Dr. Mark McGovern is a Professor in the Department of Psychiatry & Behavioral Sciences and, by courtesy, the Department of Medicine at Stanford University School of Medicine.
Most people who need health care do not receive it. And of those who do, wide variation exists in the quality of the care they receive. Gaps in health care access and quality are worse for certain groups, such as underrepresented minorities and persons living in low-resourced urban and rural areas, and/or in poverty. Enormous disparities exist in health care systems, both private and public. Dr. McGovern is a leader in using rigorous methods of dissemination and implementation (D&I) science to close these gaps in equitable health care delivery.
His mission is to get the best health care possible to the people who need it the most.
Dr. McGovern's primary focus is the implementation and sustainment of evidence-based interventions and guideline adherent care in public and private health care systems and organizations. Within the hub of the Center for Dissemination and Implementation (CDI) which he directs, Dr. McGovern is the Principal Investigator (PI) and leads three national dissemination and implementation (D&I) centers: The Center for Dissemination and Implementation At Stanford (C-DIAS); The Research Adoption Support Center (RASC); and, the Mental Health Technology Transfer Center Network Coordinating Center (MHTTC). The 3 centers are federally-funded, respectively by the National Institute on Drug Abuse (P50DA05402), the National Institutes of Health Healing Addiction Long Term (HEAL) initiative (U2CDA057717), and the US Department of Health and Human Services Substance Use and Mental Health Services Administration (H79SM081726). Dr. McGovern is also the PI on a multi-site adaptive implementation trial across a state system of care, which aims to integrate addiction medications for persons with opioid use disorder who are receiving services in specialty or primary care organizations (R01DA052975). In addition, he conducts D&I research and practice projects in federally-qualified health centers (FQHCs) across the State of California, in the Stanford Division of Primary Care and Population Health, and in specialty addiction and mental health treatment organizations nationwide. He leads, facilitates and/or actively engages networks advancing D&I science in health, including the NIDA Clinical Trials Network Translation & Implementation Special Interest Group, the NIDA Clinical Trials Western States Node Translation & Implementation Workgroup, the Stanford University Network for Dissemination & Implementation Research (SUNDIR), the VA Palo Alto HSR&D Center for Innovation to Implementation, and the Stanford Medicine Center for Improvement. He is on the Core Faculty of the National Institute of Mental Health Implementation Research Institute at the Washington University in St. Louis. Dr. McGovern is a collaborator on multiple projects as a co-investigator, consultant, or advisory board member. He is a mentor to numerous individuals across the country and at Stanford, from university undergraduates to mid-career faculty and clinical administrators at academic institutions and health care systems nationwide.
Professor - University Medical Line, Psychiatry and Behavioral Sciences
Director, Center for Dissemination and Implementation (CDI), Department of Psychiatry (2017 - Present)
Fellowship, Northwestern University School of Medicine at Northwestern Memorial Hospital, Emergency and crisis intervention; Psychoanalytic psychotherapy (1985)
Residency, Northwestern University School of Medicine at Northwestern Memorial Hospital, Clinical Psychology (1984)
Ph.D., Temple University, Clinical Psychology (1986)
M.A., Temple University, Clinical Psychology (1982)
BA, LaSalle College, Psychology (1977)
Stagewise Implementation-To-Target- Medications for Addiction Treatment (SITT-MAT)
The purpose of this study is to expand access to medications for opioid use disorder (MOUD) in specialty addiction programs in Washington State. Sixty-four addiction treatment programs will participate in an adaptive implementation strategy trial that uses a stagewise implementation-to-target (stepped "care" type) approach whereby organizations engage in increasingly intensive implementation strategies as needed. Organizations are moved to a follow-up/sustainment arm once they have met the implementation targets described below. The design also includes an external comparator arm, which consists of 510 addiction treatment programs that are not participating in the study and will mimic as study controls. The sequence of implementation strategies are: 1. Enhanced Monitoring and Feedback 2. NIATx/MAT Academy 3. Randomization to either NIATx Internal Facilitation or NIATx External Facilitation 4. Assignment to NIATx External Facilitation if outcome targets are not achieved in the NIATx Internal Facilitation arm Implementation targets are: 1. Reach - At least 75% of patients with opioid use disorder (OUD) receiving MOUD for three consecutive months 2. Adoption - At least 1 integrated MOUD prescriber actively prescribing MOUD 3. Implementation - a total score ≥ 4 on the Integrating Medications for Addiction Treatment (IMAT) Index. Contextual moderators and mediators of performance on target outcomes as a function of the implementation strategy step will be examined, as will the costs associated with participation in the sequence of implementation strategies.
Independent Studies (3)
- Medical Scholars Research
MED 370 (Win)
- Medical Scholars Research
PSYC 370 (Sum)
- Undergraduate Research
PSYC 199 (Aut, Win, Spr, Sum)
- Medical Scholars Research
Med Scholar Project Advisor
Stimulant use among patients in opioid treatment settings: Provider perspectives.
