Treating comorbid substance use disorders in schizophrenia
This literature review examines the pharmacological and psychosocial treatment approaches for people with schizophrenia and comorbid substance use disorder(s) (SUD). The results show that despite the high prevalence of comorbid SUD among people with schizophrenia, there is a considerable shortage of rigorously conducted randomized controlled treatment trials. Although there is some evidence for clozapine, and for the adjunctive use of agents such as naltrexone for comorbid alcohol dependence, the available literature largely comprises case studies, case series, open label studies and retrospective surveys. In terms of psychosocial approaches, there is reasonable consensus that integrated approaches are most appropriate. Regarding specific aspects of care, motivational interviewing, cognitive behavioral therapy, contingency management, and family interventions have an emerging supportive literature. The authors state there is no ‘one size fits all’, and a flexible approach with the ability to apply specific components of care to particular individuals, is required. Group-based therapies and longer-term residential services have an important role for some patients, but further research is required to delineate more clearly which patients will benefit from these strategies. The authors conclude that although there is growing evidence that integrated and well articulated interventions that encompass pharmacological and psychosocial parameters can be beneficial for people with schizophrenia and comorbid SUD, there remains a considerable gap in the literature available to inform evidence-based practice
Keywords: psychotherapy treating co-morbid substance use in schizophrenia pharmacotherapy psychological treatment schizophrenia alcohol cannabis cocaine heroin module 1 module 4
Lubman, D. I., King, J. A., & Castle, D. J. (2010). Treating comorbid substance use disorders in schizophrenia. International Review of psychiatry, 22(2), 191-201.
Psychotherapy for schizophrenia in an ACT team context
This case study discusses the treatment of a man diagnosed with schizophrenia with severe social anxiety. CBT approaches were used and treatment was conducted by a psychotherapist within the context of ACT services. CBT and ACT were found to be complementary, and the combination of approaches was found to be effective helping to reduce the client’s social anxiety. However, the client decided after all that he did not want to continue therapy. The authors recommend that clinicians working within ACT teams attempt to incorporate CBT approaches to better address the needs of their clients.
Smith, S.M., & Yanos, P.T. (2009). Psychotherapy for schizophrenia in an ACT team context. Clinical Case Studies, 8(6), 454-462. doi: 10.1177/1534650109352006
NPACT: Enhancing programs of assertive community treatment for the seriously ill.
This two-group community comparison design study examines the impact on psychiatric and physical outcomes through enhancing a standard Program of Assertive Treatment (PACT) with Advanced Practice Psychiatric Mental Health Nurses (APNs) and stabilized consumer peer providers (NPACT). Evaluations were conducted at baseline and at 6 months to assess six outcome variables: psychiatric symptoms, community adjustment, disability, physical symptoms, health promotion orientation, and consumer satisfaction. Significant improvements over time were demonstrated for both groups on all variables. However, treatment effects for NPACT over PACT were demonstrated for psychiatric symptoms, community functioning, and consumer satisfaction. NPACT subjects endorsed more medical problems at baseline than did PACT subjects. This may be due to subjects being more likely to disclose physical health symptoms to nurses. In conclusion, enhancements for PACT using advanced practice nurses and consumer peer providers have the potential to address both health and mental health problems of the seriously mentally ill.
Kane, C.F., & Blank, M.B. (2004). NPACT: Enhancing programs of assertive community treatment for the seriously ill. Community Mental Health Journal, 40 (6), 549-559.
Assertive community treatment: Evidence based hope for the seriously mentally ill.
This editorial summarizes the overall evidence of ACT, including a paragraph about primary care (i.e., access to primary care and early evidence-based studies that describe the scope of the problem) . The overall conclusion of the editorial is that there is hope for those suffering from serious mental illness with ACT.
Keywords: primary care community treatment evidence based practice mentally illness health care services psychiatric nurses module 1
Rice, M.J. (2011). Assertive community treatment: Evidence based hope for the seriously mentally ill. Journal of the American Psychiatric Nurses Association, 17(1), 13-15. doi: 10.1177/1078390310396708
The inextricable nature of mental and physical health: Implications for integrative care.
This article provides evidence that physical health problems are caused and exasperated by psychological factors and psychological distress leads to physical disease. It argues that new approaches are needed to assure adequate professional knowledge of behavioral health at basic licensure, to increase the use of advanced practice psychiatric–mental health nurses in primary care set¬tings, to identify and teach behavioral competencies for primary care providers, and to fund the design and evaluation of integrative models of care.
Keywords: primary care health care reform primary health care mental health systems hospitals health services module 4
Weiss, S., Haber, J., Horowitz, J., Stuart, G., & Wolfe, B. (2009). The inextricable nature of mental and physical health: Implications for integrative care. Journal of the American Psychiatric Nurses Association, 15(6), 371–382. doi: 10.1177/1078390309352513
Program fidelity in Assertive Community Treatment: development and use of a measure.
Describes the development of the Dartmouth Assertive Community Treatment Scale (DACTS) and the results of applying it to 50 diverse programs.
Keywords: critical ingredients community mental health services deinstitutionalization psychotic disorders/rehabilitation module 1
Teague, G. B., Bond, G. R., & Drake, R. E. (1998). Program fidelity in Assertive Community Treatment: development and use of a measure. American Journal of Orthopsychiatry, 68, 216-232.
