Integrating services for schizophrenia and substance abuse.

Over the past decade, several studies have attempted to determine whether integrating psychiatric and substance abuse treatment leads to better outcome for patients with comorbid schizophrenia and substance use disorders. A recent (1999) Cochrane Review (1) analyzed the effectiveness of prospective randomized studies of integrated treatment approaches, and concluded that there was no clear evidence for superiority of integrated treatment. This paper describes one such integrated treatment approach, in Beth Israel Medical Center's COPAD (Combined Psychiatric and Addictive Disorders) program. We summarize findings from an initial outcome study and a recent replication study; and describe clinical and research issues relevant to this population. Our data suggests the benefits of integrated treatment for patients with addictive disorders and schizophrenia, at least with regard to treatment retention. Clinical issues for such patients include identification of patients at risk, proper assessment and treatment planning, decision-making about mainstreaming vs. referral to specialized programs, and the importance of initial engagement and ongoing reengagement in successful treatment.

Pilot study of bright-light therapy reflected toward the eyes for the pruritus of chronic liver disease.

OBJECTIVE: It is proposed that the pruritus of cholestasis is, in part, centrally mediated by endogenous opioid peptides. The expression of these peptides and their receptors on neurons displays a circadian rhythm, as does the scratching activity in patients with cholestasis and pruritus. Because light has regulatory effects on circadian rhythms via retinothalamic pathways, we hypothesized that bright-light therapy (BLT) reflected toward the eyes might alter the pruritus of cholestasis. To test this hypothesis, we studied the effect of BLT on this form of pruritus. METHODS: Eight patients with chronic liver disease of different etiologies and pruritus were studied in an open-label, pilot study of 8-wk duration. BLT (10,000 lux) was administered for up to 60 min twice a day. Pruritus was assessed subjectively by a visual analog scale from which a visual analog score (VAS) was derived, and objectively, by a scratching activity monitoring system that recorded hourly scratching activity (HSA). RESULTS: In seven of the eight patients studied, the mean HSA was lower during BLT. BLT was associated with a mean decrease in HSA of 32.2% (p = 0.123). The mean VAS for pruritus was lower in six patients during BLT; the mean VAS score derived from the eight patients studied decreased by 42% (p = 0.05) during treatment. CONCLUSIONS: The results of this short-term study suggest that the pruritus of cholestasis is responsive to bright light reflected toward the eyes and that in some patients, BLT may ameliorate this form of pruritus.

Adding group psychotherapy to medication treatment in dysthymia: a randomized prospective pilot study.

Patients with dysthymia have been shown to respond to treatment with antidepressant medications, and to some degree to psychotherapy. Even patients successfully treated with medication often have residual symptoms and impaired psychosocial functioning. The authors describe a prospective randomized 36-week study of dysthymic patients, comparing continued treatment with antidepressant medication (fluoxetine) alone and medication with the addition of group therapy treatment. After an 8-week trial of fluoxetine, medication-responsive subjects were randomly assigned to receive either continued medication only or medication plus 16 sessions of manualized group psychotherapy. Results provide preliminary evidence that group therapy may provide additional benefit to medication-responding dysthymic patients, particularly in interpersonal and psychosocial functioning.

Cerebral metabolism in opiate-dependent subjects: effects of methadone maintenance.

BACKGROUND: The long-term effects of opiate use on human brain are not known. The goal of this preliminary study was to determine whether human subjects with histories of opiate dependence have persistent differences in brain function as compared with individuals without substance use disorders, and whether methadone maintenance reverses or ameliorates the potential abnormality. METHOD: Positron emission tomographic (PET) [18F]fluorodeoxyglucose (FDG) method was used to compare the regional cerebral metabolic rate for glucose(rCMRglc) in three groups: four opiate-dependent subjects currently receiving methadone maintenance therapy (MM), four opiate-dependent subjects not receiving methadone maintenance therapy (MW), and a comparison group of five subjects without substance use disorders. RESULTS: A significant difference in rCMRglc in the anterior cingulate gyrus was found between the MW and Control groups (Mann-Whitney U=2.0, p=0.05). Generally speaking, rCMRglc's in MM subjects were intermediate between those of MW and Control groups, although the difference did not reach statistical significance. CONCLUSIONS: The results of this study suggest that neurobiological abnormalities can persist in the brain of a chronic opiate user several years after detoxification from methadone. Future research is needed to replicate these results and to determine whether the observed rCMRglc differences are related to opiate use or to neurochemical abnormalities that play a role in developing addictive behavior.

