Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder: a clinical trial

Neural correlates of saccade planning in 6-month-old infants were investigated by high-density event-related potentials. Subjects made saccades to a target stimulus following a time gap from fixation stimulus offset (gap trials) or with the fixation stimulus still present (overlap trials). Like adults, infants were slower to make a saccade to the target when the fixation stimulus was still present. Strikingly, infants did not show clear evidence of the pre-saccadic components observed in adults which are thought to reflect cortical saccade planning processes. They did, however, show a left frontal positivity, which we suggest reflects cortical disinhibition of the colliculus initiated by fixation stimulus offset, and clear post-saccadic lambda waves. These results indicate that the frontal cortex already plays a role in action control by 6 months of age, while other aspects of cortical action planning may not yet be present in certain task situations.     

Assessing substance use disorder in persons with severe mental illness

Assessment of dually diagnosed patients consists of three steps: detection, diagnosis, and specialized assessment for treatment planning. Each of these is informed by recent research.     

Gender differences in homeless persons with schizophrenia and substance abuse

The purpose of this study was to test the generalizability of previous research on gender differences between men and women with co-occurring schizophrenia and substance abuse. One hundred eight patients with schizophrenia or schizo-affective disorder involved in a study of treatment for homeless persons were interviewed for information regarding substance use, social functioning and support, comorbid disorders, victimization, medical illness, and legal troubles. We found that women had more children and were more socially connected than men. Women also had higher rates of sexual and physical victimization, comorbid anxiety and depression, and medical illness than men. We conclude that homeless women with dual disorders, like women with substance use disorders in the general population, have distinct characteristics, vulnerabilities, and treatment needs compared with men. In addition to comprehensive treatment of psychiatric and substance use disorders, gender-specific services should be developed, including prevention and treatment of victimization and related problems as well as help with accessing medical services.     

Mental illness and substance use among sheltered homeless persons in lower-density population areas

OBJECTIVE: The prevalence of mental illness and substance abuse in homeless populations has been studied primarily in large urban areas. This study examines a sheltered homeless population in two counties of lower-density population, Dauphin and Cumberland counties in central Pennsylvania, to assess the prevalence of mental illness and substance abuse. METHODS: A total of 81 homeless adults from nine emergency shelters were interviewed using a structured questionnaire. RESULTS: The estimated lifetime prevalence rate of major depressive disorder was 26.6 percent; 6.4 percent of the sample showed evidence of psychotic thinking. Almost one-third reported previous hospitalization for emotional problems, and about one-third reported a suicide attempt. The estimated lifetime prevalence rate of alcohol or drug abuse or dependence was almost 60 percent. CONCLUSIONS: Although mental illness, especially psychosis, and substance abuse may be somewhat less prevalent among homeless persons in lower-density population areas than in large urban areas, they are nevertheless significant problems.     

Longitudinal assessment of inpatient use and functioning of seriously mentally ill veterans with and without co-occurring substance use disorders

Within a fungal species, a subset of individuals may have more than the minimal complement of chromosomes. If the extra chromosomes are composed primarily of DNA not found in all representatives of the species, they are most appropriately referred to as supernumerary chromosomes. The patterns of repeated DNA sequences on certain supernumerary chromosomes suggest that they have a different evolutionary history from the essential chromosomes in the same genome. Supernumerary chromosomes can carry functional genes and, in at least two fungal species, genes on such chromosomes play important roles in host-pathogen interactions. Supernumerary chromosomes that confer an adaptive advantage in certain habitats, such as the ability to cause disease on a specific host, may be referred to as "conditionally dispensable" chromosomes in order to reflect their importance in some, but not all, growth conditions. In addition to describing the structural and functional characteristics of known supernumerary chromosomes in fungi, this review discusses the relative merits of the terms that have been used to describe them, and establishes experimental criteria for their identification.     

Multisite randomized trial of behavioral interventions for women with co-occurring PTSD and substance use disorders.

