Management of co-occurring substance use disorders

Reviewing the breadth of current knowledge on schizophrenia, this handbook provides clear, practical guidelines for effective assessment and treatment in diverse contexts. Leading authorities have contributed 61 concise chapters on all aspects of the disorder and its clinical management. In lieu of exhaustive literature reviews, each chapter summarizes the current state of the science; highlights key points the busy practitioner needs to know; and lists recommended resources, including seminal research studies, invaluable clinical tools, and more. Comprehensive, authoritative, and timely, the volume will enable professionals in any setting to better understand and help their patients or clients with severe mental illness.

The role of assisted self-help in services for alcohol-related disorders

Potentially harmful substance use is common, but many affected people do not receive treatment. Brief face-to-face treatments show impact, as do strategies to assist self-help remotely, by using bibliotherapies, computers or mobile phones. Remotely delivered treatments offer more sustained and multifaceted support than brief interventions, and they show a substantial cost advantage as users increase in number. They may also build skills, confidence and treatment fidelity in providers who use them in sessions. Engagement and retention remain challenges, but electronic treatments show promise in engaging younger populations. Recruitment may be assisted by integration with community campaigns or brief opportunistic interventions. However, routine use of assisted self-help by standard services faces significant challenges. Strategies to optimize adoption are discussed. ----- ----- Research Highlights: ► Many people with risky or problematic drinking do not currently receive treatment. ► Assisted self-help has a significant impact and can be delivered at low cost. ► Maximal effects from assisted self-help require engagement of potential users. ► Marketing campaigns and integration into existing service models may assist.

Dropout from internet-based treatment for psychological disorders

Purpose: The purpose of this review was to present an in-depth analysis of literature identifying the extent of dropout from Internet-based treatment programmes for psychological disorders, and literature exploring the variables associated with dropout from such programmes. ----- ----- Methods: A comprehensive literature search was conducted on PSYCHINFO and PUBMED with the keywords: dropouts, drop out, dropout, dropping out, attrition, premature termination, termination, non-compliance, treatment, intervention, and program, each in combination with the key words Internet and web. A total of 19 studies published between 1990 and April 2009 and focusing on dropout from Internet-based treatment programmes involving minimal therapist contact were identified and included in the review. ----- ----- Results: Dropout ranged from 2 to 83% and a weighted average of 31% of the participants dropped out of treatment. A range of variables have been examined for their association with dropout from Internet-based treatment programmes for psychological disorders. Despite the numerous variables explored, evidence on any specific variables that may make an individual more likely to drop out of Internet-based treatment is currently limited. ----- ----- Conclusions: This review highlights the need for more rigorous and theoretically guided research exploring the variables associated with dropping out of Internet-based treatment for psychological disorders.

A polymorphism in the dysbindin gene (DTNBP1) associated with multiple psychiatric disorders including schizophrenia

Background A number of studies have found associations between dysbindin (DTNBP1) polymorphisms and schizophrenia. Recently we identified a DTNBP1 SNP (rs9370822) that is strongly associated with schizophrenia. Individuals diagnosed with schizophrenia were nearly three times as likely to carry the CC genotype compared to the AA genotype. Methods To investigate the importance of this SNP in the function of DTNBP1, a number of psychiatric conditions including addictive behaviours and anxiety disorders were analysed for association with rs9370822. Results The DTNBP1 polymorphism was significantly associated with post-traumatic stress disorder (PTSD) as well as nicotine and opiate dependence but not alcohol dependence. Individuals suffering PTSD were more than three times as likely to carry the CC genotype compared to the AA genotype. Individuals with nicotine or opiate dependence were more than twice as likely to carry the CC genotype compared to the AA genotype. Conclusions This study provides further support for the importance of DTNBP1 in psychiatric conditions and suggests that there is a common underlying molecular defect involving DTNBP1 that contributes to the development of several anxiety and addictive disorders that are generally recognised as separate clinical conditions. These disorders may actually be different expressions of a single metabolic pathway perturbation. As our participant numbers are limited our observations should be viewed with caution until they are independently replicated.

Neuronal nicotinic acetylcholine receptors as pharmacotherapeutic targets for the treatment of alcohol use disorders

Alcohol use disorders (AUDs) are complex and developing effective treatments will require the combination of novel medications and cognitive behavioral therapy approaches. Epidemiological studies have shown there is a high correlation between alcohol consumption and tobacco use, and the prevalence of smoking in alcoholics is as high as 80% compared to about 30% for the general population. Both preclinical and clinical data provide evidence that nicotine administration increases alcohol intake and nonspecific nicotinic receptor antagonists reduce alcohol-mediated behaviors. As nicotine interacts specifically with the neuronal nicotinic acetylcholine receptor (nAChR) system, this suggests that nAChRs play an important role in the behavioral effects of alcohol. In this review, we discuss the importance of nAChRs for the treatment of AUDs and argue that the use of FDA approved nAChR ligands, such as varenicline and mecamylamine, approved as smoking cessation aids may prove to be valuable treatments for AUDs. We also address the importance of combining effective medications with behavioral therapy for the treatment of alcohol dependent individuals.