Journal of substance use and addiction treatment
INTRODUCTION: Methadone maintenance therapy (MMT) has been a pillar of opioid addiction treatment. Opioid treatment programs (OTPs) have been faced with an escalating threat of stimulant use and related overdose deaths among patients. We know little about how providers currently address stimulant use while maintaining treatment for opioid use disorder.METHODS: We conducted 5 focus groups with 36 providers (n = 11 prescribers; 25 behavioral health staff), and collected an additional 46 surveys (n = 7 prescribers; 12 administrators; 27 behavioral health staff). Questions focused on perceptions of patient stimulant use and interventions. We applied inductive analysis to identify themes relevant to identification of stimulant use, use trends, intervention approaches, and perceived needs to improve care.RESULTS: Providers indicated a trend of rising stimulant use among patients, especially those experiencing homelessness or comorbid health conditions. They reported a range of approaches to patient screening and intervention, including medication and harm reduction, improving treatment engagement, increasing level of care, and providing incentives. Providers expressed less agreement as to which of these interventions were effective, and though providers saw stimulant use as a common and severe problem, they reported little problem recognition and interest in treatment from their patients. A particular concern of providers was the prevalence and danger of synthetic opioids, such as fentanyl. They sought more research and resources to identify effective interventions and medications to address these issues. Also notable was an interest in contingency management (CM) and use of reinforcements/rewards to encourage stimulant use reduction.CONCLUSION: Providers face challenges in treating patients who use both opioids and stimulants. Although methadone is available to treat opioid use, no such "silver bullet" exists for stimulant use disorder. The rise in stimulant and synthetic opioid (e.g., fentanyl) combination products is presenting an extraordinary challenge for providers whose patients are at unprecedented risk for overdose. Providing OTPs with more resources to address polysubstance use is critical. Existing research indicates strong support for CM in OTPs, but providers reported regulatory and financial barriers to implementation. Further research should develop effective interventions that are accessible to providers in OTPs.
View details for DOI 10.1016/j.josat.2023.209012
View details for PubMedID 36931604
Evaluating the Implementation of a Model of Integrated Behavioral Health in Primary Care: Perceptions of the Healthcare Team.
Journal of primary care & community health
2023; 14: 21501319221146918
OBJECTIVES: This study aims to compare primary care providers and medical assistants in degrees of comfort, confidence, and consistency when addressing behavioral health concerns with patients before and after the implementation of a model of integrated behavioral health in primary care (IBHPC), and evaluate whether these perceptions differ based on increased access to behavioral health clinicians.METHODS: This longitudinal study was conducted at 2 primary care clinics in Northern California while implementing an IBHPC model. The Integrated Behavioral Health Staff Perceptions Survey was administered to assess the comfort, confidence, and consistency of behavioral health practices. Confidential online surveys were distributed to primary care faculty and staff members before and post-implementation. Responses from providers and medical assistants were compared between pre- and post-implementation with linear regression analyses. The relationships between accessibility to behavioral health clinicians and a change in comfort, confidence, and consistency of behavioral health practices were explored using a linear mixed-effects model.RESULTS: A total of 35 providers and medical assistants completed the survey both before and post-implementation of IBHPC. Over time, there were increasingly positive perceptions about the consistency of behavioral health screening (P=.03) and overall confidence in addressing behavioral health concerns (P=.005). Comfort in addressing behavioral health concerns did not significantly change for either providers or staff over time. Medical assistants were initially more confident and comfortable addressing behavioral health concerns than providers, but providers' attitudes increased post-IBHPC implementation. Improved access to behavioral health clinicians was associated with greater consistency of screening and referral to specialty mental health care (P<.001).CONCLUSION: The present study is the first to explore differences in provider and medical assistant perceptions during the course of an IBHPC implementation. Findings underscore the importance of integrating medical assistants, along with providers, into all phases of the implementation process.
View details for DOI 10.1177/21501319221146918
View details for PubMedID 36625239
Methamphetamine-associated heart failure: a systematic review of observational studies.
Heart (British Cardiac Society)
To conduct a systematic review of observational studies on methamphetamine-associated heart failure (MethHF) .Six databases were searched for original publications on the topic. Title/abstract and included full-text publications were reviewed in duplicate. Data extraction and critical appraisal for risk of bias were performed in duplicate.Twenty-one studies are included in the final analysis. Results could not be combined because of heterogeneity in study design, population, comparator, and outcome assessment. Overall risk of bias is moderate due to the presence of confounders, selection bias and poor matching; overall certainty in the evidence is very low. MethHF is increasing in prevalence, affects diverse racial/ethnic/sociodemographic groups with a male predominance; up to 44% have preserved left-ventricular ejection fraction. MethHF is associated with significant morbidity including worse heart failure symptoms compared with non-methamphetamine related heart failure. Female sex, methamphetamine abstinence and guideline-directed heart failure therapy are associated with improved outcomes. Chamber dimensions on echocardiography and fibrosis on biopsy predict the extent of recovery after abstinence.The increasing prevalence of MethHF with associated morbidity underscores the urgent need for well designed prospective studies of people who use methamphetamine to accurately assess the epidemiology, clinical features, disease trajectory and outcomes of MethHF. Methamphetamine abstinence is an integral part of MethHF treatment; increased availability of effective non-pharmacological interventions for treatment of methamphetamine addiction is an essential first step. Availability of effective pharmacological treatment for methamphetamine addiction will further support MethHF treatment. Using harm reduction principles in an integrated addiction/HF treatment programme will bolster efforts to stem the increasing tide of MethHF.
View details for DOI 10.1136/heartjnl-2022-321610
View details for PubMedID 36456204
Stepped implementation-to-target: a study protocol of an adaptive trial to expand access to addiction medications.
