David A. Smelson

Serious Mental Illness and Tobacco Addiction: A Model Program to Address This Common but Neglected Issue

Tobacco addiction among persons with serious mental illness (SMI) has been largely ignored. About 75 to 85% of persons with schizophrenia, bipolar disorder, and other SMI use tobacco; most will either die and/or have reduced quality of life because of tobacco-caused medical diseases. Tobacco addiction is the most common co-occurring disorder for the SMI population. A dramatic reduction in tobacco use in the general population has occurred during the past 40 years; however, there has been almost no reduction for smokers with SMI. The University of Medicine and Dentistry of New Jersey program targets smokers with SMI and provides outreach services, clinical treatment and research, and consultation to other community-based mental health treatment agencies in New Jersey. Clinical and research evidence supports motivation-based treatment, blending mental health and addiction treatment approaches, and integrating tobacco dependence treatment within mental health settings. The unique barriers and clinical issues for this population are described.

Addressing tobacco use disorder in smokers in early remission from alcohol dependence: The case for integrating smoking cessation services in substance use disorder treatment programs

Despite the declining overall rate of cigarette smoking in the general population in the United States, the prevalence of smoking is estimated to be as high as 80% among treatment-seeking alcoholics. The serious adverse health effects of tobacco and heavy alcohol use are synergistic and recent evidence suggests that smoking slows the process of cognitive recovery following alcohol abstinence. In addition, substantial evidence shows that treatment for tobacco dependence does not jeopardize alcohol abstinence. In this paper, we focus on the impact and treatment implications of tobacco dependence among treatment-seeking alcoholics through a review of five areas of research. We begin with brief reviews of two areas of research: studies investigating the genetic and neurobiological vulnerability of comorbid tobacco and alcohol dependence and studies investigating the consequences of comorbid dependence on neurobiological and cognitive functioning. We then review literature on the effects of smoking cessation on drinking urges and alcohol use and the effectiveness of smoking cessation interventions with alcoholic smokers. Finally, we offer recommendations for research with an emphasis on clinical research for enhancing smoking cessation outcomes in this population.

Risperidone Decreases Craving and Relapses in Individuals with Schizophrenia and Cocaine Dependence

Objective: To examine the efficacy of atypical neuroleptics for decreasing craving and drug relapses during protracted withdrawal in individuals dually diagnosed with schizophrenia and cocaine dependence. Method: We conducted a 6-week, open-label pilot study comparing risperidone with typical neuroleptics in a sample of withdrawn cocaine-dependent schizophrenia patients. Results: Preliminary results suggest that individuals treated with risperidone had significantly less cue-elicited craving and substance abuse relapses at study completion. Further, they showed a trend toward a greater reduction in negative and global symptoms of schizophrenia. Conclusion: Atypical neuroleptics may help reduce craving and relapses in this population. Future research should include more rigorous double-blind placebo-controlled studies with this class of medications.

Using A Pharmacy-Based Intervention To Improve Antipsychotic Adherence Among Patients With Serious Mental Illness

Background: Similar to patients with other chronic disorders, patients with serious mental illness (SMI) are often poorly adherent with prescribed medications. Objective: We conducted a randomized controlled trial examining the effectiveness of a pharmacy-based intervention (Meds-Help) in increasing antipsychotic medication adherence among Department of Veterans Affairs (VA) patients with SMI. We also examined the impact of Meds-Help on psychiatric symptoms, quality of life, and satisfaction with care. Methods: We enrolled 118 patients from 4 VA facilities with schizophrenia, schizoaffective, or bipolar disorder who were on long-term antipsychotics but had antipsychotic medication possession ratios (MPRs) <0.8 in the prior year. Patients were randomized to usual care (UC; n = 60) or the pharmacy-based intervention (Meds-Help; n = 58). We reassessed adherence at 6 and 12 months, at which time patients completed Positive and Negative Symptom Scales (PANSS), Quality of Well-being Scales (QWB), and Client Satisfaction Questionnaires (CSQ-8). Results: Prior to enrollment, Meds-Help and UC patients had mean antipsychotic MPRs of 0.54 and 0.55, respectively. At 6 months, mean MPRs were 0.91 for Meds-Help and 0.64 for UC patients; at 12 months, they were 0.86 for Meds-Help and 0.62 for UC patients. In multivariate analyses adjusting for patient factors, Meds-Help patients had significantly higher MPRs at 6 and 12 months (P < .0001). There were no significant differences between groups in PANSS, QWB, or CSQ-8 scores, but power to detect small effects was limited. Conclusions: Congruent with prior studies of patients with other disorders, a practical pharmacy-based intervention increased antipsychotic adherence among patients with SMI. However, SMI patients may require additional care management components to improve outcomes.