Treatment of dementia-associated agitation with gabapentin.

The authors describe the use of gabapentin in the treatment of 4 outpatients with dementia-associated agitation. On the basis of clinical case reports and the Overt Agitation Severity Scale, all 4 patients had reduced agitation with gabapentin. Three of 4 patients were successfully titrated to a full dose of 2,400mg/day. These findings suggest a possible role for gabapentin in the behavioral management of patients with dementia.

Hypofrontality and negative symptoms in patients with dementia of Alzheimer type.

OBJECTIVE: The purpose of the current study was to examine the relation between regional cerebral blood flow (rCBF) and negative symptoms (NS) in patients with dementia of Alzheimer type (DAT). BACKGROUND: Negative symptoms in neuropsychiatric disorders were associated with altered rCBF in frontal cortex. METHODS: Twenty-five subjects with a diagnosis of DAT were administered the Scale for the Assessment of Negative Symptoms (SANS), the Positive and Negative Symptom Scale, the Hamilton Rating Scale for Depression, and the Mini-Mental State Examination. The subjects were divided into two groups by means of a median split with regard to NS severity (high NS group, N = 12; low NS group, N = 13). Each patient underwent a single photon emission tomography scan using 99mTc-HMPAO at rest. Cortical and subcortical regions of interest were symmetrically defined in each hemisphere. Cortical-to-cerebellar perfusion ratios were established quantitatively using ADAC software. RESULTS: High NS group subjects had a significantly lower rCBF than low NS group subjects in the frontal cortex and cingulate gyrus (MANOVA: p = 0.022) as a result of differences in the dorsolateral prefrontal cortex bilaterally (right: F = 12.12, p = 0.002; left: F = 6.55, p = 0.02) and in the frontal cortex, mainly in the right hemisphere (right: F = 6.33, p = 0.02; left: F = 3.26, p = 0.08). For all the subjects (N = 25), there were negative correlations between the SANS total score and rCBF, most prominently in the dorsolateral prefrontal cortex bilaterally (right: r = -0.48, p <0.01; left: r = -0.49, p = 0.01). No significant correlation was found between rCBF in any of the regions of interest and either the Mini-Mental State Examination or the Hamilton Rating Scale for Depression scores. CONCLUSIONS: This study indicates that decreased perfusion in the frontal cortex is associated with NS severity but not with measures of cognitive impairment or depressive symptoms in DAT patients. These results support the hypothesis that the frontal lobes may be involved in the cause of NS in DAT, and they underscore the importance of NS evaluation in neuroimaging studies.

Depression and demoralization among Russian-Jewish immigrants in primary care.

The purpose of this study was to examine the levels and nature of psychological distress and depression among Russian-Jewish émigrés in primary care. Fifty-seven consecutive patients at the primary care clinic were assessed with the Hamilton Depression Scale (Ham-D). The subjects completed self-rating scales, including the Beck Depression Inventory (BDI), Life Orientation Test, Beck Hopelessness Scale, Attributional Style Questionnaire, and Snaith-Hamilton Pleasure Scale. Data on demographics and physical complaints were collected and analyzed. Of the patients studied, 82.5% experienced psychological distress (BDI > or = 10), and 43.9% had clinically significant depressive symptoms (Ham-D > or = 17). BDI and Ham-D scores were significantly correlated with the number of psychosomatic complaints, hopelessness, lack of optimism, anhedonia, and dysfunctional attributional style. The distressed, but not depressed, patients had preservation of hedonic capacity. The authors found a high rate of depression based upon Ham-D scores among the Russian-Jewish émigrés in primary care. The authors suggest that this high rate is attributable to a culturally specific tendency to express distress in somatic terms. The nature of distress was phenomenologically similar to demoralization.

Interpersonal change in brief supportive psychotherapy.

As a substudy of a manual-based outcome study of the Beth Israel Brief Psychotherapy Program, the authors studied the efficacy of supportive psychotherapy in personality change, with particular attention to changes that outlast the period of treatment. They examined results from the Inventory of Interpersonal Problems (IIP) at intake, 40th-session termination, and 6-month follow-up in the first 20 subjects randomized to the supportive group. Eight subjects (40%) dropped out, but their initial IIP scores did not differ from those of follow-up completers. Six of 10 subjects with complete 6-month follow-up data showed significant improvement in interpersonal problems (4 cases P < 0.001; 2 cases P < 0.05). In a case method design, using the IIP mapped to an interpersonal circumplex model, the authors graphically demonstrate lasting positive changes in interpersonal functioning in subjects treated with supportive psychotherapy.

