Nancy H. Covell

Validity of Self-Reported Drug Use Among People with Co-Occurring Mental Health and Substance Use Disorders

Abstract Objectives: The validity of self-reports of drug use from individuals who abuse substances has been questioned. Results from studies examining the accuracy of such self-reports have been mixed, indicating the need for closer examinations of the factors associated with concordance between self-reported drug use and results of urine screens. Methods: As part of a larger study examining the effectiveness of interventions for people with co-occurring mental health and substance use disorders, we examined the agreement between self-report and urine screens for recent drug use. Results: Overall, the concordance between self-report and results from urine screens was high (80-84% agreement overall and 75–79% for the subset where the urine screen indicated recent drug use). Estimates for the likelihood of use of marijuana and cocaine within the past 30 days were 15% and 32%, respectively, based on urine screens, 25% and 35% based on self-report, and 28% and 43% based on information from both sources combined. About 1/3 of individuals who had at least one positive urine screen misrepresented their drug use at least once. Such misrepresentation tended to increase with time in the study. Conclusions: The relatively high concordance rates between self-report and urine screens indicate that situations can be structured so that individuals with co-occurring mental health and substance use disorders report instances of substance use accurately most of the time. Given the observed increase in failure to report use through time, the utility of biological markers may be more valuable as clients develop relationships with clinicians.

Effectiveness of switching from long-acting injectable fluphenazine or haloperidol decanoate to long-acting injectable risperidone microspheres: an open-label, randomized controlled trial.

OBJECTIVE This multisite randomized trial addressed risks and benefits of staying on long-acting injectable haloperidol or fluphenazine versus switching to long-acting injectable risperidone microspheres. METHOD From December 2004 through March 2008, adult outpatients with a Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition diagnosis of schizophrenia or schizoaffective disorder who were taking haloperidol decanoate (n = 40) or fluphenazine decanoate (n = 22) were randomly assigned to stay on current long-acting injectable medication or switch to risperidone microspheres and followed for 6 months under study protocol and an additional 6 months naturalistic follow-up. Kaplan-Meier and Cox regression analyses were used to examine the primary outcome (time to treatment discontinuation), and random regression models were used to examine secondary outcomes. RESULTS Groups did not differ significantly in time to treatment discontinuation through 6 months of protocol-driven treatment. When the 6-month naturalistic follow-up period was included, time to treatment discontinuation was significantly shorter for individuals assigned to switch than for individuals assigned to stay (10% of stayers discontinued versus 31% of switchers; P = .01). Groups did not differ with respect to psychopathology, hospitalizations, sexual side effects, new-onset tardive dyskinesia, or new-onset extrapyramidal symptoms. However, those randomized to switch to long-acting injectable risperidone microspheres had greater increases in body mass (increase of 1.0 body mass index [BMI] versus decrease of -0.3 BMI; P = .00) and prolactin (maximum increase to 23.4 ng/mL versus decrease to 15.2 ng/mL, P = .01) compared to those randomized to stay. CONCLUSION Switching from haloperidol decanoate or fluphenazine decanoate to risperidone microspheres resulted in more frequent treatment discontinuation as well as significant weight gain and increases in prolactin. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00044655.

Use of integrated dual disorder treatment via assertive community treatment versus clinical case management for persons with co-occurring disorders and antisocial personality disorder.

We conducted secondary analyses of data from a randomized trial testing the effectiveness of Assertive Community Treatment (ACT) in delivery of integrated dual disorder treatment (IDDT) to explore the impact of IDDT delivered through ACT teams compared with standard clinical case management for dually-disordered persons with and without antisocial personality disorder (ASPD). This analysis included 36 individuals with ASPD and 88 individuals without ASPD. Participants with ASPD assigned to ACT showed a significantly greater reduction in alcohol use and were less likely to go to jail than those in standard clinical case management, whereas participants without ASPD did not differ between the 2 case management approaches. There were no significant differences for other substance use or criminal justice outcomes. This study provides preliminary evidence that persons with co-occurring serious mental illness, substance use disorders, and ASPD may benefit from delivery of IDDT through ACT teams.

