Implementing guidelines for interventions in Swedish substance abuse treatment: A national evaluation of outcomes from 2010 to 2014.

In 2009, the Swedish government launched a nationwide dissemination and implementation project regarding substance abuse treatment, Knowledge to Practice (KTP), which was commissioned by the Swedish National Board of Health and Welfare (SoS). AIM: The study aimed to evaluate the effectiveness of a national project to disseminate and implement evidence-based assessment instruments and treatment methods, and to promote cross-sectional collaboration in substance abuse treatment. DESIGN AND RECRUITMENT: This study was a naturalistic prospective follow-up study of a sample of 3063 participants in 203 municipalities via five consecutive online surveys. Of the 21 Swedish regions, we included 20. All participants, representing 79.5% of the population, were employed in substance abuse treatment/care within social work and psychiatry. We used individual background variables and factors in the organizational readiness for change (ORC) questionnaire for prediction. METHODS: We calculated descriptive statistics using SPSS 24.0. We applied latent profile analysis (LPA) to identify respondents with distinct growth profiles across five assessment points. Next, we calculated multilevel growth curve analyses using full information maximum likelihood analysis (FIML) in Mplus 8.3. In the analyses, we nested "within-person change" (level 1) in "between-persons analysis" (level 2). We, in turn, nested these in municipalities/regions (level 3). We included both respondents and organizational predictors in levels 2 and 3. We tested four statistical models in the multilevel analyses to predict the outcome. RESULTS: The annual response rate was 59% on average across the five years. Respondents were a homogenous group with regard to education and years of employment, and two thirds were women. We identified four different trajectories nationwide, which showed different growth profiles for the use of methods and assessment instruments. Our results showed a larger between-region variation than within-region variation in outcome indicators. Some regions were more successful than others over the five years. At the respondent level, the years of employment in treatment work was associated with increased use of assessment instruments, while the ORC factor, institutional resources, predicted decreased use of assessment instruments. Specialist competence and the ORC factors staff attributes (job satisfaction, efficacy, and influence) and institutional resources predicted increased use of psychosocial treatment methods. The ORC factor organizational climate was positively associated with increased cross-sectional collaboration activities.

Prediction of psychiatric comorbidity on premature death in a cohort of patients with substance use disorders: a 42-year follow-up.

BACKGROUND: We need to better understand how the use of different substances and psychiatric comorbidity influence premature death generally and cause-specific death by overdose, intoxication and somatic disorders in people with substance use disorders. METHOD: A cohort of 1405 patients consecutively admitted to a Swedish detoxification unit for substance use disorders in 1970-1995 was followed-up for 42 years. Substances were identified by toxicological analyses. Mortality figures were obtained from a national registry. Causes of death were diagnosed by forensic autopsy in 594 patients deceased by 2012. Predictions were calculated by competing risks analysis. RESULTS: Forty-two per cent of the cohort died during follow-up; more men than women (46.3% vs 30.4%). The standardised mortality ratio (SMR) was calculated as the ratio of observed deaths in males and females in specific age groups in the cohort versus expected deaths in corresponding groups in the general population. SMR was 5.68 for men (CI 95%; 5.04-6.11) and 4.98 (CI 95%; 4.08-5.88) for women. The crude mortality rate (number of deaths divided by number of person observation years) was 2.28% for men and 1.87% for women. Opiates predicted increased risk of premature death while amphetamine and cannabis predicted lower risk. Comorbid psychiatric disorders were identified in 378 cases and personality disorders in 763 cases. Primary psychoses or mood/depression and anxiety disorders predicted a higher risk of premature mortality. Death by overdose was predicted by male gender, younger age at admission to substance treatment, opiate use, and comorbid depression and anxiety syndromes. Cannabis and amphetamine use predicted a lower risk of overdose. Death by intoxication was predicted by male gender, use of sedatives/hypnotics or alcohol/mixed substances, primary psychoses and depression/anxiety syndromes. Premature death by somatic disorder was predicted by male gender and alcohol/mixed abuse. CONCLUSION: Psychiatric comorbid disorders were important risk factors for premature drug-related death. Early identification of these factors may be life-saving in the treatment of patients with substance use disorders.

