Increasing treatment adherence among outpatients with depression and cocaine dependence: results of a pilot study.

OBJECTIVE: This pilot study examined the effect of a modified motivational therapy intervention on outpatient treatment adherence and completion for patients with comorbid depressive disorder and cocaine dependence. METHOD: Depressed cocaine patients, stabilized with antidepressant medications on an inpatient psychiatric unit, were consecutively assigned on discharge to motivational therapy (N = 11) or treatment-as-usual (N = 12) during the first month of outpatient care. Patients were compared on treatment adherence and completion and on 1-year rehospitalization rates. RESULTS: Motivational therapy patients attended significantly more treatment sessions during month 1, completed 30 and 90 days of outpatient care at higher rates, and experienced fewer psychiatric rehospitalizations and days in the hospital during the first year from entry into outpatient treatment. CONCLUSIONS: An outpatient program combining individual and group motivational therapy sessions holds promise for improving treatment adherence and completion among depressed patients with cocaine dependence.

Disproportionate lethality in psychiatric patients with concurrent alcohol and cocaine abuse.

OBJECTIVE: The aim of this study was to examine the association between active, concomitant cocaine and alcohol abuse and the prevalence and severity of current suicidal and homicidal behavior among hospitalized psychiatric patients. METHOD: Three groups of patients--with cocaine and alcohol abuse (N = 38), alcohol abuse only (N = 38), and cocaine abuse only (N = 25)--consecutively admitted to a psychiatric and substance abuse dual-diagnosis unit were comparatively examined for the presence of current suicidal and homicidal behavior. RESULTS AND CONCLUSIONS: Logistic regression analysis revealed that the alcohol and cocaine abuse group had a higher likelihood of associated current homicidal behavior than the alcohol-only and the cocaine-only groups.

Self-help activities in cocaine dependent patients entering treatment: results from NIDA collaborative cocaine treatment study.

Although little is known about self-help attendance among cocaine dependent patients, clinicians frequently recommend this treatment. Cocaine dependent patients (519) entering a psychotherapy study were therefore surveyed regarding their recent self-help group attendance and participation. During the previous week, 34% had attended a self-help group. Of self-help attenders who actively participated 55% initiated abstinence within the next month, compared with 40% of non-attenders and 38% of non-participating attenders (P < 0.01). These findings support the potential short-term positive prognostic significance of self-help attendance and participation in cocaine dependent patients.

Approaches to patient and family education with affective disorders.

This paper provides an overview of prevalence, types, effects and treatment for affective disorders, with particular emphasis on educational and psychoeducational interventions. It reviews several models of psychoeducation including the approaches used in various programs at the Psychiatric hospital in which the authors work. These approaches are based on the Psychoeducational Model of Family Treatment developed by Dr. Carol Anderson and colleagues. Outcome data from several studies are also presented evidencing the positive impact of these interventions on patients and families.

Predictors of self-help group attendance in cocaine dependent patients.

OBJECTIVE: While referral to self-help groups for patients dependent on drugs other than alcohol has become widespread in the substance abuse treatment field, little is known about the characteristics of people who attend these groups. This study examines particular sociodemographic and clinical characteristics as possible predictors of attendance at self-help groups in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. METHOD: A multicenter study randomly assigned 487 patients (76.8% men) to one of four psychosocial treatments for cocaine dependence. Patients were treated for 24 weeks. Among other measures, the Weekly Self-Help Questionnaire was administered each week and completed, at least once, by 411 subjects. RESULTS: Approximately two thirds of the patients attended one or more self-help meetings during the 24-week period. Patients initially more likely to attend self-help groups frequently were those who were unemployed, had no religious preference, had more severe baseline drug use and reported treatment for prior substance-related problems. Patients with more severe baseline drug use and those who previously received treatment for substance-related problems were more likely to maintain frequent attendance throughout the study period. Only severity of baseline drug use predicted more frequent attendance during Month 6, although there was a trend in Month 6 favoring more frequent attendance by women. These findings remained significant when treatment condition was added to the models. CONCLUSIONS: Although these findings are consistent with past research on alcohol dependent individuals, they challenge popular clinical notions about the types of people who attend self-help groups. These findings demonstrate that self-help groups can appeal to a wide variety of cocaine dependent patients.

Fluoxetine versus placebo in depressed alcoholics: a 1-year follow-up study.

The authors conducted a first study to evaluate the long-term efficacy of fluoxetine for decreasing the depressive symptoms and the drinking of patients with comorbid major depressive disorder and alcohol dependence. This study consisted of a 1-year naturalistic follow-up of 31 patients who previously had completed a 3-month double-blind, placebo-controlled study of fluoxetine in depressed alcoholics. The fluoxetine group continued to demonstrate less depressive symptoms and less drinking than the placebo group at the 1-year follow-up evaluation. The results of the 1-year follow-up evaluation suggest persistent efficacy for fluoxetine for treating the depressive symptoms and the drinking of depressed alcoholics.

Characterizing female bipolar alcoholic patients presenting for initial evaluation.

This study examined gender differences of age and race-matched group of bipolar disorder (BPO) patients with comorbid alcohol dependence (AD; n = 65; males = 35, females = 30) to a group of BPO patients without comorbid AD (n = 61; males = 22, females = 39). The two groups were also similar on marital status and frequency of BPO subtypes. The results revealed that female bipolar alcoholic patients were more likely to report depressive symptoms as compared to either male bipolar alcoholics or both male and female non-alcoholic bipolar patients. When compared to male bipolar alcoholics, they had higher frequency of depressed mood, slow motor behavior, low self-esteem, decreased libido, decreased appetite, and higher general anxiety symptoms. On the other hand, female bipolar alcoholics differed from female non-alcoholic bipolar patients on reports of mood lability, depressed mood, low self-esteem, suicidal indicators, decreased libido, and general anxiety symptoms. These results raise the question of whether alcohol increases the frequency of depressive symptoms among female bipolar patients.

