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...on Co-occurring Disorders
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www.ProjectCork.org
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Spring 2005
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A review of research on residential programs for people with severe mental illness and co-occurring substance use disorders.
Brunette MF; Mueser KT; Drake RE. Drug and Alcohol Review 23(4): 471-481, 2004. (54 refs.)
Substance use disorder is the most common and clinically significant co-morbidity among clients with severe mental illnesses, associated with poor treatment response, homelessness and other adverse outcomes. Residential programs for clients with dual disorders integrate mental health treatment, substance abuse interventions, housing and other supports. Ten controlled studies suggest that greater levels of integration of substance abuse and mental health services are more effective than less integration. Because the research is limited by methodological problems, further research is needed to establish the effectiveness of residential programs, to characterize important program elements, to establish methods to improve engagement into and retention in residential programs and to clarify which clients benefit from this type of service. Copyright 2004, Carfax Publishing.
Racial differences in hepatitis B and hepatitis C and associated risk behaviors in veterans with severe mental illness.
Butterfield MI; Bosworth HB; Stechuchak KM; Frothingham R; Bastian LA; Meador KG et al. Journal of the National Medical Association 96(1): 43-52, 2004. (59 refs.)
Racial differences in the seroprevalence of and risks for hepatitis B (HBV) and hepatitis C (HCV) were examined in military veterans with severe mental illnesses (SMI). Participants (376; 155 Caucasian, 221 African American) were inpatients at a Veterans Affairs (VA) psychiatric unit in Durham, N.C., from 1998 to 2000. Prevalence rates of HBV and HCV were 21.3% and 18.9%, respectively. African Americans had a higher HBV seroprevalence than did Caucasians: 27.6% versus 12.3%; odds ratio (OR) 2.73; 95% confidence interval (Cl)=1.55, 4.79. Although not statistically significant, HCV seroprevalence was also higher for African Americans than it was for Caucasians: 21.3% versus 15.5%; OR=1.47; 95% CI=0.86, 2.53. No racial difference was observed for injection drug use (IDU), the strongest risk indicator for both HBV and HCV. Multivariable analyses indicated that African-American race, IDU, and multiple sex partners in the past six months were related to an increased risk of HBV, whereas IDU and smoking crack cocaine were both independently related to an increased risk of HCV. Thus, veterans with SMI-particularly African-American veterans-have high rates of HBV and HCV infection. African-American veterans have significantly higher rates of HBV than do Caucasian veterans, which persist after controlling for prominent risk behaviors. Copyright 2004, National Medical Association.
No increased levels of the nicotine metabolite cotinine in smokers with schizophrenia. (review).
Bozikas VP; Niopas I; Kafantari A; Kanaze FI; Gabrieli C; Melissidis P et al. Progress in Neuro-Psychopharmacology & Biological Psychiatry 29(1): 1-6, 2005. (47 refs.)
The prevalence of smoking cigarettes has repeatedly been found to be greater in schizophrenia as compared with other psychiatric patients and the general population. Patients with schizophrenia have been found to engage in heavy smoking and consumption of higher doses of nicotine, probably by deeper inhalation of cigarettes. The aim of the current study was to assess nicotine exposure through smoking by measuring urinary cotinine, the major nicotine metabolite, in a group of smokers from Greece of smokers with schizophrenia and smokers from the general population. Participants were current smokers and belonged to one of two groups: 35 patients with schizophrenia and 48 healthy controls matched in age, education, and gender. The quantitative analysis of cotinine. the major metabolite of nicotine. in urine samples was performed by a modified high performance liquid chromatography (HPLC). Patients with schizo-phrenia who smoke presented a significantly larger time interval between last cigarette smoked and urine sample collection, as well as a significantly higher average number of cigarettes consumed daily than normal smokers. Urinary cotinine levels of patients with schizophrenia who smoke did not significantly differ from that of normal smokers when adjusted for average number of cigarettes per day and time interval between last cigarette smoked and urine collection. These results suggest that patients with schizophrenia did not present higher nicotine exposure through smoking compared with smokers from the community. The pharma-cokinetic or pharmacodynamic properties of nicotine, as well as patient medications of the patients may explain our findings. Copyright 2005, Elsevier Science Ltd.