The authors compared the effectiveness of the Seeking Safety group, cognitive–behavioral treatment for substance use disorder and posttraumatic stress disorder (PTSD), to an active comparison health education group (Women’s Health Education [WHE]) within the National Institute on Drug Abuse’s Clinical Trials Network. The authors randomized 353 women to receive 12 sessions of Seeking Safety (M = 6.2 sessions) or WHE (M = 6.0 sessions) with follow-up assessment 1 week and 3, 6, and 12 months posttreatment. Primary outcomes were the Clinician Administered PTSD Scale (CAPS), the PTSD Symptom Scale–Self Report (PSS-SR), and a substance use inventory (self-reported abstinence and percentage of days of use over 7 days). Intention-to-treat analysis showed large, clinically significant reductions in CAPS and PSS-SR symptoms (d = 1.94 and 1.12, respectively) but no reliable difference between conditions. Substance use outcomes were not significantly different over time between the two treatments and at follow-up showed no significant change from baseline. Study results do not favor Seeking Safety over WHE as an adjunct to substance use disorder treatment for women with PTSD and reflect considerable opportunity to improve clinical outcomes in community-based treatments for these co-occurring conditions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The impact of assertive community treatment on the social relationships of people who are homeless and mentally ill

Two randomized experiments compared the effectiveness of the assertive community treatment (ACT) team against other treatments (outpatient therapy, drop-in center, and brokered case management) in improving the social relationships of individuals who were both homeless and suffered from severe and persistent mental illness. In both studies clients assigned to ACT teams reported having more professionals in their social networks than clients assigned to the other treatments. Clients did not report significant differences between treatment conditions on most of the other social relationship dimensions. Further attention to developing social skills and network interventions within ACT teams are recommended.     

Course of psychiatric and substance abuse syndromes co-occurring with bipolar disorder after a first psychiatric hospitalization

BACKGROUND: Patients with bipolar disorder frequently meet criteria for other psychiatric and substance abuse diagnoses. To clarify relationships among these disorders, the authors examined the course of syndromes co-occurring with bipolar disorder for 12 months after a first hospitalization. METHOD: Seventy-seven patients were recruited from consecutive inpatient admissions who met DSM-III-R criteria for bipolar disorder, manic or mixed with psychosis. The 12-month syndromal course of co-occurring DSM-III-R alcohol and drug abuse disorders, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and other anxiety disorders were longitudinally recorded. RESULTS: The rates of all syndromes, except other anxiety disorders, were elevated. OCD demonstrated an interval course that frequently mirrored the course of the bipolar disorder. The courses of PTSD and substance abuse syndromes were separate from that of the bipolar disorder in many of those with both syndromes. Alcohol and drug abuse syndromes were strongly correlated. CONCLUSION: The obsessive-compulsive syndrome may represent an alternative expression of bipolar disorder in some patients. In contrast, PTSD appears to represent a truly separate disorder, which is possibly more prevalent in bipolar patients due to a shared risk factor. Substance abuse does not appear to simply result from attempts at self-medication or from the impulsivity of mania. These results suggest that future studies examining the course of syndromes co-occurring with bipolar disorder are warranted.     

Gender differences in psychiatric comorbidity among adolescents with substance use disorders.

The authors examined gender differences in rates of comorbid psychiatric disorders among adolescents with 1 or more psychoactive substance use disorders. Baseline diagnostic data were obtained from 135 adolescents, ages 12 to 19, and their parents-guardians, who participated in a study to develop and efficacy test Integrated Family and Cognitive-Behavioral Therapy. Rates of attention-deficit/hyperactivity disorder and conduct disorder were higher among drug-abusing male adolescents compared with drug-abusing female adolescents. However, high rates of disruptive behavior disorders also characterized drug-abusing female adolescents. Similarly, drug-abusing female adolescents exhibited a higher rate of major depression compared with drug-abusing male adolescents. However, rates of dysthymia, double depression (i.e., major depression and dysthymia), and bipolar disorder were equivalent between genders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cost-effectiveness of assertive community treatment teams

