Noosha Niv

Gender and comorbidity among individuals with opioid use disorders in the NESARC study.

This study examines gender differences in the association of lifetime mental and substance use disorders among individuals with opioid use disorders in the United States. The sample (N=578) is from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), which is a representative household survey. Bivariate analyses and logistic regression modeling were conducted. About 70% of the sample had a lifetime non-substance use Axis I disorder; women were about twice as likely as men to have either a mood or anxiety disorder. About half of the sample had a personality disorder, with women more likely to have paranoid disorder and men more likely to have antisocial personality disorder. Individuals with a lifetime mental disorder were about three times more likely than others to be dependent on other substances, independent of gender. The study demonstrated an inverse relationship between lifetime mental and other substance use disorders, with women having significantly higher odds for several of the mental disorders and men having greater odds of other substance use disorders.

The validity of using patient self-report to assess psychotic symptoms in schizophrenia.

Brief, reliable and valid measures of psychosis can be very useful in both clinical practice and research, and for identifying unmet treatment needs in persons with schizophrenia. This study examines the concurrent validity and receiver operating characteristics of the psychosis scale of the Revised Behavior and Symptom Identification Scale (BASIS-R). The study was conducted with 71 adults with schizophrenia who were randomly sampled from a large mental health clinic. Study participants at the West Los Angeles Veterans Healthcare Center were assessed using the BASIS-R, a subjective, self-report measure, and the UCLA Brief Psychiatric Rating Scale (BPRS), a clinician-rated measure administered by highly trained research staff. The psychosis scale of the BASIS-R shows good concurrent validity with the psychosis items on the BPRS. Using the BPRS as the gold standard for measuring psychosis, receiver operating characteristics suggest that both the weighted and unweighted versions of the BASIS-R psychosis scale adequately identify psychosis that is moderate or greater or severe. The performance of the two versions was similar. Unweighted scores are easier to calculate, and we therefore recommend cutoff scores based on the unweighted BASIS-R. We identified a cutoff score of 0.5 to best detect moderate or greater psychosis, and a cutoff score of 1.0 to best detect severe or extremely severe psychosis. The BASIS-R has potential as an assessment tool and screening instrument in schizophrenia.

Routine outcomes monitoring to support improving care for schizophrenia: Report from the VA mental health QUERI

In schizophrenia, treatments that improve outcomes have not been reliably disseminated. A major barrier to improving care has been a lack of routinely collected outcomes data that identify patients who are failing to improve or not receiving effective treatments. To support high quality care, the VA Mental Health QUERI used literature review, expert interviews, and a national panel process to increase consensus regarding outcomes monitoring instruments and strategies that support quality improvement. There was very good consensus in the domains of psychotic symptoms, side-effects, drugs and alcohol, depression, caregivers, vocational functioning, and community tenure. There are validated instruments and assessment strategies that are feasible for quality improvement in routine practice.

Pharmacological Treatment of Schizophrenia and Co-Occurring Substance Use Disorders

Substance abuse among individuals with schizophrenia is common and is often associated with poor clinical outcomes. Comprehensive, integrated pharmacological and psychosocial treatments have been shown to improve these outcomes. While a growing number of studies suggest that second-generation antipsychotic medications may have beneficial effects on the treatment of co-occurring sub-stance use disorders, this review suggests that the literature is still in its infancy. Few existing well controlled trials support greater efficacy of second-generation antipsychotics compared with first-generation antipsychotics or any particular second-generation antipsychotic. This article focuses on and reviews studies involving US FDA-approved medications for co-occurring substance abuse problems among individuals with schizophrenia.Comprehensive treatment for individuals with schizophrenia and co-occurring substance use disorders must include specialized, integrated psychosocial intervention. Most approaches use some combination of cognitive-behavioural therapy, motivational enhancement therapy and assertive case management. The research on antipsychotic and other pharmacological treatments is also reviewed, as well as psychosocial treatments for individuals with schizophrenia and cooccurring substance use disorders, and clinical recommendations to optimize care for this population are offered.

The role of substance use in families' attributions and affective reactions to their relative with severe mental illness.

This study compared relatives’ attributions and affective reactions toward patients with severe mental illness (SMI) only (N = 32) and patients with dual SMI and a substance use disorder (N = 36). Family members of patients with dual disorders perceived their ill relatives to have greater control over the causes of their psychiatric symptoms and to be more responsible for their symptoms than did family members of patients with SMI only. Key relatives of dual-diagnosed patients also reported more negative affect toward the patient than did key relatives of patients with SMI only, but the two groups did not differ in their level of positive affect. Consistent with attribution theory, severity of patients’ substance abuse was positively associated with relatives’ attributions of controllability, which, in turn, were positively associated with judgments of responsibility. Furthermore, judgments of responsibility were positively related to negative affect and inversely related to positive affect.