Severely mentally ill consumers' perspectives on drug use.
Alvidrez J; Kaiser D; Havassy BE. Journal of Psychoactive Drugs 36(3): 347-355, 2004. (27 refs.)
Substance use disorders have serious negative consequences for severely mentally ill (SMI) adults, but many do not receive adequate substance abuse treatment. As part of a larger project on access barriers to substance abuse treatment for SMI clients, this qualitative study examined two potential client-level barriers to treatment: minimization of drug problems and perceived acceptability of drug use to reduce psychiatric symptoms. Open-ended interviews about drug use were conducted with 24 SMI adults with substance use problems. The majority of respondents identified drug use as a major problem in their lives. Respondents were aware of the impact of drugs on psychiatric symptoms, and most believed that the negative effects of drug use outweighed any short-term benefits. Nearly all respondents believed it was not acceptable for SMI adults to use drugs except marijuana. Contrary to findings in the literature that SMI adults deny or minimize drug problems, most respondents acknowledged the seriousness of their drug use, were aware of the negative effects of drug use on their psychiatric symptoms, and endorsed abstinence as the optimal treatment goal. These findings have implications for substance abuse treatment for SMI clients, particularly interventions that emphasize education about drug use as a way to increase motivation for treatment. Copyright 2004, Haight-Ashbury Publishing.
Preliminary evidence of an association between childhood abuse and cannabis dependence among African American first-episode schizophrenia-spectrum disorder patients. (rapid communication).
Compton MT; Furman AC; Kaslow NJ. Drug and Alcohol Dependence 76(3): 311-316, 2004. (29 refs.)
Cannabis dependence is a prevalent comorbid substance use disorder among patients early in the course of a schizophrenia-spectrum disorder. Determining risk factors for substance abuse may be helpful in designing interventions to reduce the psychosocial morbidity associated with substance abuse among this population. This study aimed to determine whether or not African American, socially disadvantaged, first-episode schizophren-ia-spectrum patients with cannabis dependence experienced greater levels of child-hood abuse and neglect compared to similar patients without comorbid cannabis dependence. Among 29 eligible patients, 18 participated in this pilot study. First-episode patients with comorbid cannabis dependence (n = 8) reported significant-ly greater childhood physical and sexual abuse compared to those without comorbid cannabis dependence (n = 10). This represents preliminary evidence of an association between childhood maltreatment and cannabis dependence among this especially vulnerable population. Childhood physical and sexual abuse may be a risk factor for the initiation of cannabis dependence and other substance use disorders in the early course of schizophrenia. Copyright 2004, Elsevier Science.
Cocaine craving and attentional bias in cocaine-dependent schizophrenic patients.
Copersino ML; Serper MR; Vadhan N; Goldberg BR; Richarme D; Chou JCY et al. Psychiatry Research128(3): 209-218, 2004. (50 refs.)
Cocaine craving has been implicated as a major factor underlying addiction and drug relapse. From a cognitive viewpoint, craving may reflect, in part, attentional processing biased in favor of drug-related cues and stimuli. Schizophrenic individuals (SZ), however, abuse cocaine in high numbers but typically manifest baseline cognitive deficits that impair their ability to selectively allocate their attentional resources. In this study, we examined the relationship between attentional bias and craving in patients with cocaine dependence (COC; n=20), schizophrenic patients comorbid for cocaine dependence (COC+SZ; n=23), and two other comparison groups using a modified version of the Stroop test to include cocaine-relevant words. Results revealed that only the COC patients demonstrated Stroop interference on the cocaine-related words. Moreover, COC patients' attentional processing biases were significantly associated with their cocaine craving severity ratings. COC+SZ patients, in contrast, did not demonstrate Stroop interference and manifested significantly fewer craving symptoms than their COC counterparts. These results suggest that COC+SZ patients' inability to selectively encode their drug-use experience may limit and shape their subjective experience. of craving cocaine and motivation for cocaine use. Copyright 2004, Elsevier Science.
