Achieving effective treatment of patients with chronic psychotic illness and comorbid substance dependence.

OBJECTIVE: The changing effectiveness of a treatment program for dual-diagnosis patients was evaluated over a 2-year period with the use of a sequential study group design. METHOD: The treatment outcome of 179 consecutively enrolled patients with chronic psychotic illness and comorbid substance dependence who entered a specialized day hospital dual-diagnosis treatment program from Sept. 1, 1994, to Aug. 31, 1996, was evaluated. The 24 months were divided into four successive 6-month periods for comparing the evolving effectiveness of the program for groups of patients entering the day hospital during these four periods. Treatment attendance, hospital utilization, and twice weekly urine toxicology analyses were used as outcome measures. RESULTS: The initial treatment engagement rate, defined as at least 2 days of attendance in the first month, increased significantly from group 1 to group 4, more than doubling. Thirty-day and 90-day treatment retention rates also substantially increased from group 1 to group 4. More patients had no hospitalization in the 6 months after entering the day hospital program than in the 6 months before entering the day hospital program. Urine toxicology monitoring indicated that the patients in group 4 were more likely than those in group 1 to remain abstinent at follow-up. CONCLUSIONS: The evolving clinical effectiveness of a developing program can be quantified by using a sequential group comparison design. The sequential outcome improvements may be related to the incremental contributions of assertive case management and skills training for relapse prevention.

Sources of diagnostic uncertainty for chronically psychotic cocaine abusers.

OBJECTIVE: This study determined the sources and frequency of diagnostic uncertainty for patients with chronic psychosis and active cocaine abuse or dependence and assessed the usefulness of prospective follow-up in clarifying diagnosis. METHODS: A total of 165 male patients with chronic psychoses and cocaine abuse or dependence on inpatient units of a Veterans Affairs medical center were evaluated using the Structured Clinical Interview for DSM-III-R (SCID-R), urine tests, hospital records, and interviews with collateral sources. An algorithm allowing key SCID-R items and diagnostic criteria to be designated as provisionally met or uncertain was applied, resulting in a provisional diagnosis and a list of alternate diagnoses. The assessment was repeated 18 months later in an attempt to resolve diagnostic uncertainty. RESULTS: In 30 cases (18 percent), initial assessment produced a definitive diagnosis, including 21 cases of schizophrenia, six of schizoaffective disorder, and three of psychostimulant-induced psychotic disorder. In the other 135 cases, a definitive diagnosis could not be reached because of one or more sources of diagnostic uncertainty, including insufficient periods of abstinence (78 percent), poor memory (24 percent), and inconsistent reporting (20 percent). Reassessment at 18 months led to definitive diagnoses in 12 additional cases. CONCLUSIONS: It was frequently difficult to distinguish schizophrenia from chronic substance-induced psychoses. Rather than concluding prematurely that psychotic symptoms are, or are not, substance induced, clinicians should initiate treatment of both psychosis and the substance use disorder in uncertain cases. The persistence or resolution of psychosis during abstinence and additional history from the stabilized patient or collateral sources may clarify the diagnosis.

Monetary reinforcement of abstinence from cocaine among mentally ill patients with cocaine dependence.

OBJECTIVE: The study investigated whether contingency management could reduce cocaine use by patients with schizophrenia. METHODS: An A-B-A research design, with two-month baseline, intervention, and follow-up phases, was used to study two homeless, treatment-resistant male outpatients with DSM-III-R diagnoses of schizophrenia and cocaine dependence. During the intervention phase, subjects provided daily urine specimens for testing for the cocaine metabolite benzoylecgonine (BE) and received $25 for each negative test. Concentrations of BE and metabolites of other illicit drugs were assayed twice a week to determine the amount of drug use in addition to frequency. Analysis of variance was used to compare drug use during the three study phases. RESULTS: During the intervention, the proportion of tests positive for cocaine was lower for both subjects. Mean urinary concentrations of BE were significantly lower during the intervention than during the baseline. CONCLUSIONS: These results suggest that modest monetary reinforcement of abstinence may decrease cocaine use among cocaine-dependent patients with schizophrenia.

Alcohol challenges in young men from alcoholic pedigrees and control families: a report from the COGA project.

OBJECTIVE: Alcoholism is a complex disorder that demonstrates genetic heterogeneity. Genetic linkage studies of alcohol dependence also suffer from the probability that many individuals who inherit an enhanced risk never develop the clinical syndrome. Thus, studies of genetic influences in alcohol abuse or dependence would benefit from the identification of characteristics of an individual that are associated with the probability of developing the disorder. A reduced responsivity to alcohol has been reported to characterize almost 40% of sons of alcoholics and to predict future alcohol abuse or dependence a decade later. This study explores the existence of this characteristic in a more heterogeneous sample that is part of a genetic pedigree study of families of alcoholics. METHOD: Eighteen to 30 year old subjects who were sons of alcohol dependent fathers and who were drinkers but not alcohol dependent were selected from pedigrees of alcoholics at all six sites of the Collaborative Study on the Genetics of Alcoholism (COGA) study. Family history negative controls matched on demography and substance use histories were selected for each subject. Data were obtained on 20 pairs of high-risk and low-risk men (40 subjects) following a challenge with 0.72 g/kg (0.9 ml/kg) of ethanol. Evaluations included measures of subjective feelings of intoxication and body sway, and changes in cortisol, ACTH and prolactin. RESULTS: The data corroborate a lower level of intensity of response to alcohol in the sons of alcoholics especially as measured by changes in cortisol, with similar but less robust changes in subjective feelings and other measures. CONCLUSIONS: The results expand upon earlier studies by using a more heterogeneous population of men at high alcoholism risk. The data highlight the possible usefulness of the reduced response to alcohol as an adjunct to future linkage analyses.