Substance abuse and schizophrenia: impediments to optimal care.

With lifetime prevalence estimates of substance abuse among schizophrenics as high as 47.01%, there is an increasing awareness of the importance of this dual diagnosis and the global deficiencies in our knowledge about this comorbid condition. Patients with substance abuse disorders and schizophrenia are problematic from a clinical, economic, and health care systems perspective. The lack of systematic research into phenomenology, etiology, and treatment approaches (both psychotherapeutic and psychopharmacologic) has hindered the development of an adequate strategy to care for the needs of these patients. Thus, these patients place a significant burden on the mental health delivery system through chronic disability, social dysfunction, frequent rehospitalizations, and poor overall treatment compliance. The authors critically review the contemporary literature relevant to concurrent substance abuse and schizophrenia, highlight major deficiencies in our knowledge, and call for research to reduce the individual, economic, and social costs of this condition.

The utility of diazepam loading in the treatment of alcohol withdrawal among psychiatric inpatients.

The aim of this study was to assess the usefulness of an objective rating scale (the modified Clinical Institute Withdrawal Assessment for Alcohol [CIWA-A]) and a diazepam loading dose (20 mg) in the management of alcohol withdrawal among hospitalized psychiatric patients. The sample consisted of 152 adult, hospitalized, psychiatric patients with comorbid alcohol dependence. Of the 152 subjects, 115 (75.7%) completed detoxification with supportive therapy only. Among the 37 patients who required pharmacotherapy (24%), 15 (40.5%) required only one 20-mg dose of diazepam, 14 (38%) required 40 mg to 100 mg, and 8 (21.6%) required doses ranging from 120 mg to 220 mg. There were no complications related to this treatment. The results suggest that the use of the objective rating scale and the diazepam loading dose appears to be safe and effective, and is a useful method for the management of alcohol withdrawal among psychiatric patients.

Naltrexone utility in depressed alcoholics.

The aim of this open-label pilot study was to evaluate the utility of naltrexone (50 mg per day) in decreasing alcohol use and to examine its impact on depressive symptoms among depressed alcoholics who have failed to abstain from alcohol use despite treatment with a selective serotonin reuptake inhibitor (SSRI). Fourteen ambulatory care patients, aged 18 to 65 years, with DSM-III-R comorbid diagnoses of alcohol dependence and major depressive disorder, who failed to abstain despite treatment with an antidepressant medication were enrolled in the study. Patients were followed for 12 weeks with weekly assessment of drinking behavior, depressive symptoms, functioning, alcohol craving, and side effects. The results of this study indicated a significant decrease in alcohol use and in urges to drink alcohol in the presence of the usual triggers. There was also a trend suggesting improvement in depressive symptoms and overall functioning. Naltrexone was well tolerated, with mild side effects reported at the onset of treatment.

Drug use problem awareness and treatment readiness in dual-diagnosis patients.

Problem awareness and treatment readiness are factors that influence treatment-seeking behavior, and thus, morbidity and outcome. The authors elucidated patterns of problem awareness and treatment readiness among hospitalized dually diagnosed patients by administering the Problem Awareness and Readiness for Treatment subscales of the Alcohol Use Inventory to 67 psychiatric inpatients with comorbid substance-related disorders and using a multivariate model approach to data analysis. The results suggested differential and interactive effects of gender, ethnicity, voluntary admission status, and a diagnosis of major depression (MDD) on drug abuse problem awareness and treatment readiness. Female gender, voluntary admission status, and a comorbid diagnosis of MDD were associated with increased awareness and readiness for treatment.

Fluoxetine versus placebo in depressed alcoholic cocaine abusers.

To date, few double-blind, placebo-controlled studies with any selective serotonin reuptake inhibitor (SSRI) antidepressant in pure cocaine abusers or in cocaine abusers with comorbid disorders have been reported. In this study, 17 patients with DSM-III-R diagnoses of major depressive disorder, alcohol dependence, and cocaine abuse were included along with 34 non-cocaine-abusing depressed alcoholics in a pharmacotherapy trial involving the SSRI antidepressant fluoxetine. All 51 patients participated in a double-blind, parallel group study of fluoxetine versus placebo in depressed alcoholics. The principal focus of this article is the one-third of the depressed alcoholics who also abused cocaine and how the treatment response of those 17 patients compared with that of the 34 depressed alcoholics who did not abuse cocaine. During the study, no significant difference in treatment outcome was noted between the fluoxetine group (N = 8) and the placebo group (N = 9) for cocaine use, alcohol use, or depressive symptoms. In addition, no significant within-group improvement was noted for any of these outcome variables in either of the two treatment groups. Indeed, across the combined sample of 17 depressed alcoholic cocaine abusers, the mean Beck Depression Inventory (BDI) score worsened slightly from 19 to 21 during the course of the study, and 71 percent of the patients continued to complain of suicidal ideations at the end of the study. The 17 cocaine-abusing depressed alcoholics showed a significantly worse outcome than the 34 non-cocaine abusing depressed alcoholics on the 24-item Hamilton Rating Scale for Depression (HAM-D) and BDI depression scales and on multiple measures of alcohol consumption. These findings suggest that comorbid cocaine abuse acts as a robust predictor of poor outcome for the drinking and the depressive symptoms of depressed alcoholics.