Substance use and psychotic-like experiences in young people: a systematic review and meta-analysis.

This study aimed to systematically review and synthesise the available evidence on the prevalence and associations between psychotic-like experiences (PLEs) and substance use in children and adolescents aged ⩽17 years, prior to the typical age of development of prodromal symptoms of psychosis. As substance use has been associated with earlier age of psychosis onset and more severe illness, identifying risk processes in the premorbid phase of the illness may offer opportunities to prevent the development of prodromal symptoms and psychotic illness. MEDLINE, PsycINFO, and CINAHL databases were searched for chart review, case-control, cohort, twin, and cross-sectional studies. Study reporting was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist, and pooled evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Searches identified 55 studies that met inclusion criteria. Around two-in-five substance users reported PLEs [rate = 0.41, 95% confidence interval (CI) 0.32-0.51; low quality evidence], and one-in-five with PLEs reported using substances (rate = 0.19, 95% CI 0.12-0.28; moderate-to-high quality evidence). Substance users were nearly twice as likely to report PLEs than non-users [odds ratio (OR) 1.77, 95% CI 1.55-2.02; moderate quality evidence], and those with PLEs were twice as likely to use substances than those not reporting PLEs (OR 1.93, 95% CI 1.55-2.41; very low quality evidence). Younger age was associated with greater odds of PLEs in substance users compared to non-users. Young substance users may represent a subclinical at-risk group for psychosis. Developing early detection and intervention for both substance use and PLEs may reduce long-term adverse outcomes.

Environmental Risk Factors in Bipolar Disorder and Psychotic Depression: A Systematic Review and Meta-Analysis of Prospective Studies.

OBJECTIVE: The aim of this systematic review and meta-analysis was to study the association between specific environmental risk factors (ERF) and later development of Bipolar disorder and Psychotic depression. METHODS: A systematic search of prospective studies was conducted in MEDLINE, EMBASE and PsycINFO databases, and supplemented by hand searching, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (registration number: CRD42018092253). Selected ERF included: pre-/peri-natal factors-paternal age at birth, maternal infection, obstetric complications, perinatal stress; early childhood factors-urbanicity at birth, childhood infection, childhood adversity; later life factors-substance misuse, ethnic minority and migration, urbanicity later in life, stressful life events, and traumatic head injury. Pooled effect sizes of the association between these ERF and affective psychoses were calculated from systematically selected studies. When studies examining each ERF were insufficient for meta-analysis, results were presented narratively. RESULTS: Forty-six studies were included for quantitative analyses among selected ERF for affective psychosis, with significant association found for paternal age >40 years (OR 1.17, 95%CI 1.12-1.23), early (OR 1.52, 95%CI 1.07-2.17) and late (OR 1.32, 95%CI 1.05-1.67) gestational age, childhood adversity (OR 1.33, 95%CI 1.18-1.50), substance misuse (OR 2.87, 95%CI 1.63-5.50), and being from an ethnic minority (OR 1.99, 95%CI 1.39-2.84). CONCLUSIONS: These results suggest some shared environmental load between non-affective and affective psychosis, implying generalized risks for psychosis rather than for specific diagnostic categories. Nonetheless, published studies for some ERF in the affective psychoses are scarce, and further longitudinal studies are needed.

A meta-analysis of the relationship between psychosis and any type of criminal offending, in both men and women.

BACKGROUND: Psychosis is known to be associated with an increased risk of violent offending, but the risk of criminal offending of any type is not so well understood, including the nature and extent of any differences in offending risk for men and women with psychosis. METHODS: A systematic search of electronic databases from 1970 to March 2020 was conducted to identify studies comparing criminal offending amongst those with psychosis to a general population sample. A meta-analysis was performed, with separate analyses undertaken for men and women. RESULTS: Eight studies, with a total of 15,446 individuals with psychosis and 186,752 controls from general population sources, met our inclusion criteria. The pooled odds ratio for any type of criminal offending for men with psychosis was 2.42 (95% CI = 1.63-3.59), and for women it was 2.81 (95% CI = 2.11-3.76). Substantial between study heterogeneity was identified. CONCLUSIONS: Although the pooled odds ratio for all types of offending was not as high as has been found for violence, those with psychotic illness were more than twice as likely to have had contact with the criminal justice system for any type of criminal offence, compared to the general population. Little difference in risk was seen for women compared to men with psychosis. Clinical risk assessments and the development of interventions to reduce risk of contact with the criminal justice system should consider that risk of offending for those with psychosis extends right across the spectrum of offence types.