Implementation science : IS
2022; 17 (1): 64
In response to the US opioid epidemic, significant national campaigns have been launched to expand access to `opioid use disorder (MOUD). While adoption has increased in general medical care settings, specialty addiction programs have lagged in both reach and adoption. Elevating the quality of implementation strategy, research requires more precise methods in tailoring strategies rather than a one-size-fits-all-approach, documenting participant engagement and fidelity to the delivery of the strategy, and conducting an economic analysis to inform decision making and policy. Research has yet to incorporate all three of these recommendations to address the challenges of implementing and sustaining MOUD in specialty addiction programs.This project seeks to recruit 72 specialty addiction programs in partnership with the Washington State Health Care Authority and employs a measurement-based stepped implementation-to-target approach within an adaptive trial design. Programs will be exposed to a sequence of implementation strategies of increasing intensity and cost: (1) enhanced monitoring and feedback (EMF), (2) 2-day workshop, and then, if outcome targets are not achieved, randomization to either internal facilitation or external facilitation. The study has three aims: (1) evaluate the sequential impact of implementation strategies on target outcomes, (2) examine contextual moderators and mediators of outcomes in response to the strategies, and (3) document and model costs per implementation strategy. Target outcomes are organized by the RE-AIM framework and the Addiction Care Cascade.This implementation project includes elements of a sequential multiple assignment randomized trial (SMART) design and a criterion-based design. An innovative and efficient approach, participating programs only receive the implementation strategies they need to achieve target outcomes. Findings have the potential to inform implementation research and provide key decision-makers with evidence on how to address the opioid epidemic at a systems level.This trial was registered at ClinicalTrials.gov (NCT05343793) on April 25, 2022.
View details for DOI 10.1186/s13012-022-01239-y
View details for PubMedID 36175963
Addressing Methamphetamine Use in Primary Care: Provider Perspectives.
Journal of addiction medicine
The opioid epidemic has evolved into a combined stimulant epidemic, with escalating stimulant and fentanyl-related overdose deaths. Primary care providers are on the frontlines grappling with patients' methamphetamine use. Although effective models exist for treating opioid use disorder in primary care, little is known about current clinical practices for methamphetamine use.Six semistructured group interviews were conducted with 38 primary care providers. Interviews focused on provider perceptions of patients with methamphetamine use problems and their care. Data were analyzed using inductive and thematic analysis and summarized along the following dimensions: (1) problem identification, (2) clinical management, (3) barriers and facilitators to care, and (4) perceived needs to improve services.Primary care providers varied in their approach to identifying and treating patient methamphetamine use. Unlike opioid use disorders, providers reported lacking standardized screening measures and evidence-based treatments, particularly medications, to address methamphetamine use. They seek more standardized screening tools, Food and Drug Administration-approved medications, reliable connections to addiction medicine specialists, and more training. Interest in novel behavioral health interventions suitable for primary care settings was also noteworthy.The findings from this qualitative analysis revealed that primary care providers are using a wide range of tools to screen and treat methamphetamine use, but with little perceived effectiveness. Primary care faces multiple challenges in effectively addressing methamphetamine use among patients singularly or comorbid with opioid use disorders, including the lack of Food and Drug Administration-approved medications, limited patient retention, referral opportunities, funding, and training for methamphetamine use. Focusing on patients' medical issues using a harm reduction, motivational interviewing approach, and linkage with addiction medicine specialists may be the most reasonable options to support primary care in compassionately and effectively managing patients who use methamphetamines.
View details for DOI 10.1097/ADM.0000000000001035
View details for PubMedID 35841323
Expanding access to medications for opioid use disorder in primary care clinics: an evaluation of common implementation strategies and outcomes.
Implementation science communications
2022; 3 (1): 72
BACKGROUND: To combat the opioid epidemic in the USA, unprecedented federal funding has been directed to states and territories to expand access to prevention, overdose rescue, and medications for opioid use disorder (MOUD). Similar to other states, California rapidly allocated these funds to increase reach and adoption of MOUD in safety-net, primary care settings such as Federally Qualified Health Centers. Typical of current real-world implementation endeavors, a package of four implementation strategies was offered to all clinics. The present study examines (i) the pre-post effect of the package of strategies, (ii) whether/how this effect differed between new (start-up) versus more established (scale-up) MOUD practices, and (iii) the effect of clinic engagement with each of the four implementation strategies.METHODS: Forty-one primary care clinics were offered access to four implementation strategies: (1) Enhanced Monitoring and Feedback, (2) Learning Collaboratives, (3) External Facilitation, and (4) Didactic Webinars. Using linear mixed effects models, RE-AIM guided outcomes of reach, adoption, and implementation quality were assessed at baseline and at 9 months follow-up.RESULTS: Of the 41 clinics, 25 (61%) were at MOUD start-up and 16 (39%) were at scale-up phases. Pre-post difference was observed for the primary outcome of percent of patient prescribed MOUD (reach) (betatime = 3.99; 0.73 to 7.26; p = 0.02). The largest magnitude of change occurred in implementation quality (ES = 0.68; 95% CI = 0.66 to 0.70). Baseline MOUD capability moderated the change in reach (start-ups 22.60%, 95% CI = 16.05 to 29.15; scale-ups -4.63%, 95% CI = -7.87 to -1.38). Improvement in adoption and implementation quality were moderately associated with early prescriber engagement in Learning Collaboratives (adoption: ES = 0.61; 95% CI = 0.25 to 0.96; implementation quality: ES = 0.55; 95% CI = 0.41 to 0.69). Improvement in adoption was also associated with early prescriber engagement in Didactic Webinars (adoption: ES = 0.61; 95% CI = 0.20 to 1.05).CONCLUSIONS: Rather than providing an all-clinics-get-all-components package of implementation strategies, these data suggest that it may be more efficient and effective to tailor the provision of implementation strategies based on the needs of clinic. Future implementation endeavors could benefit from (i) greater precision in the provision of implementation strategies based on contextual determinants, and (ii) the inclusion of strategies targeting engagement.
