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...on co-occurring disorders
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www.ProjectCork.org
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Winter 2007
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Cigarette smoking and overweight/obesity among individuals with serious mental illnesses: A preventive perspective. (review).
Compton MT; Daumit GL; Druss BG. Harvard Review of Psychiatry14(4): 212-222, 2006. (138 refs.)
Background: Cigarette smoking and lifestyle factors underlying overweight/obesity (such as unhealthy diet and physical inactivity) appear to play a major role in the excess medical morbidity and mortality among persons with serious mental illnesses. The literature on the prevalence, etiology, prevention, and treatment of these two risk factors, in the context of serious mental illnesses, are reviewed following a preventive approach. Methods: The review relied upon searches of the MEDLINE database, from 1996 through April 2006, restricted to the English language. Original research, review articles, and clinical guidelines relevant to the topics of cigarette smoking, unhealthy diet, physical inactivity, and overweight/obesity among individuals with serious mental illnesses were identified. Results: Compared to those without a mental illness, individuals with a current mental illness are more than twice as likely to smoke cigarettes and more than 50% more likely to be overweight/obese, presumably the product of unhealthy diet and physical inactivity. Various biological, iatrogenic, and social factors place psychiatric patients at risk for these and other adverse health behaviors. Studies suggest that many of the same preventive approaches developed for general medical populations are likely to be effective in persons with serious mental disorders, though specialized approaches also are needed. Domains of prevention include primary prevention (population-based strategies to reduce the incidence of these adverse health behaviors), secondary prevention (early detection and treatment), and tertiary prevention (pharmacological and psychosocial treatments to reduce the burden of illness among those with the behaviors in question). However, mental health clinicians commonly lack the training or expertise to provide these services. Conclusions: The high prevalence, adverse effects, and efficaciousness of treatments for smoking and obesity in persons with serious mental illnesses suggest the importance of addressing these problems in this population. Both further research and dissemination efforts are needed to ensure that patients with serious mental illnesses receive the appropriate preventive and clinical services for these two adverse health conditions. Copyright 2006, Harvard University.
Smoking as a complex but critical covariate in neurobiological studies of posttraumatic stress disorders: A review. (review).
Rasmusson AM; Picciotto MR; Krishnan-Sarin S. Journal of Psychopharmacology 20(5): 693-707, 2006. (168 refs.)
As smoking rates in the general population continue to fall in response to new information and changing social values, the continued high rate of smoking among persons with psychiatric disorders has caught the attention of society at many levels: public health officials, medical and mental health care providers, and concerned family members alike. As a consequence, research studies aimed at quantifying the problem and understanding its cause have increased dramatically over the past several years. The following review first examines epidemiological studies that have revealed a bidirectional causal relationship between tobacco dependence and posttraumatic stress disorder (PTSD), one of several mental health disorders in which tobacco dependence remains prevalent and resistant to intervention. Second. we use a translational neuroscience perspective to discuss possible neurobiological. mediators of the relationship between PTSD and tobacco dependence, hoping to spur further human and animal research that will elucidate pathogenetic mechanisms involved and inspire novel treatment interventions. Finally, to enable more effective clinical research in this area, we provide an overview of effective scientific methods for assessing and managing 'smoking status' as an experimental variable in clinical research studies of PTSD as well as other mental health disorders. Copyright 2006, Sage Publications.
Families of persons with substance use and mental disorders: A literature review and conceptual framework. (review).
Townsend AL; Biegel DE; Ishler KJ; Wieder B; Rini A. Family Relations 55(4): 473-486, 2006. (104 refs.)
There are significant knowledge gaps concerning the experiences of families of persons with co-occurring substance and mental disorders and the impact of families on treatment of individuals with these disorders. This paper presents a conceptual framework for examining family involvement of adults in treatment for co-occurring substance and mental disorders. An overview of the characteristics, problems, and needs of these individuals and their family members is presented. The extant literature pertaining to our conceptual framework is reviewed with focus on predictors of family involvement with clients, predictors of family member involvement in clients' treatment, and consequences of family involvement for client treatment outcomes. Gaps in the research literature and implications for future research and practice are discussed. Copyright 2006, National Council on Family Relations.