Implementing Peer-Assisted Case Management to Help Homeless Veterans with Mental Illness Transition to Independent Housing

Formerly homeless mentally ill veterans are at an important crossroads when they move from living in an institutional setting such as a shelter or supportive residential facility to independent living. We hypothesized that peer advisors, veterans with severe mental illness who had been homeless previously, graduated from a Healthcare for Homeless Veterans program, and subsequently maintained independent, stable housing could assist other veterans make a successful transition to independent living. Pilot data suggests that participants who received peer advisors were more likely to follow up with assessments than were controls. In this report, we describe a pilot peer advisor program, its implementation, and pilot data on program administration.

Does Assertive Community Treatment Increase Medication Adherence for People With Co-occurring Psychotic and Substance Use Disorders?

OBJECTIVE: This study analyzed data from a randomized trial to examine the impact on medication adherence of integrated treatment delivered via assertive community treatment (ACT) versus standard clinical case management (SCCM). METHOD: Data from the original study included 198 study participants with co-occurring psychotic and substance use disorders who were randomly assigned to receive integrated treatment via ACT or SCCM and were followed for 3 years. We applied mixed-effects logistic regression to estimate group (ACT vs. SCCM) by time effects on a self-report measure of medication adherence. Adherence was dichotomized as 20% or more missed medication days (“poor adherence”) versus less than 20% missed medication days (“adequate adherence”). RESULTS: Participants who were assigned to ACT reported significant improvement in medication adherence compared with those assigned to SCCM. CONCLUSIONS: Integrated treatment delivered via ACT may benefit persons with co-occurring psychotic and substance use disorders who are poorly adherent to medications.

Characteristics of Project Liberty Clients That Predicted Referrals to Intensive Mental Health Services

OBJECTIVE The authors describe characteristics of Project Liberty crisis counseling recipients that predicted referral to more intensive professional mental health treatments over the two-year period after the terrorist attacks on the World Trade Center. METHODS Random-effects ordinal regression models were applied to data from 684,500 logs of Project Liberty service encounters for individual counseling sessions. RESULTS Overall, about 9 percent of individual counseling visits ended with a referral to professional mental health services. Individuals needing intensive mental health treatment continued to enter Project Liberty for two years after the World Trade Center attacks. The strongest predictor of referral was having reactions to the attack that fell into a greater number of the four domains assessed-behavioral, emotional, physical, or cognitive domains. Individuals with reactions in four domains were most likely to be referred. Those who had greater attack-related exposure were also more likely to be referred. CONCLUSIONS It is important to provide long-term access to brief counseling and triage services and to target these interventions specifically to individuals displaying greater distress or impairment and having more traumatic exposure.

Longitudinal Course of Clients With Co-occurring Schizophrenia-Spectrum and Substance Use Disorders in Urban Mental Health Centers: A 7-Year Prospective Study

OBJECTIVE A previous longitudinal study in rural New Hampshire showed that community mental health center clients with co-occurring schizophrenia-spectrum and substance use disorders (SZ/SUD) improved steadily and substantially over 10 years. The current study examined 7 years of prospective clinical and functional outcomes among inner-city Connecticut (CT) community mental health center clients with SZ/SUD. METHOD Participants were 150 adults with SZ/SUD, selected for high service needs, in 2 inner-city mental health centers in CT. Initially, all received integrated mental health and substance abuse treatments for at least the first 3 years as part of a clinical trial. Assessments at baseline and yearly over 7 years measured progress toward 6 target clinical and functional outcomes: absence of psychiatric symptoms, remission of substance abuse, independent housing, competitive employment, social contact with non-users of substances, and life satisfaction. RESULTS The CT SZ/SUD participants improved significantly on 5 of the 6 main outcomes: absence of psychiatric symptoms (45%-70%), remission of substance use disorders (8%-61%), independent housing (33%-47%), competitive employment (14%-28%), and life satisfaction (35%-53%). Only social contact with nonusers of substances was unimproved (14%-17%). CONCLUSIONS Many urban community mental health center clients with SZ/SUD and access to integrated treatment improve significantly on clinical, vocational, residential, and life satisfaction outcomes over time, similar to clients with SZ/SUD in rural areas. Thus, the long-term course for people with SZ/SUD is variable but often quite positive.