View details for DOI 10.1186/s43058-022-00306-1
View details for PubMedID 35794653
Rapid adaptation during the COVID crisis: Challenges experienced in delivering service to those with Opioid Use Disorders.
Implementation research and practice
2022; 3: 26334895221096295
Adaptation is an accepted part of implementing evidence-based practices. COVID-19 presented a unique opportunity to examine adaptation in evolving contexts. Delivering service to people with opioid use disorder during the pandemic required significant adaptation due to revised regulations and limited service access. This report evaluated changes to addiction medication services caused by the pandemic, challenges encountered in rapidly adapting service delivery, and initial impressions of which changes might be sustainable over time.Qualitatively-evaluated structured interviews (N = 20) were conducted in late 2020 with key informants in Pinellas County (FL) to assess the pandemic's impact. Interviewees represented a cross-section of the professional groups including direct SUD/HIV service providers, and sheriff's office, Department of Health, and regional clinical program administrative staff. The interview questions examined significant changes necessitated by the pandemic, challenges encountered in adapting to this evolving context, and considerations for sustained change.The most significant changes to service delivery identified were rapid adaptation to a telehealth format, and modifying service consistent with SAMHSA guidance, to allow for 'take-home' doses of methadone. Limitations imposed by access to technology, and the retraining of staff and patients to give and receive service differently were the most common themes identified as challenging adaptation efforts. Respondents saw shifts towards telehealth as most likely to being sustained.COVID-19 provided an unprecedented opportunity to examine adaptation in a fast-paced, dynamic, and evolving context. Adaptations identified will only be sustained through multisystem collaboration and validation. Results suggest that additional components could be added to implementation frameworks to assess rapid adaptation during unplanned events, such as access to additional resources or local decision-making that impacts service delivery. Findings will also be integrated with quantitative data to help inform local policy decisions.Adaptation is an accepted part of implementing evidencebased practices. COVID-19 presented a unique opportunity to examine rapid adaptation necessitated within evolving contexts. Delivering services to people with opioid use disorder required significant adaptation due to changing regulations and limited access to lifesaving services. This study examined changes in service delivery due to the pandemic, challenges encountered in rapid adaptation, and initial impressions of which changes might be sustainable over time. Qualitatively-evaluated structured interviews were conducted with a cross-section of professional groups (direct substance use disorder (SUD) and human immunodeficiency virus (HIV) service providers, and sheriff's office, Department of Health, and clinical program administrative staff) in Pinellas County (FL). The most significant changes to service delivery were rapid adaptation to a telehealth format and increased allowance for 'takehome' doses of methadone medication. Limitations imposed by access to technology, as well as the education of and staff and patients were the most common themes identified as challenges. Respondents saw shifts towards telehealth as most likely to be sustained. COVID-19 provided an unprecedented opportunity to examine adaptation in a fast-paced, dynamic, and evolving context. Adaptations will only be sustained through multisystem collaboration and validation. Findings suggest that additional components could be added to implementation frameworks to assess rapid adaptation during unplanned events, such as access to additional resources or local decision-making that impacts service delivery.
View details for DOI 10.1177/26334895221096295
View details for PubMedID 37091103
View details for PubMedCentralID PMC9924287
Wait No Longer: Reducing Medication Wait-Times for Individuals with Co-Occurring Disorders*
JOURNAL OF DUAL DIAGNOSIS
View details for DOI 10.1080/15504263.2022.2052225
View details for Web of Science ID 000779788100001
The Emergency Department Longitudinal Integrated Care (ED-LINC) intervention targeting opioid use disorder: A pilot randomized clinical trial.
Journal of substance abuse treatment
INTRODUCTION: Opioid use disorder (OUD) and related comorbid conditions are highly prevalent among patients presenting to emergency department (ED) settings. Research has developed few comprehensive disease management strategies for at-risk patients presenting to the ED that both decrease illicit opioid use and improve initiation and retention in medication treatment for OUD (MOUD).METHODS: The research team conducted a pilot pragmatic clinical trial that randomized 40 patients presenting to a single ED to a collaborative care intervention (n=20) versus usual care control (n=20) conditions. Interviewers blinded to patient intervention and control group status followed-up with participants at 1, 3, and 6months after presentation to the ED. The 3-month Emergency Department Longitudinal Integrated Care (ED-LINC) collaborative care intervention for patients at risk for OUD included: 1) a Brief Negotiated Interview at bedside, 2) overdose education and facilitation of MOUD, 3) longitudinal proactive care management, 4) utilization of the statewide health information exchange platform for 24/7 tracking of recurrent ED utilization, and 5) weekly caseload supervision that incorporated measurement-based care treatment assessment with stepped-up care for patients with recalcitrant symptoms.RESULTS: Overall, the ED-LINC intervention was feasibly delivered and acceptable to patients. The pilot study achieved >80% follow-up rates at 1, 3, and 6months. In adjusted longitudinal mixed model regression analyses, no statistically significant differences existed in days of opioid use over the past 30days for ED-LINC intervention patients when compared to patients receiving usual care (incidence-rate ratio (IRR) 1.50, 95% CI 0.54-4.16). The unadjusted mean number of days of illicit opioid use decreased at the 1-month and 3-month follow-up time points for both groups. ED-LINC intervention patients had increased rates of MOUD initiation compared to control patients (50% versus 30%); intervention versus control comparisons did not achieve statistical significance, although power to detect significant differences in the pilot was limited.CONCLUSIONS: The ED-LINC intervention for patients with OUD can be feasibly implemented and warrants testing in larger scale, adequately powered randomized pragmatic clinical trial investigations. Clinicaltrials.gov NCT03699085.
