A Scoping Review of Autism and the Way It Changes the Presentation of Suicidal Thoughts and Behavior Compared to the General Population.

Autism spectrum conditions are a group of neurodevelopmental conditions that carries an array of co-occurring diagnoses, including a heightened risk of suicide attempts and suicide. This scoping review examined primary research focusing on autism and suicidality, to understand what is currently known on the topic, including how autism changes the presentation of suicidal thoughts and behavior; and to assess the suicide awareness and prevention education programs currently available for autistic people, their families, and health professionals and support workers. A comprehensive search (November 2021) across Scopus, PubMed and CINAHL identified 39 articles from 38 studies. Three themes emerged, with five subthemes. 1. The prevalence of suicidality in autistic people; 2. The presentation of suicidality in autistic people, including (a) risk of suicidality; (b) gender, age, employment and education; (c) co-occurring psychiatric conditions; (d) autism traits and social communication; (e) intellectual disability; and 3. Autism-specific approaches to suicidal thoughts, behavior and prevention. Findings were mixed, including conflicting evidence on the risk of autism and suicidality, and limited evidence of resources related to autism-specific suicide awareness or information, and education or prevention programs.

Conducting Systematic Reviews of the Quality and Psychometric Properties of Health-Related Measurement Instruments: Finding the Right Tool for the Job.

Many health-related measurement instruments have been developed to measure psychological constructs and whilst several instruments are usually available for a particular study, finding the right tool for the job is important. Systematic reviews of measurement properties of instruments have long been identified as a valuable strategy to ensure that we select the right tool to assess mental health. There are many important steps and procedures to guide these types of systematic reviews to find the "best fit" and this paper summarizes some of these key processes and steps. The selection of instrument(s) to use should be made considering the most recent comprehensive review of the quality of the outcome measurement instrument based on unbiased assessment of its psychometric properties, responsiveness, and generalizability of results. Researchers planning to conduct a systematic review of health-related measurement instruments should design the review beforehand using standardized frameworks. Conducting systematic reviews of the quality and psychometric properties of health-related measurement instruments is important to ensure we choose the best tool for the research question and target population.

How People with Autism Access Mental Health Services Specifically Suicide Hotlines and Crisis Support Services, and Current Approaches to Mental Health Care: A Scoping Review.

For people with autism spectrum disorder (ASD), the risk of mental illness, including suicidality, has a higher prevalence than the general population. This scoping review explored how people with ASD access suicide hotlines/crisis support services; and current approaches to delivering mental health services (MHS) to people with ASD. A search identified 28 studies meeting the selection criteria with analysis revealing four key findings. The support received by the person with ASD influenced how they accessed MHS; people often encounter barriers to accessing MHS; a separation exists between autism and MHS; and no studies on accessing or delivering MHS through crisis hotlines. The presence of such autism-specific crisis hotlines and the dearth of studies suggest a void in the existing research.

A Qualitative Systematic Review of Caregivers' Experiences of Caring for Family Diagnosed with Schizophrenia.

Objective: To synthesise qualitative research that explored caregivers' experiences of caring for family diagnosed with schizophrenia.Methods: Electronic databases including PsycINFO, PubMed, CINAHL and Scopus were searched to identify relevant journal articles published from 2000 to March 2019. Quality was assessed and thematic synthesis of the qualitative research evidence undertaken. Papers were screened and independently appraised by two reviewers using The Critical Appraisal Skills Programme (CASP) for Qualitative Studies Checklist. The review was guided by Thomas and Harden's framework for thematic synthesis of qualitative research evidence.Results: The breadth of information across the 43 papers was noteworthy. Review of the findings noted that almost all of what was discussed fell into three broad themes: the 'feelings' of the caregiver towards their role, the patient and others, including the health system; the 'impacts' of the diagnosis and their caregiving role on the caregiver; and the 'needs' of the caregiver to improve the patient's quality of life and thereby the caregiver's quality of life. Within needs also came recommendations for future changes.Conclusion: Studies have shown that the caregiving process is a complex one, with both negative and positive emotional reactions, societal barriers, such as stigma and isolation, and unmet needs, such as timely, relevant and helpful information. Meeting the needs identified by caregivers has the capacity to address the impacts of the illness and caregiving and thereby reduce the negative feelings associated with the caregiver role.