Reduced psychiatric symptoms at 6 and 12 months' follow-up of psychotherapeutic and psychoeducative group interventions for children exposed to intimate partner violence.

BACKGROUND: Long-term follow-up studies of interventions for children exposed to intimate partner violence are few, and the sustainability of their outcomes often remains unexplored and uncertain. Current research including follow-up assessment suggests that treatment gains may be maintained or continue post termination. In addition some children may show increased levels of symptoms. OBJECTIVE: The present effectiveness study investigated the long-term outcomes of two established group interventions for children exposed to intimate partner violence and their non-offending parent. PARTICIPANTS AND SETTING: The study included 50 children, 24 girls and 26 boys, aged 4 to 13 years attending a psychotherapeutic child and adolescent mental health service intervention and a psychoeducative community-based intervention. METHODS: Background information, child and parental mental health problems, trauma symptoms, and exposure to violence were assessed pre- and post treatment and at 6 and 12 months' follow-up. RESULTS: Sustained treatment gains and late improvements in children's internalizing and externalizing symptoms and in symptoms of traumatic stress were recorded from post treatment to the follow-up assessments (p = .004- .044; d = 0.29-0.67). No significant increase in symptoms was reported. Additionally, very little continued or renewed child exposure to violence was reported. CONCLUSIONS: The results of the study indicate that the children did benefit from the two interventions studied and that the outcomes of reduced child symptoms and protection from exposure to violence were sustainable. Children with severe trauma symptoms benefited the most, though maternal psychological problems may for some have hindered recovery. Clinical implications are discussed.

Outcomes of psychotherapeutic and psychoeducative group interventions for children exposed to intimate partner violence.

Witnessing violence toward a caregiver during childhood is associated with negative impact on children's health and development, and there is a need for effective interventions for children exposed to intimate partner violence in clinical as well as in community settings. The current effectiveness study investigated symptom reduction after participation in two established group interventions (one community-based psychoeducative intervention; one psychotherapeutic treatment intervention) for children exposed to intimate partner violence and for their non-offending parent. The study included 50 children-24 girls and 26 boys-aged 4-13 years and their mothers. Child and maternal mental health problems and trauma symptoms were assessed pre- and post-treatment. The results indicate that although children showed benefits from both interventions, symptom reduction was larger in the psychotherapeutic intervention, and children with initially high levels of trauma symptoms benefited the most. Despite these improvements, a majority of the children's mothers still reported child trauma symptoms at clinical levels post-treatment. Both interventions substantially reduced maternal post-traumatic stress. The results indicate a need for routine follow-up of children's symptoms after interventions.

The five-year costs and benefits of extended psychological and psychiatric assessment versus standard intake interview for women with comorbid substance use disorders treated in compulsory care in Sweden.

BACKGROUND: Women with comorbid substance use disorders are an extremely vulnerable group having an increased relative risk of negative outcomes such as incarceration, morbidity and mortality. In Sweden, women with comorbid substance use disorders may be placed in compulsory care for substance abuse treatment. Clinical intake assessment procedures are a distinct aspect of clinical practice and are a foundation upon which client motivation and continued treatment occurs. METHOD: The current study is a naturalistic quasi-experiment and aims to assess the five-year costs and benefits of a standard intake interview versus an extended psychological and psychiatric assessment for a group of chronic substance abusing women placed in compulsory care in Sweden between 1997 and 2000. Official register data on criminal activity, healthcare use, compulsory care stays and other services was retrieved and all resources used by study participants from date of index care episode was valued. In addition, the cost of providing the intake assessment was estimated. RESULTS: Results show that the extended assessment resulted in higher net costs over five years of between 256,000 and 557,000 SEK per person for women placed in care via the Law on Compulsory Care for Substance Abusers (LVM). Higher assessment costs made up a portion of this cost. The majority of this cost (47-57%) falls on the local municipality (social welfare) and 11.6-13.7% falls on the individual patient. CONCLUSIONS: Solid evidence supporting the clinical utility or incremental validity of assessment for improving treatment outcomes in this setting was not confirmed.

Organizational Readiness for Change (ORC) test used in the implementation of assessment instruments and treatment methods in a Swedish National study.

