Characteristics of recent violence among entrants to acute mental health and substance abuse services.

OBJECTIVE: The aim of this study was to describe the characteristics of recent interpersonal violence perpetrated and experienced by individuals recruited from acute crisis mental health and substance abuse treatment settings and to examine differences among incidents involving individuals with mental disorders only (MDO), substance use disorders only (SDO), and co-occurring mental and substance use disorders (COD). METHOD: Participants (N = 419) were interviewed about their involvement in specific acts of violence in the past 30 days. Participants were also asked about where each incident took place, who was involved, whether individuals were injured, and whether alcohol or drugs were used before the incident. We examined distributions of violence characteristics for the full sample and used logistic regression analyses to test differences among incidents involving participants with MDO, SDO, and COD. RESULTS: Approximately 41% (n = 171) of the sample was involved in at least one incident of violence as a perpetrator or a victim, generating a total of 379 incidents. Far more incidents of violence involved victimization (62%) than perpetration (38%). Most incidents were isolated and involved only perpetration or only victimization. However, a total of 98 (26%) incidents occurred with another incident and constituted 49 episodes of violence that included incidents of perpetration and victimization. Characteristics of perpetration and victimization incidents were similar, except that victimization incidents involved more serious types of violence. The majority of incidents took place outdoors and did not result in injuries. Participants used drugs or alcohol prior to over 40% of incidents. Most incidents of perpetration (70%) targeted someone known to the participant. Diagnostic group was the strongest predictor of type of injury, location of incident, and use of alcohol and drugs before the incident. Individuals with substance use disorders, either alone or co-occurring with mental disorders, were more likely to report that violent incidents took place outdoors. Individuals with mental disorders, either alone or co-occurring with substance use disorders, were less likely to report alcohol and drug use prior to involvement in violence. CONCLUSIONS: Violence is common among individuals entering acute crisis mental health and substance abuse treatment. We found that such persons are more likely to report being victims of violence than perpetrators of violence. In contrast to prior studies, we found that most incidents took place outdoors. Although individuals in different diagnostic groups were no more or less likely to perpetrate or experience violence, they perpetrated and experienced violence under different circumstances. Implications and directions for future research and practice are discussed.

Effects of substance dependence on outcomes of patients in a randomized trial of two case management models.

OBJECTIVE: The effectiveness of a community-based intensive clinical case management program was compared with that of a hospital-based expanded brokerage case management program for seriously mentally ill adults with and without substance dependence. METHODS: The sample of 268 frequently hospitalized psychiatric patients was recruited during acute psychiatric hospitalization. More than half of the sample (53 percent) was diagnosed as having at least one current DSM-III-R substance dependence disorder co-occurring with their primary major mental disorder. Subjects were stratified by substance dependence status and randomly assigned to one of the case management programs. They were interviewed before hospital discharge and at one, two, and six months after discharge to assess psychosocial and drug use variables. Subjects' service use was examined for the six months before and after hospitalization. RESULTS: The hypothesis that substance-dependent subjects would benefit more from intensive clinical case management was not supported. Substance dependence predicted negative outcomes independent of the case management intervention. The hypothesis that the two case management approaches would be equally effective for subjects not dependent on substances was also not borne out. Intensive clinical case management was the superior treatment for subjects who were not dependent on substances. Fewer of them required psychiatric hospitalization in the six-month postdischarge period than in the six-month period before hospital admission. CONCLUSIONS: The negative outcomes for substance-dependent subjects in both programs suggest that the two case management models were relatively ineffective for these patients. Results suggest that intensive clinical case management can be effective within the first six months for nondependent adults with serious mental illness.

Detection of illicit opioid and cocaine use in methadone maintenance treatment.