Psychosocial interventions for people with both severe mental illness and substance misuse.

BACKGROUND: Even low levels of substance misuse by people with a severe mental illness can have detrimental effects. OBJECTIVES: To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care. SEARCH METHODS: The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness. DATA COLLECTION AND ANALYSIS: Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison. MAIN RESULTS: Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence). AUTHORS' CONCLUSIONS: We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.

Prevalence and Risk Factors of Emergency Department Presentations with Methamphetamine Intoxication or Dependence: A Systematic Review and Meta-analysis.

Background: Methamphetamine intoxication presentations to emergency departments (EDs) including trauma centres, general EDs and psychiatric emergency services have risen world-wide. Objectives: A review of the clinical characteristics of patients presenting to a trauma centre or ED with methamphetamine intoxication or dependence to aid development of health service policy and training for health personnel. Methods: PubMed, PsycINFO, CINAHL and Scopus (1990-2017) were searched. A systematic review of all clinical characteristics was conducted, and a meta-analysis undertaken for variables with standard measures (prevalence, age, gender); 23 studies met the inclusion criteria of which 17 could be used in the meta-analysis. Results: Methamphetamine-related presentations were characterised by cardiac complications, psychiatric symptoms and aggression with safety risk to health personnel. The pooled prevalence of methamphetamine positive cases in emergency settings was higher in studies using toxicology analysis to determine methamphetamine use (8 studies, 22.8% 95% CI 15.4-32.5) compared to self-reporting (9 studies 5.7%, 95% CI 2.8-11.2, Q = 12.42, p < 0.001). Pooled variance of methamphetamine positive cases was 57.1% in men and 42.9% in women. The mean age of those who were methamphetamine positive was 28.4 years and for those methamphetamine negative cases it was 38.4 years. Conclusions: In this review, we found a higher prevalence of methamphetamine use amongst males and in the younger demographic. Targeted training programmes for frontline staff and management approaches for prompt multi-disciplinary service engagement are recommended as well as appropriate resourcing, such as mental health staff in EDs or mental health beds to accommodate this subgroup of the patient cohort.

Validating the 4A's test in screening for delirium in a culturally diverse geriatric inpatient population.

OBJECTIVE: To measure the diagnostic accuracy of the 4A's test in screening for delirium in geriatric inpatients from culturally diverse backgrounds. METHODS: A prospective study was conducted with patients admitted to the geriatric and orthogeriatric services of a tertiary teaching hospital. Consenting participants aged 65 years and over were screened for delirium with the 4AT by nursing staff within 72 h of admission. The diagnosis of delirium was made separately by expert assessors, responsible for the participant's clinical care, blinded to the 4AT score, within 30 min of the 4AT assessment using the DSM 5 criteria and the Confusion Assessment Method. Interpreters were used for non-English speaking patients. The Informant Questionnaire for Cognitive Decline in the Elderly was completed by a carer/relative to assess for probable dementia. RESULTS: A total of 257 participants (mean age 85) were recruited over five months. Delirium was diagnosed in 159 (62%) by the expert assessors and 158 (62%) by the 4AT assessment. A total of 205 participants (80% of total population) had probable dementia. The sensitivity and specificity of the 4AT were 87% and 80%, respectively, in detecting delirium overall, 86% and 71% in people with probable dementia and 91% and 71% for non-English speaking participants. The area under the receiver operating characteristic curve for delirium in the whole population was 0.92, 0.89 in the probable dementia subgroup and 0.90 in non-English speaking participants. CONCLUSIONS: The 4AT is a sensitive and specific screening tool for delirium in geriatric inpatients, including those with probable dementia or who are non-English speaking. Copyright © 2016 John Wiley & Sons, Ltd.

How shortcomings in the mental health system affect the use of involuntary community treatment orders.