Development of a comprehensive measure to assess clinical issues in dual diagnosis patients: The Substance Use Event Survey for Severe Mental Illness
Bennett ME; Bellack AS; Gearon JS. Addictive Behaviors 31(12): 2249-2267, 2006. (61 refs.)
This paper provides a description of The Substance Use Event Survey for Severe Mental Illness (SUESS), a brief (20-30 min) interview that assesses clinical issues and domains that are relevant patients with substance use disorders and severe mental illness. First, we discuss the need for a new clinical measure for dual diagnosis patients, as well as our process of creating domains and items and developing the content of the assessment. Second, we provide a first look at the performance of the SUESS in a large sample of dually diagnosed patients from several large scale studies, including how patients responded to the instrument and their ability to complete the items. Third, we present initial reliability data on the SUESS. Finally, we include some initial validity data, including comparison of the self-report of substance use questions to urinalysis results, and verification of the service use information from medical record review. The SUESS appears to be a useful assessment that is tolerated and understood by dual diagnosis patients, and shows good preliminary reliability and validity. Copyright 2006, Elsevier Science.
Availability of integrated care for co-occurring substance abuse and psychiatric conditions
Ducharme LJ; Knudsen HK; Roman PM. Community Mental Health Journal 42(4): 363-375, 2006. (20 refs.)
The co-occurrence of psychiatric conditions and substance abuse presents significant challenges for behavioral healthcare providers. The need for integrated care has received substantial recent attention from clinical, research, and funding entities. However, the availability of integrated care has been low, carrying potential adverse implications for quality of care and treatment outcomes. This article describes the prevalence and key correlates of the availability of integrated care for co-occurring conditions within public and private-sector addiction treatment programs. Several organizational attributes, caseload characteristics, and service provision patterns were associated with the availability of integrated care. Copyright 2006, Kluwer Academic.
A 12-year follow-up study of psychiatric symptomatology among cocaine-dependent men.
Herbeck DM; Hser Y-I; Lu ATH; Stark ME; Paredes A. Addictive Behaviors 31(11): 1974-1987, 2006. (37 refs.)
This prospective longitudinal study examines patterns of psychiatric symptomatology among men admitted to treatment for cocaine dependence in 1988-1989. Study participants were interviewed at treatment intake, and at 1 year, 2 years and 12 years after treatment. The Hopkins Symptom Checklist-58 (SCL) and Natural History Interview were administered at the 4 time points. Of the 266 study participants interviewed at the 12-year follow-up, 138 (52%) had been cocaine abstinent for 5 years or more. Repeated measures ANOVA assessed changes in SCL scores over time for cocaine-abstinent and non-abstinent men. Both groups had similarly high mean SCL scores at treatment intake, and reductions in symptom severity 1 year after treatment. By 12-year follow-up, the abstinent group reported significantly lower SCL scores than the non-abstinent group on 4 of the 5 symptom measures. Additionally, cocaine-abstinent men reported lower rates of depressive and psychotic disorders, and lower use of psychopharmacologic and inpatient treatment than non-abstinent men. These findings suggest that severe psychiatric symptomatology persists among individuals unable to achieve a stable recovery from cocaine dependence. Copyright 2006, Elsevier Science.
The Beck Depression Inventory in patients undergoing opiate agonist maintenance treatment.
Hesse M. British Journal of Clinical Psychology 45(Part 3): 417-425, 2006. (28 refs.)
Background and objectives. The Beck Depression Inventory (BDI) is a widely used measure of depression severity in both research and clinical contexts. This study aimed at assessing its stability and associations with ongoing drug use in a sample of patients in opiate agonist maintenance treatment who were not abstinent from illicit drugs. Design and method. The study was a prospective, naturalistic study. Subjects in enhanced or standard psychosocial services along with opiate agonist maintenance treatment were administered the BDI and the European Addiction Severity Index (EuropASI) twice by research technicians, approximately 2 weeks after intake and at 18 months follow-up. Findings. There were rather small mean changes from intake to follow-up in the BDI, and mean-level stability in subjects was rather high as evidenced by a high intra-class correlation between intake score and follow-up score. The stability of the BDI was reduced at high levels of drug use severity at intake, and BDI was a moderate predictor of drug use severity at follow-up. Conclusions. The BDI measures a construct that is both stable and of predictive validity in a sample of non-abstinent opiate agonist maintenance patients, although very severe drug use at baseline appeared to reduce the stability of the BDI. Copyright 2006, British Psychological Society.