Cognitive behavioural therapy for major psychiatric disorder: does it really work? A meta-analytical review of well-controlled trials.
This meta-analytical review of the CBT for major psychiatric disorders states that although cognitive behavioural therapy (CBT) is claimed to be effective in schizophrenia, major depression and bipolar disorder, there have been negative findings in well-conducted studies and meta-analyses have not fully considered the potential influence of blindness or the use of control interventions. In the current meta-analysis it found that CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates.
Keywords: psychotherapy bipolar disorder cognitive therapy depression schizophrenia cognitive-behavioural therapy (cbt) module 4
Lynch, D., Laws, K. R., & McKenna, P. J. (2010). Cognitive behavioural therapy for major psychiatric disorder: does it really work? A meta-analytical review of well-controlled trials. Psychological medicine, 40(01), 9-24. doi:10.1017/S003329170900590X
From the hospital to the community: a shift in the primary locus of care.
A community-based mental health team assertively providing a variety of support services to both the patient and the community can effectively treat the patient, substantially reduce use of the hospital, and virtually eliminate the revolving-door syndrome
Stein, Leonard, I., and Test, Mary Ann. (1979) From the hospital to the community: a shift in the primary locus of care. New Directions for Mental Health Services, 1, 15-32.
Assertive Community Treatment Literature Review.
Provides a detailed overview of ACT and the outcomes associated with the evidence-based practice. The implementation issues are also discussed in great detail, with particular attention to issues related to staffing, financing, and geographical differences in implementing ACT.
Linkins, K., Tunkelrott, T., Dybdal, K., & Robinson, G. (2000, April 28). Assertive Community Treatment Literature Review. Falls Church, VA: Lewin Group, Inc.
Cost-effectiveness of Assertive Community Treatment versus standard case management for persons with co-occurring severe mental illness and substance use disorders.
Examines the cost-effectiveness of ACT in comparison to standard case management.
Keywords: effectiveness of act mental illness substance use disorders quality of life standard case management case management cost-effectiveness/cost-benefit module 1
Clark, R. E., Teague, G. B., Ricketts, S. K., Bush, P. W., Xie, H., McGuire, T. G. et al. (1998). Cost-effectiveness of Assertive Community Treatment versus standard case management for persons with co-occurring severe mental illness and substance use disorders. Health Services Research, 33, 1285-1308.
Assertive Community Treatment: An update of randomized trials.
Reviews outcomes of randomized controlled trials of ACT including studies of special populations (i.e., homeless, dual diagnoses).
Keywords: effectiveness of act community mental health services schizophrenia rehabilition schizophrenia psychology module 1
Burns, B. J. & Santos, A. B. (1995). Assertive Community Treatment: An update of randomized trials. Psychiatric Services, 46, 669-675.
Economic impacts of Assertive Community Treatment: A review of the literature.
Focuses on economic impact of ACT on hospital use, emergency-room use, use of outpatient services, housing costs.
Keywords: effectiveness of act cost effectiveness/cost benefit mental disorders/therapy community mental health services/economics module 1
Latimer, E. (1999). Economic impacts of Assertive Community Treatment: A review of the literature. Canadian Journal of Psychiatry, 44, 443-454.
Moving Assertive Community Treatment into standard practice
Describes ACT, summarizes its effectiveness for different client populations, and discusses cost effectiveness. This article also discusses the critical components of ACT and how it has been adapted locally. Additionally, the authors outline issues that mental health system administrators, ACT staff, and consumers are likely to face when implementing ACT.
Keywords: effectiveness of act cost effectiveness/cost benefit mental disorders/rehabilitation module 1
Phillips, S., Burns, B., Edgar, E., Mueser, K. T., Linkins, K. W., Rosenheck, R. A. et al. (2001). Moving Assertive Community Treatment into standard practice, Psychiatric Services, 52 (6), 771-779.
Assertive Community Treatment for people with severe mental illness: Critical ingredients and impact on patients.
Summarizes the results of 25 studies of the effectiveness of ACT. Includes information on cost-effectiveness and fidelity.
Bond, G. R., Drake, R. E., Mueser, K. T., & Latimer, E. (2001). Assertive Community Treatment for people with severe mental illness: Critical ingredients and impact on patients. Disease Management & Health Outcomes, 9, 141-159.
Assertive community treatment of severe mental illness: a Canadian experience.
The study assessed one-year outcomes for 110 clients with serious mental illness who were randomly assigned to an assertive community rehabilitation program that provides psychiatric rehabilitation services in community settings or to hospital-based rehabilitation programs. Key elements of the community program include a multidisciplinary team on call 24 hours a day, in vivo treatment, and instruction and assistance in basic living skills. Data from client interviews after one year of service were used to assess clients' quality of life, satisfaction with services, and psychopathology. Clients in the assertive community rehabilitation program were more likely to be maintained in community settings and reported better quality of life than clients in the hospital-based programs.
Lafave, H.G., de Souza, H.R, and Gerber, G.J. (1996). Assertive community treatment of severe mental illness: a Canadian experience. Psychiatric Services 47(7), 757-9.