Organizational climate and related factors are associated with outcome and are as such of vital interest for healthcare organizations. Organizational Readiness for Change (ORC) is the questionnaire used in the present study to assess the influence of organizational factors on implementation success. The respondents were employed in one of 203 Swedish municipalities within social work and psychiatric substance/abuse treatment services. They took part in a nationwide implementation project organized by the Swedish Association of Local Authorities and Regions (SALAR), commissioned by the Swedish National Board of Health and Welfare. AIM: The aims were: (a) to identify classes (clusters) of employees with different ORC profiles on the basis of data collected in 2011 and (b) to investigate ORC profiles which predicted the use of assessment instruments, therapy methods and collaborative activities in 2011 and 2013. DESIGN AND RECRUITMENT: The evaluation study applied a naturalistic design with registration of outcome at consecutive assessments. The participants were contacted via official e-mail addresses in their respective healthcare units and were encouraged by their officials to participate on a voluntary basis. STATISTICS: Descriptive statistics were obtained using SPSS version 23. A latent profile analysis (LPA) using Mplus 7.3 was performed with a robust maximum likelihood estimator (MLR) to identify subgroups (clusters) based on the 18 ORC indexes. RESULTS: A total of 2402 employees responded to the survey, of whom 1794 (74.7%) completed the ORC scores. Descriptive analysis indicated that the respondents were a homogenous group of employees, where women (72.0%) formed the majority. Cronbach's alpha for the 18 ORC indexes ranged from α=0.67 to α=0.78. A principal component analysis yielded a four-factor solution explaining 62% of the variance in total ORC scores. The factors were: motivational readiness (α=0.64), institutional resources (α=0.52), staff attributes (α=0.76), and organizational climate (α=0.74). An LPA analysis of the four factors with their three distinct profiles provided the best data fit: Profile 3 (n=614), Profile 2 (n=934), and Profile 1 (n=246). Respondents with the most favorable ORC scores (Profile 3) used significantly more instruments and more treatment methods and had a better collaborating network in 2011 as well as in 2013 compared to members in Profile 1, the least successful profile. CONCLUSION: In a large sample of social work and healthcare professionals, ORC scores reflecting higher institutional resources, staff attributes and organizational climate and lower motivational readiness for change were associated with a successful implementation of good practice guidelines for the care and treatment of substance users in Sweden. Low motivational readiness as a construct may indicate satisfaction with the present situation. As ORC proved to be an indicator of successful dissemination of evidence-based guidelines into routine and specialist healthcare, it can be used to tailor interventions to individual employees or services and to improve the dissemination of and compliance with guidelines for the treatment of substance users.

Did you get any help? A post-hoc secondary analysis of a randomized controlled trial of psychoeducation for patients with antisocial personality disorder in outpatient substance abuse treatment programs.

BACKGROUND: People in treatment for substance use disorder commonly have comorbid personality disorders, including antisocial personality disorder. Little is known about treatments that specifically address comorbid antisocial personality disorder. METHODS: Self-rated help received for antisocial personality disorder was assessed during follow-ups at 3, 9 and 15 months post-randomization of a randomized trial of psychoeducation for people with comorbid substance use and antisocial personality disorder (n = 175). RESULTS: Randomization to psychoeducation was associated with increased perceived help for antisocial personality disorder. Perceived help for antisocial personality disorder was in turn associated with more days abstinent and higher treatment satisfaction at the 3-month follow-up, and reduced risk of dropping out of treatment after the 3-month follow-up, and perceived help mediated the effects of random assignment on days abstinent at 3-month. CONCLUSIONS: Brief psychoeducation for antisocial personality disorder increased patients' self-rated help for antisocial personality disorder in substance abuse treatment, and reporting having received help for antisocial personality disorder was in turn associated with better short-term outcomes, e.g., days abstinent, dropout from treatment and treatment satisfaction. TRIAL REGISTRATION: ISRCTN registry, ISRCTN67266318 , retrospectively registered 17/7/2012.

Women with comorbid substance dependence and psychiatric disorders in Sweden: a longitudinal study of hospital care utilization and costs.

