Six-month outcomes for patients who switched to olanzapine treatment.

OBJECTIVE: This study evaluated the outcomes of patients in a community mental health center who switched from treatment with another antipsychotic to olanzapine treatment. It also sought to determine whether simultaneous access to case management and psychosocial rehabilitation and olanzapine leads to enhanced functional improvement. METHODS: Six-month outcomes for a consecutive series of 104 patients who switched from a conventional antipsychotic medication to olanzapine were evaluated. Forty-nine patients in the same treatment program who continued to take conventional antipsychotics were also monitored as a reference group. Outcomes of the group receiving olanzapine were compared with their own baseline status and with outcomes of the reference group. RESULTS: At six months, patients in the olanzapine group demonstrated significant improvement over baseline across multiple measures of symptoms and psychosocial function. Compared with the reference group, the olanzapine group was more symptomatic at baseline and demonstrated significantly greater improvement at follow-up on the Brief Psychiatric Rating Scale and all subscales; Mini Psychiatric Rating Scale negative symptom, disorganization, anxiety, depression, and medication side effects items; and Clinical Global Improvement scale and Case Manager's Rating Scale-Plus illness factors. There was a trend toward superior improvement in psychosocial functioning among patients in the olanzapine group that achieved significance when patients in acute relapse at baseline were excluded. CONCLUSIONS: Olanzapine is effective in managing markedly to severely ill patients with psychotic disorders in a community mental health center. Simultaneous treatment with olanzapine, case management, and psychosocial rehabilitation leads to enhanced functional improvement among nonrelapsing patients.

[Integrated treatment for severe mental illness and substance abuse: Effective components of programs for persons with co-occurring disorders.]. / Troubles mentaux graves et abus de substances : composantes efficaces de progammes de traitements intégrés à l'intention des personnes présentant une comorbidité

Traditional approaches to treating clients with co-occurring disorders based sequential or parallel mental health and substance abuse treatments have failed, leading to the development of integrated treatment programs. In this article we define integrated treatment for clients with co-occurring disorders, and identify the core components of effective integrated programs, including: assertive outreach, comprehensiveness, shared decision-making, harm-reduction, long-term commitment, and stage-wise (motivation-based) treatment. The concept of stages of treatment is described to illustrate the different motivational states through which clients progress as they recover from substance abuse: engagement, persuasion, active treatment, and relapse prevention. The stages of treatment have clinical utility for guiding clinicians in identifying appropriate treatment goals matched to clients' motivational states, and selecting interventions based on these goals. By recognizing each client's current stage of treatment, clinicians can optimize outcomes by selecting interventions that are appropriate to the client's current motivational state or stage of treatment, and minimize clients dropping out from treatment. Effective integrated treatment programs for clients with co-occurring disorders differ in the specific services they provide, but share common elements in their philosophy and values. Research documents the beneficial effects of these programs, which bodes well for the long-term prognosis of clients with co-occurring disorders.

Recovery-oriented psychopharmacology: redefining the goals of antipsychotic treatment.

The traditional goals of psychopharmacology stem from the medical model. Rehabilitation interventions attempt to improve aspects of functioning in patients with chronic illnesses that are not responsive to biological intervention. Recovery is a concept emanating from the consumer self-help movement. It describes a move away from the patient role defined by a diagnostic label toward community membership defined by relationships and responsibilities in the community. Comprehensive care for people with psychotic disorders can include attention to each realm. This article provides an overview of the 3 models of care and describes a role for the psychopharmacologist in each as well as his or her unique potential to incorporate all 3. We outline potential synergistic benefits of integrating recovery-, rehabilitation-, and medical-model thinking into the practice of psychopharmacology and explore implications for the goals and outcomes of treatment for people with psychotic disorders.

Effectiveness of combining atypical antipsychotics and psychosocial rehabilitation in a community mental health center setting.

This article presents a consecutive case series of 70 patients treated with olanzapine, case management, and psychosocial rehabilitation in a community mental health setting. This group demonstrated highly significant improvement on all analyzed measures of symptoms and psychosocial function at 6-month follow-up. These findings suggest that results of efficacy studies of olanzapine will generalize to the community mental health setting. Furthermore, prescribing olanzapine in combination with case management and rehabilitation yields positive functional outcomes.