Common or distinct pathways to psychosis? A systematic review of evidence from prospective studies for developmental risk factors and antecedents of the schizophrenia spectrum disorders and affective psychoses.

BACKGROUND: Identifying the unique and shared premorbid indicators of risk for the schizophrenia spectrum disorders (SSD) and affective psychoses (AP) may refine aetiological hypotheses and inform the delivery of universal versus targeted preventive interventions. This systematic review synthesises the available evidence concerning developmental risk factors and antecedents of SSD and AP to identify those with the most robust support, and to highlight remaining evidence gaps. METHODS: A systematic search of prospective birth, population, high-risk, and case-control cohorts was conducted in Medline and supplemented by hand searching, incorporating published studies in English with full text available. Inclusion/exclusion decisions and data extraction were completed in duplicate. Exposures included three categories of risk factors and four categories of antecedents, with case and comparison groups defined by adult psychiatric diagnosis. Effect sizes and prevalence rates were extracted, where available, and the strength of evidence synthesised and evaluated qualitatively across the study designs. RESULTS: Of 1775 studies identified by the search, 127 provided data to the review. Individuals who develop SSD experience a diversity of subtle premorbid developmental deficits and risk exposures, spanning the prenatal period through early adolescence. Those of greatest magnitude (or observed most consistently) included obstetric complications, maternal illness during pregnancy (especially infections), other maternal physical factors, negative family emotional environment, psychopathology and psychotic symptoms, and cognitive and motor dysfunctions. Relatively less evidence has accumulated to implicate this diversity of exposures in AP, and many yet remain unexamined, with the most consistent or strongest evidence to date being for obstetric complications, psychopathology, cognitive indicators and motor dysfunction. Among the few investigations affording direct comparison between SSD and AP, larger effect sizes and a greater number of significant associations are commonly reported for SSD relative to AP. CONCLUSIONS: Shared risk factors for SSD and AP may include obstetric complications, childhood psychopathology, cognitive markers and motor dysfunction, but the capacity to distinguish common versus distinct risk factors/antecedents for SSD and AP is limited by the scant availability of prospective data for AP, and inconsistency in replication. Further studies considering both diagnoses concurrently are needed. Nonetheless, the prevalence of the risk factors/antecedents observed in cases and controls helps demarcate potential targets for preventative interventions for these disorders.

Stimulant use disorders in people with psychosis: a meta-analysis of rate and factors affecting variation.

OBJECTIVE: Stimulant abuse and dependence often complicate the care of people with psychotic disorders. This study systematically reviews the prevalence estimates reported for stimulant abuse and dependence in people with psychotic disorders, and examines personal, clinical, regional and methodological factors which explain variation in these rates. METHODS: PsychINFO, EMBASE and MEDLINE (1946-2013) were searched systematically for studies reporting on stimulant drug use disorders in representative samples of people with psychotic disorders. Random effects models estimated the pooled rate of a stimulant use disorder, defined to include stimulant abuse and stimulant dependence. Study characteristics associated with heterogeneity in rates of stimulant use disorder were examined by subgroup analyses for categorical variables, by meta-regression for continuous independent variables and by multiple meta-regression. RESULTS: Sixty-four studies provided 68 estimates of lifetime or recent stimulant use disorders in 22,500 people with psychosis. The pooled rate of stimulant use disorder was 8.9% (95% CI 7.4%, 10.5%). Higher rates of stimulant use disorders were reported in studies of affective psychosis, studies from inpatient settings, studies from the USA and Australia, and studies with higher rates of cannabis disorder; in multiple meta-regression analysis these factors explained 68% of between-study variance. Rates of stimulant use disorder were stable over time, and unrelated to age, sex, stage of psychosis, type of stimulant drug or study methodology factors. CONCLUSIONS: Reported rates of stimulant use disorder in people with psychosis are much higher than in the general population but vary widely and are associated with regional, service setting and clinical differences between studies. It is likely that stimulants contribute to the overall burden of psychosis, and that social and environmental factors combine with drug and illness-related factors to influence stimulant use in psychosis.

Morning cortisol levels in schizophrenia and bipolar disorder: a meta-analysis.