View details for DOI 10.1016/j.jsat.2021.108666
View details for PubMedID 34952745
Feasibility and Preliminary Efficacy of a Public Mobile App to Reduce Symptoms of Postdisaster Distress in Adolescent Wildfire Survivors: Sonoma Rises
In October 2017, Northern California experienced devastating and historic wildfires leaving the community in need of support to foster emotional resilience during the recovery process. Adolescents represent a particularly vulnerable population in the wake of disaster, and digital mental health interventions may hold promise for reaching teens at scale. The present study examined the feasibility and efficacy of a mobile mental health app for disaster, Sonoma Rises. A multiple-baseline single-case experimental design (SCED) utilizing a research-enabled version of the app was employed with seven adolescents who experienced significant damage to their homes and schools in the wildfires. Participants completed daily mood ratings, weekly measures of posttraumatic stress symptoms, internalizing and externalizing symptoms, psychosocial functioning, and then pre-post-measures of anxiety, depression, wellbeing, sleep, academic engagement, and perceived social support as well as quantitative and qualitative measures of intervention satisfaction and feasibility. Sonoma Rises was found to be feasible in terms of engagement, satisfaction, and likelihood of recommending to a friend. During the study, another wildfire occurred and all participants underwent a prolonged mandated evacuation and were subject to a series of extended power outages. Uptake of the publicly available version of the Sonoma Rises app among the general population was modest but engagement among users was sustained. Lessons learned are offered to contribute to the science and practice of building, disseminating, and implementing digital tools to conduct more equitable disaster mental health outreach and research. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
View details for DOI 10.1037/ser0000576
View details for Web of Science ID 000733335700001
View details for PubMedID 34780209
Sustainment of Integrated Care in Addiction Treatment Settings: Primary Outcomes From a Cluster-Randomized Controlled Trial.
Psychiatric services (Washington, D.C.)
OBJECTIVE: Integrated treatment services are the gold standard for addressing co-occurring mental and substance use disorders, yet they are not readily available. The Network for the Improvement of Addiction Treatment (NIATx) was hypothesized to be an effective strategy to implement and sustain integrated mental health and substance use care in addiction treatment programs. This study examined sustainment of integrated services for up to 2 years after the active implementation phase.METHODS: The effectiveness of NIATx strategies to implement and sustain integrated services was evaluated by using a cluster-randomized, waitlist control group design. Forty-nine addiction treatment organizations were randomly assigned to either NIATx1 (active implementation strategy) or NIATx2 (waitlist control). The Dual Diagnosis Capability in Addiction Treatment Index was used to evaluate organizations' capability to provide integrated care. The NIATx Stages of Implementation Completion scale was used to assess participation in and adherence to the NIATx implementation process. Linear mixed-effects modeling was used to evaluate changes from baseline to end of the sustainment period.RESULTS: Both cohorts sustained their capability to provide integrated treatment services. Both groups achieved successful implementation and sustained integrated services to a similar degree, regardless of sustainment year. Sustainment did not vary as a function of NIATx adherence.CONCLUSIONS: The delivery of integrated treatment services was sustained for 2 years after receipt of active implementation support. Future research should consider how contextual factors may predict, mediate, and moderate sustainment outcomes.
View details for DOI 10.1176/appi.ps.202000293
View details for PubMedID 34346729
Protecting patients and staff in residential treatment centers during exposure to COVID-19: commentary.
Addiction science & clinical practice
2021; 16 (1): 49
BACKGROUND: The COVID-19 pandemic has created a crisis in access to addiction treatment. Programs with residential components have been particularly impacted as they try to keep infection from spreading in facilities and contributing to further community spread of the virus. This crisis highlights the ongoing daily trade-offs that organizations must weigh as they balance the risks and benefits of individual patients with those of the group of patients, staff and the community they serve.MAIN BODY: The COVID-19 pandemic has forced provider organizations to make individual facility level decisions about how to manage patients who are COVID-19 positive while protecting other patients, staff and the community. While guidance documents from federal, state, and trade groups aimed to support such decision making, they often lagged pandemic dynamics, and provided too little detail to translate into front line decision making. In the context of incomplete knowledge to make informed decisions, we present a way to integrate guidelines and local data into the decision process and discuss the ethical dilemmas faced by provider organizations in preventing infections and responding to COVID positive patients or staff.CONCLUSION AND COMMENTARY: Provider organizations need decision support on managing the risk of COVID-19 positive patients in their milieu. While useful, guidance documents may not be capable of providing support with the nuance that local data and simulation modeling may be able to provide.
View details for DOI 10.1186/s13722-021-00258-2
View details for PubMedID 34330335
The Integrating Medications for Addiction Treatment (IMAT) Index: A measure of capability at the organizational level.
Journal of substance abuse treatment
2021; 126: 108395
Primary care provides a treatment opportunity for many persons with opioid use disorder (OUD). The push to integrate and expand reach and adoption of medications for opioid use disorder (MOUD) within primary care has been a major focus of national, state and health systems endeavors. To guide high capability MOUD practice, we introduce the Integrating Medications for Addiction Treatment (IMAT) Index. The research team has developed IMAT along similar lines to other organizational measures of integrated services capability. We present the development and validation of the measure, and suggest its applicability for systems and organizations, as well as for process improvement and implementation research. Forty-one primary care clinics completed the IMAT at two time points: baseline and 9-month follow-up. Findings support the IMAT Index as psychometrically acceptable and pragmatically useful. It has good internal consistency, as well as concurrent and predictive validity. Changes in IMAT scores between baseline and follow-up significantly predicted increases in proportion of patients on MOUD. The IMAT has the potential to support both scientific and public health care activities.
