Mary F. Brunette

Psychosocial Interventions for Adults with Severe Mental Illnesses and Co-Occurring Substance Use Disorders: A Review of Specific Interventions

Abstract A growing body of research supports the effectiveness of integrated treatment for people with co-occurring severe mental illness and substance use disorders (dual disorders), but the effects of specific interventions are less clear. This review focuses on the effects of specific psychosocial interventions for dual disorders, including individual, group, and family modalities, as well as structural (e.g., case management model), procedural (e.g., contingency management), residential, and rehabilitation (e.g., vocational) interventions, with an emphasis on randomized controlled trials. Controlled research on specific individual interventions has focused mainly on motivation enhancement approaches for clients in the earlier stages of treatment, and has reported improved retention in treatment and substance abuse outcomes. Group interventions have been most extensively studied, with findings indicating that a variety of different treatment approaches specifically designed for dual disorder clients (e.g., emphasizing education, motivational enhancement, cognitive-behavioral counseling) are more effective at improving substance abuse outcomes than no group treatment or standard 12-Step approaches. Structural studies suggest that increasing the intensity of integrated dual disorder treatment produces only modest benefits. Residential dual disorder programs show great promise, especially for clients who are homeless and without psychosocial supports. Research on family therapy, procedural interventions, or rehabilitation is too premature at this time to draw any conclusions, although promising results have emerged in each area. Future avenues for research on specific interventions for dual disorders are considered.

Gender Differences in Homeless Persons with Schizophrenia and Substance Abuse

The purpose of this study was to test thegeneralizability of previous research on genderdifferences between men and women with co-occurringschizophrenia and substance abuse. One hundred eightpatients with schizophrenia or schizoaffective disorderinvolved in a study of treatment for homeless personswere interviewed for information regarding substanceuse, social functioning and support, comorbid disorders, victimization, medical illness, and legaltroubles. We found that women had more children and weremore socially connected than men. Women also had higherrates of sexual and physical victimization, comorbid anxiety and depression, and medical illnessthan men. We conclude that homeless women with dualdisorders, like women with substance use disorders inthe general population, have distinct characteristics, vulnerabilities, and treatment needs comparedwith men. In addition to comprehensive treatment ofpsychiatric and substance use disorders, gender-specificservices should be developed, including prevention and treatment of victimization and relatedproblems as well as help with accessing medicalservices.

A Randomized Trial of Clozapine Versus Other Antipsychotics for Cannabis Use Disorder in Patients With Schizophrenia

Objective: Cannabis use disorder is the most common co-occurring drug use disorder in people with schizophrenia and is associated with poor outcomes. The authors launched a randomized controlled trial to assess the impact of clozapine compared with treatment as usual on cannabis use in patients with schizophrenia and co-occurring cannabis use disorder. Methods: Thirty-one patients with schizophrenia and co-occurring cannabis use disorder were randomly assigned to switch to clozapine or to stay on their current antipsychotic and were then followed weekly for 12 weeks. Blinded raters assessed participants weekly with the Timeline Followback for substance use and the expanded Brief Psychiatric Rating Scale for symptoms. Longitudinal random effects models were used to investigate the time-varying differences in cannabis use and other outcomes between the treatment as usual and clozapine groups. Results: The two groups differed in average intensity of cannabis use by approximately 4.5 joints/week, with lesser use in the clozapine group (t = −1.77; df = 28.5; p = .086; effect size ∼ 0.6). Symptoms and functioning were not different between the two groups. Conclusions: Clozapine may reduce cannabis use among patients with schizophrenia and co-occurring cannabis use disorder. Further controlled trials are warranted.

