Reliability and clinical utility of DSM-IV substance-induced psychiatric disorders in acute psychiatric inpatients.

The goal of his study was to evaluate in 1,951 acute psychiatric inpatients the reliability, construct, convergent, and predictive validity of substance-induced psychiatric syndrome ratings made by clinical attending pschiatrists. The primary admitting condition for each subject was categorically rated by clinical attendings as not, mildly, moderately, or mostly substance-induced at both admission and discharge. Individual substance categories were associated with characteristic demographic, clinical treatment response, and length of stay, findings indicating good construct, predictive validity, and clinical utility. A linear dimensional approach to rating substance-induced syndromes in acute clinical populations may be preferable to the simple dichotomous approach used in DSM-IV.

Nefazodone treatment of major depression in alcohol-dependent patients: a double-blind, placebo-controlled trial.

Depression is the most common comorbid psychiatric illness in patients with alcohol dependence. This double-blind study tested the efficacy of nefazodone versus placebo for the treatment of depression in actively drinking alcohol-dependent patients who were also participating in weekly group treatment for alcoholism. Sixty-four subjects with major depression disorder and alcohol dependence with a history of at least one prior episode of depression when not drinking were randomly assigned to receive 12 weeks of either nefazodone or placebo and participated in a weekly psychoeducational group on alcoholism. Subjects were assessed every 2 weeks for depression, anxiety, side effects, and drinking frequency. Subjects taking nefazodone were significantly more likely to complete the study (62%) than those taking placebo (34%). Analyses of covariance using drinks per week as a time-dependent covariate showed lower Hamilton Rating Scale for Depression scores at week 8 for end-point analysis and at weeks 8 and 12 for completers. The endpoint analysis demonstrated a significantly greater response in the nefazodone group (48%) than in the placebo group (16%). Both groups showed a similarly significant decrease in the average number of alcoholic drinks consumed per day over the course of the study. Although the number of adverse effects was significantly greater for the nefazodone group, there were no severe adverse events, and nefazodone was well tolerated. Nefazodone is a safe and effective antidepressant to use in a population of alcohol-dependent patients with depression who have a high degree of comorbidity. Nefazodone treatment was superior to placebo in alleviating depression in these patients but did not add any advantage over the psychoeducational group in terms of drinking outcomes.

Shorter hospital stays and more rapid improvement among patients with schizophrenia and substance disorders.

OBJECTIVE: Length of stay and treatment response of inpatients with acute schizophrenia were examined to determine whether differences existed between those with and without comorbid substance-related problems. METHODS: The sample comprised 608 patients with a diagnosis of schizophrenia or schizoaffective disorder treated on hospital units with integrated dual diagnosis treatment. They were rated on admission and discharge by a psychiatrist using a structured clinical instrument. Patients with no substance-related problems were compared with those with moderate to severe problems using t tests, chi square tests, and analysis of variance. RESULTS: When analyses controlled for age, gender, and other clinical variables, dually diagnosed patients were found to have improved markedly faster compared with patients without a dual diagnosis. Their hospital stays were 30 percent shorter on both voluntary and involuntary units. They also showed somewhat greater symptomatic improvement and no increase in 18-month readmission rates. On admission the dual diagnosis group was more likely to be younger, male, and homeless and more likely to be a danger to self and others. Severity of psychosis was the same at admission for the two groups, but the dually diagnosed patients were rated as less psychotic at discharge. CONCLUSIONS: Dually diagnosed patients with schizophrenia appear to stabilize faster during acute hospitalization than those without a dual diagnosis. The authors hypothesize that substance abuse may temporarily amplify symptoms or that these patients may have a higher prevalence of better-prognosis schizophrenia. The availability of integrated dual-focus inpatient treatment and a well-developed outpatient system may also have helped these patients recover more rapidly.

Treatment satisfaction compared with outcome in severe dual disorders.

This paper examines patient (N = 75) ratings of treatment satisfaction and outcome for severely mentally ill dually diagnosed outpatients participating in long-term integrated dual focus treatment. In addition, it compares these ratings with case manager ratings of patient outcome over a one year period. Satisfaction ratings ranged from very good to excellent. Combined means of several outcomes ratings indicated that most patients rated themselves as improved. Satisfaction with over-all care and with case management was significantly, though weakly (r = .3 and .31, respectively, p < .05), related to patient ratings of overall outcome. While most patients rated that they had improved, satisfaction with treatment was only weakly related to either patient or case manager rated clinical outcomes. These findings indicate the relatively independent relationship of satisfaction with treatment outcome and caution against over generalizing the meaning of treatment satisfaction measures.

Assertive Community Treatment for patients with chronic and severe mental illness who abuse drugs.