Urine toxicology is the gold standard for estimating the prevalence of illicit drug use in methadone maintenance treatment (MMT). The frequency of urine testing may be crucial for establishing accurate use rates. Infrequent testing may lead programs to undercount active drug users and to target interventions too narrowly. This study compared results from frequent testing (twice per week) versus less frequent testing of 166 patients at four MMT programs. As part of a research study, all patients were tested by research staff for opioid and cocaine use twice per week on a fixed schedule for 10 weeks. During the same period, the four MMT programs tested the patients according to their standard protocols, approximately weekly (one program) or every 3-4 weeks (three programs). The research tests identified approximately 50% more illicit opioid users and 70% more cocaine users than the less frequent program tests. Patients who were drug positive according to the research tests but drug negative according to the program tests tended to be infrequent users. The data suggest that standard urine testing practices in MMT programs may result in underestimates of the prevalence of opioid and cocaine use. More frequent testing, even for time-limited periods, should produce more accurate depictions of drug use prevalence and help indicate the direction of interventions.

Factors associated with lapses to heroin use during methadone maintenance.

This prospective, observational study investigated factors predicting a lapse to heroin use in 74 heroin-abstinent methadone maintenance patients. After baseline data collection, participants were assessed twice per week for 7 weeks and again at 6 months after baseline. Proportional hazards regression and logistic regression were used to investigate the effects of study predictors on heroin use. A goal of absolute heroin abstinence consistently predicted a lower risk of a lapse, whereas marijuana use was associated with a greater risk. Stress variables were not predictive. The abstinence goal and stress results were consistent with the authors' previous studies of other drug treatment samples. This line of research suggests that factors influencing lapses are similar across drug treatment populations and the role of stress in precipitating relapse remains unresolved.

Relationship of cocaine and other substance dependence to well-being of high-risk psychiatric patients.

OBJECTIVE: The co-occurrence of substance dependence disorders was determined in a sample of 160 frequently hospitalized adults with severe mental illness, and the relationship between substance dependence and psychosocial functioning and well-being was examined. METHODS: A structured interview was used to assess subjects for co-occurring current DSM-III-R substance dependence disorders during an acute psychiatric hospitalization. They were administered a structed interview that included the subscales of the Addiction Severity Index, the Center for Epidemiological Studies-Depression Scale, Lehman's Quality of Life Interview, Rosenberg's Self-Esteem Scale, the Mastery Scale, and questions about service needs. RESULTS: Seventy-eight of the subjects (48.8 percent) were diagnosed as having at least one current substance dependence disorder. Most subjects with comorbid substance dependence were polysubstance dependent (55.1 percent), and almost half (44.9 percent) met criteria for cocaine dependence. Subjects who were substance dependent were significantly overrepresented among those diagnosed with bipolar disorder, psychotic disorder not otherwise specified, and major depression. When the analysis controlled for demographic characteristics and primary diagnosis, comorbidity was related to depressive symptoms, adverse life conditions, and diminished life satisfaction in several domains. Substance-dependent subjects were significantly more likely to have been arrested and jailed than nondependent subjects. Cocaine-dependent subjects were significantly less satisfied than all other subjects with their living situation and personal safety and more likely to request assistance for their drug and alcohol use problems. CONCLUSIONS: The findings corroborate high rates of co-occurring substance dependence disorders among frequently hospitalized patients with severe mental illness. They also reveal a high prevalence of cocaine dependence and a dramatic pattern of negative correlates of cocaine dependence. The findings suggest that successful interventions for substance dependence may improve these patients' life circumstances and that psychiatric patients may be particularly receptive to such interventions during hospitalization.

Traumatic events and post-traumatic stress disorder in cocaine users entering private treatment.