View details for DOI 10.1016/j.jsat.2021.108395
View details for PubMedID 34116810
Rising From the Ashes by Expanding Access to Community Care After Disaster: An Origin Story of the Wildfire Mental Health Collaborative and Preliminary Findings
In October of 2017 and 2019, Sonoma County California endured historic wildfires and subsequent community trauma. The Sonoma Wildfire Mental Health Collaborative was created to (a) democratize access to evidence-based mental health resources and services for personal recovery and long-term community resilience building, and to (b) measure the reach and efficacy of the strategies employed in order to create a knowledge base to inform disaster response in other communities. Offerings included a mind-body yoga program and training in Skills for Psychological Recovery (SPR) for counselors who wished to provide services to individuals impacted by the wildfires. An evaluation of the mental health strategies employed revealed that (a) the mind-body program was well-received, with a high degree of satisfaction and self-reported benefit among individuals who attended trauma-informed yoga classes and (b) counselors found SPR to be a practical, flexible short-term intervention for individuals in the aftermath of the wildfires and expressed moderate to high levels of intent to use it in practice. Importantly, the evaluation of the 2017 wildfire mental health response was compromised by the Kincade Fire in 2019, in which prolonged mandatory evacuations and power outages impacted response rates. The origin story is shared for how a community collaborative was built. Lessons learned are discussed and recommendations summarized so as to contribute to the science and practice of disaster mental health outreach. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
View details for DOI 10.1037/ser0000553
View details for Web of Science ID 000733109800001
View details for PubMedID 34180706
A mapping review of NIDA-funded implementation research studies on treatments for opioid and/or stimulant use disorders.
Drug and alcohol dependence
2021; 225: 108767
BACKGROUND: The biomedical research enterprise invests greatly in discovery-oriented science, but significantly less in how to implement the most effective of these innovations. The return on investment in public health benefit is therefore low. In the context of substance-related overdose epidemics, presently with opioids and/or stimulants, the gap in proven treatments and routine access is amplified. Implementation research is designed to deepen understanding of how best to scale-up proven treatments. This study assessed how implementation research has been deployed in the National Institute on Drug Abuse (NIDA) efforts to address the opioid and stimulant epidemics.METHODS: Adapting a procedure developed to categorize HIV-focused research, a four-stage systematic mapping review of NIDA-funded R01, R34, R61, and U studies pertaining to opioids and/or stimulants funded between 2015 and 2019 was performed. Abstracts were retrieved using NIH Research Portfolio Online Reporting Tools. Key study characteristics were abstracted and coded by two independent reviewers.RESULTS: An initial search across NIH institutes yielded 5963 relevant records. Of these, 666 (11.2 %) were NIDA funded. One-hundred-and-thirty-four (20.1 %) of the 666 studies were opioid and/or stimulant treatment related. Of these, 28 (4.2 %) were categorized as Implementation Preparation (IP), and 16 (2.4 %) were categorized as Implementation Research (IR). Over the five-year period, there was a gradual increase in both IP and IR studies.CONCLUSIONS: Implementation research is a small but slowly growing component of the federal portfolio to address substance-related public health issues. To more effectively respond to contemporary overdose epidemics, implementation research must take on an even more significant role.
View details for DOI 10.1016/j.drugalcdep.2021.108767
View details for PubMedID 34052689
"it's like riding a bike" - exposure, adherence, and experience with niatx implementation strategies increases treatment encounters for individuals with co-occurring substance use disorders and mental health disorders
View details for Web of Science ID 000652220000010
Opening the "black box": Four common implementation strategies for expanding the use of medications for opioid use disorder in primary care.
Implementation research and practice
2021; 2: 26334895211005809
Despite the persistent increase in overdose deaths, access to medications for opioid use disorders remains limited. Recent federal funding aimed at increasing access prompts a need to understand if implementation strategies improve access.This is an analysis of data from 174 primary care clinics enrolled in a state-wide medications for opioid use disorders (MOUD) implementation effort in California. We examined clinic use of one of four implementation strategies: learning collaboratives, Project Extension for Community Health care Outcomes (ECHO), didactic webinars, and clinical skills trainings. The primary implementation outcome was categorical change in new patients prescribed buprenorphine. Univariate and multivariate logistic regressions were used to determine the impact of clinic attendance in all or individual implementation strategies, respectively, on patient growth.Clinics attending learning collaboratives, Project ECHO, and clinical skills trainings had significantly higher odds of patient growth (odds ratio [OR] = 3.56; 95% confidence interval [CI] = 1.78, 7.10, p < .001), (OR = 3.39; 95% CI = 1.59, 7.24, p < .01), (OR = 3.90, 95% CI = 1.64, 9.23, p < .01) than non-attending clinics. The impact of attendance at learning collaboratives (OR = 5.81, 95% CI = 1.89, 17.85; p < .01), didactic webinars (OR = 3.59; 95% CI = 1.04, 12.35; p < .05), and clinical skills trainings (OR = 3.53, 95% CI = 1.06, 11.78, p < .05) on patient growth was greater for Federally Qualified Health Centers. When comparing strategies in multivariate models, only the relationship between learning collaborative attendance and new patients prescribed buprenorphine remained significant (OR = 2.57; 95% CI = 1.12, 5.88; p < .05).This study reported on a large, statewide, implementation-as-usual project offering four typical implementation strategies. Clinic attendance at learning collaboratives, a multi-component strategy, had the most consistent impact on new patients prescribed buprenorphine. These results suggest that while a broad array of strategies was initially reasonable, optimizing the selection of implementation strategies could be more effective.Access to life-saving medications for opioid use disorder, such as buprenorphine, remains limited despite strong evidence of effectiveness. Systems and organizations often select from a variety of implementation strategies aimed at expanding access to these medications. However, scant research exists to enable these organizations to select the most effective and efficient strategies. Our study-within a large state-wide system of care-examined the impact of primary care clinic attendance in four common implementation strategies on new patients prescribed buprenorphine. Learning collaboratives were the strategy that most consistently improved outcomes. These results highlight the challenges to strategy selection inherent in implementation-as-usual systems-level approaches. The field needs evidence-based information on which implementation strategies are most likely to yield desired implementation outcomes.
