Clinically useful assessments: substance use and comorbid psychiatric disorders.

This review addresses the assessment of substance use and related constructs with persons having severe and persistent mental illness. The review contains two major sections. The first section focuses on issues particular to the assessment of substance use and abuse in the context of major mental illness; these include the social and motivational context of assessment, the impact of mental status and acute symptoms, limitations associated with acute and chronic cognitive impairment, and the psychosocial relevance of assessment items. The second section highlights a selected set of substance assessment tools for use with this population; evidence for the reliability, validity, and/or feasibility of these tools is summarized. Each instrument meets the criteria of being: (a). relatively brief; (b). easy to administer and interpret; and (c). useful for treatment planning, motivational feedback, and/or monitoring change.

Prevalence and correlates of sexual activity and HIV-related risk behavior among psychiatric outpatients.

This study investigates the prevalence and correlates of sexual activity and HIV-risk behavior among adults with a mental disorder. Demographic, psychiatric, sexual behavior, and substance-use data were available for 1,558 outpatients. During the past year, 69% were sexually active and 23% engaged in risky behavior. Risk markers included multiple sexual partners (19%), a sexually transmitted disease (4%), sex trading (3%), injection drug use (1%), and needle sharing (<1%). Being sexually active and being at risk for HIV infection were associated with alcohol and drug use, psychiatric diagnoses other than schizophrenia, and younger age. Married patients were more likely to be sexually active but less likely to engage in risk behavior. Screening for HIV risk in psychiatric settings can identify patients who may benefit from risk reduction programs.

Enhancing readiness-to-change substance abuse in persons with schizophrenia. A four-session motivation-based intervention.

This article describes a four-session intervention designed for persons with co-occurring substance abuse and schizophrenia-spectrum disorders, to be administered as an add-on module to supplement ongoing mental health treatment in an outpatient setting. The intervention targets those dually diagnosed individuals with low readiness-to-change as indicated by current use, and/or low level of engagement in treatment for substance abuse. The intervention is designed to increase problem recognition, to enhance motivation to change maladaptive patterns of substance use, and to facilitate engagement in substance abuse treatment. To achieve these goals, the authors have adopted constructs from the Transtheoretical Model of Change, the authors used principles of motivational and harm reduction interventions, and tailored them to the target population.

Assessing sexual risk behaviour with the Timeline Followback (TLFB) approach: continued development and psychometric evaluation with psychiatric outpatients.

This paper describes a series of 4 studies, designed to provide evidence of the feasibility, reliability, and validity of the Timeline Followback (TLFB) method when used to assess sexual risk behaviour with psychiatric outpatients. This population was selected because patients often have difficulty completing assessments of sexual risk behaviours due to deficits in attention, memory, and communication skills. All 4 studies demonstrated the feasibility of the HIV-risk TLFB. Study 1 also demonstrated that it can be completed in 20 min, and scored in less than 10 min. Qualitative data revealed that both patients and assessors found the features of the TLFB helpful. Study 2 provided evidence that the HIV-risk TLFB can be reliably scored by interviewers whereas Study 3 demonstrated that this measure can be completed reliably by patients and that TLFB of sexual behaviour were consistent over time. Study 4 provided initial evidence for the validity of the HIV-risk TLFB but also suggested that the TLFB may yield frequency estimates that are slightly less than those obtained with single-item measures. We conclude that the TLFB is feasible, reliable, and valid, even in a population known to have difficulty with self-report measures.

Psychiatric outpatients report their experiences as participants in a randomized clinical trial.

We conducted exit interviews with 45 outpatients with severe and persistent mental illness (SPMI) who had participated in a randomized clinical trial. The interviews followed a semistructured format and were audiotaped for later transcription and rating by two independent raters. Content analyses of the interviews revealed that most participants evaluated their experiences quite favorably. For example, most noted that the assessment process was thought-provoking and motivational and that the intervention groups led to increased self-confidence and new friendships. Although a few participants noted that the assessment contained sensitive material, all appreciated the frequent reminders that information disclosed was strictly confidential. These results indicate that persons living with a SPMI often enjoy participating in behavioral research, which can yield immediate benefits to patient-participants. Exit interview research such as this can help investigators to understand reasons for consent and participation, to identify needs for protocol modifications, and to facilitate the integration of evidence-based interventions into the mental health care systems.

The relation of alcohol use to HIV-risk sexual behavior among adults with a severe and persistent mental illness.