Nicotine use in schizophrenia and disinhibition.
Dervaux A; Bayle FJ; Laqueille X; Bourdel MC; Le Borgne MH; Olie JP et al. Psychiatry Research 128(3): 229-234, 2004. (35 refs.)
The role of personality in nicotine use has been little studied in patients with schizophrenia. The objectives of the present study were to compare impulsivity, sensation seeking and anhedonia in a group of schizophrenic patients with and without current cigarette smoking. One hundred patients with schizophrenia or schizoaffective disorder (DSM-III-R criteria) were assessed with the Positive and Negative Syndrome Scale, the Fagerstrom Scale, the Barratt Impulsivity Scale, the Zuckerman Seeking Sensation Scale, and the Chapman Physical Anhedonia Scale. Among these patients, 67% were current smokers. The mean scores for sensation seeking were higher in the group of smokers than in the group of nonsmokers. The differences were found exclusively with the "disinhibition" subscale. No significant difference was found for impulsivity and physical anhedonia mean scores. The scores on the Sensation Seeking Scale were especially low in nonsmokers. Cigarette smoking could influence disinhibition and possibly help to normalize inhibition in schizophrenic patients. Copyright 2004, Elsevier Science.
Incidence and clinical correlates of aggression and violence at presentation in patients with first episode psychosis.
Foley SR; Kelly BD; Clarke M; McTigue O; Gervin M; Kamali M; Larkin C; O'Callaghan E; Browne S. Schizophrenia Research 72(2-3): 161-168, 2005. (22 refs.)
This study aimed to identify the incidence and clinical correlates of aggression and violence in first episode psychosis. We prospectively recruited subjects with a first episode of DSM-psychosis presenting from a geographically defined catchment area to a secondary referral psychiatric service over a four-year period (n = 157). We used the Modified Overt Aggression Scale to retrospectively assess aggression (a hostile or destructive mental attitude, including verbal aggression, physical aggression and/or violence) and violence (the exercise of physical force), blind to diagnosis. One in three patients with psychosis was aggressive at the time of presentation. One patient in 14 engaged in violence that caused, or was likely to cause, injury to other people. Aggression was independently associated with drug misuse (odds ratio (OR) 2.80, 95% confidence interval 1.12-6.99) and involuntary admission status (OR = 3.62, 95% CI 1.45-9.01). Violence in the week prior to presentation was associated with drug misuse (OR = 2.75, CI 1.04 - 7.24) and involuntary admission status (OR = 3.21 CI 1.21-8.50). Violence in the week following presentation was associated with poor insight (OR 2.97, CI 1.03-8.56) and pre-contact violence (OR 3.82. CI 1.34-10.88). In patients with schizophrenia, violence in the week following presentation was associated with drug misuse (OR = 7.81, CI 1.33-45.95) and high psychopathology scores (OR = 20.59. CI 1.66-254.96). Overall, despite a high rate of verbal aggression, physical violence towards other people is uncommon in individuals presenting with first episode psychosis. Copyright 2005, Elsevier Science, Ltd.
Implementing integrated treatment for co-existing substance use and severe mental health problems in assertive outreach teams: Training issues.
Graham H. Drug and Alcohol Review 23(4): 463-470, 2004
This study sought to evaluate systematically training and implementation of a specific integrated treatment approach for co-occurring problem substance use and mental health within existing assertive outreach (AO) teams. The AO team was treated as a whole unit rather than as individual clinicians. They were provided with training and supervision to deliver a cognitive - behavioural integrated treatment approach. In a quasi-experimental time-lag design three teams were trained immediately and two others after an 18-month delay. There was evidence that teams acquired confidence and skills relevant to working with combined problems and that these gains were maintained over time. These results were replicated in the two teams trained after the delay. This study suggests that training mental health staff to use an integrated treatment approach is well received and produces lasting changes in confidence and skills. However, there are a number of issues related to staff training, shifting attitudes and implementation of integrated approaches into routine mental health practice. These issues are considered and suggestions made for staff training. Copyright 2004, Taylor & Francis.