The Assertive Community Treatment model of mental health service delivery has been extensively studied and has undergone various modifications over the past twenty years. This article describes a modified ACT Team approach to the treatment of individuals who suffer from severe comorbid mental illness and substance abuse. Demographics of patients who are chosen to receive these intensive services, service utilization patterns, and elements of team treatment are discussed. Comparisons with less severely ill dual diagnosis patients who receive more traditional case management services are reviewed.

Predictors and outcome of discharge against medical advice from the psychiatric units of a general hospital.

OBJECTIVE: The study examined predictors of discharge against medical advice (AMA) and outcomes of psychiatric patients with AMA discharges, as measured by poorer symptom ratings at discharge and higher rates of rehospitalization. METHODS: A total of 195 patients discharged AMA from general hospital psychiatric units were compared retrospectively with 2,230 regularly discharged patients. AMA status was defined as signing out against medical advice, being absent without leave, or being administratively discharged. All patients received standardized assessments within 24 hours of admission and at discharge. Demographic characteristics, psychiatric history, DSA-IV psychiatric and substance use diagnoses, and scores on an expanded 32-item version of the Psychiatric Symptom Assessment Scale were compared. RESULTS: The groups did not differ in primary psychiatric diagnoses. Patients discharged AMA were significantly less likely to be Caucasian or to be functionally impaired due to physical illness. They were more likely to live alone, have a substance use diagnosis, use more psychoactive substances, and have more previous hospitalizations. Patients discharged AMA had significantly shorter lengths of stay, higher rehospitalization rates, and more severe symptoms at discharge, even when length of stay was taken into account. The differences between the groups in male gender and young age were better accounted for by a greater likelihood of substance abuse in these groups. CONCLUSIONS: The results suggest a profile of patients who may be discharged AMA. Such patients have worse outcomes and are more likely to be high utilizers of inpatient resources. Aggressive identification of patients likely to be discharged AMA and early discharge planning for appropriate outpatient treatment are recommended.

Use of anticonvulsants in benzodiazepine withdrawal.

The problem of dependence on benzodiazepines has been aggravated by iatrogenic physiologic dependence on these medications and by polysubstance abusing patients using them in addition to other agents. A safe, rapid, and effective way to detoxify patients from benzodiazepines is of prime importance to facilitate further treatment of their psychiatric or substance use disorder. Patients withdrawing from these agents may experience physiologic withdrawal, rebound, and recurrence. In this paper the authors review the typical syndrome associated with withdrawal from benzodiazepines and discuss treatment of benzodiazepine withdrawal using carbamazepine and valproate.

Managing disability benefits as part of treatment for persons with severe mental illness and comorbid drug/alcohol disorders. A comparative study of payee and non-payee participants.

The objective of this pilot study is to describe the use of a Social Security representative payee program as a clinical intervention integrated into long-term, dual-disorder treatment of severely mentally ill outpatients with comorbid drug/alcohol disorders. Compared with non-payees, patients selected to be payee participants were more likely to be male, have a diagnosis of schizophrenia, have a history of high inpatient utilization, and have higher current ratings of psychiatric symptoms, substance use, and functional disability. Despite these higher severity ratings, which usually predict poor outpatient compliance and higher rate of adverse outcomes, the payee participants attended about twice the number of outpatient service sessions as non-payees and were no more likely to be currently homeless, hospitalized, or incarcerated. The payee intervention is described, and ethical and research issues are discussed.

Determinants of suicidal ideation: the role of substance use disorders.

BACKGROUND: This study tested the hypothesis that the amount of psychoactive substance consumed (frequency and/or quantity), life problems resulting from this use, and a DSM-IV diagnosis of substance abuse/dependence are independent risk factors associated with increased suicidal ideation in a population of psychiatric inpatients with major depressive disorder. METHOD: 891 hospitalized patients with a primary diagnosis of nonpsychotic major depressive disorder (MDD) received a standardized, psychiatrist-administered assessment battery. To examine the relationship between admission suicidality and demographic, psychiatric history, and admission variables, chi-square analyses were used for categorical data and one-way ANOVAs were used for continuous indices. Stepwise hierarchical multiple regression analyses were performed to determine the set of variables that was independently related to admission suicidality level. RESULTS: There was general agreement between our findings and previous literature in regard to the association between severity of Axis I diagnosis, depressed mood, hopelessness, male gender, unemployment, involuntary treatment, and alcohol/drug problems and higher suicidal ideation. In our sample of hospitalized patients with unipolar major depressive disorder, higher current drug and/or alcohol dependency and high current use of alcohol or other substances of abuse were independently associated with higher levels of suicidal ideation. CONCLUSION: This association with higher suicidal ideation lends support to the importance of treating patients for both alcohol/drug problems and depression in an effort to decrease their risk for future suicide. We hope that our findings will improve the care that patients with dual diagnoses receive.

Representative payee practices of community mental health centers in Washington State.