BACKGROUND: Substance use disorders are regarded as one of the most prevalent, deadly and costly of health problems. Research has consistently found that the prevalence of other psychiatric disorders among those with substance related disorders is substantial. Combined, these disorders lead to considerable disability and health years lost worldwide as well as extraordinary societal costs. Relatively little of the literature on substance dependence and its impact on healthcare utilization and associated costs has focused specifically on chronic drug users, adolescents or women. In addition, the research that has been conducted relies largely on self-reported data and does not provide long-term estimates of hospital care utilization. The purpose of this study is to describe the long-term (24-32 year) healthcare utilization and it's associated costs for a nationally representative cohort of chronic substance abusing women (adults and adolescents) remanded to compulsory care between 1997-2000 (index episode). As such, this is the first study investigating healthcare costs for women in compulsory treatment in Sweden. METHODS: Women (n = 227) remanded to compulsory care for substance abuse were assessed at intake and their hospital care utilization was retrieved 5-years post compulsory care from national records. Unit costs for ICD-10 diagnoses were applied to all hospital care used from 1975-2006. Attempts are made to estimate productivity losses associated with hospitalization and premature death. RESULTS: Upon clinical assessment it was found that a majority of these women had a comorbid psychiatric disorder (primarily personality disorder). The women followed in this study were admitted to hospital five to six times that of the general population and had stays six to eight times that of the general population. Total direct healthcare costs per person over the study period averaged approximately $173,000 and was primarily the result of psychiatric department visits (71 %) and inpatient treatment (98.5 %; detoxification and short-term rehabilitation). CONCLUSIONS: Women placed in compulsory care use more hospital resources than that of the general Swedish population and when compared to international research of hospital care use and substance abuse. Direct hospital costs vary greatly over the life course. Effective services can have significant economic benefit.

Buprenorphine maintenance program with contracted work/education and low tolerance for non-prescribed drug use: a cohort study of outcome for women and men after seven years.

BACKGROUND: A seven-year follow-up of heroin dependent patients treated in a buprenorphine-maintenance program combining contracted work/education and low tolerance for non-prescribed drug use. Gender-specific differences in outcome were analysed. METHODS: A consecutively admitted cohort of 135 men and 35 women, with eight years of heroin abuse/dependence on average was admitted to enhanced buprenorphine maintenance treatment. Standardized interviews, diagnostic assessments of psychiatric disorders and psychosocial conditions were conducted at admission and at follow-ups. Outcome associated with gender was reported for abstinence, retention, psychiatric symptoms, employment and criminal convictions. RESULTS: 148 patients started treatment. After seven years, 94/148 patients (64%) were retained in the program, employed and abstinent from drugs and alcohol. Women had more continuous abstinence, retention and employment than men (76% versus 60%). After one year patients with a high-risk consumption of alcohol were no longer heavy consumers of alcohol and remained so throughout the study (p < .001). All women regained custody of their children. At admission, more women than men had been admitted for psychiatric disorders (70%/44%) and to compulsory care for substance abuse (30%/18%). Initial gender differences of psychiatric co-morbidity decreased and were no longer significant after one year. More men than women had been imprisoned (62% versus 27%) or in non-institutional care (80% versus 49%). Criminal convictions were reduced from 1751 convictions at admission to 742 (58%) after seven years. Eight patients in the entire cohort died over the 7 years (0.7% per year). One patient died in the completers group while still in the program (0.1% per year). CONCLUSIONS: After seven years, two thirds of the patients in the program were abstinent and employed. Convictions ceased in the completers group. One patient died in the completers group. Women had superior long-term outcome compared to men: more continuous abstinence, employment and fewer convictions. Women also lived with their children to a higher extent than men. The positive outcome highlights the importance of maintaining high structure in combining pharmacological treatment with a focus on employment and psychological treatment and low tolerance for non-prescribed drug use.

Childhood socio-economic status, school failure and drug abuse: a Swedish national cohort study.