Antisocial personality disorder, conduct disorder, and substance abuse in schizophrenia.

The validity of subtypes based on antisocial personality disorder (APD) or childhood conduct disorder without adult APD (CD only) in patients with schizophrenia (or schizoaffective disorder) and a substance use disorder (abuse or dependence) was examined. APD patients scored lower on personality measures related to socialization and higher on antisocial behavior, psychopathy, and aggression. APD patients also reported higher rates of aggression and legal problems. APD, and to a lesser extent CD only, was associated with more severe psychiatric symptoms, an earlier age of onset of substance abuse, more severe symptoms of substance abuse, and a stronger family history of substance abuse and psychiatric hospitalization. The findings suggest that schizophrenia patients with APD represent a high-risk subgroup vulnerable to more severe substance abuse, psychiatric impairment, aggression, and legal problems.

The role of self-help programs in the rehabilitation of persons with severe mental illness and substance use disorders.

Substance abuse treatment programs in the United States frequently incorporate self-help approaches, but little is known about the use of self-help groups by individuals with dual disorders. This paper brings together several current studies on the role of self-help programs in treating substance use disorders among individuals with severe mental illness. These studies indicate that only a minority of individuals with dual disorders become closely linked to self-help. Psychiatric diagnosis and possibly social skills are correlates of participation. Dually disorders consumers often experience the use of 12-step philosophy and jargon by mental health professionals as alienating and unempathic. The authors propose suggestions for incorporating self-help approaches into the comprehensive community care of individuals with dual disorders.

Group treatment for dually diagnosed clients.

Group treatment is a widely practiced intervention for persons with dual diagnoses. This chapter reviews the rationale for group treatment and discusses four different approaches to group intervention: twelve-step, educational-supportive, social skills, and stagewise treatment.

Family history of alcoholism in schizophrenia.

Previous research has shown that family history of alcoholism (FHA) is associated with several aspects of the development and expression of alcohol use disorder in people who are not mentally ill. This study examined FHA in a group of 66 schizophrenic outpatients who were well characterized in terms of their alcohol use and were followed prospectively in treatment for 4 years. The FHA-positive probands (42.4% of the group) were more likely to have alcohol use disorder. Contrary to our prediction, the relationship between FHA and alcoholism in the probands was significant for women but not for men. Among schizophrenic probands with alcoholism, positive FHA was associated with more severe alcoholism and with the use of other drugs. Probands with positive FHA also responded less well to alcoholism treatment than did probands with negative FHA. These exploratory findings have significant implications for understanding risk, for conducting assessment, and for studying treatment, but should be confirmed in larger and more representative samples of people with schizophrenia.

Correlates and outcomes of alcohol use disorder among rural outpatients with schizophrenia.

BACKGROUND: The use of alcohol by persons with schizophrenia is common and has been associated with increased severity of psychiatric symptoms, multiple psychosocial problems, abuse of other drugs, and poor treatment outcomes. Most of the previous research in this area has been with urban patients. METHOD: The authors examined the correlates and outcomes of alcohol use in a rural sample of 75 DSM-III-R outpatients with schizophrenia. Based on multiple measures, 25% (N = 19) of 75 rural patients with schizophrenia were diagnosed with current co-occurring alcohol use disorders. Clinicians' ratings and self-reported symptoms were used to examine correlates of alcohol use, and the study group was followed prospectively for 1 year to identify all episodes of rehospitalization, incarceration, or literal homelessness. RESULTS: Alcohol use disorder was statistically significantly associated with unstable housing, conceptual disorganization, denial of mental illness, and rehospitalization during 1-year follow-up. Several trends suggested that alcohol use was also related to positive symptoms of psychosis. CONCLUSION: Among rural patients with schizophrenia, alcohol use appears to play a significant role in destabilizing psychosocial adjustment. These results replicate similar findings in urban settings.

Treatment of substance abuse in severely mentally ill patients.