Increased peripheral levels of morning cortisol have been reported in people with schizophrenia (SZ) and bipolar disorder (BD), but findings are inconsistent and few studies have conducted direct comparisons of these disorders. We undertook a meta-analysis of studies examining single measures of morning cortisol (before 10 a.m.) levels in SZ or BD, compared to controls, and to each other; we also sought to examine likely moderators of any observed effects by clinical and demographic variables. Included studies were obtained via systematic searches conducted using Medline, BIOSIS Previews and Embase databases, as well as hand searching. The decision to include or exclude studies, data extraction and quality assessment was completed in duplicate by LG, SM and AS. The initial search revealed 1459 records. Subsequently, 914 were excluded on reading the abstract because they did not meet one or more of the inclusion criteria; of the remaining 545 studies screened in full, included studies were 44 comparing SZ with controls, 19 comparing BD with controls, and 7 studies directly comparing schizophrenia with bipolar disorder. Meta-analysis of SZ (N=2613, g=0.387, p=0.001) and BD (N=704, g=0.269, p=0.004) revealed moderate quality evidence of increased morning cortisol levels in each group compared to controls, but no difference between the two disorders (N=392, g=0.038, p=0.738). Subgroup analyses revealed greater effect sizes for schizophrenia samples with an established diagnosis (as opposed to 'first-episode'), those that were free of medication, and those sampled in an inpatient setting (perhaps reflecting an acute illness phase). In BD, greater morning cortisol levels were found in outpatient and non-manic participants (as opposed to those in a manic state), relative to controls. Neither age nor sex affected cortisol levels in any group. However, earlier greater increases in SZ morning cortisol were evident in samples taken before 8 a.m. (relative to those taken after 8 a.m.). Multiple meta-regression showed that medication status was significantly associated with morning cortisol levels in SZ, when the effects of assay method, sampling time and illness stage were held constant. Heightened levels of morning cortisol in SZ and BD suggest long-term pathology of the hypothalamic-pituitary-adrenal (HPA) axis that may reflect a shared process of illness development in line with current stress-vulnerability models.

Cultivating an entrepreneurial mindset.

Now as never before, familiar challenges require bold, novel approaches. Registered dietitians will benefit by cultivating an entrepreneurial mindset that involves being comfortable with uncertainty, learning to take calculated risks, and daring to just try it. An entrepreneur is someone who takes risks to create something new, usually in business. But the entrepreneurial mindset is available to anyone prepared to rely only on their own abilities for their economic security and expect no opportunity without first creating value for others.

Systematic meta-analysis of childhood social withdrawal in schizophrenia, and comparison with data from at-risk children aged 9-14 years.

Social withdrawal is a robust childhood risk factor for later schizophrenia. The aims of this paper were to assess the evidence for childhood social withdrawal among adults with schizophrenia and, comparatively, in children aged 9-14 years who are putatively at-risk of developing schizophrenia. We conducted a meta-analysis, including cohort and case-control studies reporting social withdrawal measured by the Child Behavior Checklist (CBCL) in adults with schizophrenia vs. controls. Further, an experimental study compared CBCL withdrawal scores from typically-developing children with scores from two groups of putatively at-risk children: (i) children displaying a triad of replicated antecedents for schizophrenia, and (ii) children with at least one first- or second-degree relative with schizophrenia or schizoaffective disorder. Six studies met inclusion criteria for the meta-analysis (N = 3828), which demonstrated a large effect of increased childhood social withdrawal in adults with schizophrenia (standardized mean difference [SMD] score = 1.035, 95% CI = 0.304-1.766, p = 0.006), with no indication of publication bias, but considerable heterogeneity (I(2) = 91%). Results from the experimental study also indicated a large effect of increased social withdrawal in children displaying the antecedent triad (SMD = 0.743, p = 0.001), and a weaker effect in children with a family history of schizophrenia (SMD = 0.442, p = 0.051). Childhood social withdrawal may constitute a vulnerability marker for schizophrenia in the presence of other antecedents and/or genetic risk factors for schizophrenia.

Systematic meta-analysis of insula volume in schizophrenia.