We investigated traumatic events, post-traumatic stress disorder (PTSD), and psychiatric comorbidity in 450 men and women entering private, hospital-based treatments for cocaine dependence. Overall prevalence of event exposure was the same for women and men; however, women were approximately five times more likely than men to be diagnosed with lifetime and current PTSD. Women experienced more PTSD than men even when exposed to the same type of event. In most subjects with PTSD, onset of the disorder preceded onset of cocaine dependence. Subjects with PTSD were more likely than those without PTSD to have additional co-occurring mental disorders. Findings from this relatively affluent, privately treated sample suggest that PTSD and cocaine dependence are related, independent of patients' resources. They further indicate that the relationship between gender and PTSD is robust across patient populations. More complex examinations of PTSD, cocaine dependence, and gender are needed to better understand these relationships and to design effective interventions.

Social relationships and abstinence from cocaine in an American treatment sample.

In an extension of earlier work relating social-relationship variables to post-treatment abstinence from abused drugs, 104 cocaine users were studied for 6 months after completing drug treatment. Social-relationship variables included social integration, perceived support and social-network cocaine use. The effects of social relationships on cocaine abstinence tended to be conditional on race. Greater social integration predicted abstinence for Caucasian Ss (n = 54), but not African-Americans (n = 50). Similar results occurred for perceived support. Social network drug-use data also showed race differences: the absence of current cocaine users and the presence of former users predicted abstinence only for Caucasians. Interpretation of these findings is complicated by the relationship we observed between race and route of cocaine administration, with African-American Ss far more likely than Caucasians to be crack smokers or injection users as compared to intranasal users. The effects of race could not be disentangled from the effects of route. Future studies of social relationships and cocaine abstinence should focus on identifying social factors that are protective for African-Americans and for smokers/injectors. Such studies are critical precursors to designing successful social-support interventions.

Effects of commitment to abstinence, positive moods, stress, and coping on relapse to cocaine use.

In a prospective study of 104 cocaine patients, a baseline assessment was conducted while Ss were in treatment. After treatment completion, Ss were assessed once a week for 12 weeks, then 6 months from study start. A goal of absolute abstinence, greater expected success in quitting, and positive moods predicted a lower risk of a lapse in the first 12 weeks of follow-up. Stress (negative moods, physical symptoms, hassles, and life events) did not predict. Use of more coping strategies predicted abstinence for Caucasian but not for African-American Ss. Baseline measures of expected success and desire to quit predicted continuous abstinence at 6 months but not at statistically significant levels. Results suggest that solidifying abstinence goals and enhancing positive moods may facilitate early abstinence.

Relapse prevention.

Although knowledge about relapse prevention is still at an early stage, the extant data highlight the importance of several constructs. 1. Motivation for abstinence remains central. The construct itself is often clouded because of its association with mystical notions such as willpower and self-control. We know that manipulation of environmental events can increase motivation. These interventions are effective, however, only as long as the contingencies are in effect. We need to develop and evaluate strategies for transferring contingency management to the natural environment, that is, to institutions and groups that can perpetuate them for the long term. Also, clarification of the kinds of abstinence goals needed to prevent relapse is important. 2. Coping skills have been studied by several investigators, but research on these, except for job-finding skills, is not encouraging. The skills usually taught may be too basic. Skills training oriented to complex targets, such as building nondrug-using networks, may be useful and should be further explored. 3. Social support is clearly important, yet we do not know how best to use it to promote abstinence. The little research available suggests that both familial and nonfamilial systems should be mobilized. We need to define abstinence-promoting supportive behaviors, identify and engage important support systems in treatment, and help patients expand their nondrug-using contacts. 4. Negative affect may be causally related to relapse. We need to continue efforts to identify dysphoric patients and develop interventions to ameliorate dysphoria concurrent with drug abuse treatment (cf. Zweben and Smith 1989). 5. Drug cue reactivity and extinction to drug cues have been demonstrated in the laboratory. What is needed in this promising line of research are (1) investigation of cues and cue-reactivity phenomena in the natural environment or in conditions closely mimicking that environment and (2) extinction methods that transfer from the treatment setting to the outside world. Other phenomena are not well understood but seem intuitively important. Maladaptive ways of responding to lapses, such as the AVE, are included here. Another is stress, which our patients and our clinical intuition tell us must play a role in relapse. Its exact role is far from clear.