A randomized prospective study comparing supportive and dynamic therapies. Outcome and alliance.

The authors report preliminary results of Brief Supportive Psychotherapy (BSP) in the Beth Israel Brief Psychotherapy Program for a sample with primarily Cluster C Axis II disorders. This study compares 24 patients treated with BSP with 25 patients treated with Short-Term Dynamic Psychotherapy (STDP). STDP was chosen because its confrontational methods contrast dramatically to BSP, which emphasizes building self-esteem, reducing anxiety, and enhancing coping mechanisms. Videotaped therapies were based on manualized 40-session protocols. Similar degrees of improvement were seen in BSP and STDP at termination and at 6-month follow-up. A study of therapeutic alliance in BSP showed stable and high levels of alliance in good-outcome cases and more variability in poor-outcome cases. These preliminary findings are consistent with other studies and suggest supportive psychotherapy may be effective for many patients, leading to significant and lasting change.

A pilot open randomized trial of valproate and phenobarbital in the treatment of acute alcohol withdrawal.

The authors conducted a randomized, open comparison of the GABAergic anticonvulsant sodium valproate (divalproex sodium; Depakote) and phenobarbital as an active control in the management of acute withdrawal from alcohol. Repeated measures ANOVA was used to assess treatment effects in the first 37 inpatients, evaluating mood, hostility, and subjective and objective measures of withdrawal at index, 3, and 5 days of detoxification. Subjective and objective ratings of abstinence symptoms and subjective mood disturbance decreased significantly in intensity in both groups over 5 days, but there were no significant treatment differences nor treatment by time interactions. Hostility scores did not differ overall, but a group by time effect was observed (F = 5.42, df = [1,13], P < 0.05), with phenobarbital subjects reporting less hostility/aggression than those in the valproate group. There were no withdrawal-related seizures or other acute sequelae. This study offers pilot confirmation that sodium valproate is as effective as phenobarbital in the management of acute alcohol withdrawal, but it is unclear whether valproate offers a clinical advantage with respect to stabilizing changes in mood and interpersonal hostility during detoxification.

Prediction of compliance with outpatient referral in patients with schizophrenia and psychoactive substance use disorders.

BACKGROUND: Most patients with concurrent schizophrenia and psychoactive substance use disorders may be adequately treated as outpatients. However, many do not comply with outpatient referrals and are therefore at heightened risk for rehospitalization. METHOD: Drawing on standardized interview data collected during an index hospitalization, we developed a logistic regression model to predict compliance with outpatient treatment. The model was tested on a confirmatory sample, and its sensitivity and specificity were further evaluated in a cross-validation study of 1000 random samples. RESULTS: In a reference sample, the logistic function distinguished compliant from noncompliant patients in 37 (76%) of 49 cases. In a confirmatory sample, compliance status was predicted for 11 (78%) of 14 patients with a sensitivity of 1.00 and a specificity of 0.67. Women and patients with negative syndrome schizophrenia were compliant with outpatient referral, whereas those with mixed syndromes were most likely to be noncompliant. Cross-validation supports the stability of the model. CONCLUSION: While most persons with schizophrenia and concurrent substance abuse comply with integrated outpatient treatment, most who cannot may be predicted in advance.

Differential diagnosis of substance-induced psychosis and schizophrenia in patients with substance use disorders.

We derived a statistical model that discriminates between substance-induced psychosis (i.e., DSM-III-R organic delusional disorder or organic hallucinosis; ODD-OH) and DSM-III-R schizophrenia in patients who have both DSM-III-R psychoactive substance use disorders (PSUD) and prominent delusions or hallucinations. A sample of 211 PSUD inpatients was divided by year of admission into data sets A and B, each of which was divided between those with concurrent schizophrenia and those with concurrent ODD-OH. A six-predictor discriminant function correctly classified 76.2 percent of all set A patients, including 83.1 percent with schizophrenia. Formal thought disorder and bizarre delusions significantly predict a diagnosis of schizophrenia, with odds ratios (OR) of 3.55:1 and 6.09:1, respectively. Suicidal ideation (OR = 0.32:1), intravenous cocaine abuse (0.18:1), and a history of drug detoxification (0.26:1) or methadone maintenance (0.18:1) demonstrate inverse relationships with a schizophrenia diagnosis. The model was validated in set B, correctly predicting the diagnostic status of 70.4 percent of patients (72.5% with schizophrenia). The pattern of presenting symptoms and clinical history differs in patients with psychosis due to PSUD and in those whose psychosis is due to schizophrenia. The model presented here contributes to the differential diagnosis of schizophrenia and ODD-OH among patients with PSUD.