BACKGROUND: Volume reduction in insular cortex may constitute an important neuropathology in schizophrenia. We provide the first meta-analysis of studies that conducted region-of-interest analyses of the magnitude of effect and pattern of insula volume reduction in schizophrenia compared with healthy control subjects. METHODS: Included studies examined insula volume in schizophrenia relative to healthy control subjects. Studies were located via electronic database searches and hand searching. Study selection, data extraction, and quality assessment were completed by two independent reviewers. Hedge's g effect sizes were calculated using Comprehensive Meta-Analysis (v.2) to quantify volumetric differences between people with and without schizophrenia, accounting for moderating influences of age, sex, illness duration, medication, whole brain volume, and potential differences in hemispheric and anatomical subregions. RESULTS: Random-effects analysis showed reductions of bilateral insula (n = 945, g = -.446, 95% confidence interval -.639 to -.252, p = .00001), with moderate heterogeneity apparent (I² = 76%). This effect was consistent across left and right insula and not influenced by illness stage or sex. Additional analyses revealed larger reductions of anterior (n = 605, g = -.643, p < 0.001; I² = 52%) than of posterior insula (n = 453, g = -.321, p = .028; I² = 55%). Meta-regression analyses did not identify any significant predictors of reduced insula volume. CONCLUSIONS: This meta-analysis indicates medium-sized reduction of insula volume in schizophrenia, of greatest magnitude in the anterior subregion. Cellular distinctions across anterior and posterior insula may contribute to understanding the neuropathology and functional significance of the observed volumetric differences.

Systematic meta-review and quality assessment of the structural brain alterations in schizophrenia.

BACKGROUND: The large quantity of systematic reviews of magnetic resonance imaging studies in schizophrenia challenges their meaningful interpretation. This meta-review synthesises the available information from systematic reviews of structural alteration in both chronic and first-episode schizophrenia. METHODS: Systematic reviews were identified using electronic databases. Review methodological quality was assessed according to the Assessment of Multiple Systematic Reviews checklist. Data were extracted in duplicate and quality assessed for consistency and precision, guided by Grading of Recommendations Assessment, Development and Evaluation recommendations. RESULTS: Integration of volumetric and voxel-based estimates allowed critical assessment of the magnitude and location of anatomical differences. There is evidence for grey matter reductions of anterior cingulate, frontal (particularly medial and inferior) and temporal lobes, hippocampus/amygdala, thalamus, and insula that may be magnified over time. Other regional alterations appear specific to illness stage or medication status. CONCLUSIONS: There is limited high quality evidence supporting grey or white matter changes in schizophrenia, which has previously been obscured by a large volume of conflicting lower quality evidence.

A systematic meta-review grading the evidence for non-genetic risk factors and putative antecedents of schizophrenia.

INTRODUCTION: Identifying the relative strength of evidence associated with non-genetic risk factors and putative antecedents of schizophrenia will guide research and may inform the design of early detection and intervention strategies. AIMS: To present and quality assess current evidence for non-genetic risk factors and putative antecedents derived from well-conducted systematic reviews that report pooled data. METHOD: Medline, Embase, CINAHL, Current Contents, and PsycINFO databases were searched systematically, and supplemented by hand searching. Review reporting quality was assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, review methodology was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) checklist, and evidence quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: Twenty-four reviews met inclusion criteria. The risk factors with the highest quality evidence, reporting medium effect sizes, were advanced paternal age, obstetric complications, and cannabis use. The strongest evidence among the putative antecedents was identified for motor dysfunction and low IQ. CONCLUSIONS: More research is required that applies sound methodological practices, taking into consideration specificity for schizophrenia and possible confounding factors, to robustly identify the non-genetic risk factors and putative antecedents of schizophrenia.

Interleukin 2 receptor antagonists for kidney transplant recipients.