AIM: To investigate whether socio-economic status (SES) in childhood and school failure at 15 years of age predict illicit drug abuse in youth and young adulthood. DESIGN, SETTING AND PARTICIPANTS: Register study in a Swedish national cohort born 1973-88 (n = 1,405,763), followed from age 16 to 20-35 years. Cox regression analyses were used to calculate hazard ratios (HR) for any indication of drug abuse. MEASUREMENTS: Our outcomes were hospital admissions, death and criminality associated with illicit drug abuse. Data on socio-demographics, school grades and parental psychosocial problems were collected from censuses (1985 and 1990) and national registers. School failure was defined as having mean school grades from the final year in primary school lower than -1 standard deviation and/or no grades in core subjects. FINDINGS: School failure was a strong predictor of illicit drug abuse with an HR of 5.87 (95% CI: 5.76-5.99) after adjustment for age and sex. Childhood SES was associated with illicit drug abuse later in life in a stepwise manner. The lowest stratum had a HR of 2.28 (95% CI: 2.20-2.37) compared with the highest stratum as the reference, when adjusted for other socio-demographic variables. In the fully adjusted model, the effect of SES was greatly attenuated to an HR of 1.23 (95% CI: 1.19-1.28) in the lowest SES category, while the effect of school failure remained high with an HR of 4.22 (95% CI: 4.13-4.31). CONCLUSIONS: School failure and childhood socio-economic status predict illicit drug abuse independently in youth and young adults in Sweden.

Substance abuse and psychiatric co-morbidity as predictors of premature mortality in Swedish drug abusers: a prospective longitudinal study 1970-2006.

BACKGROUND: Few longitudinal cohort studies have focused on the impact of substances abused and psychiatric disorders on premature mortality. The aim of the present study was to identify predictors of increased risk of drug related death and non drug related death in substance abusers of opiates, stimulants, cannabis, sedatives/hypnotics, hallucinogens and alcohol over several decades. METHODS: Follow-up study of a consecutive cohort of 561 substance abusers, admitted to a detoxification unit January 1970 to February 1978 in southern Sweden, and followed up in 2006. Demographic and clinical data, substance diagnoses and three groups of psychiatric diagnoses were identified at first admission. Causes of death were coded according to ICD-10 and classified as drug related deaths or non drug related deaths. To identify the incidence of some probable risk factors of drug related premature death, the data were subjected to a competing risks Cox regression analysis. RESULTS: Of 561 patients in the cohort, 11 individuals had either emigrated or could not be located, and 204/561 patients (36.4%) were deceased by 2006. The cumulative risk of drug related death increased more in the first 15 years and leveled out later on when non drug related causes of death had a similar incidence. In the final model, male gender, regular use of opiates or barbiturates at first admission, and neurosis were associated with an increased risk of drug related premature death, while cannabis use and psychosis were associated with a decreased risk. Neurosis, mainly depression and/or anxiety disorders, predicted drug related premature death while chronic psychosis and personality disorders did not. Chronic alcohol addiction was associated with increased risk of non drug related death. CONCLUSIONS: The cohort of drug abusers had an increased risk of premature death to the age of 69. Drug related premature death was predicted by male gender, the use of opiates or barbiturates and depression and anxiety disorders at first admission. The predicted cumulative incidence of drug related death was significantly higher in opiate and barbiturate abusers over the observed period of 37 years, while stimulant abuse did not have any impact. Alcohol contributed to non drug related death.

Poly-substance use and antisocial personality traits at admission predict cumulative retention in a buprenorphine programme with mandatory work and high compliance profile.