Social support and relapse: commonalities among alcoholics, opiate users, and cigarette smokers.

Links between social support and relapse were examined in a study of alcoholics, cigarette smokers, and opiate users completing treatment for drug use (N = 221). Subjects were followed weekly until relapse for a maximum of 12 weeks after the end of treatment. Structural and functional social support and support for abstinence and drug use were investigated. With demographic variables and drug-treatment group controlled, greater structural support (as measured by an index of social integration and by partner status) predicted a lower risk of relapse. Greater experienced partner support for abstinence also predicted lower risk. Social network members' use of the subject's problem drug predicted heightened relapse risk, but the effect was not statistically significant. This study contributes to a cross-drug model of relapse. It highlights the importance of social integration and abstinence-specific functional support in predicting the risk of relapse, independent of the particular drug of abuse.

Commitment to abstinence and acute stress in relapse to alcohol, opiates, and nicotine.

The effects of commitment to abstinence and acute stress on return to drug use were examined in a study of treated alcoholics, opiate users, and cigarette smokers (N = 221). Subjects were followed for 12 weeks or until they used their problem drug for 7 consecutive days. Commitment to absolute abstinence at end of treatment was related to a lower risk of returning to use and longer time between the first use and relapse. Withdrawal symptoms and negative and positive moods predicted first drug use, but only when assessed retrospectively. Prospective analyses failed to reveal a link between these variables and return to use. These findings suggest a reevaluation of current models of relapse. Acute stress may be less important in precipitating return to drug use than previously believed.

Factors predicting utilization of acute psychiatric inpatient services by frequently hospitalized patients.

A three-month cohort of admissions (N = 300) to an acute psychiatric inpatient unit of a county general hospital was studied to identify factors that differentiate patients with multiple admissions over a 12-month period from those with only a single admission. Patients with more than one admission made up 32 percent of the cohort. Compared with single-admission patients, they were significantly more likely to be chronically unemployed and to have a diagnosis of schizophrenic or affective disorder. Regression analyses indicated that the number of prior psychiatric hospitalizations was the strongest predictor of both the number of hospitalizations and the number of days hospitalized; other significant predictors were a secondary diagnosis of personality disorder, chronic unemployment, self-referral, and being black. The findings indicate that many of the problems of multiple-admission patients are rooted in social disadvantage, and efforts to devise effective interventions should not focus on psychopathology alone.

A survey of the problems and needs of homeless consumers of acute psychiatric services.

Efforts to alter the repeated use costly hospital-based psychiatric services and the underuse of community mental health services by some homeless adults have yielded few successes. To better understand these failed efforts, the authors interviewed 112 self-identified homeless recidivists in San Francisco on several demographic variables, the problems they face in living in the community, and the resources they feel they need to be able to remain in the community. Most striking among the findings was the low priority respondents accorded to the psychiatric and social services currently offered by community mental health agencies; instead the respondents often blamed their inability to avoid readmissions on their lack of basic resources for survival. The authors discuss the relevance of the findings for mental health research, funding policies, and programming.

Chronic heroin use during methadone treatment: a test of the efficacy of high maintenance doses.

A pilot study was conducted at two maintenance programs to test the effect of increasing the methadone dose of clients who continue chronic heroin use after stabilization on methadone. Program 1 subjects (Group 1) received substantial dose increases for a 14-week period; Program 2 subjects (Group 2) received no dose modifications during the same period. Results show Group 1 reported an alleviation of physical and psychological complaints but did not decrease illicit opiate use. Group 2 maintained the low level of complaints reported at baseline and, unexpectedly, decreased opiate abuse. Because the two maintenance programs differed in clinical practices and in enforcement of rules, it was concluded that clients who continue chronic heroin use need not only long-term dosage increases, but also clear, consistently applied program policies.