Summer 2009, Volume 12 No 4
By Mark de la Hey
Integrated psychological treatment shows promise for people with co-occurring substance use disorders and depression, but not for those with substance use disorders combined with anxiety, according to research from the University of Aarhus in Denmark. Using a comprehensive search of the Medline and PsycINFO databases, the author found nine trials that compared integrated treatment for substance use disorders and either depression or anxiety with programs that treated substance use disorders alone.
Meta-analyses showed that integrated treatment for substance abuse and depression resulted in more days abstinent from substance use and lower levels of depressive symptoms and also led to longer treatment program retention. However, only days abstinent proved to be statistically significant. The author therefore concludes that, while integrated treatment for depression and substance abuse appears promising, further study is needed to replicate these findings. No meta-analysis could be carried out for studies of integrated treatment for substance abuse and anxiety disorders. However, the review conducted in this study found little evidence that integrated treatment would benefit individuals with a combination of substance use disorders and anxiety. On the contrary, several of the studies found that integrated treatment resulted in worse outcomes than treatment focusing on substance use alone. The author sees a need to develop new forms of treatment for people with comorbid substance use disorders and anxiety.
BMC Psychiatry, February 20, 2009, v. 9(6), doi: 10.1186/1471-244X-9-6. Morton Hesse, Centre for Alcohol and Drug Research, University of Aarhus, Copenhagen, Denmark.
A new study from Princess Royal Maternity in Glasgow, Scotland, highlights the risk of withdrawal in babies born to women prescribed substitute methadone during pregnancy. The study looked at 450 infants born to drug-dependent women prescribed substitute methadone. Forty-six per cent of these infants developed the withdrawal symptoms characteristic of neonatal abstinence syndrome (NAS), requiring pharmacological treatment. Forty-eight per cent of the infants were admitted to the neonatal unit with an average hospital stay of 10 days. Although infants born to drug-misusing mothers represented almost three per cent of hospital births, they occupied 18 per cent of total cot days in the neonatal unit during the period of the study. An infant’s risk of developing NAS turned out to be primarily related to the methadone dose given to their mothers. However, infants who were breast fed for 72 hours or more during the study were significantly less likely to require treatment for NAS. The authors explain that the beneficial effects of breast feeding are due to its soothing effect on infants and the fact that small amounts of the drugs taken by the mother are excreted in their breast milk, thus reducing withdrawal symptoms in the baby. Based on their findings, the researchers recommend that mothers who use drugs be encouraged to breast feed their babies. They also recommend a prolonged neonatal stay to watch for signs of NAS, to support breast feeding and to provide parenting support to mothers.
BJOG, April 2009, v. 116: 665-671. C. Dryden et al., Neonatal Unit, Princess Royal Maternity, Glasgow,United Kingdom.
“Wet” Housing reduces Health Costs for People with Alcohol Problems
Programs that provide housing for homeless people with severe alcohol problems without requiring them to become abstinent can significantly reduce health care costs, according to new research from the University of Washington in Seattle. Researchers followed 95 individuals housed in a Housing First program in Seattle, which provides housing to homeless people with severe alcohol problems without requiring abstinence or participation in an alcohol treatment program. A comparison group consisted of 39 individuals on a waiting list for housing. The researchers found that the average monthly cost of services for Housing First participants declined from $4,066 in the year preceding the study to $1,492 after six months in housing and $958 after 12 months. Total costs for those in the housed group declined from $8.2 million in the year before the study to $4.1 million in the year after enrolment in the study, for a reduction in total costs of $4.1 million. After six months, total costs were 53 per cent less for those given housing compared with those on the waiting list. In addition, the average daily number of drinks consumed among participants in the housing program dropped from 16 per day prior to housing to 11 per day by the end of the study, even though participants were not required to abstain from drinking or to enter treatment. The researchers conclude that permanent housing would achieve the best cost savings because the savings in this study increased the longer participants were housed.
Journal of the American Medical Association, April 1, 2009, v. 301: 1349–1357. Mary E. Larimer et al., Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington.
Drugs often involved in Sexual Assault
Drugs are used to facilitate a significant number of sexual assaults, according to new research from Women’s College Hospital in Toronto. Researchers screened 882 sexual assault victims at seven hospital-based sexual assault treatment centres in Ontario, looking for evidence that the victims had been drugged. Most victims were screened within 24 hours of the assault. Twenty-one per cent met criteria for suspected drug-facilitated sexual assault. Reasons for suspecting that they had been surreptitiously drugged included the presence of total or partial amnesia, loss of consciousness, drowsiness, confusion, dizziness or light-headedness, nausea or vomiting and a hangover or symptoms inconsistent with the amount of alcohol or drugs the participant recalled consuming. Based on self-report, 12 per cent of study participants reported consuming over-the-counter medications in the three days before being examined, while 33 per cent had consumed prescription medications and 21 per cent had used street drugs. Sixty-five per cent had consumed alcohol immediately before the assault. Those who suspected they had been drugged were more than two times as likely as other sexual assault victims to have been seen in a large urban centre. Given that drug-facilitated sexual assault is often associated with the victims’ own voluntary substance use, the authors of this study emphasize the importance of public awareness campaigns to increase awareness of the effects of alcohol, especially in combination with street drugs and prescription or over-the-counter medications.