Objective The aim of the present study was to examine stakeholder perspectives on how the operation of the mental health system affects the use of involuntary community treatment orders (CTOs). Methods A qualitative study was performed, consisting of semi-structured interviews about CTO experiences with 38 purposively selected participants in New South Wales (NSW), Australia. Participants included mental health consumers (n=5), carers (n=6), clinicians (n=15) and members of the Mental Health Review Tribunal of NSW (n=12). Data were analysed using established qualitative methodologies. Results Analysis of participant accounts about CTOs and their role within the mental health system identified two key themes, namely that: (1) CTOs are used to increase access to services; and (2) CTOs cannot remedy non-existent or inadequate services. Conclusion The findings of the present study indicate that deficiencies in health service structures and resourcing are a significant factor in CTO use. This raises questions about policy accountability for mental health services (both voluntary and involuntary), as well as about the usefulness of CTOs, justifications for CTO use and the legal criteria regulating CTO implementation. What is known about this topic? Following the deinstitutionalisation of psychiatric services over recent decades, community settings are increasingly the focus for the delivery of mental health services to people living with severe and persistent mental illnesses. The rates of use of involuntary treatment in Australian community settings (under CTOs) vary between state and territory jurisdictions and are high by world standards; however, the reasons for variation in rates of CTO use are not well understood. What does this paper add? This paper provides an empirical basis for a link between the politics of mental health and the uptake and usefulness of CTOs. What are the implications for practitioners? This paper makes explicit the real-world demands on the mental health system and how service deficiencies are a significant determinant in the use of CTOs. Practitioners and policy makers need to be candid about system limitations and how they factor in clinical and legal justifications for using involuntary treatment. The results of the present study provide data to support advocacy to improve policy accountability and resourcing of community mental health services.

Brokering Community Engagement: Proactive Strategies for Supporting Indigenous Australians with Mental Health Problems.

This qualitative study explored the experiences of mental health employees working with Indigenous clients living with mental illness. Interviews were conducted with 20 mental health workers to identify strategies they adopt to facilitate community engagement with Indigenous clients. Using a thematic analysis approach, 'Brokering community engagement' was the umbrella theme from which two subthemes related to community engagement for the service and clients emerged (1) enabling connections -community and family; and (2) recovery and reconnecting with community. Participant insights enabled a deeper understanding of the role of community in the recovery process for Indigenous clients and highlight the importance of community engagement as a primary, yet multifaceted strategy used by mental health workers in the communities they serve.

The lived experience of involuntary community treatment: a qualitative study of mental health consumers and carers.

OBJECTIVE: To describe the lived experiences of people subject to community treatment orders (CTOs) and their carers. METHOD: We recruited 11 participants (five mental health consumers and six carers) through consumer and carer networks in NSW, Australia, to take part in interviews about their experiences. We analysed the interview data set using established qualitative methodologies. RESULTS: The lived experiences were characterised by 'access' concerns, 'isolation', 'loss and trauma', 'resistance and resignation' and 'vulnerability and distress'. The extent and impact of these experiences related to the severity of mental illness, the support available for people with mental illnesses and their carers, the social compromises associated with living with mental illness, and the challenges of managing the relationships necessitated by these processes. CONCLUSIONS: The lived experience of CTOs is complex: it is one of distress and profound ambivalence. The distress is an intrinsic aspect of the experience of severe mental illness, but it also emerges from communication gaps, difficulty obtaining optimal care and accessing mental health services. The ambivalence arises from an acknowledgement that while CTOs are coercive and constrain autonomy, they may also be beneficial. These findings can inform improvements to the implementation of CTOs and the consequent experiences.

The Sydney Mental Health Client Mortality Audit: what does it tell us and what are we to do?

OBJECTIVES: To examine the characteristics of those mental health clients of an Australian metropolitan health service who died during a 6 year period, 2005 - 2010. METHODS: The medical records, and where available, coronial post-mortem examinations were audited for 109 people with schizophrenia who died while they were clients of the mental health service. RESULTS: The mean age of death for men was 45 years and for women, 47 years, compared to the general population's male and female life expectancy of 79 and 84 years, respectively. About one-half of the deaths were due to suicide (n = 55), followed by natural causes (n = 42; 39%), undetermined causes (n = 7), and accidents or acts of violence (n = 5). Smoking rates, diagnosed diabetes and hypertension were higher in the group that died from natural causes. Morbid obesity (body mass index (BMI) > 35 kg/m(2)) rates were higher in the group that died of natural causes (38%), compared with the suicide group (5%). CONCLUSIONS: While suicide accounts for the majority of those dying prematurely in this study cohort, it appears that for those who survive the risk of suicide in the earlier period of a chronic psychotic illness, there is yet another threat to life expectancy: death from preventable cardiorespiratory disorders, due to a poor lifestyle and social deprivation.

