Measuring depression levels in HIV-infected patients as part of routine clinical care using the nine-item Patient Health Questionnaire (PHQ-9).

Little is known about the psychometric properties of depression instruments among persons infected with HIV. We analyzed data from a large sample of patients in usual care in two US cities (n=1467) using the nine-item Patient Health Questionnaire (PHQ-9) from the PRIME-MD. The PHQ-9 had curvilinear scaling properties and varying levels of measurement precision along the continuum of depression measured by the instrument. In our cohort, the scale showed a prominent floor effect and a distribution of scores across depression severity levels. Three items had differential item functioning (DIF) with respect to race (African-American vs. white); two had DIF with respect to sex; and one had DIF with respect to age. There was minimal individual-level DIF impact. Twenty percent of the difference in mean depression levels between African-Americans and whites was due to DIF. While standard scores for the PHQ-9 may be appropriate for use with individual HIV-infected patients in cross-sectional settings, these results suggest that investigations of depression across groups and within patients across time may require a more sophisticated analytic framework.

Crack cocaine, alcohol, and other drug use patterns among homeless persons with other mental disorders.

This study examined the co-occurrence of cocaine, alcohol, marijuana, and other drug use among treatment seeking homeless persons to determine whether alcohol use predicted cocaine use differently than marijuana and other drugs predicted cocaine use. Participants were 141 homeless persons with substance use and other nonpsychotic mental disorders seeking drug treatment at a metropolitan health care agency for homeless persons. They were 72.3% male, 27.7% female, 82.7% African American, 17.3% Caucasian, with an average age of 37.7 (SD 7.1) years and had 13.1 (SD 2.4) average years of education. Results supported the assertion that cocaine use was strongly associated with extent of alcohol use and that the association between cocaine and alcohol was stronger than the association between cocaine and other drug use, including marijuana. Participants with cocaine plus alcohol disorders were retained longer in treatment than disorders of cocaine only with no differences in abstinence outcome. The findings should drive further research into the use of alcohol as a trigger or predictor of cocaine use, the deleterious effects of the combined use of cocaine and alcohol, and specialized treatments for polysubstance users.

Prevalence of nonpsychotic mental disorders does not affect treatment outcome in a homeless cocaine-dependent sample.

This study presents the prevalence and treatment outcome of DUAL diagnoses (psychoactive substance use disorders [PSUD] plus other nonpsychotic mental disorders) among a population of homeless persons participating in a behavioral day treatment and contingency management drug abuse treatment program. Participants were 128 persons: 76.6% male, 23.4% female; 82.2% African-American, 17.2% Caucasian. There were 46 (35.9%) PSUDs and 82 (64.1%) DUAL participants. Cocaine (96.9%) and alcohol disorders (57.8%) were most prevalent overall, and 60.2% of participants had two or more psychoactive substance use disorders. DUAL participants had significantly more alcohol disorders than PSUDs (62.2% versus 50.0%). The most prevalent mental disorders (other than substance use) for the total and DUAL samples were, respectively, mood (51.6% and 80.5%) and anxiety (35.9% and 56.1%), and 31.3% and 48.8% had more than two mental disorders. The DUAL group had more severe problems than the PSUD group at baseline in alcohol, medical condition, employment/support, and psychiatric status areas on the ASI. Both groups showed treatment improvements at 6-months follow-up with the DUAL group showing greater mean changes than the PSUD group in five of the seven ASI areas. These findings are discussed in terms of effect of dual diagnoses on treatment outcome and study limitations related to a retrospective design and select sample of nonpsychotic mental disorders.

Abstinent-contingent housing and treatment retention among crack-cocaine-dependent homeless persons.

This study investigated Behavioral Day Treatment attendance in relation to treatment outcome among homeless persons dependent on crack-cocaine. Participants (N = 141) were 72.3% male and 82.7% African American. Days attended, activities attended, and follow-up rates over a 12-month period were positively affected by the more attractive treatment of providing immediate, rent-free, abstinent-contingent housing during a 2-month Behavioral Day Treatment program. Results replicated previous findings that abstinence is a function of treatment attendance and more treatment is associated with greater abstinence. The loss of predictive power at long-term follow-up, limitations of a retrospective design, need to identify most predictive therapeutic activity types, and potential influence of mental disorders were discussed. Analytical techniques used in this study allows for the planning, predictability, and measurement of drug abuse treatment success as a function of service utilization.

Measuring self-efficacy in substance abuse intervention in obstetric practices.

BACKGROUND: This study presents findings on the effect of an office-based obstetrics training program (given the acronym OBIWOM) on substance use assessment, management, and referral self-efficacy among obstetricians and staff of private, community-based obstetric practices. METHODS: Participants were obstetricians and staff from 10 of 27 available community-based, private obstetric practices in the target areas, for a practice participation rate of 37%. This study used a delayed treatment design to compare self-efficacy between practice staff randomly assigned to an immediate or delayed intervention group. RESULTS: Self-efficacy increased significantly after intervention from baseline to first follow-up for the immediate group, while no change was shown for the delayed (control) group. The impact of the intervention on self-efficacy was replicated in the assessment construct only after the intervention for the delayed group. CONCLUSION: This research shows that education and training can effectively improve self-efficacy in obstetricians and their staff in the management of substance use and pregnancy.

Initiating abstinence in cocaine abusing dually diagnosed homeless persons.

This study measured effectiveness of behavioral day treatment plus abstinence contingent housing and work therapy (DT+) versus behavioral day treatment alone (DT). A randomized controlled trial assessed participants at baseline, 2 and 6 months. Participants (N=110) met criteria for cocaine abuse or dependence, non-psychotic mental disorders, and homelessness. DT+ achieved greater abstinence at 2 and 6 months and more days housed at 6 months than DT. Effectiveness of DT+ was demonstrated, with greatest impacts on abstinence outcomes. Results replicated earlier work demonstrating effectiveness of behavioral day treatment and contingency management as an effective combination for cocaine abusing homeless persons.