Health professionals' recognition of co-occurring alcohol and depressive disorders in youth: a survey of Australian general practitioners, psychiatrists, psychologists and mental health nurses using case vignettes

Objective: To examine whether health professionals who commonly deal with mental disorder are able to identify co occurring alcohol misuse in young people presenting with depression. Method: Between September 2006 and January 2007, a survey examining beliefs regarding appropriate interventions for mental disorder in youth was sent to 1710 psychiatrists, 2000 general practitioners (GPs), 1628 mental health nurses, and 2000 psychologists in Australia. Participants within each professional group were randomly given one of four vignettes describing a young person with a DSM-IV mental disorder. Herein is reported data from the depression and depression with alcohol misuse vignettes. Results: A total of 305 psychiatrists, 258 GPs, 292 mental health nurses and 375 psychologists completed one of the depression vignettes. A diagnosis of mood disorder was identified by at least 83.8% of professionals, with no significant differences noted between professional groups. Rates of reported co-occurring substance use disorders were substantially lower, particularly among older professionals and psychologists. Conclusions: GPs, psychologists and mental health professionals do not readily identify co-occurring alcohol misuse in young people with depression. Given the substantially negative impact of co-occurring disorders, it is imperative that health-care professionals are appropriately trained to detect such disorders promptly, to ensure young people have access to effective, early intervention.

Integrating treatment for mental and physical disorders and substance misuse in Indigenous primary care settings

Objective: Australian Indigenous peoples in remote and rural settings continue to have limited access to treatment for mental illness. Comorbid disorders complicate presentations in primary care where Indigenous youths and perinatal women are at particular risk. Despite this high comorbidity there are few examples of successful models of integrated treatment. This paper outlines these challenges and provides recommendations for practice that derive from recent developments in the Northern Territory. Conclusions: There is a strong need to develop evidence for the effectiveness of integrated and culturally informed individual and service level interventions. We describe the Best practice in Early intervention Assessment and Treatment of depression and substance misuse study which seeks to address this need.

Classifying Socially-Valued Role Functioning Among Community Residents with Psychiatric Disorders

An increased emphasis on community-based care has not ensured that people recovering from psychiatric disorders return to active and valued roles in their local communities. Although clinical recovery remains a priority for mental health services there is increasing recognition of the need for functional recovery to be attained and demonstrated in roles valued by the wider community. With this need in mind, a method for classifying socially-valued role functioning among people with schizophrenia or schizoaffective disorder was developed and trialed. Participants (n = 104) were recruited via mental health, psychosocial rehabilitation, and other community support services. Socially-valued roles were investigated via participation in five categories: (1) self-care and home duties; (2) caring for others; (3) self-development, voluntary work or rehabilitation; (4) formal education or training; and (5) employment. Activities were classified by primary role type and role status level at baseline, six, and 12 months. Current role status was assessed along with highest and lowest status in the previous year. Preliminary psychometric results were favorable. Research applications are now recommended for monitoring socially-valued role functioning in community settings.

Psychological interventions for alcohol misuse among people with co-occurring depression or anxiety disorders: A systematic review

Abstract OBJECTIVE: Depression, anxiety and alcohol misuse frequently co-occur. While there is an extensive literature reporting on the efficacy of psychological treatments that target depression, anxiety or alcohol misuse separately, less research has examined treatments that address these disorders when they co-occur. We conducted a systematic review to determine whether psychological interventions that target alcohol misuse among people with co-occurring depressive or anxiety disorders are effective. DATA SOURCES: We systematically searched the PubMed and PsychINFO databases from inception to March 2010. Individual searches in alcohol, depression and anxiety were conducted, and were limited to 'human' published 'randomized controlled trials' or 'sequential allocation' articles written in English. STUDY SELECTION: We identified randomized controlled trials that compared manual guided psychological interventions for alcohol misuse among individuals with depressive or anxiety disorders. Of 1540 articles identified, eight met inclusion criteria for the review. DATA EXTRACTION: From each study, we recorded alcohol and mental health outcomes, and other relevant clinical factors including age, gender ratio, follow-up length and drop-out rates. Quality of studies was also assessed. DATA SYNTHESIS: Motivational interviewing and cognitive-behavioral interventions were associated with significant reductions in alcohol consumption and depressive and/or anxiety symptoms. Although brief interventions were associated with significant improvements in both mental health and alcohol use variables, longer interventions produced even better outcomes. CONCLUSIONS: There is accumulating evidence for the effectiveness of motivational interviewing and cognitive behavior therapy for people with co-occurring alcohol and depressive or anxiety disorders.