Staff's views on managing symptoms of dementia in nursing home residents.

Aim To identify the most common and distressing behavioural and psychological symptoms of dementia (BPSD) in nursing homes and to identify staff preferences regarding its behavioural management. Method A descriptive cross-sectional survey was completed by a self-selected sample of 247 staff working in 21 nursing homes in a defined catchment area. The survey contained items relating to experience in aged care work, attitudes towards BPSD, ratings of the importance of certain behavioural strategies for managing BPSD, and the Challenging Behaviour Scale. Results Shouting, wandering and restlessness had the highest incidence, frequency and difficulty ratings. Frequency of BPSD and level of satisfaction with how they were managed had the greatest effect on overall level of difficulty in managing behaviours. Staff rated discussing behavioural concerns at a group level and with senior nursing staff as the most important behavioural strategies. Conclusion A strong relationship was found between frequency and difficulty of BPSD. Therefore, interventions targeted at lowering frequency of BPSD are recommended. Communication across a number of levels may enhance the implementation of behavioural interventions.

A phase II randomised controlled trial of intranasal oxytocin in anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) is an eating disorder (ED) with high mortality rates and limited response to existing treatments, prompting the need to identify effective agents and adjuncts. There is evidence for an emerging role for the neuropeptide oxytocin (OT) in the pathophysiology of AN, with studies showing a perturbed oxytocinergic system in patients with AN. Preliminary evidence has demonstrated that intranasal OT (IN-OT) can produce anxiolytic effects in AN, as well as reducing concern about eating, and dysfunctional attentional biases related to the disorder. IN-OT is a non-invasive treatment option for AN that requires investigation as an adjunct to nutritional rehabilitation. METHODS: This multi-site study (Trial Registration:ACTRN1261000897460) sought to replicate and extend a previous randomised placebo-controlled pilot trial of repeated dose IN-OT in patients with AN hospitalised for nutritional rehabilitation. Patients with AN (N=61) received daily IN-OT (18 IU twice per day) or placebo for four weeks, whilst undergoing inpatient hospital treatment. Outcome measures included ED psychopathology (primary) as measured by the Eating Disorder Examination (EDE) and Body Mass Index (BMI; secondary). Participants were assessed pre- and post-treatment, and at six months following the intervention. The effects of the first and last doses of IN-OT on responses (anxiety ratings and salivary cortisol) to a high-energy snack were also examined. RESULTS: Sixty-one female inpatients (Mage=24.36,SD=7.87) with an average BMI of 16.24 (range: 11.43-18.55), were recruited into the study. No significant differences were found between placebo and OT groups at any of the time points on the outcomes of interest, but significant improvements in almost all psychological parameters in both groups were evident over time. IN-OT did not significantly reduce anxiety nor salivary cortisol in response to a high-calorie snack. CONCLUSION: This is the largest randomised placebo-controlled trial of repeated dose intranasal OT in people with AN, during refeeding. The therapeutically promising findings of the pilot study were not replicated. Limitations and reasons for the non-replication included relatively large variance, baseline psychopathology scores being higher in this patient group, potential ceiling effects in BMI and ED psychopathology as well as differing comorbidities.

Psychosocial interventions for people with both severe mental illness and substance misuse.