The long cane can be used as a mobility aid for visually handicapped people. According to a questionnaire completed by Japanese cane users, it seems they are not always satisfied with using long canes for a variety of reasons. In this study, hand-transmitted vibration from the long cane due to tapping the ground was measured because an exposure to repeated shock-type tapping vibration may affect the hand-arm system. A sighted female wearing a blindfold participated. The measurement was carried out in different conditions with three different ground materials both indoor and outdoors. The vibration at three axes of the cane grip and one axis at the wrist were measured. The pinch forces between an index finger and the grip were also measured using a strain gauge in order to observe how the vibration characteristics depend on the changing forces. Measurement, evaluation and assessment were based on the International Standard (ISO 5349). The estimated daily exposure time and the transmissibility were obtained in order to investigate the severity of the hand-transmitted vibration caused by the long cane. It was found that the characteristics of tapping vibration depend on different measurement conditions and the vibration might be associated with a health risk over a long life span.     

Program fidelity in assertive community treatment: development and use of a measure

Assertive community treatment (ACT) is a complex community-based service approach to helping people with severe mental disorders live successfully in the community. Effective replication of the model and research on critical elements require explicit criteria and measurement. A measure of program fidelity to ACT and the results of its application to fifty diverse programs are presented.     

Overdiagnosis of major psychiatric disorders in individuals with substance use disorders and personality disorders: the downside of the Woodruff principle

Major vascular injury can result during use of the Ilizarov technique for lower extremity limb lengthening. Vascular reconstruction may be accomplished while leaving the external fixation ring in place. Continued distraction is made possible by leaving sufficient redundancy in the vascular graft.     

Clinical implications of the co-occurrence of substance use and other psychiatric disorders.

The co-occurrence of substance use and psychiatric disorders is the rule rather than the exception in mental health and substance use treatment settings across the United States. Such co-occurrence may call for special assessment and evaluation procedures, modified treatment plans, and specialized follow-up. Treatment of co-occurrence of substance abuse and psychiatric disorders requires more cross-disciplinary collaboration; greater integration of substance use, mental health, and social services treatment approaches; and modifications in the training of care providers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Long-term patterns of service use and cost among patients with both psychiatric and substance abuse disorders

OBJECTIVES: This is a longitudinal study designed to determine: (1) if patients dually diagnosed with psychiatric and substance abuse disorders incur higher health care costs than other psychiatric patients and (2) if higher costs can be attributed to particular subgroups of the dually diagnosed or types of care. METHODS: Two cohorts of veterans treated in Veterans Affairs mental health programs at the start of fiscal year 1991 were followed for 6 years: one cohort of inpatients (n = 9,813) and the other of outpatients (n = 58,001). Data were analyzed on utilization of all types of Veterans Affairs health care. Repeated measures analysis of variance was used to examine cost differentials between dually diagnosed patients and other patients. RESULTS: Dually diagnosed outpatients incurred consistently higher health care costs than other psychiatric outpatients, attributable to higher rates of inpatient psychiatric and substance abuse care; however, this difference decreased with time. Costs were substantially higher in the inpatient cohort overall, but there were no differences in cost between dually diagnosed and other patients. CONCLUSIONS: In an atmosphere of cost cutting and moves toward outpatient care, the dually diagnosed may lose access to needed mental health services. Possibilities of developing more intensive outpatient services for these patients should be explored.     

Evaluation of methods for detecting substance use disorder in persons with severe mental illness.

Substance use disorders are frequently undiagnosed in psychiatric settings. One possible reason for this underdiagnosis is the lack of screening procedures designed or validated specifically for psychiatric patients. To evaluate the utility of current detection methods, (a) criterion diagnoses were established of alcohol use disorder and drug (cannabis or cocaine) use disorder on 320 patients with severe mental illness recently admitted to a psychiatric hospital, using a combination of structured diagnostic interviews and clinician ratings, and (b) the classification accuracy of several substance abuse measures developed for the general population was examined. For this particular sample, demographic variables, clinical variables, medical exams, laboratory tests, and collateral reports did not yield accurate detection. Screens based on self-report were superior to these other approaches but still yielded modest sensitivity. The results suggest that many individuals are classified incorrectly with current techniques. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Trajectories of change in adolescent substance use and symptomatology: Impact of paternal and maternal substance use disorders.

