Daryle Deering

Health status of clients receiving methadone maintenance treatment using the SF-36 health survey questionnaire

This study investigated the health status of a representative sample of clients (35 Maori, 72 non-Maori) receiving methadone maintenance treatment in New Zealand, using the SF-36 health survey. The publication of New Zealand norms in 1999 enabled comparisons of the health of the Methadone Treatment Programme study participants with that of the New Zealand population. Although over 50% of participants rated their health as good, very good or excellent, 44% rated their health as fair or poor and compared with population norms, the health of the study participants was significantly poorer on all eight SF-36 scales. Male and female participants rated their health similarly to male and female clients attending another New Zealand Methadone Treatment Programme. Results highlighted the impact of a chronic disorder and co-existing health-related problems on the health and well-being and day-to-day functioning of this client group. Higher frequency of benzodiazepine use was associated with poorer social functioning, mental health and role functioning and higher frequency of cannabis use was associated with poorer role functioning due to emotional problems. Findings support routine monitoring of health status with clients receiving methadone maintenance treatment as a guide to preventative and treatment interventions and health maintenance strategies.

Youth retention: Factors associated with treatment drop-out from youth alcohol and other drug treatment

INTRODUCTION AND AIMS This study examined factors associated with treatment drop-out among young people aged 13-19 years attending alcohol and other drug (AOD) treatment. DESIGN AND METHODS Data were gathered from structured interviews (n = 79) and a clinical file search of 184 randomly selected young people who had attended youth specific AOD treatment services in Aotearoa, New Zealand during 2003 or 2004. RESULTS The median length of stay was 2.7 months for those attending day/residential services (n = 42) and 4.0 sessions for those attending outpatient services (n = 37) 16.7% of participants from day/residential services dropped out of treatment early (within the first month) and 32.4% of participants from outpatient treatment services dropped out of treatment early (before the third session). Fixed client characteristics, such as age, sex, ethnicity, substance use and mental health diagnoses were not found to be associated with treatment retention. Dynamic client characteristics, such as motivation to attend treatment and expectations about treatment outcomes and program characteristics, such as positive experiences with treatment staff and feeling involved in the treatment process were found to be associated with treatment retention. DISCUSSION AND CONCLUSIONS The findings of this study support previous research indicating that fixed client characteristics are not sufficient to explain youth retention in AOD treatment. Of more use are dynamic client characteristics and program variables. These findings stress the potential for improving treatment retention by creating more youth appropriate services.

A randomized trial of combined citalopram and naltrexone for nonabstinent outpatients with co-occurring alcohol dependence and major depression.

Abstract Despite the high rate of co-occurrence of major depression and alcohol dependence, the role of pharmacotherapy in their treatment remains unclear. In the new era of naltrexone for alcohol dependence, it is notable that only 1 study to date has examined the efficacy of antidepressant medication prescribed concurrently with naltrexone. We aimed to determine whether combining naltrexone with citalopram produced better treatment outcomes than naltrexone alone in patients with co-occurring alcohol dependence and depression, and to investigate whether either sex or depression type (independent or substance-induced depression) moderated treatment response. Participants were 138 depressed alcohol-dependent adults who were not required to be abstinent at the commencement of the trial. They were randomized to 12 weeks of citalopram or placebo, plus naltrexone and clinical case management. Treatment was well attended, and medications were reasonably well tolerated with high adherence rates. Substantial improvements in both mood and drinking occurred in both groups, with no significant differences between groups on any of the mood or drinking outcome measures, whether or not other variables were controlled for. No interaction effect was found for independent/substance-induced depression status, whereas there was a marginal effect found by sex, with greater improvement in 1 drinking outcome measure (percent days abstinent) in women taking citalopram. These findings suggest that citalopram is not a clinically useful addition to naltrexone and clinical case management in this treatment population. Independent/substance-induced depression status did not predict treatment response. Findings for sex were equivocal.

Models of care delivery in mental health nursing practice: a mixed method study.

The aim of this study was to identify the conceptual models that underpin mental health nursing care in clinical settings. This study is a modification of a previous study which evaluated the influence of implicit models of mental disorder on processes of decision making within community-based teams. Participants completed questionnaires in response to a scenario. A range of explanatory conceptual models were identified in respect to aetiology, treatment and recovery. In a forced choice the participants ranked a medical model of care above other models as underpinning care delivery. The content analysis found that the participants used a psychodynamic framework for understanding the causes of mental distress but described the nursing interventions in terms of supporting a medical model of care. Nursing care is dominated by a medical model which constrains mental health nursing. This potentially creates tension between what nurses believe to be the problem and the responses available for nurses in their clinical setting. A range of psychosocial approaches to mental health care delivery have been developed, but there seems to be problems with their implementation in practice. Further research is required to explore how broader therapeutic interventions can be implemented by nurses within multidisciplinary systems of mental health care delivery.

Retention of adolescents with substance dependence and coexisting mental health disorders in outpatient alcohol and drug group therapy

The aim of this study was to investigate characteristics that might enhance retention among adolescents attending outpatient alcohol and drug group therapy within a youth mental health setting. An important goal was to provide information for nurses and other clinicians who work with adolescents with coexisting substance use and mental health disorders. A retrospective file audit reviewed the files of 64 adolescents who attended a weekly alcohol and drug group between 2002 and 2004. Five characteristics were shown to have a significant impact on enhancing participant group retention. These were Māori and Pacific Island ethnicity, past or current legal charges, youth drug court (YDC) involvement, having a diagnosis of cannabis dependence, and a diagnosis of conduct disorder. Logistic regression found that YDC involvement on its own significantly predicted treatment retention. In an area of limited research, the findings from this study expand the literature on enhancing treatment retention for a vulnerable and hard-to-engage adolescent group with complex treatment needs, and highlight the need for further investigation of the potential role of the YDC. From a practice perspective, the findings support group therapy interventions as a cost-effective treatment modality for assisting adolescents with coexisting substance use and mental health issues, including those with conduct disorder and YDC involvement.