View details for DOI 10.1177/26334895211005809
View details for PubMedID 37090014
View details for PubMedCentralID PMC9978648
Integrating Behavioral Health and Primary Care (IBH-PC) to improve patient-centered outcomes in adults with multiple chronic medical and behavioral health conditions: study protocol for a pragmatic cluster-randomized control trial.
2021; 22 (1): 200
BACKGROUND: Chronic diseases that drive morbidity, mortality, and health care costs are largely influenced by human behavior. Behavioral health conditions such as anxiety, depression, and substance use disorders can often be effectively managed. The majority of patients in need of behavioral health care are seen in primary care, which often has difficulty responding. Some primary care practices are providing integrated behavioral health care (IBH), where primary care and behavioral health providers work together, in one location, using a team-based approach. Research suggests there may be an association between IBH and improved patient outcomes. However, it is often difficult for practices to achieve high levels of integration. The Integrating Behavioral Health and Primary Care study responds to this need by testing the effectiveness of a comprehensive practice-level intervention designed to improve outcomes in patients with multiple chronic medical and behavioral health conditions by increasing the practice's degree of behavioral health integration.METHODS: Forty-five primary care practices, with existing onsite behavioral health care, will be recruited for this study. Forty-three practices will be randomized to the intervention or usual care arm, while 2 practices will be considered "Vanguard" (pilot) practices for developing the intervention. The intervention is a 24-month supported practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Each practice's degree of behavioral health integration will be measured using the Practice Integration Profile. Approximately 75 patients with both chronic medical and behavioral health conditions from each practice will be asked to complete a series of surveys to measure patient-centered outcomes. Change in practice degree of behavioral health integration and patient-centered outcomes will be compared between the two groups. Practice-level case studies will be conducted to better understand the contextual factors influencing integration.DISCUSSION: As primary care practices are encouraged to provide IBH services, evidence-based interventions to increase practice integration will be needed. This study will demonstrate the effectiveness of one such intervention in a pragmatic, real-world setting.TRIAL REGISTRATION: ClinicalTrials.gov NCT02868983 . Registered on August 16, 2016.
View details for DOI 10.1186/s13063-021-05133-8
View details for PubMedID 33691772
Sustainability planning in the US response to the opioid crisis: An examination using expert and text mining approaches.
2021; 16 (1): e0245920
Between January 2016 and June 2020, the Substance Abuse and Mental Health Services Administration rapidly distributed $7.5 billion in response to the U.S. opioid crisis. These funds are designed to increase access to medications for addiction treatment, reduce unmet treatment need, reduce overdose death rates, and provide and sustain effective prevention, treatment and recovery activities. It is unclear whether or not the services developed using these funds will be sustained beyond the start-up period. Based on 34 (64%) State Opioid Response (SOR) applications, we assessed the states' sustainability plans focusing on potential funding sources, policies, and quality monitoring. We found variable commitment to sustainability across response plans with less than half the states adequately describing sustainability plans. States with higher proportions of opioid prescribing, opioid misuse, and poverty had somewhat higher scores on sustainment. A text mining/machine learning approach automatically rated sustainability in SOR applications with an 82% accuracy compared to human ratings. Because life saving evidence-based programs and services may be lost, intentional commitment to sustainment beyond the bolus of start-up funding is essential.
View details for DOI 10.1371/journal.pone.0245920
View details for PubMedID 33507985
What Are Patient Preferences for Integrated Behavioral Health in Primary Care?
Journal of primary care & community health
2021; 12: 21501327211049053
Background: Behavioral health services, integrated into primary care practices, have become increasingly implemented. Although patient satisfaction has been studied, limited information exists about patient preferences for integrated behavioral health in primary care and how perceptions may vary. Objective: To determine patient preferences for integrated behavioral health within primary care and explore differences across patient groups. Methods: A self-report survey was distributed within a quality improvement initiative in an academic health system. A brief 8-item self-report questionnaire of perceptions and preferences for integrated behavioral health was administered to 752 primary care patients presenting before their visits at two primary care clinics. Participation was voluntary, responses were anonymous, and all patients presenting during a three-week timeframe were eligible. Results: In general, patients preferred to have behavioral health concerns addressed within primary care (n=301; 41%) rather than referral to a specialist (7.5%; n=55). There was no evidence of variation in preferences by demographic characteristics. Comfort levels to receive behavioral health services (P<.001) and perceived needs being met were significantly associated with preferences for receiving IBHPC (P<.001). Conclusion: This project provided valuable data to support the implementation of integrated behavioral health services in primary care clinics. In general, patients prefer to have behavioral health issues addressed within their primary care experience rather than being referred to specialty mental health care. This study adds to an expanding pool of studies exploring patient preferences for integrated behavioral health in primary care.