OBJECTIVE: A survey was conducted to evaluate the representative payee practices of community mental health centers (CMHCs) in Washington State, with emphasis on whether and how benefit disbursement practices were linked to patients' clinical behaviors, especially substance use. METHODS: A survey was pilot tested with several clinicians and sent to all 80 licensed CMHCs in Washington State. Data were analyzed using t tests, Pearson r correlations, and regression analysis. RESULTS: Of 41 responding agencies, 30 (73 percent) reported providing payee services for at least some of their patients, approximately one-third of whom had a dual diagnosis of a mental illness plus an alcohol or drug disorder. The frequency of benefit disbursement, but not the overall amount of funds disbursed, was moderately to highly linked by contingency management to patients' money management skills, substance use, and level of functioning; it was less tightly linked to treatment attendance. Larger and more experienced programs reported tighter linkage between benefit disbursement frequency and patients' behavior than did smaller programs. Responses also indicated a significant need for more clearly articulated guidelines for payee benefit management. CONCLUSIONS: Despite a lack of studies demonstrating the effectiveness of representative payee practices, CMHCs appear to be using contingency techniques to link benefit disbursement to clinical behaviors. Further studies of these practices, their outcomes, and associated ethical issues are needed.

Illness severity and treatment services for dually diagnosed severely mentally ill outpatients.

This study of a frequently endorsed, but untested, model of outpatient treatment for persons with coexisting severe mental illness and substance use disorders assessed how the amount of treatment services delivered was related to an individual's global severity of illness, whether different modes of treatment were related to different aspects of illness, how noncompliance with treatment was related to the severity of illness and amount of services delivered, and how the diagnosis of schizophrenia/schizoaffective influenced these issues. Participants with high total severity of illness (TSI) received about twice the number of appointments (20.7 vs. 12.3) per month as those with low TSI scores. Higher TSI was also related to a DSM-IV diagnosis of schizophrenia/schizoaffective, being in a lower "phase" of treatment, representative payee benefit management, homelessness, and more hospitalizations. Participants with higher psychiatric symptom severity received significantly more case management and medication services, but not group therapy or day treatment. Severity of substance use condition was significantly related only to case management. This model of treatment was found to be successful in delivering higher levels of treatment services to those needing them.

The CAGE questionnaire and the Short Michigan Alcohol Screening Test in trauma patients: comparison of their correlations with biological alcohol markers.

STUDY OBJECTIVES: To explore and compare the sex-specific correlation of two standard behavioral screening instruments, the Short Michigan Alcohol Screening Test (SMAST) and the CAGE, with a weighted scale that combines the three most commonly used biological alcohol markers (blood alcohol level, mean corpuscular volume, and gamma-glutamyltransferase level). DESIGN: A prospective cohort study. SETTING: Regional level I trauma center, in Seattle, Washington. PARTICIPANTS: 1980 male and 602 female patients 18 years of age or older, admitted with blunt or penetrating trauma. MAIN RESULTS: Spearman rank correlations were used to compare the two screening measures with the weighted scale. The CAGE was found to correlate better than the SMAST with the weighted combination. Correlations for both measures were higher in women than in men. Among the individual biological alcohol markers used to construct the weighted scale, blood alcohol level was the marker that displayed the strongest correlation with both the CAGE and the SMAST. CONCLUSION: We conclude that the CAGE questionnaire showed a higher correlation with a combination of biological alcohol markers than did the SMAST, and that the CAGE may be the questionnaire of choice for identification of alcohol problems in patients seen in trauma centers.

Differential diagnosis and psychopharmacology of dual disorders.

There are multiple potential interactions of substances of abuse with psychiatric illnesses. The individual agents, the stage of abuse, withdrawal, or recovery, and the patient's psychiatric illness must be considered as an integrated whole to ascertain the appropriate interventions. Polysubstance abuse can cause still more complicated interactions. Assessment of differential treatment needs for both the psychiatric illness component and the substance use disorder component permits both elements to be approached, often simultaneously, and can facilitate treatment of both. Ignoring either component can lead to inappropriate treatment or exacerbation of illness. The high rate of comorbidity of chemical dependence and other psychiatric illnesses is intriguing in light of studies that demonstrate vulnerability to drug abuse associated with specific alleles of the dopamine D2 receptor gene in some families. It is hoped that further investigations will shed light on the complex interactions and associations between chemical dependency and other psychiatric illnesses and result in new treatment strategies for both. In the past, many substance abuse treatment programs used to emphasize the complete cessation of all medications including some potentially beneficial prescription medications. This was likely because of previous excessive prescription by physicians of sedatives or benzodiazepines. Increasingly, recovery programs support intelligent, responsible use of nonaddictive psychiatric medications, and AA World Services prints a pamphlet supporting such physician-supervised use. Conversely, psychiatrists previously frequently overlooked or neglected diagnosis and treatment of chemical-dependency disorders. Greater efforts are needed to focus equal energy on diagnosis and treatment of chemical-dependency disorders in "psychiatric" populations. Many studies show that physicians neglect to collect adequate information and are not sufficiently aggressive in referring patients to chemical dependence treatment programs. By combining knowledge and appropriate therapeutic interventions from both psychiatric and addiction treatment fields, the needs of the dually diagnosed patient can be met more adequately.