Disability income, cocaine use, and repeated hospitalization among schizophrenic cocaine abusers--a government-sponsored revolving door?

BACKGROUND: Many patients with serious mental illness are addicted to drugs and alcohol. This comorbidity creates additional problems for the patients and for the clinicians, health care systems, and social-service agencies that provide services to this population. One problem is that disability income, which many people with serious mental illness receive to pay for basic needs, may facilitate drug abuse. In this study, we assessed the temporal patterns of cocaine use, psychiatric symptoms, and psychiatric hospitalization in a sample of schizophrenic patients receiving disability income. METHODS: We evaluated 105 male patients with schizophrenia and cocaine dependence at the time of their admission to the hospital. They had severe mental illness and a long-term dependence on cocaine, with repeated admissions to psychiatric hospitals; many were homeless. The severity of psychiatric symptoms and urinary concentrations of the cocaine metabolite benzoylecgonine were evaluated weekly for 15 weeks. RESULTS: Cocaine use, psychiatric symptoms, and hospital admissions all peaked during the first week of the month, shortly after the arrival of the disability payment, on the first day. The average patient spent nearly half his total income on illegal drugs. CONCLUSIONS: Among cocaine-abusing schizophrenic persons, the cyclic pattern of drug use strongly suggests that it is influenced by the monthly receipt of disability payments. The consequences of this cycle include the depletion of funds needed for housing and food, exacerbation of psychiatric symptoms, more frequent psychiatric hospitalization, and a high rate of homelessness. The troubling irony is that income intended to compensate for the disabling effects of severe mental illness may have the opposite effect.

Drug use among primary alcoholic veterans.

Many people with alcohol dependence use other drugs. However, not much is known about the relationship between their past drug use (not necessarily dependence) and their prognosis following treatment. The goal of this study is first to determine the drug use rates among primary alcoholic men and then to evaluate the possible relationship between past drug use and future alcohol or drug use relapse. As a result, 630 primary alcoholic veterans were recruited from a 28-day inpatient Alcohol and Drug Treatment Program at the San Diego VA Medical Center. Among them, almost two-thirds also had a history of drug use. Subjects were divided into the following four groups which were determined by their lifetime drug use histories: Group I (N = 226) consisted of drug abstainers, Group 2 (N = 142) was made up of alcoholics who had used only marijuana, Group 3 (N = 210) contained stimulant users who had never used opiates, and Group 4 (N = 52) included all opiate users. Comparisons of the four groups at a 3-month follow-up revealed that alcoholic men who had a history of stimulant or opiate use (Groups 3 and 4) were more likely to have had a drug use relapse. However, the four groups had similar alcohol relapse rates.

The prognostic importance of blackouts in young men.

In order to test the commonly held perception that blackouts are an early diagnostic sign of alcoholism, we evaluated a sample of 230 nonalcoholic young men longitudinally over an 8-12 year follow-up period. Consistent with the literature, blackouts were a common occurrence in this cohort, with 26% of the men reporting blackouts by their early twenties, and 30% of the subjects experiencing blackouts over the approximately 10-year follow-up. Alcohol-related amnestic episodes were associated with the quantity and frequency of drinking, and men with blackouts (especially four or more) were more likely to have other problems related to their heavy drinking. Although few alcoholics will report not having had such amnestic spells, blackouts are not sensitive indicators of the risk for developing alcoholism. The data suggest that blackouts should be viewed as an important warning sign of problem drinking, but not as the "hallmark" of alcoholism.

Characteristics of men with alcoholic hallucinosis.

The goal of this study was to evaluate the characteristics of primary alcoholics with alcoholic hallucinosis. Six hundred and forty-three primary alcoholic men were recruited from a 28-day Alcohol and Drug Treatment Program at the San Diego VA Medical Center. Subjects only experiencing perceptual abnormalities during alcohol withdrawal, drug-related hallucinosis, as well as those having abnormal sensations that did not meet criteria for hallucinations were excluded from the present study. The remaining 532 subjects were divided into Group 1 (n = 48), which consisted of subjects with a DSM-IIIR and ICD-10 diagnosis of alcoholic hallucinosis, and Group 2 (n = 484) which consisted of those without any history of hallucinations. A comparison of the two groups revealed that Group 1 men were younger at the onset of alcohol problems, consumed more alcohol per occasion, developed more alcohol-related life problems, and had higher rates of drug experimentation as well as more different types of drugs used. This study suggests that primary alcoholics who consume more drugs and/or alcohol might be at an increased risk for developing alcoholic hallucinosis.