A review of research on smoking cessation interventions for adults with schizophrenia spectrum disorders

Background: Recent studies show that 75–85% of people with schizophrenia spectrum disorders in the United States smoke cigarettes, compared with 23% of the general population. Moreover, people with these illnesses on average have life expectancies 25 years lower than the general population, and smoking is a contributor. Aims: To review intervention research and evaluate the methods and clinical findings associated with attempts to eliminate, or reduce, smoking in people with schizophrenia spectrum disorders. Methods: PubMed and PsychInfo were searched from early 1990 through 2007 with select keywords. Thirteen treatment studies addressing smoking cessation interventions in people with schizophrenia spectrum disorders or severe mental illness were identified. Results: Nicotine replacement therapy, psychosocial interventions, and bupropion have been studied. Overall, treatment compliance was moderate, quit rates were low, and relapse to smoking was high. Modest evidence supports the efficacy of bupropion an...

Integrated Care: Tobacco Use and Mental Illness: A Wake-Up Call for Psychiatrists

Tobacco use results in numerous consequences for individuals with mental illnesses and other substance use disorders, yet it is not adequately addressed by behavioral health professionals, including psychiatrists. This column describes current inaction among behavioral health professionals and some possible reasons for it and recommends next steps. Psychiatrists should provide treatment for all patients with a co-occurring tobacco use disorder and provide leadership to change policies and practices in treatment centers. Psychiatrists can be vital leaders of the effort to reduce the toll of tobacco use among people with mental illnesses, addictions, or both. A national movement for addressing tobacco use in the behavioral health field can be galvanized if more psychiatrists participate.

Smoking and Quitting Beliefs, Attitudes, and Behaviors Among Smokers With Severe Mental Illness From Three Race/Ethnicity Groups

Objective: Most people with severe mental illness do not use evidence-based smoking cessation treatments. Ethnic and racial identification among people with severe mental illness may add complexity to their participation in smoking cessation interventions. The purpose of this qualitative study was to explore smoking and smoking cessation attitudes, beliefs, and behaviors among three race/ethnicity groups of smokers with severe mental illness. Methods: Researchers inquired into day-to-day smoking activities and quit attempts in six focus groups with 36 randomly selected African American, Latino, and White smokers with severe mental illness. Transcripts were reviewed to identify prominent themes, and first-person perspectives were selected to provide a description of smoking norms, motivation to quit, and sources of quit information. Results: Participants of all three race/ethnicity groups reported that multiple facets of their lives contributed to smoking initiation and maintenance, including the belief that smoking was a key strategy for coping with mental illness symptoms, reinforcement within institutional living situations and treatment environments, and lack of resources to obtain effective treatments. African Americans and Latinos with severe mental illnesses tended to seek advice about smoking from a broad social network of family and friends and expressed misinformation about and mistrust of medical cessation treatments. Conclusions: Smoking cessation policies and interventions for smokers with severe mental illness should be tailored to address the smoking culture in mental health settings and the variation in health-seeking attitudes and behaviors across race/ethnicity groups.

A qualitative study of how individuals with severe mental illness assess smoking risks

Background: This qualitative paper describes perceptions of smoking risk and ways of thinking about risk for 31 persons with a Severe Mental Illness (SMI). Research has shown that many people with SMI want to quit smoking, and, like many other disadvantaged groups, make many quit attempts. Aim: The authors undertook a qualitative study to explore views and experiences about smoking and quitting, within a general context of what it means to them to live a healthy lifestyle. Method: A purposive sample of former smokers, current smokers, and individuals who had never smoked was chosen to participate in a semi-structured interview. Questions targeted various lifestyle domains, narrowing to focus more specifically on smoking habits, attempts to quit, and thoughts about the future in relation to health and smoking. Techniques of grounded theory were used to categorize and interpret themes. Results: The results indicate that many current smokers interpret and frame perceptions of health risks from smoking in rel...

Implications of research on comorbidity for the nature and management of substance misuse

This chapter provides a critical evaluation of different models concerning the etiology of the high rate of substance use disorders (SUD) in patients with severe mental illnesses (SMI). Common factor models posit that high rates of comorbidity are the result of shared vulnerabilities to both disorders. Research shows that clients with comorbid disorders are more likely to have relatives with SUD than are similar patients with only SMI. It is suggested that genetic risk for dual disorders may be enacted through gene-environment interactions, whereby substance misuse acts as an environmental stressor on the developing brain. A variety of different models posit that SMI increases clients vulnerability to developing SUD. These models can be broadly divided into three types, which include psychosocial risk factor models, the supersensitivity model, and the brain reward circuitry dysfunction model. Alleviation of dysphoria represents a more general model than self-medication that proposes people with SMI are prone to misuse substances in response to distress. Models proposing that psychotomimetic drug misuse can lead to long-term psychotic disorders typically build on the catecholamine hypothesis of schizophrenia or affective disorders, and are supported by basic animal research on drug effects. It is suggested that further significant advances in the basic science of addiction in people with SMI may be required before substantial leaps in effectiveness of interventions can be achieved.