The authors examined the relationship between alcohol use and HIV-risk sexual behavior and tested whether alcohol use immediately prior to sex is related to decreased condom use. The participants were 159 adults living with a severe and persistent mental illness. Each participated in a structured interview to assess all sexual and drug-use behavior over a 3-month period. Analysis of 3,026 sexual behaviors reported by 123 sexually active participants indicated that at the global level, participants who drank more heavily were more likely to have engaged in sexual risk behavior. At the event level, however, alcohol use was not related to condom use during vaginal or anal intercourse; that is, participants who used condoms when sober tended to use them to the same extent when drinking.

Measuring readiness-to-change substance misuse among psychiatric outpatients: I. Reliability and validity of self-report measures.

OBJECTIVE: The high rates of comorbid substance use disorders among persons living with severe and persistent mental illness (SPMI) have increased interest in assessing and enhancing motivation to change substance misuse in this population. This study provides evidence for the psychometric adequacy of three self-report measures of readiness-to-change. METHOD: The sample consisted of 84 persons (65% men) with co-occurring substance abuse or dependence and an SPMI. After a psychiatric assessment, participants completed three measures of readiness-to-change, which yielded seven subscales: (1) the Stages of Change Readiness and Treatment Eagerness Scale (ambivalence about change, recognition of substance-related problems, taking steps), (2) Decisional Balance Scale (pros of using, cons of using) and (3) the Alcohol and Drug Consequences Questionnaire (costs of quitting, benefits of quitting). RESULTS: All of the subscales were stable over time, and 6 of the 7 subscales demonstrated excellent internal consistency. Reliability indices were comparable when analyses were repeated on subsets of participants defined by diagnosis, cognitive function, positive symptoms and negative symptoms. A pattern of theoretically meaningful intercorrelations provided convergent evidence of validity, and a general lack of relationships with demographic variables and indices of psychiatric status provided discriminant evidence of validity. CONCLUSIONS: These findings support efforts to quantify readiness-to-change substance misuse among persons with an SPMI.

Implementing dual diagnosis services for clients with severe mental illness.

After 20 years of development and research, dual diagnosis services for clients with severe mental illness are emerging as an evidence-based practice. Effective dual diagnosis programs combine mental health and substance abuse interventions that are tailored for the complex needs of clients with comorbid disorders. The authors describe the critical components of effective programs, which include a comprehensive, long-term, staged approach to recovery; assertive outreach; motivational interventions; provision of help to clients in acquiring skills and supports to manage both illnesses and to pursue functional goals; and cultural sensitivity and competence. Many state mental health systems are implementing dual diagnosis services, but high-quality services are rare. The authors provide an overview of the numerous barriers to implementation and describe implementation strategies to overcome the barriers. Current approaches to implementing dual diagnosis programs involve organizational and financing changes at the policy level, clarity of program mission with structural changes to support dual diagnosis services, training and supervision for clinicians, and dissemination of accurate information to consumers and families to support understanding, demand, and advocacy.

Understanding binge drinking: introduction to the special issue.

Widespread interest in binge drinking, demonstrated by scientists, public policymakers, and educators, served as the impetus for assembling this special issue. The contents represent state-of-the-science conceptualizations and empirical work on the topic of binge drinking. This issue begins with 2 invited articles and contains a selection of empirical articles that reflect experimental and correlational designs, longitudinal studies of the course and correlates of binge drinking, and controlled-intervention trials. These articles address the construct validity of binge drinking as well as its utility as a high-risk marker in both theory-testing and intervention contexts. This introductory article discusses several advantages and disadvantages of continued use of the term binge drinking and suggests alternatives for use in research and applied contexts.

Differential utility of three indexes of risky drinking for predicting alcohol problems in college students.

This study evaluated the relationship between alcohol-related problems and 3 indexes of risky drinking in college student drinkers: number of drinks consumed per week, frequency of binge drinking, and estimated blood alcohol levels (BALs). Use of 2 independent samples (N1 = 204, N2 = 181) allowed a cross-validation of obtained associations. Results indicated that neither binge drinking frequency nor BAL were more highly related to alcohol-related problems than was weekly drinking. Furthermore, BAL did not provide unique explanatory power in accounting for alcohol-related problems; mixed results were obtained regarding the relationship of binge drinking estimates with problems.

Peer influences on college drinking: a review of the research.

