpatient drug-free). Nearly two thirds (64%) of the sample had at least one comorbid mental disorder, most often conduct disorder. Comorbid youth were more likely to be drug or alcohol dependent and had more problems with family, school, and criminal involvement. Although comorbid youth reduced their drug use and other problem behaviors after treatment, they were more likely to use marijuana and hallucinogens, and to engage in illegal acts in the 12 months after treatment, as compared with the noncomorbid adolescents. Integrated treatment protocols need to be implemented within drug treatment programs in order to improve the outcomes of adolescents with comorbid substance use and mental disorders.     

Outcomes and service use among homeless persons with serious mental illness and substance abuse

OBJECTIVE: This study compared baseline characteristics and clinical improvement after 12 months among homeless persons with a diagnosis of serious mental illness with and without a comorbid substance use disorder. METHODS: The study subjects were 5,432 homeless persons with mental illness who were participating in the Center for Mental Health Services' Access to Community Care and Effective Services and Supports (ACCESS) program. Analysis of covariance was used to compare clients who had dual diagnoses and those who did not and to identify any association between service use and clinical improvement. RESULTS: Follow-up data were available for 4,415 clients (81 percent). At baseline, clients with dual diagnoses were worse off than those without dual diagnoses on most clinical and social adjustment measures. Clients with dual diagnoses also had poorer outcomes at follow-up on 15 (62 percent) of 24 outcome measures. However, among clients with dual diagnoses, those who reported extensive participation in substance abuse treatment showed clinical improvement comparable to or better than that of clients without dual diagnoses. On measures of alcohol problems, clients with dual diagnoses who had a high rate of participation in self-help groups had outcomes superior to those of other clients with dual diagnoses. Clients with dual diagnoses who received high levels of professional services also had superior outcomes in terms of social support and involvement in the criminal justice system. CONCLUSIONS: Homeless persons with dual diagnoses had poorer adjustment on most baseline measures and experienced significantly less clinical improvement than those without dual diagnoses. However, those with dual diagnoses who received extensive substance abuse treatment showed improvement similar to those without at 12 months.     

Social support and service use among homeless persons with serious mental illness.

It has been widely hypothesized that persons with greater social support use fewer health care services, although previous studies have shown variable results. This study examines the relationship between levels of social support and formal service use among clients entering 18 community treatment programs for homeless persons with serious mental illness as part of the ACCESS demonstration project of the U.S. Center for Mental Health Services. Baseline and follow-up data on 1,828 clients entering the ACCESS program were used to evaluate the relationship between individual client socio-demographic and clinical characteristics, seven measures of social support, and levels of formal service use in this population. Three measures of social support were positively related to the use of outpatient medical services and one each to the use of substance abuse services and the total days of service use. Six out of seven measures of social support were positively related to the receipt of multiple services. It appears that social support is most strongly associated with improved access to an array of different services--a very important need among this population.     

The relationship between supply and hospitalization rates for mental illness and substance use disorders

This study investigated the extent to which mental illness and substance use hospitalization rates were related to the supply of psychiatric treatment services. Supply variables, notably the per capita rate of psychiatrists, primary care physicians, and specialty units, were strongly related to mental illness and substance use hospitalization rates to acute care hospitals across 114 small geographic areas in Iowa. The supply of outpatient services was not related to hospitalization rates. The need to study the reliability of patient assessment processes, refine guidelines and admissions criteria, and understand the contributions of supply variables to hospitalization rates are indicated by these results. A conceptual model is offered within which the dynamic cycle from patient functioning to service delivery may be framed.     

A focus group analysis of relapse prevention strategies for persons with substance use and mental disorders

OBJECTIVE: The authors conducted a qualitative, thematic analysis of focus group data to determine the strategies and supports persons with dual diagnoses rely on in their relapse prevention efforts. METHODS: Data from four focus group sessions conducted at a large psychosocial rehabilitation center were analyzed for recurrent responses about what was most helpful in maintaining remission and grouped into major categories and subcategories. Each focus group comprised four to nine consumers who had been in remission from substance use for at least six months. A total of 27 consumers participated in the focus groups. RESULTS: The data indicate that maintaining stable housing, relying on "positive" social support, engaging in prayer or relying on a "higher power," participating in a meaningful activity, and thinking differently about life are important strategies for consumers in their attempts to stay clean. Just as frequently mentioned in the groups were conscious attempts to eat regularly, get sufficient sleep, and look presentable. CONCLUSION: Although this study was exploratory in nature, it identified areas for further qualitative study of strategies for relapse prevention among persons with dual diagnoses.     