The effects of paternal and maternal substance use disorders (SUDs) on trajectories of change in adolescent offspring nicotine, alcohol, and drug use and symptomatology were investigated in a population-based sample of adolescent twins (N = 1,514). Adolescent and parental substance phenotypes were assessed when most adolescents were 11 years old, with 2 assessments of adolescents approximately every 3 years thereafter. Growth curves were fit using hierarchical linear modeling. Results indicated acceleration of substance involvement during adolescence, particularly for boys. Paternal and maternal SUD were each associated with more extreme trajectories. There was evidence for an additive, rather than interactive, combined parental effect. Findings help clarify the impact of paternal and maternal SUD on the development of substance involvement during adolescence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Kinds of therapy for persons with psychiatric disorders and their families

The paper presents a 17-year-old girl with a big trichobezoar in the stomach, diagnostic and treatment proceeding. In our opinion upper GI tract endoscopy is the most useful adjunct to the diagnosis of all types of stomach besoars.     

Methodological innovation to increase the utility and efficiency of psychotherapy research for patients with co-occurring mental health and substance use disorders.

Psychotherapy research with chronic and difficult-to-treat populations, such as those with co-occurring mental health and addictive disorders, can employ flexible research designs, which allow for a systematic yet nonlinear relationship between efficacy and effectiveness designs. Outcomes research can bypass the efficacy-effectiveness dichotomy through use of a hybrid model (Carroll & Rounsaville, 2003) conducted in the context of community treatment settings in collaboration with community providers. We present the case for using this methodological approach as a means of advancing psychotherapy research and practice, while translating and disseminating empirically supported treatments with more efficiency. A hybrid model study conducted within the National Institute on Drug Abuse’s Clinical Trials Network illustrates the application. These findings inform new directions for future research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Physical and mental comorbidity of substance use disorders in psychiatric consultations. European Consultation-Liaison Workgroup

Comorbidity of substance use disorders with physical and mental disorders was investigated among 1249 consecutive psychiatric consultation patients admitted to six general hospitals in Finland. Of the patients 354 (28%) were diagnosed with substance use disorders (ICD-10), of which 22% were due to use of at least two different types of psychoactive substances. Alcohol dependence (117/226) in male patients and acute drug intoxication (49/128) at a similar rate as alcohol dependence (44/128) in female patients were the most common clinical conditions. With few exceptions, all substance use disorders were comorbid and in 63% of affected patients comprised a "triple diagnosis" (i.e., physical, mental, and substance use diagnoses concurrently). Poisonings and personality disorders in both sexes, digestive system diseases in men, and injuries in women were related to substance use disorders. Conclusions for service provision were: (1) the high level of co-occurrence of physical and mental disorders with substance use disorders calls for comprehensive, multi-disciplinary assessment of any substance use problems ascertained in psychiatric consultations; (2) poisoning with substance use involvement and mental comorbidity was the most common combined clinical condition justifying provision of addiction psychiatric emergency consultations in general hospitals; (3) polydrug use indicating severe problems and complex treatment needs should be identified; and (4) psychiatric referrals of patients with physical alcohol-related disorders should be ensured in general hospitals.     

The helping alliance in case management for homeless persons with severe mental illness

This study examined the role of the helping alliance in case management with homeless persons who have a severe mental illness. A strong alliance after two months of treatment was marginally associated with three outcomes: higher consumer satisfaction, less severe global symptom severity, and greater hostility. The only outcome associated with the alliance after fourteen months of treatment was consumer satisfaction. Several variables predicted a strong helping alliance at month two, including: being African American, low hostility, more perceived needs, and more program contacts. The only variable that predicted a strong alliance at month fourteen was a strong alliance at month two.