Cannabis use and psychotic disorders: An update.
Hall W; Degenhardt L; Teesson M. Drug and Alcohol Review 23(4): 433-443, 2004. (86 refs.)
This paper evaluates three hypotheses about the relationship between cannabis use and psychosis in the light of recent evidence from prospective epidemiological studies. These are that: (1) cannabis use causes a psychotic disorder that would not have occurred in the absence of cannabis use; (2) that cannabis use may precipitate schizophrenia or exacerbate its symptoms; and (3) that cannabis use may exacerbate the symptoms of psychosis. There is limited support for the first hypothesis. As a consequence of recent prospective studies, there is now stronger support for the second hypothesis. Four recent prospective studies in three countries have found relationships between the frequency with which cannabis had been used and the risk of receiving a diagnosis of schizophrenia or of reporting psychotic symptoms. These relation-ships are stronger in people with a history of psychotic symptoms and they have persisted after adjustment for potentially confounding variables. The absence of any change in the incidence of schizophrenia during the three decades in which cannabis use in Australia has increased makes it unlikely that cannabis use can produce psychoses that would not have occurred in its absence. It seems more likely that cannabis use can precipitate schizophrenia in vulnerable individuals. There is also reasonable evidence for the third hypothesis that cannabis use exacerbates psychosis. Copyright 2004, Carfax Publishing.
Applicability of the Fagerstrom Test for Nicotine Dependence in smokers with schizophrenia.
Steinberg ML; Williams JM; Steinberg HR; Krejci JA; Ziedonis DM. Addictive Behaviors 30(1): 49-59, 2005. (34 refs.)
Up to 90% of individuals with schizophrenia smoke cigarettes, and many show signs of heavy dependence. Although the severity of nicotine dependence is often measured by the six-item Fagerstršm Test for Nicotine Dependence (FTND), this measure, in its current form, may not be as appropriate in this population-or in others who's smoking is regulated by others-as in the general population due to differences in smoking patterns, living arrangements, and daily routines. These factors may produce an underestimate of nicotine dependence, which may have clinical implications for successful medical detoxification if the FTND scores are used to guide the dosage of nicotine replacement medication. Data indicate poor internal consistency reliability (=.4581) and a factor pattern lacking simple structure (i.e., two nonmeaningful factors/components with substantial cross loadings) when administered to smokers with schizophrenia. Specific examples of problematic items and how these may contribute to an underestimate of tobacco dependence severity are discussed, as well as ways to modify the FTND to be more appropriate for this population. Copyright 2005, Elsevier Science Ltd.
Gender differences in response to homelessness services.
Rich AR; Clark C. Evaluation and Program Planning 28(1): 69-81, 2005. (62 refs.)
This study examines the importance of considering gender in evaluating the effectiveness of homelessness service interventions among solitary adults with severe mental illnesses. The participants received services in one of two types of evidenced-based homelessness intervention programs: a comprehensive housing program or a specialized case management program. Using a quasi-experimental research design with non-random assignment to conditions, we examined changes in housing status, mental health, substance use, quality of life and physical health from baseline to 6 and 12 months afterward. One hundred and fifty-two participants completed the baseline interview and 108 were available for at least one of the follow-up interviews. The results indicated that males had significantly greater reductions in homelessness in the comprehensive housing program than in the specialized case management program. whereas females showed a more complex pattern. Women in both programs showed significant reductions in homelessness, but females in the specialized case management program achieved greater stable housing time because women in the comprehensive housing program were more likely to have their time, in stable housing reduced by stays in psychiatric hospitals. We conclude that variables such as gender that have been shown to influence the etiology, nature, and course of homelessness should also be considered in evaluating the effectiveness of homeless services interventions. Copyright 2005, Elsevier Science, Ltd.
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