Smoking cessation approaches for persons with mental illness or addictive disorders

OBJECTIVE: Persons with psychiatric illnesses are about twice as likely as the general population to smoke tobacco. They also tend to smoke more heavily than other smokers. This critical review of the literature identified 24 empirical studies of outcomes of smoking cessation approaches used with samples of persons with mental disorders. METHODS: The authors conducted searches of large health care and other databases for the years 1991 through 2001, using the key terms smoking, smoking cessation, nicotine, health/hospital/smoke-free policy, and psychiatry/ mental/substance abuse disorders. RESULTS AND CONCLUSIONS: The majority of interventions combined medication and psychoeducation. Although the studies were not uniform enough to allow a meta-analysis, the recorded quit rates of patients with psychiatric disorders were similar to those of the general population. Clinicians could usefully devote more effort to smoking cessation in populations with mental illness or addictions.     

Feasibility testing of a peer support programme for prisoners with common mental disorders and substance use

Background

The prevalence of mental disorders and substance use among prisoners is high. Convicted prisoners of ‘good behaviour’ can be part of a peer support system in prisons.

Aim

To evaluate the feasibility of a peer support programme for prisoners with common mental disorders and substance use in prison.

Method

The study used a mixed method research design, with a quasi-experimental approach (single group pre-post without control). It was conducted in two phases: Phase I. Thirty-five peers/convicted prisoners were recruited through advertisements on the prisoners' community radio station. Volunteers with good behaviour reports were given training over 5 days to recognise mental and substance use disorders and provide basic peer support in prison; their attitudes and knowledge were tested before and after the training. Phase II. Feasibility of the peer support programme was tested by (i) recording the number of cases identified and referred, (ii) pre- and post-evaluation of well-being, coping, and symptom severity of those supported and (iii) evaluating qualitatively the experience of the peer supporters and service users.

Results

Thirty-five peer supporters identified 49 cases over 3 months. These cases showed significant improvement in well-being (Z −1.962; p < 0.050) and reduction in symptom severity (Z −1.913; 0.056). There was a significant improvement in the peers supporters' self-esteem from pre- to post-training (t −3.31; p < 0.002), improvement in their benevolence (t −4.37; p < 0.001) and a significant reduction in their negative attitudes to mental illness (Z −3.518; p < 0.001). A thematic model of peer support encompassed self-experienced benefits for the peer supporter, wider recognition of peer supporters in the prison, challenges to this kind of support, experience of training and visions for future work.

Conclusion

The peer support programme was experienced positively by the peer-supporters and supported. Common mental disorders, substance use and suicidality were recognised and appropriately referred. A full-scale evaluation of this promising programme is warranted.     

A peer-support, group intervention to reduce substance use and criminality among persons with severe mental illness

OBJECTIVE: This study compared the effectiveness of two interventions in reducing alcohol use, drug use, and criminal justice charges for persons with severe mental illnesses: first, a community-oriented group intervention with citizenship training and peer support that was combined with standard clinical treatment, including jail diversion services, and second, standard clinical treatment with jail diversion services alone. METHODS: A total of 114 adults with serious mental illness participated in a 2 x 3 prospective longitudinal, randomized clinical trial with two levels of intervention (group and peer support for the experimental condition and standard services for the control) and three interviews (baseline, six months, and 12 months). Self-report questionnaires assessed alcohol and drug use, and program databases assessed criminal justice contacts. The authors used a mixed-models analysis to assess alcohol and drug use, repeated-measures analysis of covariance to assess criminal justice charges, and correlational analyses to assess the relation between intervention participation and outcome variables. RESULTS: The experimental group showed significantly reduced alcohol use in comparison with the control group. Further, results showed a significant group-by-time interaction, where alcohol use decreased over time in the experimental group and increased in the control group. Drug use and criminal justice charges decreased significantly across assessment periods in both groups. CONCLUSIONS: Of the outcomes, only decreased alcohol use was attributable to the experimental intervention. Although this may be a chance finding, peer- and community-oriented group support and learning may facilitate decreased alcohol use over time.     

Prevalence of human immunodeficiency virus,hepatitis B,and hepatitis C among homeless persons with co-occurring severe mental illness and substance use disorders

This study was undertaken to determine the prevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) among homeless persons with co-occurring severe mental illness (SMI) and substance use disorders and to determine associated risk factors. As part of a longitudinal study of the effectiveness of integrated treatment for homeless persons with SMI and substance abuse or dependence, serological testing was performed to ascertain the prevalence of HIV, HBV, and HCV. At baseline, 6.2% of participants (11/172) were HIV-positive. Nearly one third of participants (37/114) had evidence of prior exposure to HBV, and 30% (34/114) were antibody positive for HCV. About 44% of participants (50/114) had a reactive test for either HBV or HCV. Having a reactive test was strongly associated with substance use, especially with a history of injection drug use. A significant threat exists to the health and well-being of homeless person with SMI due to high prevalence of blood-borne pathogens. Mental health providers need to play a proactive role in the identification of health-related needs and to assist with access to general health services for persons with SMI.