The Appropriateness of Routine Medication Treatment for Schizophrenia

OBJECTIVE Although national guidelines specify appropriate strategies for the treatment of schizophrenia, this disorder presents challenges to clinicians and health-care organizations. To improve care, it is useful to understand how often patients receive appropriate treatment. Most research evaluating treatment was performed when first-generation antipsychotic medications were the modal treatment. Given that most prescriptions are now for second-generation medications, this study describes current clinical problems and the appropriateness of treatment in routine practice. METHOD Between 2002 and 2004, a random sample of patients (n = 398) were interviewed at baseline and 1 year at 3 Department of Veterans Affairs mental health clinics. Symptoms and side effects were assessed. Analyses examined whether prescribing were consistent with guidelines in patients with significant psychosis, depression, parkinsonism, akathisia, tardive dyskinesia, or elevated weight. RESULTS Few patients met criteria for depression, parkinsonism, or akathisia. A total of 44% of patients had significant psychosis, 11% had tardive dyskinesia, and 46% were overweight. Medication was appropriate in 27% of patients with psychosis, 25% of patients with tardive dyskinesia, and 2% of patients with elevated weight. Management of elevated weight improved modestly over time. Treatment was more likely to improve for patients whose psychiatrists had more than 12 patients with schizophrenia in their caseload. CONCLUSION Compared with the 1990s, outpatients are more likely to have significant psychosis. The rate of appropriate treatment of psychosis is unchanged. Weight gain has become a prevalent side effect, yet treatment is rarely changed in response to weight. There is a need for interventions that improve management of psychosis and weight.

Understanding Drug Use over the Life Course: Past, Present, and Future

Over the past 20 years, much exciting addiction research has been conducted. Extensive knowledge has been gathered about comorbid issues, particularly mental health disorders, HIV, and criminal justice involvement. Health services addiction research has become increasingly sophisticated, shifting its focus from patients to consider also services, organizations, and financing structures. Furthermore, through several long-term follow-up studies, empirical evidence convincingly demonstrates that drug dependence is not an acute disorder, and is best understood through a life course perspective with an emphasis on chronicity. This article highlights three major directions for future addiction research: developing strategies for chronic care (including longitudinal intervention studies), furthering cross-system linkage and coordination, and utilizing innovative methods (e.g., growth curve modeling, longitudinal mixed methods research) to strengthen the evidence base for the life course perspective on drug addiction.

Pregnant Women in Women-Only and Mixed-Gender Substance Abuse Treatment Programs: A Comparison of Client Characteristics and Program Services

This study compared characteristics of pregnant women treated in women-only (WO) and mixed-gender (MG) substance abuse treatment programs and compared services provided by these two types of programs. Participants were 407 pregnant women who were admitted to 7 WO programs and 29 MG programs in 13 counties across California during 2000–2002. Pregnant women treated in WO programs demonstrated greater severity in drug use, legal problems, and psychiatric problems than those treated in the MG programs. They were also less likely to be employed and more likely to be homeless. Women-only programs were more likely to offer child care, children’s psychological services, and HIV testing. The greater problem severity of pregnant women treated in WO programs suggests that these specialized services are filling an important gap in addiction services, although further expansion is warranted in psychiatric, legal, and employment services.

Impact of Court-Mandated Substance Abuse Treatment on Clinical Decision Making

California’s Proposition 36 offers nonviolent drug offenders community-based treatment as an alternative to incarceration or probation without treatment. The study objective was to examine how substance abuse treatment providers perceive the impact of Proposition 36 on their clinical decision making. Program surveys were completed by 115 treatment programs in five California counties to assess the impact of the law on clinical decision making, and five focus groups were conducted with 37 treatment providers to better understand their perspectives. Compared to residential programs, outpatient programs reported that the policy impacted them to a greater extent in terms of drug testing, reporting to criminal justice personnel, and determining client discharge. Providers in the focus groups particularly highlighted their changing roles in assessing clients’ treatment needs and determining the best routes of care for them. The findings indicate that alternate strategies for determining treatment placement and continuing care should be developed.

The Sociologic Basis of Drug and Alcohol Addiction

The sociologic model of addiction emphasizes the impact of environment and social relations on the development of addictive disorders. Developmental theories assert that socialization occurs in the context of primary relationships. Hence, this chapter focuses on the roles of parents, siblings, spouses, and peers as etiologic factors in the development and maintenance of addiction. Environmental stressors, including childhood abuse and neglect, exposure to violence, and poverty, are also examined as risk factors for substance use disorders. Other environmental factors, such as lack of appropriate law enforcement and societal attitudes and messages about substance use, have also been implicated in addiction. However, a review of these greater causes is beyond the scope of this chapter.