BACKGROUND: Continuous abstinence and retention in treatment for alcohol and drug use disorders are central challenges for the treatment providers. The literature has failed to show consistent, strong predictors of retention. Predictors and treatment structure may differ across treatment modalities. In this study the structure was reinforced by the addition of supervised urine samples three times a week and mandatory daily work/structured education activities as a prerequisite of inclusion in the program. METHODS: Of 128 patients consecutively admitted to buprenorphine maintenance treatment five patients dropped out within the first week. Of the remaining 123 demographic data and psychiatric assessment were used to predict involuntary discharge from treatment and corresponding cumulative abstinence probability. All subjects were administered the Structured Clinical Interview for DSM-IV-TR, and the Symptom Checklist 90 (SCL-90), the Alcohol Use Disorder Identification Test (AUDIT), the Swedish universities Scales of Personality (SSP) and the Sense of Coherence Scale (SOC), all self-report measures. Some measures were repeated every third month in addition to interviews. RESULTS: Of 123 patients admitted, 86 (70%) remained in treatment after six months and 61 (50%) remained in treatment after 12 months. Of those discharged involuntarily, 34/62 individuals were readmitted after a suspension period of three months. Younger age at intake, poly-substance abuse at intake (number of drugs in urine), and number of conduct disorder criteria on the SCID Screen were independently associated with an increased risk of involuntary discharge. There were no significant differences between dropouts and completers on SCL-90, SSP, SOC or AUDIT. CONCLUSION: Of the patients admitted to the programme 50% stayed for the first 12 months with continuous abstinence and daily work. Poly-substance use before intake into treatment, high levels of conduct disorder on SCID screen and younger age at intake had a negative impact on retention and abstinence.

Causes of premature mortality in Swedish drug abusers: a prospective longitudinal study 1970-2006.

AIMS: To evaluate premature mortality and causes of death from young adulthood to middle age in a cohort of drug users followed during almost four decades. DESIGN: Follow-up study of a consecutive cohort of patients with drug abuse/dependence. METHODS: A cohort of 561 drug abusers, admitted to a detoxification and short-term rehabilitation unit 1970-1978 was followed to December 31st, 2006. Standardized interviews and hospital records with toxicological analyses were used for demographic data, substance use and psychiatric diagnoses at admission. For Follow-up analyses, autopsy protocols including toxicology tests and death certificates were obtained for assessment of causes of death which were coded according to ICD-10. Age-group standardized mortality ratios were calculated independently for both sexes. RESULTS: 204 persons (36.4%) were deceased by 2006. SMR was 5.94 for the cohort. Compared to an age- and gender-matched population, the risk of premature death was about eighteen times higher between the ages of 20-44 and about five times higher from 45 up to the age of 69. Of 120 (59%) drug-related deaths, 43 were opiate overdoses, and 3 were overdose from amphetamine. A total of 53 (26%) persons died violent deaths: 39 suicides, of which 25 were drug-related, 3 homicides and 12 accidents. The Swedish national causes of death register underestimated drug-related death by 37% and suicide by 85% compared to the results from this study. CONCLUSIONS: The cohort of drug abusers had an increased risk of premature often drug-related and violent death well into middle age, and to a great extent the drug addicts died from the same drug they had abused when they were first admitted for treatment. The underestimation of drug-related death and suicide in some national death cause registers could be reduced if the doctor routinely records ICD codes when issuing death certificates and autopsy protocols.

Influence of personality disorder features on social functioning in substance-abusing women five years after compulsive residential treatment.

BACKGROUND: Personality disorders (PD) are related to negative outcome in substance abuse treatment, and in the general population, personality disorders are related to negative outcome in overall functioning. Little is known about the impact of PD on adjustment following substance abuse treatment. METHODS: A cohort of 132 women was followed for 5 years after their index treatment episode in compulsory treatment. During treatment, patients were assessed with the SCID-II. At follow-up, patients were administered a timeline follow-back interview covering their functioning, including employment status over the years, and linked with hospital and criminal justice registers. RESULTS: The impact of PD on functioning varied substantially between disorders and outcome domains. Conduct disorder alone was associated with criminal justice involvement, and conduct disorder and avoidant PD features were associated with unemployment. Dependent PD and obsessive-compulsive personality disorder features were positively associated with employment. Borderline PD features were associated with hospital admissions. DISCUSSION: We discuss how strategies associated with various PDs may foster or hinder social adjustment in general and employment patterns in particular.

Personality disorder features as predictors of symptoms five years post-treatment.