How successful is the dual diagnosis good practice guide?
Laker C. British Journal of Nursing 15(14): 787-790, 2006. (29 refs.)
Evidence from the US shows that integrated treatment programmes for dually diagnosed patients are more successful than parallel treatment programmes. In the UK the Dual Diagnosis Good Practice Guide (DDGPG, 2002), advocates a move towards an integrated system of care delivery. However, the paucity of evidence in the UK and the entrenched nature of the established mental health and addictions services means that current policy is derived from limited information and is struggling to address the process of change. By definition, dual diagnosis is a complex interaction between a range of mental health and substance misuse problems leading to difficulties in allocating appropriate skill mixes to teams. Ethical and legal issues in the mental health services cause conflict with the treatment concepts for substance misuse. The advent of the DDGPG is positive, but there is a clear need for further work in this area. Copyright 2006, Mark Allen Publishing.
Recent-onset ecstasy use: Association with deviant behaviors and psychiatric comorbidity.
Martins SS; Mazzotti G; Chilcoat HD. Experimental and Clinical Psychopharmacology 14(3): 275-286, 2006. (74 refs.)
Background: Despite increases in ecstasy (MDMA) use in the United States, little is known about characteristics linked with recent-onset ecstasy use, especially psychiatric symptoms and deviant behaviors. Aims: To test whether individuals with high levels of other drug use are more likely to be recent-onset ecstasy users; to test whether psychiatric symptoms in adults are associated with recent-onset ecstasy use; to explore the association between recent-onset ecstasy use and concomitant deviant behaviors in adolescents and adults. Methods: Data from the 2001 National Survey on Drug Use and Health. Findings: Recent-onset ecstasy use was significantly more likely to occur among adolescents and adults (18-34 years old) who engaged in deviant behaviors during the past year as compared with those who did not. Higher levels of deviancy indicated a higher likelihood of being a recent-onset ecstasy user, and associations were strongest with nonviolent deviant behaviors such as selling illegal drugs and stealing. Associations between deviant behaviors and recent-onset ecstasy use were similar in strength to associations between deviant behaviors and recent-onset cocaine and marijuana use, respectively. Adults who had past-year psychiatric symptoms (both depressive and panic symptoms) were twice as likely to be recent-onset ecstasy users as compared with those without past-year psychiatric symptoms. Greater levels of drug involvement increased the odds of being a recent-onset ecstasy user. Conclusion: Recent-onset ecstasy use seems to be associated with a range of other behavioral problems and may reflect one aspect of a larger problem behavior syndrome. Copyright 2006, American Psychological Association.
Lifetime psychiatric comorbidity of alcohol dependence and bulimia nervosa in women
Duncan AE; Neuman RJ; Kramer JR; Kuperman S; Hesselbrock VM; Bucholz KK. Drug and Alcohol Dependence 84(1): 122-132, 2006. (47 refs.)
Previous work from our group revealed two groups of women with bulimia nervosa (BN), one with, and one without alcohol dependence (AD). The current study sought to determine whether women with lifetime BN and AD (BN+AD+) were more similar to women with BN and no AD (BN+AD-) or to women with AD and no BN (BN-AD+) in terms of lifetime psychiatric comorbidity and psychological functioning. Data on BN and AD from 407 female relatives in a family study of alcoholism were used to create three mutually exclusive groups: BN+AD+ (n = 30), BN+AD- (n = 55), and BN-AD+ (n = 322). Bivariate analyses revealed fewer differences between BN+AD+ and BN-AD+ women than between BN+AD+ and BN+AD- women. BN+AD+ women were more likely than BN+AD- women to have drug dependence, conduct disorder, and suicidality, and were more likely to have major depression, lower GAF scores, and to engage in unsafe sex than both BN+AD and BN-AD+ women. After adjusting for other psychopathology and demographic variables, BN+AD+ women were more likely than BN+AD women to have major depression, drug dependence, and tobacco dependence and more likely than BN-AD+ women to have major depression and obsessive-compulsive disorder. These results suggest that BN+AD+ women exhibit more severe psychopathology than either BN+AD- or BN-AD+ women and may represent a distinct subgroup within bulimia nervosa or alcohol dependence. Copyright 2006, Elsevier Science.