The efficacy of olanzapine for decreasing cue-elicited craving in individuals with schizophrenia and cocaine dependence: a preliminary report

Objective: Although a growing body of research suggests that atypical neuroleptic medications are efficacious in the treatment of cocaine addiction among individuals with schizophrenia, more rigorously controlled trials are needed. To extend this research, we performed a 6-week double-blind study comparing olanzapine to haloperidol with the primary objective of reducing cue-elicited cocaine craving and the secondary aims of decreasing substance use, improving psychiatric symptoms, and determining an effect size for future studies. Methods: Thirty-one subjects with cocaine dependence and schizophrenia were randomized to olanzapine or haloperidol, underwent a cue-exposure procedure, and completed psychiatric and substance abuse ratings. Results: Individuals in the olanzapine group who completed the study had a significant reduction on the energy subscale of the Voris Cocaine Craving Scale at study completion compared with individuals in the haloperidol group. The olanzapine-treated group also had lower, but not statistically significant, PANSS General Psychopathology Subscale scores and fewer positive urine toxicology screens compared with those in the haloperidol group. Conclusion: This small, but rigorously controlled, pilot trial provides additional evidence for the use of atypical antipsychotics for the treatment of individuals with co-occurring schizophrenia and cocaine dependence. Reductions in craving were associated with medium to large effect sizes.

Neuropsychological Deficits in Withdrawn Cocaine-Dependent Males

Previous research suggests that cocaine abuse may result in neuropsychological deficits. To examine this further, we compared cocaine-withdrawn patients (N = 35) to normal controls (N = 17) on tasks of attention, concentration, perceptual-motor speed, and cognitive flexibility. The withdrawn cocaine patients performed significantly worse on Arithmetic, Grooved Peg Board Dominant and Non-Dominant, and Trails B tests. These findings suggest that withdrawn cocaine-dependent patients have more neuropsychological impairment than normal controls.

Supporting the education goals of post-9/11 veterans with self-reported PTSD symptoms: A needs assessment.

PURPOSE The influx of young adult veterans with mental health challenges from recent wars combined with newly expanded veteran education benefits has highlighted the need for a supported education service within the Veterans Administration. However, it is unknown how such a service should be designed to best respond to these needs. This study undertook a qualitative needs assessment for education supports among veterans with post-9/11 service with self-reported PTSD symptoms. METHODS Focus groups were held with 31 veterans, 54% of whom were under age 30. Transcripts were analyzed and interpreted using a thematic approach and a Participatory Action Research team. RESULTS Findings indicate a need for age relevant services that assist with: education planning and access, counseling for the G.I. Bill, accommodations for PTSD symptoms, community and family re-integration, and outreach and support. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE The veterans recommended that supported education be integrated with the delivery of mental health services, that services have varied intensity, and there be linkages between colleges and the Veterans Health Administration.

Wireless Technologies, Ubiquitous Computing and Mobile Health: Application to Drug Abuse Treatment and Compliance with HIV Therapies

Beneficial advances in the treatment of substance abuse and compliance with medical therapies, including HAART, are possible with new mobile technologies related to personal physiological sensing and computational methods. When incorporated into mobile platforms that allow for ubiquitous computing, these technologies have great potential for extending the reach of behavioral interventions from clinical settings where they are learned into natural environments.

Chronic Illness with Complexities: Mental Illness and Substance Use Among Veteran Clinic Users with Diabetes

Objective: Create a taxonomy and examine the predictors of the often co-occurring conditions of substance use disorders and mental illness in veterans with diabetes. Design: Merged Veteran Health Administration and Medicare fee-for-service claims data (N = 485,893). Results: Thirty-one percent of patients with diabetes were diagnosed with either mental illness or substance use and had higher rates of diabetes-related complications. Women were more likely to have serious mental illness; African Americans and Latinos more likely to have drug and/or alcohol use. Conclusion: Prevalence of substance use disorder and mental illness differed by socio-demographics, suggesting the need for tailored diabetes management interventions.

Risperidone diminishes cue-elicited craving in withdrawn cocaine-dependent patients.

Dopamine, the neurotransmitter involved in the rewarding effects of cocaine (1), is present in the retina, where it plays a role in the amplitude of retinal responses to light, as evidenced by the electroretinogram (ERG) (2). We previously reported that withdrawn cocaine-dependent patients have significantly reduced ERG blue-cone response when compared with normal controls (3). The subgroup of patients with blunted ERG responses (< 0.5 microvolts) showed significantly greater increases from baseline craving scores (4) after being exposed to cocaine cues in a laboratory (Smelson and others, unpublished observations).