Personality disorders are associated with dysfunction in a variety of areas. Recent longitudinal research has shown that personality disorders are also predictive of problems later in life, as well as of poor response to treatment of depression and anxiety. This study assessed whether personality disorder features were associated with psychiatric symptoms in a cohort of women treated for substance abuse in Sweden. Patients were diagnosed with personality disorders using the Structured Clinical Interview for DSM-IV (SCID-II) personality questionnaire and SCID-II interview, and were then administered a self-report questionnaire designed to measure symptoms of psychiatric illness, the Symptoms Checklist-90 (SCL-90), during and five years after treatment. Concurrently, features of all personality disorders, except histrionic, were associated with SCL-90 score. At five-year follow-up, most personality disorders remained associated with SCL-90 score, with the exception of paranoid and schizoid personality disorder. After controlling for baseline score on the SCL-90, conduct disorder, borderline personality disorder, and narcissistic personality disorder remained significantly associated with symptoms at follow-up. After controlling for abstinence and baseline score, only borderline personality disorder features remained associated with SCL-90 score at follow-up. Patients with personality disorders should be monitored after treatment for psychiatric symptoms.

Antisocial personality disorder as a predictor of criminal behaviour in a longitudinal study of a cohort of abusers of several classes of drugs: relation to type of substance and type of crime.

Mixed findings have been made with regard to the long-term predictive validity of antisocial personality disorder (ASPD) on criminal behaviour in samples of substance abusers. A longitudinal record-linkage study of a cohort of 1052 drug abusers admitted 1977-1995 was undertaken. Subjects were recruited from a detoxification and short-term rehabilitation unit in Lund, Sweden, and followed through criminal justice registers from their first treatment episode to death or to the year 2004. In a ML multinomial random effects regression, subjects diagnosed with antisocial personality disorders were 2.16 times more likely to be charged with theft only (p<0.001), and 2.44 times more likely to be charged committing multiple types of crime during an observation year (p<0.001). The findings of the current study support the predictive validity of the DSM-III-R diagnosis of ASPD. ASPD should be taken seriously in drug abusers, and be targeted in treatment to prevent crime in society.

Validity of self-reported criminal justice system involvement in substance abusing women at five-year follow-up.

BACKGROUND: Few studies have compared self-reported criminal behaviour with high-quality databases of criminal offences and judicial sanctions. Self-reported problems from drug abusers are generally believed to be valid. We assessed the validity of self-reported theft, drug offences and prison sentences from a five-year follow-up of female substance abusers who were originally treated in a compulsory care unit in Lund, run by the Swedish Board of Institutional Care. METHODS: Data from a total of 106 of a consecutive sample of 132 women inter-viewed in a five-year follow-up. All were thoroughly assessed for somatic complaints, psychiatric and psychological problems, background factors with standardized instruments. Data over the five years were linked to official records of judicial sanctions, retrieved from The National Council for Crime Prevention, Stockholm, Sweden. Register data have a full cover for the whole cohort. The current data base contain full data back to 1975 up to 2004. RESULTS: Agreement was assessed for each year, as well as for the total period. Statistical control was performed for other types of crimes and prison. Although statistically significant, agreement was modest, and in contrast to previous studies, patients under-reported violence charges. CONCLUSION: The findings suggest that self-reports of criminal behaviour from women can be used with some caution, and that the validity of self-report may vary between types of criminal justice system involvement.

Criminal behavior in antisocial substance abusers between five and fifteen years follow-up.

Antisocial personality disorder (ASPD) is one of the most common co-occurring disorders in substance abusers, characterized among other things by a high propensity for criminal actions. A cohort of 125 substance abusers were followed in a longitudinal design. Patients were diagnosed with ASPD at an index treatment episode, interviewed at five-year follow-up, and followed-up through the Swedish criminal justice register by 2005 for the years 1995-2003. ASPD and non-ASPD subjects were compared using Mann Whitney U test for ordinal variables (number of offenses and months in prison) and chi-square tests for categorical variables. A total of 107 were alive by 1995, when the period of observation began. ASPD diagnosed at baseline was related to criminal offenses and incarceration during the follow-up from 5 to 15 years. For most categories, ASPD diagnosis was associated with higher frequency of offense. An ASPD diagnosis based on SCID-II interview made at five-year follow-up was related to the number of offenses but unrelated to incarceration. In a sample of drug abusers, ASPD was associated with high levels of criminal behavior, even years after the diagnosis was given. A diagnosis based on clinical observation during treatment was at least as predictive of criminal behavior as a diagnosis based on a SCID-II interview.