The dually diagnosed patient with psychotic symptoms.

The dual diagnoses of substance use disorder with other psychiatric disorder is especially problematic in psychotic or other chronically mentally ill patients. Such patients have a more fragile mental status which can be adversely affected by psychoactive substances of abuse. In addition, most such patients need to take potent psychiatric medications which themselves may interact with substances. This article reviews substance induced versus true comorbid major psychiatric disorders and discusses the major classes of psychiatric medications in terms of abuse potential and their abilities to either help or hinder substance disorder recovery.

Adjunctive treatment of benzodiazepine discontinuation syndromes: a review.

The variety of pharmacologic and psychotherapeutic approaches to facilitate benzodiazepine discontinuation are reviewed. Strategies to attenuate physiologic withdrawal with clonidine, propranolol and carbamazepine have been inconsistently effective. Strategies to prevent relapse by substituting medications that could later be discontinued more easily (i.e., antidepressants and azapirones) appear more useful but have been less well studied. Psychotherapeutic approaches appear to work, but specific therapeutic components are unclear and non-specific "placebo" effects may play an important role.

A descriptive study of trauma, alcohol, and alcoholism in young adults.

Young adults, 18-20 years of age, admitted to a trauma center via the emergency department, were studied to determine if they had been drinking prior to their injury event. The prevalence of self-reported chronic alcohol problems was examined using the short Michigan Alcohol Screening Test (SMAST). Of the 319 subjects, 131 (41%) tested positive for alcohol, including about one-half of those with intentional injuries and 38% with unintentional injuries. Approximately 22% had blood alcohol concentrations of 100 mg/dL or more, indicating they were legally intoxicated at the time of their injury. Of study subjects who completed the SMAST, 49% attained scores suggesting potential or probable alcoholism, and 20% had already sought some type of treatment, despite their young age. Health-care practices and policies related to these findings include routine screening of trauma patients for alcohol abuse and integration of chemical dependency intervention services with trauma care.

Alcohol counseling in a general medicine clinic. A randomized controlled trial of strategies to improve referral and show rates.

We conducted a controlled trial of two interventions to increase the number of patients receiving alcohol counseling in an academic, general medicine clinic. Ongoing randomization yielded similar groups of patients and providers. By applying a two-item alcoholism-screening instrument incorporated into the routine intake process, nursing staff were successful in screening 90.4% of the 1,328 eligible patients seen during a 4-month study period. Of the patients screened, 428 (35.6%) were found to be positive. In those groups where nurses were allowed to refer directly on the basis of a positive screening result, over four times as many patients (10.8% versus. 2.3%) accepted appointments for counseling, as did patients seen by physicians providing standard care. Patients who were briefly introduced to the alcohol counselor at the time referral were no more likely to keep their first, formal appointments than were patients scheduled in the usual manner. Patients who did receive counseling had their diagnoses confirmed by the 25-item Michigan Alcoholism Screening Test. We conclude that the adoption of an alcohol screening program in our clinic increased the number of patients appropriately referred for counseling.

Drug and alcohol dependence and psychiatric populations: the need for diagnosis, intervention, and training.

The comorbidity of psychiatric disorders and alcohol and drug dependence is high. The prevalence rate for each disorder is high as determined by studies in general and patient populations. Moreover, the severity of the course is likely to be greater when the two disorders are combined, prompting the attention of clinicians and researchers. Of importance, the intoxication and withdrawal from alcohol and drugs produce psychiatric symptoms and syndromes that can mimic psychiatric disorders. The prevalence rates for comorbidity of both categories of disorders vary according to the populations studied, methodological approaches used, and duration of longitudinal follow-up postdiagnosis of the disorders. It is evident from a review of the literature that there is a growing urgency for proper diagnosis, improved training programs, and treatment intervention strategies for alcohol and drug dependence in psychiatric populations. Suggestions for broad assessment and specific interventions for alcohol/drug dependence in psychiatric settings are offered, and increased time in psychiatric residency training is recommended.

A pilot assessment at one month of 17 dual diagnosis patients.

A pilot one-month follow-up of 17 inpatients diagnosed with both psychiatric and substance abuse disorders showed that 12 patients reported abstinence and five had relapsed. Significant associations were found between reported abstinence and a diagnosis of a depressive disorder, high motivation for abstinence, and the patient's perception that a specific discharge plan for substance abuse treatment had been developed.