BACKGROUND: Interleukin 2 receptor antagonists (IL2Ra) are used as induction therapy for prophylaxis against acute rejection in kidney transplant recipients. Use of IL2Ra has increased steadily since their introduction, but the proportion of new transplant recipients receiving IL2Ra differs around the globe, with 27% of new kidney transplant recipients in the United States, and 70% in Australasia receiving IL2Ra in 2007. OBJECTIVES: To systematically identify and summarise the effects of using an IL2Ra, as an addition to standard therapy, or as an alternative to another immunosuppressive induction strategy. SEARCH STRATEGY: We searched the Cochrane Renal Group's specialised register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE to identify new records, and authors of included reports were contacted for clarification where necessary. SELECTION CRITERIA: Randomised controlled trials (RCTs) in all languages comparing IL2Ra to placebo, no treatment, other IL2Ra or other antibody therapy. DATA COLLECTION AND ANALYSIS: Data was extracted and assessed independently by two authors, with differences resolved by discussion. Dichotomous outcomes are reported as relative risk (RR) and continuous outcomes as mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS: We included 71 studies (306 reports, 10,537 participants). Where IL2Ra were compared with placebo (32 studies; 5,784 patients) graft loss including death with a functioning graft was reduced by 25% at six months (16 studies: RR 0.75, 95% CI 0.58 to 0.98) and one year (24 studies: RR 0.75, 95% CI 0.62 to 0.90), but not beyond this. At one year biopsy-proven acute rejection was reduced by 28% (14 studies: RR 0.72, 95% CI 0.64 to 0.81), and there was a 19% reduction in CMV disease (13 studies: RR 0.81, 95% CI 0.68 to 0.97). There was a 64% reduction in early malignancy within six months (8 studies: RR 0.36, 95% CI 0.15 to 0.86), and creatinine was lower (7 studies: MD -8.18 micromol/L 95% CI -14.28 to -2.09) but these differences were not sustained.When IL2Ra were compared to ATG (16 studies, 2211 participants), there was no difference in graft loss at any time point, or for acute rejection diagnosed clinically, but the was benefit of ATG therapy over IL2Ra for biopsy-proven acute rejection at one year (8 studies:, RR 1.30 95% CI 1.01 to 1.67), but at the cost of a 75% increase in malignancy (7 studies: RR 0.25 95% CI 0.07 to 0.87) and a 32% increase in CMV disease (13 studies: RR 0.68 95% CI 0.50 to 0.93). Serum creatinine was significantly lower for IL2Ra treated patients at six months (4 studies: MD -11.20 micromol/L 95% CI -19.94 to -2.09). ATG patients experienced significantly more fever, cytokine release syndrome and other adverse reactions to drug administration and more leucopenia but not thrombocytopenia. There were no significant differences in outcomes according to cyclosporine or tacrolimus use, azathioprine or mycophenolate, or to the study populations baseline risk for acute rejection. There was no evidence that effects were different according to whether equine or rabbit ATG was used. AUTHORS' CONCLUSIONS: Given a 38% risk of rejection, per 100 recipients compared with no treatment, nine recipients would need treatment with IL2Ra to prevent one recipient having rejection, 42 to prevent one graft loss, and 38 to prevent one having CMV disease over the first year post-transplantation. Compared with ATG treatment, ATG may prevent some experiencing acute rejection, but 16 recipients would need IL2Ra to prevent one having CMV, but 58 would need IL2Ra to prevent one having malignancy. There are no apparent differences between basiliximab and daclizumab. IL2Ra are as effective as other antibody therapies and with significantly fewer side effects.

A consideration of contemporary factors influencing professional development in health research.

Numerous contemporary factors, including issues pertaining to continuing education and professional development, influence nursing careers in all areas of health research. This article provides an overview of international trends, practices, and questions that impinge on nurse educators and health researchers. These factors include the status of randomized controlled trials, the influence of evidence-based practice, gaps between research results and patient requirements, and the relationships between available evidence and clinical decision making. Added to this research and evidence environment are government concerns about the relevance and usefulness of health research. Finally, the questions an individual career researcher may ask, specifically regarding specialization versus a broad research agenda, are considered.

Meta-analyses in prevention and treatment of urinary tract infections.

Urinary tract infections (UTI) are common, and complications result in significant morbidity and mortality and also consume resources. This overview summarizes the current evidence for the prevention and treatment of UTI in adults and children from meta-analyses. The quality and applicability of this evidence in clinical practice for different patient groups is discussed. Suggestions are made for future research, because it is apparent that there are evidence gaps for particular subgroups of people.

Views of Australian mental health stakeholders on clients' problematic drug and alcohol use.

INTRODUCTION AND AIMS: Substance misuse by people with a serious mental illness may exacerbate psychiatric symptoms and contribute to relapse. The aim of the study was to ascertain the views of a wide range of Australian mental health service providers on staff education and training, client contact and management, assessment, and treatment effectiveness and service delivery. DESIGN AND METHODS: A survey was sent to a sample of 171 mental health stakeholders in Australia identified through internet searches, state and territory mental health departments and professional organisations. RESULTS: Of the 66 respondents (39% response rate), the substances identified to be most problematic were alcohol and cannabis. Integrated service models of treatment were identified as the most preferable and effective. Barriers to treatment included client motivation to reduce substance use, poor communication and coordination between treatment services, and lack of specific services for dual diagnosis clients. Almost all indicated a need for further training in the area of dual diagnosis. DISCUSSION AND CONCLUSIONS: Dual diagnosis is common and the reality is that this vulnerable clientele will continue to challenge service providers and treatment approaches into the foreseeable future. Issues include the organization and delivery of treatment services, education and training, resource allocation, collaboration between treatment agencies and clinically relevant research evaluating the effectiveness of practice. It is thus surprising that with so much investment in this area the majority of stakeholders are still dissatisfied with access to and the level of care for dual diagnosis clients.