Physical examination of substance abusers. How to gather evidence of concealed problems.

How can physicians make appropriate treatment decisions in substance abusers who have serious medical illness, especially when patients may not offer the information needed? Drs Westreich and Rosenthal summarize common physical findings that suggest abuse of specific substances. Recognizing these signs allows physicians to reliably diagnose chemical use, leads to improve outcomes, and lends weight to recommendations for substance-abuse therapy.

Methadone withdrawal psychosis.

BACKGROUND: Methadone is a typical mu-opioid receptor agonist that is widely used for maintenance and detoxification treatment of opiate-dependent patients. Although methadone withdrawal syndrome is well described, it generally does not include psychosis. METHOD: Having observed new onset psychosis in a patient on methadone taper, the authors identified three other such patients by chart review. All met DSM-III-R criteria for opioid dependence. Distinctive features of their clinical presentation, pharmacotherapy received, and follow-up were recorded. RESULTS: Two patients had no history of psychosis, one patient had a psychotic episode 21 years prior to admission, and one patient was diagnosed with schizophrenia but remained asymptomatic for at least 1 year while treated with only methadone. Psychosis resolved spontaneously in one case, whereas the other cases required neuroleptic treatment. In one case, methadone resumption was required. None of the patients developed typical methadone withdrawal syndrome. CONCLUSION: The above results suggest that opioid taper may be a period of high risk for development of psychosis. This risk is probably higher in patients with preexisting CNS illness. Clinicians caring for patients in opioid withdrawal should be aware of this risk. Further research is required to evaluate whether methadone withdrawal psychosis represents a clinical manifestation of opioid agonist modulation of dopaminergic neurotransmission in the human brain.

Positive and negative syndrome typology in schizophrenic patients with psychoactive substance use disorders.

Our objective was to begin to elucidate the interrelationship between psychoactive substance use disorders (PSUD) and schizophrenia in patients who concurrently have both disorders. A series of 29 psychiatric inpatients with concurrent Research Diagnostic Criteria (RDC)-diagnosed schizophrenia and PSUD (PSUD/S patients) were evaluated with rating inventories including the Schedule for Assessment of Negative Symptoms (SANS) and the Schedule for Assessment of Positive Symptoms (SAPS). Subjects had chronic schizophrenia with a mean duration of 9.9 years, and virtually all (93.1%) regularly abused cocaine and alcohol, as well as marijuana. The majority of subjects (58.6%) had mixed-syndrome typology, as defined by Andreasen; 24.1% had negative syndrome; and 16.7% had positive syndrome. Contrary to predictions, negative-syndrome PSUD/S patients had fewer years post-onset of schizophrenia than those patients with positive syndrome. In contrast to other schizophrenic patients, in whom the trajectory of symptoms is believed to change from a predominance of positive symptoms to a predominance of negative symptoms over the course of illness, in a sample of patients with comorbid PSUD/S we found the opposite pattern. This may have implications in the development of PSUD among certain schizophrenics, and may help to guide both psychiatric and substance abuse treatment of such patients.

Supportive therapy as the treatment model of choice.

Supportive and expressive techniques in psychotherapy can be located on a continuum. Traditionally, psychotherapy has been oriented toward the expressive end of the continuum, applying the model of psychoanalytic or expressive therapy to all therapy. The authors propose that for most patients, the model for individual dynamic psychotherapy should be based on concepts from the supportive end of the continuum.

The feasibility of smoking bans on psychiatric units.

We conducted a prospective study of a smoking ban on a general inpatient psychiatry service in response to staff concerns about the feasibility of a proposed hospital-wide ban. Demographic information, smoking history, and DSM III-R diagnoses were obtained for consecutively admitted patients during two study conditions: smoking and nonsmoking. A log of p.r.n. medication, seclusion, restraint, elopement, incident reports, and smoking-related discharges was kept for each patient. Chi-square analysis of 232 patients for whom demographic, smoking, diagnostic, and log data were complete showed no significant differences between study conditions for demographic or diagnostic variables. Two-tailed t-test analysis of the log data for these 232 patients showed no significant difference in disruptive incidents during smoking and nonsmoking conditions (p = 0.183). Fifty staff members answered pre- and post-ban questionnaires. Paired t-test analysis demonstrated a significant change in staff attitude toward supporting the ban. These data indicate that smoking can be stopped on inpatient psychiatry units without increases in unit disruption or adverse effects on staff morale.