BACKGROUND: Even low levels of substance misuse by people with a severe mental illness can have detrimental effects. OBJECTIVES: To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care. SEARCH METHODS: For this update (2013), the Trials Search Co-ordinator of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (July 2012), which is based on regular searches of major medical and scientific databases. The principal authors conducted two further searches (8 October 2012 and 15 January 2013) of the Cochrane Database of Systematic Reviews, MEDLINE and PsycINFO. A separate search for trials of contingency management was completed as this was an additional intervention category for this update. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness. DATA COLLECTION AND ANALYSIS: We independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of relative risk (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. For all meta-analyses we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison. MAIN RESULTS: We included 32 trials with a total of 3165 participants. Evaluation of long-term integrated care included four RCTs (n = 735). We found no significant differences on loss to treatment (n = 603, 3 RCTs, RR 1.09 CI 0.82 to 1.45, low quality of evidence), death by 3 years (n = 421, 2 RCTs, RR 1.18 CI 0.39 to 3.57, low quality of evidence), alcohol use (not in remission at 36 months) (n = 143, 1 RCT, RR 1.15 CI 0.84 to 1.56,low quality of evidence), substance use (n = 85, 1 RCT, RR 0.89 CI 0.63 to 1.25, low quality of evidence), global assessment of functioning (n = 171, 1 RCT, MD 0.7 CI 2.07 to 3.47, low quality of evidence), or general life satisfaction (n = 372, 2 RCTs, MD 0.02 higher CI 0.28 to 0.32, moderate quality of evidence).For evaluation of non-integrated intensive case management with usual treatment (4 RCTs, n = 163) we found no statistically significant difference for loss to treatment at 12 months (n = 134, 3 RCTs, RR 1.21 CI 0.73 to 1.99, very low quality of evidence).Motivational interviewing plus cognitive behavioural therapy compared to usual treatment (7 RCTs, total n = 878) did not reveal any advantage for retaining participants at 12 months (n = 327, 1 RCT, RR 0.99 CI 0.62 to 1.59, low quality of evidence) or for death (n = 493, 3 RCTs, RR 0.72 CI 0.22 to 2.41, low quality of evidence), and no benefit for reducing substance use (n = 119, 1 RCT, MD 0.19 CI -0.22 to 0.6, low quality of evidence), relapse (n = 36, 1 RCT, RR 0.5 CI 0.24 to 1.04, very low quality of evidence) or global functioning (n = 445, 4 RCTs, MD 1.24 CI 1.86 to 4.34, very low quality of evidence).Cognitive behavioural therapy alone compared with usual treatment (2 RCTs, n = 152) showed no significant difference for losses from treatment at 3 months (n = 152, 2 RCTs, RR 1.12 CI 0.44 to 2.86, low quality of evidence). No benefits were observed on measures of lessening cannabis use at 6 months (n = 47, 1 RCT, RR 1.30 CI 0.79 to 2.15, very low quality of evidence) or mental state (n = 105, 1 RCT, Brief Psychiatric Rating Scale MD 0.52 CI -0.78 to 1.82, low quality of evidence).We found no advantage for motivational interviewing alone compared with usual treatment (8 RCTs, n = 509) in reducing losses to treatment at 6 months (n = 62, 1 RCT, RR 1.71 CI 0.63 to 4.64, very low quality of evidence), although significantly more participants in the motivational interviewing group reported for their first aftercare appointment (n = 93, 1 RCT, RR 0.69 CI 0.53 to 0.9). Some differences, favouring treatment, were observed in abstaining from alcohol (n = 28, 1 RCT, RR 0.36 CI 0.17 to 0.75, very low quality of evidence) but not other substances (n = 89, 1 RCT, RR -0.07 CI -0.56 to 0.42, very low quality of evidence), and no differences were observed in mental state (n = 30, 1 RCT, MD 0.19 CI -0.59 to 0.21, very low quality of evidence).We found no significant differences for skills training in the numbers lost to treatment by 12 months (n = 94, 2 RCTs, RR 0.70 CI 0.44 to 1.1, very low quality of evidence).We found no differences for contingency management compared with usual treatment (2 RCTs, n = 206) in numbers lost to treatment at 3 months (n = 176, 1 RCT, RR 1.65 CI 1.18 to 2.31, low quality of evidence), number of stimulant positive urine tests at 6 months (n = 176, 1 RCT, RR 0.83 CI 0.65 to 1.06, low quality of evidence) or hospitalisations (n = 176, 1 RCT, RR 0.21 CI 0.05 to 0.93, low quality of evidence).We were unable to summarise all findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low or very low due to high or unclear risks of bias because of poor trial methods, or poorly reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. AUTHORS' CONCLUSIONS: We included 32 RCTs and found no compelling evidence to support any one psychosocial treatment over another for people to remain in treatment or to reduce substance use or improve mental state in people with serious mental illnesses. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high quality trials are required which address these concerns and improve the evidence in this important area.