Drug and alcohol education for consumer workers and caregivers: a pilot project assessing attitudes toward persons with mental illness and problematic substance use.

With the development of peer support networks in the mental health system, formal training should be provided regarding the adverse effects of substance use. Four educational workshops were conducted with caregivers and consumer workers to increase their knowledge and confidence to support people with a dual diagnosis. Workshops were evaluated through presurvey and postsurvey. The workshops were well received, and postworkshop, participants reported fewer negative attitudes toward people with a dual diagnosis and increased understanding and knowledge regarding substance misuse. This study highlights the effectiveness of targeted workshops for caregivers and consumer workers and advocates that nurses take a more active role in educational projects involving stakeholders.

Evaluation of a transition to practice programme for mental health nursing.

AIM: This paper is a report of a study assessing nurses' satisfaction with a 12-month transition to practice programme into mental health nursing and its impact on their perceived knowledge, confidence and self-concept. BACKGROUND: Transition to practice programmes are necessary to facilitate graduate nurses' professional adjustment into nursing and experienced nurses' movement from one clinical setting or speciality to another. Role transition can be a difficult process, and those who have realistic expectations may experience less stress during the actual transition. METHOD: A quantitative evaluation design carried out in Australia, using questionnaires for data collection. The study began in 2005 and the participants were three groups (n = 45) of Registered Nurses who all completed the programme during 2006 and 2007. FINDINGS: Forty-four nurses (98%) completed pre- and postprogramme surveys. There was a relatively high level of satisfaction with the programme. Most participants found all aspects of the programme to be substantially positive, with the majority intending to continue to work in mental health nursing at programme completion. Data concerning knowledge of and confidence in undertaking a number of nursing tasks showed statistically significant gains postprogramme for most items. No differences were found in The Nurses' Self-Concept Questionnaire scores between pre- and post-test phases, apart from a trend towards improved communication and caring. CONCLUSION: Transition programmes have the potential to make a positive contribution to the mental health nursing workforce. Continuing professional development opportunities are essential to ensure that skill development is maintained. Future longitudinal research could ascertain the benefits of the programme on staff retention.

Psychosocial treatments for people with co-occurring severe mental illness and substance misuse: systematic review.

AIM: This study is a report of a systematic review to assess current evidence for the efficacy of psychosocial interventions for reducing substance use, as well as improving mental state and encouraging treatment retention, among people with dual diagnosis. BACKGROUND: Substance misuse by people with a severe mental illness is common and of concern because of its many adverse consequences and lack of evidence for effective psychosocial interventions. DATA SOURCES: Several electronic databases were searched to identify studies published between January 1990 and February 2008. Additional searches were conducted by means of reference lists and contact with authors. REVIEW METHODS: Results from studies using meta-analysis, randomized and non-randomized trials assessing any psychosocial intervention for people with a severe mental illness and substance misuse were included. RESULTS: Fifty-four studies were included: one systematic review with meta-analysis, 30 randomized controlled trials and 23 non-experimental studies. Although some inconsistencies were apparent, results showed that motivational interviewing had the most quality evidence for reducing substance use over the short term and, when combined with cognitive behavioural therapy, improvements in mental state were also apparent. Cognitive behavioural therapy alone showed little consistent support. Support was found for long-term integrated residential programmes; however, the evidence is of lesser quality. Contingency management shows promise, but there were few studies assessing this intervention. CONCLUSION: These results indicate the importance of motivational interviewing in psychiatric settings for the reduction of substance use, at least in the short term. Further quality research should target particular diagnoses and substance use, as some interventions may work better for some subgroups.

The association between substance use and the needs of patients with psychiatric disorder, levels of anxiety, and caregiving burden.

The influence of substance use on patient's needs and caregiving consequences has received insufficient research attention. We sought to determine whether patients with comorbid substance use have higher levels of need, anxiety, depression, and caregiving consequences than those of patients who do not use substances. A total of 520 patients participated, and those who used substances (n = 216) reported higher levels of unmet needs, anxiety, and caregiving consequences than did patients who did not use substances. Carers of patients who used substances also reported higher anxiety and more caregiving consequences. Very few patients were actively involved in treatment programs to reduce their substance use.