Peer pressure is consistently implicated in the excessive drinking of college students. However, both theory and empirical findings suggest that peer pressure is a combination of three distinct influences: overt offers of alcohol, modeling, and social norms. Overt offers of alcohol can range from polite gestures to intense goading or commands to drink. Modeling occurs when the student's behavior corresponds to another student's concurrent drinking behavior. Perceived social norms can serve to make excessive alcohol use appear common and acceptable to the student. This review critically examines the literature on each form of peer influence and provides suggestions for future research.

Temporal stability of alcohol screening measures in a psychiatric setting.

The authors evaluated the test-retest reliability of two common screening instruments administered in a psychiatric setting. The Michigan Alcoholism Screening Test (MAST; M. L. Selzer, 1971) and the CAGE (D. Mayfield, G. McLeod, & P. Hall, 1974) were administered twice, separated by a 1-week interval, to 71 people receiving outpatient psychiatric services and 64 people in the community with no reported history of psychiatric care. The MAST (r = .95) and the CAGE (r = .80) demonstrated adequate test-retest reliability and showed little evidence of variation with respect to degree or direction when administered in a psychiatric setting. Compared to a nonclinical sample, reliability estimates obtained in a psychiatric setting were only slightly lower and more variable. In the psychiatric sample, younger men who had a history of alcohol use disorder were found to be the least reliable. Overall, data suggest that people with severe and persistent mental disorders can offer reliable information about their alcohol-related problems.

Assessing positive and negative symptoms in outpatients with schizophrenia and mood disorders.

The Positive and Negative Syndrome Scale (PANSS) was developed to assess symptomatology in inpatients with schizophrenia. We examined its reliability and validity among outpatients with schizophrenia (N = 75) and mood disorders (N = 61). Because the hypothesized three-scale structure of the PANSS has not been supported by existing research, we also examined its factor structure. Interrater reliability for individual items and the positive and negative scales was demonstrated. Evidence supported the internal consistency of each scale in the overall sample and the schizophrenia group but was mixed among those with mood disorders. PANSS scores were higher in the schizophrenia group. These scores, in turn, were lower than those generally reported among inpatients with schizophrenia, providing known-groups validity evidence. Four of five factors were similar to those reported among inpatients with schizophrenia. Together, these results support the use of the PANSS among outpatients and reinforce existing support for assessing positive and negative symptoms in mood disorders.

HIV risk sensitization following a detailed sexual behavior interview: a preliminary investigation.

We administered a detailed structured interview of sexual HIV risk behavior to 110 college students (46% women; mean age = 19.7 years; range = 18-41 years) and assessed their perceived risk of HIV infection before and after the interview. The sexual behavior assessment consisted of 29 single-item frequency questions, followed by a 90-day Timeline Followback interview. Results indicate that sexually active participants experienced HIV risk sensitization during the interview, whereas participants who were not sexually active did not. Among the sexually active participants, those who had multiple sexual partners were more sensitized to their risk than participants with only one partner, and those who engaged in vaginal sex evidenced increased risk perception, but participants who had only oral sex did not. These findings indicate that detailed sexual behavior assessments influence participants' motivation to reduce their risk behavior. This may be helpful in increasing the effectiveness of brief risk behavior interventions such as HIV counseling and testing. These findings may also have implications for the generalizability of HIV prevention interventions to contexts that do not include such detailed assessments.

Utility of collateral information in assessing substance use among psychiatric outpatients.

PURPOSE: This study addressed the utility of collateral informants for validating self-reported substance use by psychiatric outpatients. METHODS: Participants were 92 men and women with severe and persistent Axis I disorders, attending outpatient programs at a public psychiatric facility. As part of a substance use assessment, each participant identified a collateral who would provide information about the participant's substance use in the last month. The collaterals consisted of family (35%), peers (23%), and others (40%) who were primarily mental health staff. RESULTS: Comparisons of participant and collateral reports showed high percent agreement with significant but modest measures of association. The likelihood that collateral reports will have information value (i.e., corroborate or exceed self-reports) was greater when the topic is illicit drug use and the frequency of contact is once a week or more. In this sample, siblings were more likely to be uninformative than other types of collaterals, whereas treatment staff were comparable to other types of collaterals in the information value of their corroborative reports. Overall, the collateral reports rarely provided more information than was provided by the participants themselves. IMPLICATIONS: This pattern is consistent with the pattern observed in non-psychiatric samples and supports the accuracy of self-reported substance use by psychiatric outpatients.

Effects of a brief motivational intervention with college student drinkers.