Sufficient conditions for effective treatment of substance abusing homeless persons.

Treatment efficacy for homeless substance abusers (primarily crack cocaine) was studied in a randomized control design with subjects (n = 176) assigned to usual care (UC) or an enhanced day treatment program plus abstinent contingent work therapy and housing (EC). Subjects met DSM-III-R criteria for Substance Use Disorder and McKinny Act criteria for homelessness. UC involved weekly individual and group counseling. EC involved a day treatment program consisting of daily attendance, transportation, lunch, manualized psychoeducational groups, and individual counseling. A total of 131 (74.4%) subjects (62 UC and 69 EC) were treated and followed. UC subjects attended 28.5% and EC attended 48.4% of expected treatment during the first 2 months. After 2 months, EC subjects experienced up to 4 months of abstinent contingent work therapy (44.9% of EC subjects) and housing (37.7% of EC subjects), with day treatment available two afternoons per week. Longitudinal Wei-Lachin analyses of medians (reported alcohol use, days homeless and employed) and proportions (cocaine toxicologies) were conducted across 2-, 6-, and 12-month follow-up points. EC had 36% fewer positive cocaine toxicologies at 2-months and 18% fewer at 6-months than UC with regression toward baseline at 12-months. EC had 8 days fewer days of reported alcohol use in the past 30 days, 52 fewer days homeless in the past 60 days, and 10 more days employed in the past 30 days from baseline to the 12-months. UC showed no changes except a temporary increase in employment at 6-months. This is one of the first demonstrations that homeless cocaine abusers can be retained and effectively treated.

Psychiatric comorbidity: prevalence in methadone maintenance treatment.

This study examines prevalence rates for DSM-III-R anxiety and affective disorders in three follow-up samples of opioid addicts who were treated with methadone maintenance. At least one anxiety disorder was diagnosed in 55% of the total sample. Affective disorders were found in 58%. At least one anxiety disorder coexisted with at least one affective disorder in 36% of the sample. The research demonstrates that opiate addiction in this sample is most often associated with other comorbid psychopathology. It suggests a need for thorough assessment for general psychopathology in opioid addicts entering addiction treatment, especially assessment for anxiety and affective disorders. It also suggests the need for treatment that focuses on diagnosed mental disorders in addition to drug counseling for the substance abuse disorder.

Making evaluation work in a substance abuse treatment program for women with children: Olivia's House.

Olivia's House represents the development and implementation of an innovative substance abuse treatment program for drug-dependent, primarily African-American women with children. This article discusses the prevalence of problems related to women and drug abuse; describes the philosophy and continuum of care of Olivia's House; delineates the program, process, outcome, dissemination, and training components of the evaluation protocol; presents preliminary evaluation findings as they relate to the overall goals of Olivia's House: and points out the obstacles to the evaluation of a residential drug abuse treatment program from women and children. This article is targeted to substance abuse service providers and evaluators challenged with the effective delivery and accountability of meaningful treatment services to persons with substance use disorders.

Malpractice litigation fear and risk management beliefs among teaching hospital physicians.

We address four major issues related to physicians' fear of litigation: What are physicians' attitudes and beliefs toward malpractice? To whom or what do they attribute the "malpractice crisis"? Is fear of litigation associated with demographic and practice variables? What measures do physicians take to reduce risk? Hospital physicians in a southeastern health science center were surveyed (N = 356). Physicians attributed the malpractice crisis to circumstances outside medicine and beyond their control, perceived some patients as suitprone, and reported altering their practice to avoid being sued. Litigation fear was associated with physicians who were female, younger, not board certified, less clinically experienced, more clinically active, defendants in prior lawsuits, and in high-risk specialties. Physicians who were especially fearful of litigation placed less value in risk-management techniques. The findings are important in understanding how the prospect of litigation is perceived by physicians and how that perception may affect medical practice.

Validity of self-reported crack cocaine use among homeless persons in treatment.

The validity of self-reported crack cocaine use among 131 homeless persons participating in an outpatient substance abuse treatment research demonstration project was assessed by comparing the concordance of self-report and urinalysis results. The subjects were participants in either a Usual Care outpatient program or an Enhanced Care day treatment program that included drug free contingent work therapy and housing. For all subjects across four evaluation points, the false negative classification by self-report (i.e., denied verified use) rate for crack cocaine use was 32.0%. Denied verified use was greater in Usual Care (34.9%) than in Enhanced Care clients (23.7%) and greater at follow-up as compared to treatment entry for all clients. The findings are explained in terms of social desirability and the influence of treatment contingencies and greater accountability specific to the Enhanced Care program. The need for validation of self-reported cocaine use data among homeless persons in settings where contingencies are present and in other drug treatment or research settings is recommended.

Treatment outcome as a function of treatment attendance with homeless persons abusing cocaine.

This research examines the influence of treatment attendance at two substance abuse outpatient treatment programs of the Birmingham Substance Abuse Homeless Project on substance abuse, homelessness, and unemployment outcomes with homeless persons abusing primarily crack cocaine. Results revealed that significant reductions across a one year period in alcohol use, cocaine use, and homelessness were more likely to occur in clients who attended an average of 4.1 treatment days per week (High attendance or Enhanced Care group) than clients who attended less than one day a week on the average (Low attendance or Usual Care and Medium attendance groups). These results are consistent with the literature suggesting that more intensive contact early in treatment results in better long-term outcome with cocaine abusers, but has now been demonstrated with homeless cocaine abusers who have additional problems associated with housing and employment.