Implementing and Maintaining Nurse-Led Healthy Living Programs in Forensic Inpatient Settings: An Illustrative Case Study

BACKGROUND: Healthy living programs (HLPs) within the context of mental health units are an applied response to the concerns of metabolic syndrome and the associated physical illnesses to which people with serious mental illness are susceptible. OBJECTIVE: To illustrate how nurses, with other health professionals and service users, have established and maintained HLPs in two locked forensic mental health units in New Zealand. DESIGN: This illustrative case study adopts a multimodal approach to data collection and analysis. Across two programs, interviews were undertaken with service users (n = 15) and staff (n = 17), minutes of meetings were analyzed for major decision points, and clinical notes were reviewed to identify which service-user health status measures (body mass index, glucose tolerance test results, blood pressure, and medication use) were recorded. RESULTS: Similarities were identified in the way the HLPs were implemented and maintained by champions who advocated for change, challenged staff attitudes, secured funding, and established new systems and protocols. Successful implementation depended on involvement of the multidisciplinary team. Each program operated within a different physical environment and adopted its own philosophical approach that shaped the style of the program. The HLPs had an impact on nurses, other staff, and on the culture of the institutions. The programs raised dilemmas about restrictions and risk versus autonomy and self-management. CONCLUSION: Understanding the effects of the clinical and philosophical contexts in which HLPs are established and the way challenges and benefits are affected by context has practical significance for the future development of health programs in forensic settings, prisons, and general mental health units.

DSM-5 alcoholism: A 60-year perspective

Alcohol continues to be the western world’s favourite recreational drug, use of which induces a compelling state of anxiolytic euphoria for several hours in most people. Overuse of alcohol is associated with a range of negative health and social consequences. These consequences relate to both the highly intoxicating and aggressogenic nature of alcohol in the short-term (Parrott and Zeichner, 2002), and toxicity from chronic overuse, with about half of alcohol deaths due to acute effects and the other half chronic illness (Connor et al., 2005), including cancers, which account for at least 25% of all alcohol-related deaths. Alcoholism has been the most commonly used term to describe the behavioural pattern of alcohol overuse in clinical practice. We use the term ‘alcoholism’ here to encompass the series of changes in formal diagnostic systems over the past 60 years since the publication of the Diagnostic and Statistical Manual of Mental Disorders, First Edition (DSM-I) in 1952. From DSM-I to DSM-IV there have been two main shifts in diagnostic conception of alcoholism (Sellman, 1994); DSM-5 represents a third, which is a return to the 1960s unitary formulation of alcoholism (Figure 1).

Profile of young people attending alcohol and other drug treatment services in Aotearoa, New Zealand: clinical file search

Objective: The aim of the present study was to provide a profile of young people attending alcohol and other drug (AOD) treatment services in Aotearoa, New Zealand. Method: Data were gathered from a clinical file search of 184 randomly selected young people aged 13–19 years who had attended one of eight youth AOD treatment services in New Zealand during 2003 or 2004. These services represented eight of the 11 youth-specific AOD services available to youth in New Zealand. Results: Young people who attend youth-specific AOD services in New Zealand present with a range of complex needs including substance use and mental health issues, criminality, family conflict and disengagement from school. A total of 62.0% were male, 56.4% had criminal convictions, 40.6% had spent some time in Child, Youth and Family Services care and 53.8% were reported to have a coexisting substance use and mental health disorder. Low rates of reporting of substance use and mental health diagnoses in treatment files suggest that substance use and mental health disorders among this population are likely to be higher than those reported. Conclusions: This paper provides a unique profile of young people attending youth-specific AOD treatments in New Zealand. Such information is useful in informing treatment planning and funding and ensuring that service development occurs to specifically meet the complex needs of this patient group.

CLINICIAN BELIEFS AND PRACTICES RELATED TO INCREASING RESPONSIVITY TO THE NEEDS OF MAORI WITH ALCOHOL AND DRUG PROBLEMS

Culturally responsive treatments are often cited as essential for successfully addressing substance use-associated problems in indigenous and other ethnicgroups. However, there has been little investigation of the support for this assertion among alcohol and drug-user treatment workers, or how it might translate into clinical practice. The current paper reports on the results of a survey of the New Zealand alcohol and drug-user treatment field, which canvassed these issues. Eighty-six percent of respondents advocated adjustment of clinical practice when working with Maori. Two key strategies were referral to specialist Maori groups or individuals and/or contacting/meeting with whanau (family). Comparisons were made between respondents who referred clients on and those who provided intervention themselves. Implications of results, limitations and future research are discussed.

Could an advance practice nurse improve detection of alcohol misuse in the emergency department

Alcohol misuse is a prevalent problem in New Zealand society, and one that exacts a considerable cost in terms of health, social cohesion, and economic productivity. Despite the burden of alcohol misuse, screening, brief assessment, and interventions for alcohol problems are frequently poorly performed within general health services. In this paper we explore the response to alcohol problems in a New Zealand emergency department and discuss difficulties encountered in improving rates of detection by emergency department personnel. We report the results of a clinical audit of alcohol screening and brief assessment and a staff education programme designed to improve practice in this area, but which met with limited success. The potential role for an advanced practice nurse providing a clinical consultation and liaison service to the emergency department staff is explored. We argue that such a role has potential to reduce the health and social costs of alcohol misuse, and to meet the national policy objective of providing a treatment response to people with alcohol-related problems in contact with health services.