Substance abuse is the most common comorbid complication of severe mental illness. Current clinical research converges on several emerging principles of treatment that address the scope, pace, intensity, and structure of dual-diagnosis programs. They include a) assertive outreach to facilitate engagement and participation in substance abuse treatment, b) close monitoring to provide structure and social reinforcement, c) integrating substance abuse and mental health interventions in the same program, d) comprehensive, broad-based services to address other problems of adjustment, e) safe and protective living environments, f) flexibility of clinicians and programs, g) stage-wise treatment to ensure the appropriate timing of interventions, h) a longitudinal perspective that is congruent with the chronicity of dual disorders, and i) optimism.

Substance abuse in schizophrenia: service utilization and costs.

Utilization and cost of institutional and outpatient services were prospectively measured over 1 year for three groups of schizophrenic patients: current substance abusers, past substance abusers, and those without a history of substance abuse. Current abusers had significantly greater utilization and cost of institutional (hospital and jail) services. Current abusers also had greater utilization of emergency services. There were no significant differences between the groups in utilization and cost of other services, including psychosocial rehabilitation, outpatient treatment (case management, psychotherapy, and psychiatric visits), and housing supports. The implications for developing cost-effective treatments for dually diagnosed individuals are discussed.

Treatment of alcoholism among schizophrenic outpatients: 4-year outcomes.

In this pilot study, the authors assessed 4-year outcomes for 18 schizophrenic outpatients with alcoholism who were treated in an innovative dual-diagnosis program. Over half (61.1%) achieved stable remissions from alcoholism. The mean duration of remission was 26.5 months.

Subjective experiences related to alcohol use among schizophrenics.

Comorbid alcohol use disorders are common in schizophrenia. Although a variety of explanatory hypotheses involving self-medication have been proposed, few data available regarding schizophrenic patients' subjective experiences while using alcohol. We report interview data from 75 DSM-III-R schizophrenic outpatients regarding their subjective responses to alcohol. Over half of our sample reported that alcohol improved social anxiety, tension, dysphoria, apathy, anhedonia, and sleep difficulties. Other nonpsychotic experiences were frequently improved as well. In contrast, no more than 15% of subjects reported that alcohol relieved any specific psychotic symptom; similar proportions of subjects reported that alcohol aggravated psychotic symptoms. Reporting that alcohol had a positive effect on nonpsychotic experiences was associated with having lifetime alcohol use disorders. Reporting that alcohol relieved psychotic symptoms was associated both with having lifetime alcohol use disorders and with the number of psychotic symptoms reported. We discuss the implications of these findings for understanding alcohol abuse and dependence among schizophrenics.

New Hampshire's specialized services for the dually diagnosed.

New Hampshire's specialized dual diagnosis services include continuous treatment teams and substance abuse treatment groups within each mental health center. These services are embedded in an extensive system of care for the dually diagnosed.

Diagnosis of alcohol use disorders in schizophrenia.

Alcohol use disorders are common comorbid conditions in schizophrenia, and their presence is associated with poor adjustment and poor treatment response. Standard alcohol assessment instruments have not been validated for use with schizophrenic patients, and several authors have questioned the validity of these patients' self-reports. A reliable and valid screening procedure for assessing alcohol use is needed. The present study used the following three methods to evaluate a rural sample of 75 outpatients with DSM-III-R schizophrenia or schizoaffective disorder: (1) clinical records; (2) research interviews using standard alcohol assessment instruments; and (3) case managers' ratings. In addition, consensus diagnoses, determined by combining information from all three methods with intensive case reviews, were used to determine the sensitivity and specificity of the other approaches. As expected, clinical evaluations frequently missed alcohol problems. Research interviews and case managers' ratings differentiated between alcoholic and nonalcoholic schizophrenic patients and were highly correlated. Case managers' ratings, which incorporated longitudinal observations of behavior and collateral reports as well as interview data, were more sensitive measures of current alcohol use disorders than research interviews. Subjects frequently manifested alcohol-related problems that interfered with community adjustment without the full dependence syndrome, suggesting that schizophrenic patients may be particularly vulnerable to negative effects of alcohol.