Canadian Medical Association Journal, March 3, 2009, v. 180: 513–519. Janice Du Mont et al., Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario.
Case Managers struggle with Client Disengagement
A new study from New York University highlights the difficulty case managers often face in building hopeful relationships with their clients when faced with the reality that many of those clients leave their programs before achieving a successful outcome. Eighteen case managers were interviewed, examining their perceptions of 29 consumers who disengaged from service with four different programs that help homeless people with co-occurring disorders to gain access to housing in New York City. Consumers were followed for one year, and disengagement was deemed to have occurred when the consumer left the program during that year. More than half of the consumers who disengaged experienced homelessness after leaving the program. Case managers tended to attribute disengagement to substance relapse or to clients finding other housing. When clients disengaged, case managers usually indicated that they had anticipated that the client would leave, based on previous experience. Most managers spoke of disengagement as an inevitable part of their work. Disengagement was almost always considered a negative outcome. Case managers generally regarded disengagement as a mistake on the part of the consumer and often felt disappointed, especially where they believed the consumer showed promise of success. They rarely saw disengagement as resulting from problems with the program itself, although they did acknowledge consumer dissatisfaction. In spite of these perceptions, case managers generally managed to remain positive and support their consumers even when they anticipated disengagement. The researchers conclude that programs serving homeless consumers should consider their own role in causing disengagement and provide more flexible recovery-oriented services that would encourage consumers to remain in the programs.”
Psychiatric Services, April 2009, v. 60: 459–464. Victoria Stanhope et al., Silver School of Social Work, New York University, New York, New York.
Early Intervention shows Promise for First-episode Psychosis
The development of specialized services for the treatment of first-episode psychosis (FEP) gives reason to believe that prognosis may be better than previously thought and indicates that there is a critical period early in the illness when intervention can be most effective. Now, a new multi-site Canadian study has found that people experiencing FEP can in fact achieve high rates of symptomatic remission after a year of early intervention treatment. The study followed 200 individuals over the course of one year of treatment at four specialized FEP programs in London, Hamilton, Toronto and Ottawa. The programs emphasized specialized early intervention, including pharmacological and psychosocial treatment. At the end of the year, 74 per cent of participants had achieved symptom remission, and 51 per cent had experienced functional recovery. In terms of functional outcome, 68 per cent were either working or in school, and 71 per cent reported being in a satisfactory relationship. These results show that intensive, integrated treatment may result in better outcomes than has previously been reported with standard care. The authors also note that the best predictors of outcome at 12 months were positive and negative symptoms at six months and the presence of substance use. They conclude that there is a need for aggressive treatment of symptoms early in the course of the illness and for more focus on substance use.
Acta Psychiatrica Scandinavica, February 5, 2009, doi: 10.1111/j.1600-0447.2009.01346.x. Natasja Menezes et al., Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, Ontario.
Adjustment Disorders common among Refugees
Research from the University of Zurich in Switzerland has found high rates of adjustment disorders (AD) among refugees from countries that have experienced recent conflict. Using data from a previous epidemiological survey, researchers looked at life events and AD diagnoses among 3,048 refugees in Algeria, Ethiopia, Gaza and Cambodia. They focused on life events that were not directly life-threatening and that are known to be related to AD, defined as maladaptive responses to psychosocial stressors such as divorce, unemployment or migration, as opposed to life-threatening events related to post-traumatic stress disorder (PTSD). The prevalence of AD among the study population ranged from six per cent in Ethiopia and 16 per cent in Gaza up to 31 per cent in Cambodia and 40 per cent in Algeria. Most refugees had experienced at least one life event related to AD, ranging from a low of 54 per cent in Gaza to a high of 100 per cent in Ethiopia. Among Ethiopian refugees, the most commonly reported AD-related life events were bad shelter conditions (100%) and lack of food (69%). Algerians were most likely to report forced social isolation (61%) and illness of a family member (51%). Gazans were more likely to report bad shelter conditions (32%). Cambodians were primarily concerned with lack of food (41%). Intrusions, failure to adapt and avoidance were the most commonly reported AD symptoms. Rates of PTSD were higher than for AD: 53 per cent in Ethiopia, 66 per cent in Cambodia, 67 per cent in Gaza and 70 per cent in Algeria. The highest rate of comorbidity was between AD and PTSD, followed by AD and anxiety disorders and AD and mood disorders. The high rates of comorbidity between AD and PTSD led the authors to conclude that the two disorders are part of a “stress response spectrum.”
Social Psychiatry and Psychiatric Epidemiology, March 31, 2009, doi: 10.1007/s00127-009-0039-z. Martin Dobricki et al., Department of Psychopathology and Clinical Intervention, University of Zurich, Zurich, Switzerland.