Treating homeless clients with severe mental illness and substance use disorders: Costs and outcomes.
Morse GA; Calsyn RJ; Klinkenberg WD; Helminiak TW; Wolff N; Drake RE et al. Community Mental Health Journal 42(4): 377-404, 2006. (44 refs.)
This study compared the costs and outcomes associated with three treatment programs that served 149 individuals with dual disorders (i.e., individuals
with co-occurring severe mental illness and substance use disorders) who were homeless at baseline. The three treatment programs were: Integrated Assertive Community Treatment (IACT), Assertive Community Treatment only (ACTO), and standard care (Control). Participants were randomly assigned to treatment and followed for a period of 24 months. Clients in the IACT and ACTO programs were more satisfied with their treatment program and reported more days in stable housing than clients in the Control condition. There were no significant differences between treatment groups on psychiatric symptoms and substance use. The average total costs associated with the IACT and Control conditions were significantly less than the average total costs for the ACTO condition. Copyright 2006, Kluwer Academic.
Addiction treatment services and co-occurring disorders: Prevalence estimates, treatment practices, and barriers.
McGovern MP; Xie HY; Segal SR; Siembab L; Drake RE. Journal of Substance Abuse Treatment 31(3): 267-275, 2006. (33 refs.)
As the model for treating co-occurring disorders in addiction treatment settings becomes articulated, service systems need data on prevalence, current practice, and barriers to the implementation of evidence-based practices. A self-report survey was administered to 45 3 addiction treatment providers (43 agency directors, 110 clinical supervisors, and 300 clinicians) from a single state system of care. Data on prevalence estimates, treatment practices, and barriers to implementing services for co-occurring disorders were obtained. The three groups estimated that several co-occurring disorders were extremely common: mood disorders (40%-42%), anxiety disorders (24%-27%), posttraumatic stress disorder (24%-27%), severe mental illnesses (16%-21%), antisocial personality disorder (18%-20%), and borderline personality disorder (17%-18%). Practice patterns for patients with these co-occurring disorders differed widely, from referral to mental health programs to provision of integrated treatment. Common barriers to providing services to persons with co-occurring disorders were lack of psychiatric personnel and resources. Comprehensive surveys of an addiction treatment service system can rapidly and economically produce estimates of prevalence, current practices, and barriers to evidence-based practices. This objective information is critical for systems intending to enhance services to persons with co-occurring disorders. Copyright 2006, Elsevier Science.
What are the policy implications of the evidence on cannabis and psychosis? (review).
Hall W; Degenhardt L. Canadian Journal of Psychiatry 51(9): 566-574, 2006. (82 refs.)
Objective: To explore the implications for mental health services, for health education about the risks of cannabis use, and for public policy toward cannabis use of observational evidence that cannabis use is a contributory cause of psychosis. Method: We considered the relation between observational evidence and action on cannabis. We examined arguments on the grounds of public health prudence for discouraging cannabis use by young individuals. With the assumption that the relation may be causal, we considered recommendations for policy in mental health services, health education, and public policy toward cannabis. Results: The observational evidence and biological plausibility of the hypothesis that cannabis is a contributory cause of psychosis is at least as strong as evidence for causal relations between heavy alcohol and amphetamine use and psychosis. On public health grounds, there is a good case for discouraging cannabis use among adolescents and young adults. It remains uncertain how best to discourage use and to whom campaigns ought be targeted. Conclusions: We should discourage young adults seeking treatment in mental health services from using cannabis and inform them of the probable mental health risks of cannabis use, especially of early and frequent use. We must exercise caution in liberalizing cannabis laws in ways that may increase young individuals' access to cannabis, decrease their age of first use, or increase their frequency of cannabis use. We should consider the feasibility of reducing the availability of high-potency cannabis products. Copyright 2006, Canadian Psychiatric Association.
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