This study consisted of a randomized controlled trial of a 1-session motivational intervention for college student binge drinkers. Sixty students who reported binge drinking 2 or more times in the past 30 days were randomly assigned to either a no-treatment control or a brief intervention group. The intervention provided students with feedback regarding personal consumption, perceived drinking norms, alcohol-related problems, situations associated with heavy drinking, and alcohol expectancies. At 6-week follow-up, the brief intervention group exhibited significant reductions on number of drinks consumed per week, number of times drinking alcohol in the past month, and frequency of binge drinking in the past month. Estimates of typical student drinking mediated these reductions. This study replicates earlier research on the efficacy of brief interventions with college students and extends previous work regarding potential mechanisms of change.

Treating substance abuse in the context of severe and persistent mental illness: clinicians' perspectives.

Patients with comorbid substance use and major mental disorders are treated frequently in the mental health system. Treatment models relevant for this subset of patients have emerged in recent years, however, few have been validated empirically and so relatively few sites benefit from this treatment development activity. Important additional sources of information about good treatment practices are the clinicians who have adopted the treatment of patients with dual disorders as a specialty. We conducted four focus groups (N = 12) with clinicians who were nominated by their peers as experienced and/or expert in treating persons with comorbid substance use and psychiatric disorders. Discussions followed a four-part outline that included (a) general questions about training and experience with the population, (b) preferred treatment methods, (c) motivational issues, and (d) recommendations to the field. Participants were trained in a variety of mental health disciplines and pursued substance abuse treatment credentials or other educational experiences outside of their primary training programs. Their treatment approaches emphasized psychoeducation, a good therapeutic relationship, and the need to be flexible regarding methods and goals. Abstinence was the preferred goal among most clinicians; even so, they expressed a pragmatic flexibility and other views consistent with the principles of harm reduction. Clinicians tended to respond to patients' ambivalent motivational states by addressing the consequences of behaviors in a nonconfrontive style; they also made use of positive incentives and external support. A number of recommendations were made to improve treatment, including greater institutional and programmatic support for the unique needs of this population.

Attitudes toward marijuana use and drug-free experience: relationships with behavior.

Attitude toward drug-free experience is conceptualized as a psychological context for drug use that influences the evaluation of perceived consequences of marijuana use. Two studies examined the moderating effect of attitude toward drug-free experience on relationships between attitudes toward marijuana and drug use. In Study 1 (N = 316), attitude toward drug-free experience emerged as a significant moderator. Participants with positive attitudes toward marijuana use and relatively low attitudes toward drug-free experience used marijuana at the highest rates. Study 2 (N = 308) provided a partial replication and extension. In a second sample, a quadratic relationship emerged between drug-free experience and marijuana use. The interaction between the two attitudes approached significance. Among the 47 participants who had used marijuana more than 100 times in their lifetime, attitude toward drug-free experience moderated the relationship between attitude toward marijuana and marijuana-related problems.

Use of the AUDIT and the DAST-10 to identify alcohol and drug use disorders among adults with a severe and persistent mental illness.

State Psychiatric Hospital outpatients (93 men, 69 women) diagnosed with a serious persistent mental illness (SPMI) completed the Alcohol Use Disorders Identification Test (AUDIT) and Drug Abuse Screening Test (DAST-10) by interview as part of a general health/behavior screening instrument. Responses to the AUDIT and DAST-10 were compared with criteria of current diagnosis and occurrence of symptoms in the last year for both alcohol and drug use disorders, respectively. Results showed that for both diagnosis and symptoms, AUDIT cutpoints of 7 and 8 had good sensitivity and specificity, and DAST-10 cutpoint of 2 was identified for both criteria. These and other findings suggest that both instruments have promising clinical utility when used with individuals diagnosed with an SPMI.

A comparison of motives for marijuana and alcohol use among experienced users.

Motivational models suggest that individuals use substances to achieve desired effects. Given different pharmacological effects across drug classes, and variations in social context, one would expect that the motives instigating use differ by drug class. However, commonalties in motives across drugs have also been observed. The purpose of this study was to examine similarities and differences across a common set of motives for alcohol and marijuana among experienced users of both drugs. Participants were 46 college students (21 women) who completed a motives assessment twice, once for marijuana and once for alcohol. All had used each drug 60 or more times in their lifetime. Social motives were more highly endorsed for alcohol than marijuana. Expansion motives were more highly endorsed for marijuana. Enhancement motives were more highly endorsed for marijuana than alcohol among women but not men. Endorsement of coping and conformity motives did not differ across drugs. Experienced users of marijuana and alcohol discriminate between their reasons for using the two drugs. These findings are discussed with regard to the differentiation between and commonalties among substances of abuse.