Carbon monoxide feedback in a motivational decision support system for nicotine dependence among smokers with severe mental illnesses.

Health concerns are common reasons for wanting to quit smoking among smokers with mental illnesses. Motivational interventions have used feedback from a carbon monoxide monitor to increase awareness of health concerns, but this device is not commonly available. Whether brief motivational interventions can be effective without this feedback is unknown. Using a randomized controlled trial, this study tested the effect of carbon monoxide feedback within a brief, multi-component, computerized motivational intervention among 124 smokers with schizophrenia or mood disorders. The main outcome was initiating cessation treatment over two months. Although participants in the carbon monoxide group increased their knowledge about the carbon monoxide, (χ(2)=6.97, df=1, p=.008), the main and secondary outcomes did not differ significantly between groups. Overall, 32% of participants initiated treatment. This study suggests that a computerized motivational decision support system can lead users to initiate cessation treatment, and that carbon monoxide feedback is not a necessary component.

Developing a quit smoking website that is usable by people with severe mental illnesses.

OBJECTIVE: Evidence-based treatments may be delivered in computerized, web-based formats. This strategy can deliver the intervention consistently with minimal treatment provider time and cost. However, standard web sites may not be usable by people with severe mental illnesses who may experience cognitive deficits and low computer experience. This manuscript reports on the iterative development and usability testing of a website designed to educate and motivate adults with severe mental illnesses to engage in smoking cessation activities. METHODS: Three phases of semi-structured interviews were performed with participants after they used the program and combined with information from screen-recorded usability data. T-tests compared the differences between uses of the first computer program version and a later version. RESULTS: Iteratively conducted usability tests demonstrated an increased ease of use from the first to the last version of the website through significant improvement in the percentage of unproductive clicking along with fewer questions asked about how to use the program. The improvement in use of the website resulted from changes such as: integrating a mouse tutorial, increasing font sizes, and increasing button sizes. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The website usability recommendations provide some guidelines for interventionists developing web tools for people who experience serious psychiatric disabilities. In general, insights from the study highlight the need for thoughtful design and usability testing when creating a website for people with severe mental illness.

Enrollment in supported employment services for clients with a co-occurring disorder.

OBJECTIVE: People with serious mental illnesses and co-occurring substance use disorders are often excluded from vocational services, despite the lack of evidence that having a substance use disorder prevents them from being able to work. This study explored enrollment in supported employment services among clients with and without co-occurring substance use disorders. METHODS: With data from electronic medical records from a psychiatric rehabilitation agency, relationships between co-occurring substance use disorders and supported employment were examined among 1,748 clients with serious mental illnesses who were consecutively admitted to the agency over a two-year period. RESULTS: Despite a similar interest in employment, clients with a co-occurring substance use disorder were 52% less likely than those without to enroll in a supported employment program. Those who were enrolled had similar competitive employment rates (25% for those with co-occurring disorders and 28% for those without). CONCLUSIONS: People with co-occurring substance disorders have reduced rates of enrollment in supported employment services.

An electronic decision support system to motivate people with severe mental illnesses to quit smoking.

OBJECTIVE: Rates of cigarette smoking are high among people with severe mental illnesses compared with the general population (45%-90% versus 20%). The authors developed a Web-based computer decision support system that is tailored for use by people with cognitive deficits and is designed to stimulate motivation to quit smoking by using evidence-based treatment. METHODS: This initial study used a quasi-experimental design to test the decision support system among a convenience sample of 41 smokers with severe mental illnesses. Researchers interviewed participants at baseline and two months later to assess for behaviors indicative of motivation to quit smoking. A negative binomial regression modeled the outcome and controlled for baseline group differences. RESULTS: Participants who used the decision support system were significantly more likely to show any behavioral motivation to quit smoking (such as meet with a clinician to discuss cessation, initiate cessation treatment, or otherwise attempt to quit) (67% versus 35%; χ(2)=4.11, df=41, p=.04). Further, using the decision support system increased by a factor of 2.97, or about 300%, the expected number of ways that a participant showed motivation. CONCLUSIONS: The encouraging results of this pilot study indicate that electronic decision supports may facilitate motivation to quit smoking and use of cessation treatment among people with severe mental illnesses.

Substance abuse relapse and factors associated with relapse in an inner-city sample of patients with dual diagnoses.

OBJECTIVE: This study documented rates of substance abuse relapse and explored factors associated with sustained remission among consumers with severe mental illness in a large, urban clinical sample. METHODS: Existing clinical records of consumers with severe mental illness and co-occurring substance use disorders who had achieved remission and who were interviewed at two or more subsequent follow-up points (12 months after remission) were reviewed. Consumers who relapsed within 12 months after remission were compared with those who maintained remission on demographic, clinical, and functional indicators. RESULTS: Of the 133 consumers who achieved remission, 91 (68 percent) had maintained remission at six-month follow-up, and 69 (52 percent) had maintained remission at 12-month follow-up. The strongest factors associated with maintenance of remission at 12 months were older age and living in Thresholds residential programs. Multivariate analysis showed that consumers who were older, held jobs, and lived in Thresholds residential programs at initial remission had a higher likelihood of maintaining remission at 12 months. To explore the potential impact of program dropout on the results, supplemental analyses using a third group without 12-month follow-up data were conducted. These analyses indicated that program dropouts were younger and less likely to live in Thresholds residential programs at initial remission. CONCLUSIONS: Age, therapeutic residential programming, and, to a lesser degree, employment appear to be potential factors to consider in the development of relapse prevention models.