Distance Training and Implementation Supports to Scale Up Integrated Treatment for People With Co-occurring Mental Health and Substance Use Disorders

Objective: Integrated, evidence-based treatment for co-occurring severe mental illness and substance use disorder (co-occurring disorders) reduces substance use, hospitalization, homelessness, incarceration, and treatment costs and promotes individuals’ recovery, independent living, and employment. This report describes and characterizes early uptake of New York States Web-based training and distance implementation supports to promote statewide dissemination of integrated, evidence-based co-occurring disorders services. Methods: Thirty-five half-hour online modules provide training on integrated evidence-based co-occurring disorders treatment. Distance supports for implementation include monthly webinars, phone calls, and virtual learning communities. The authors calculated the proportion of programs with one or more practitioners who accessed the Web-based resources and the cumulative number of modules completed as an indicator of the reach of the Web-based approach to scaling up an innovation. They also calculated the number and proportion of staff per program who accessed the Web-based resources as an indicator of critical mass that may be needed for sustainability. Results: Of 369 programs participating in the initiative, 232 (63%) had at least one staff member accessing the online modules; 30% of programs had one-third or more of their staff accessing the online modules, and total attendance at webinars was close to 700. Staff who started taking the training averaged a little more than 6 modules, with 8,862 modules completed across staff to date. Conclusions: Early uptake of the New York State initiative suggests that distance learning and supports may be a feasible vehicle to train practitioners in large treatment delivery systems.

Special Section on Implications of CATIE: Implications of CATIE for Mental Health Services Researchers

The authors discuss the implications of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) for mental health services researchers, in particular the need to monitor and change prescriber behavior to encourage informed medication selection. Given the complexity and variability of response to antipsychotic medications in CATIE, use of restricted formularies is not the answer. Rather, services researchers should collaborate with service systems to develop interventions to identify questionable prescriber practices and develop interventions to change them. The CATIE results also suggest that some quality measures for antipsychotic treatment, such as the proportion of a population taking second-generation antipsychotics, need to be revisited by researchers. Also, because the CATIE findings highlighted the prevalence of cardiac and metabolic disorders among treatment populations and the potential impact of antipsychotics on these conditions, services researchers should use secondary data to monitor whether prescribers are providing appropriate screening and treatment. Given the health risks of some antipsychotics, services researchers should develop ways to identify individuals at risk, encourage behavior change among prescribers, and support informed and shared decision making about medications. Mental health services researchers can build relationships with multiple stakeholders, including service system administrators, service providers, and consumers, to help translate results from trials such as CATIE into policy and practice.

Predictors of Incarceration Among Urban Adults With Co-Occurring Severe Mental Illness and a Substance Use Disorder

OBJECTIVE People with severe mental illness and a co-occurring substance use disorder (co-occurring disorders) who live in urban areas experience high rates of incarceration. This study examined sociodemographic, clinical, economic, and community integration factors as predictors of incarceration among people with co-occurring disorders. METHODS This secondary analysis used data from a randomized controlled trial of assertive community treatment versus standard case management. In the parent study, researchers interviewed 198 people with co-occurring disorders from two urban mental health centers in Connecticut at baseline and every six months for three years. Researchers tracked incarceration, clinical engagement and status, employment, living situation, social relationships, and substance use. The study reported here used bivariate analyses and logistic regression analyses to compare individuals who were incarcerated during the study period with those who were not. RESULTS The overall incarceration rate was 38% during the study period. In multivariate analyses, prior incarceration predicted incarceration during the study period (odds ratio [OR]=3.26). Two factors were associated with a reduced likelihood of incarceration: friendships with individuals who did not use substances (OR=.19) and substance use treatment engagement (OR=.60). CONCLUSIONS Positive social relationships and engagement in substance use treatment are promising service and policy targets to prevent incarceration in this high-risk population.