Pharmacologic Treatments for Co-Occurring Substance Use Disorders in Patients with Schizophrenia: A Research Review

Abstract Substance use disorders are a common comorbidity in patients with schizophrenia, and are associated with a variety of negative outcomes. Research assessing pharmacotherapy of substance use disorders in patients with schizophrenia is in its infancy, but preliminary data indicate that, in particular, atypical antipsychotic medications may help patients with co-occurring disorders reduce substance use. Clozapine, despite its potential side effects, shows the most promise. Data related to other medications, which may also be helpful in patients with schizophrenia, are reviewed. Further controlled trials are needed to assess the impact of atypical antipsychotics, mood stabilizers, and other agents on substance abuse in patients with schizophrenia. Until such data are avail-Mary F. Brunette, Douglas L. Noordsy, and Alan I. Green are affiliated with the Department of Psychiatry, Dartmouth Medical School. able, clinicians should follow established principles of pharmacotherapy for patients with dual disorders, which include using medications to treat both disorders simultaneously over time in the context of psychosocial treatment for dual disorders.

Comparison of Early Intervention Services vs Treatment as Usual for Early-Phase Psychosis: A Systematic Review, Meta-analysis, and Meta-regression

Importance The value of early intervention in psychosis and allocation of public resources has long been debated because outcomes in people with schizophrenia spectrum disorders have remained suboptimal. Objective To compare early intervention services (EIS) with treatment as usual (TAU) for early-phase psychosis. Data Sources Systematic literature search of PubMed, PsycINFO, EMBASE, and ClinicalTrials.gov without language restrictions through June 6, 2017. Study Selection Randomized trials comparing EIS vs TAU in first-episode psychosis or early-phase schizophrenia spectrum disorders. Data Extraction and Synthesis This systematic review was conducted according to PRISMA guidelines. Three independent investigators extracted data for a random-effects meta-analysis and prespecified subgroup and meta-regression analyses. Main Outcomes and Measures The coprimary outcomes were all-cause treatment discontinuation and at least 1 psychiatric hospitalization during the treatment period. Results Across 10 randomized clinical trials (mean [SD] trial duration, 16.2 [7.4] months; range, 9-24 months) among 2176 patients (mean [SD] age, 27.5 [4.6] years; 1355 [62.3%] male), EIS was associated with better outcomes than TAU at the end of treatment for all 13 meta-analyzable outcomes. These outcomes included the following: all-cause treatment discontinuation (risk ratio [RR], 0.70; 95% CI, 0.61-0.80; Pu2009<u2009.001), at least 1 psychiatric hospitalization (RR, 0.74; 95% CI, 0.61-0.90; Pu2009=u2009.003), involvement in school or work (RR, 1.13; 95% CI, 1.03-1.24; Pu2009=u2009.01), total symptom severity (standardized mean difference [SMD], −0.32; 95% CI, −0.47 to −0.17; Pu2009<u2009.001), positive symptom severity (SMD, −0.22; 95% CI, −0.32 to −0.11; Pu2009<u2009.001), and negative symptom severity (SMD, −0.28; 95% CI, −0.42 to −0.14; Pu2009<u2009.001). Superiority of EIS regarding all outcomes was evident at 6, 9 to 12, and 18 to 24 months of treatment (except for general symptom severity and depressive symptom severity at 18-24 months). Conclusions and Relevance In early-phase psychosis, EIS are superior to TAU across all meta-analyzable outcomes. These results support the need for funding and use of EIS in patients with early-phase psychosis.