View details for DOI 10.1177/21501327211049053
View details for PubMedID 34670441
Improving Medication Access within Integrated Treatment for Individuals with Co-Occurring Disorders in Substance Use Treatment Agencies.
Implementation research and practice
Background: The best approach to provide comprehensive care for individuals with co-occurring disorders (CODs) related to substance use and mental health is to address both disorders through an integrated treatment approach. However, only 25% of behavioral health agencies offer integrated care and less than 7% of individuals who need integrated treatment receive it. A project used a cluster-randomized waitlist control group design to evaluate the effectiveness of Network for the Improvement of Addiction Treatment (NIATx) implementation strategies to improve access to addiction and psychotropic medications.Methods: This study represents a secondary analysis of data from the NIATx project. Forty-nine agencies were randomized to Cohort1 (active implementation group, receiving the NIATx strategy [n=25]) or Cohort2 (waitlist control group [n=24]). Data were collected at three time points (Baseline, Year1 and Year2). A two-level (patient within agency) multinomial logistic regression model investigated the effects of implementation strategy condition on one of four medication outcomes: both medication types, only psychotropic medication, only addiction medication, or neither medication type. A per-protocol analysis included time, NIATx fidelity, and agency focus as predictors.Results: The intent-to-treat analysis found a statistically significant change in access to addiction versus neither medication, but Cohort1 compared to Cohort2 at Year1 showed no differences. Changes were associated with the experimental intervention and occurred in the transition from Year 1 to Year 2, where greater increases were seen for agencies in Cohort2 versus Cohort1. The per-protocol analysis showed increased access to both medications and addiction medications from pre- to post-intervention for agencies in both cohorts; however, differences in change between high- and low-implementation agencies were not significant.Conclusions: Access to integrated services for people with CODs is a long-standing problem. NIATx implementation strategies had limited effectiveness in improving medication access for individuals with CODs. Implementation strategy adherence is associated with increased medication access.
View details for DOI 10.1177/26334895211033659
View details for PubMedID 34988462
COVID-19 Adaptations in the Care of Patients with Opioid Use Disorder: a Survey of California Primary Care Clinics.
Journal of general internal medicine
With the onset of the COVID-19 crisis, many federal agencies relaxed policies regulating opioid use disorder treatment. The impact of these changes has been minimally documented. The abrupt nature of these shifts provides a naturalistic opportunity to examine adaptations for opioid use disorder treatment in primary care.To examine change in medical and behavioral health appointment frequency, visit type, and management of patients with opioid use disorder in response to COVID-19.A 14-item survey queried primary care practices that were enrolled in a medications for opioid use disorder statewide expansion project. Survey content focused on changes in service delivery because of COVID-19. The survey was open for 18 days.We surveyed 338 clinicians from 57 primary care clinics located in California, including federally qualified health centers and look-alikes. A representative from all 57 clinics (100%) and 118 staff (34.8% of all staff clinicians) participated in the survey.The survey consisted of seven dimensions of practice: medical visits, behavioral health visits, medication management, urine drug screenings, workflow, perceived patient demand, and staff experience.A total of 52 of 57 (91.2%) primary care clinics reported practice adaptations in response to COVID-19 regulatory changes. Many clinics indicated that both medical (40.4%) and behavioral health visits (53.8%) were now exclusively virtual. Two-thirds (65.4%) of clinics reported increased duration of buprenorphine prescriptions and reduced urine drug screenings (67.3%). The majority (56.1%) of clinics experienced an increase in patient demand for behavioral health services. Over half (56.2%) of clinics described having an easier or unchanged experience retaining patients in care.Many adaptations in the primary care approach to patients with opioid use disorder may be temporary reactions to COVID-19. Further evaluation of the impact of these adaptations on patient outcomes is needed to determine whether changes should be maintained post-COVID-19.
View details for DOI 10.1007/s11606-020-06436-3
View details for PubMedID 33511572
The prospects for sustaining evidence-based responses to the US opioid epidemic: state leadership perspectives.
Substance abuse treatment, prevention, and policy
2020; 15 (1): 84
BACKGROUND: The US 21st Century Cures Act provided $7.5 billion in grant funding to states and territories for evidence-based responses to the opioid epidemic. Currently, little is known about optimal strategies for sustaining these programs beyond this start-up funding.METHODS: Using an inductive, conventional content analysis, we conducted key informant interviews with former and current state leaders (n=16) about barriers/facilitators to sustainment and strategies for sustaining time-limited grants.RESULTS: Financing and reimbursement, service integration, and workforce capacity were the most cited barriers to sustainment. Status in state government structure, public support, and spending flexibility were noted as key facilitators. Effective levers to increase chances for sustainment included strong partnerships with other state agencies, workforce and credentialing changes, and marshalling advocacy through public awareness campaigns.CONCLUSIONS: Understanding the strategies that leaders have successfully used to sustain programs in the past can inform how to continue future time-limited, grant-funded initiatives.
View details for DOI 10.1186/s13011-020-00326-x
View details for PubMedID 33148283
Treatment for opioid use disorder in the Florida medicaid population: Using a cascade of care model to evaluate quality
AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE
View details for DOI 10.1080/00952990.2020.1824236
View details for Web of Science ID 000577655900001
What constitutes "behavioral health"? Perceptions of substance-related problems and their treatment in primary care.
Addiction science & clinical practice
2020; 15 (1): 29
BACKGROUND: Integrating behavioral health in primary care is a widespread endeavor. Yet rampant variation exists in models and approaches. One significant question is whether frontline providers perceive that behavioral health includes substance use. The current study examined front line providers': 1. definition of behavioral health, and 2. levels of comfort treating patients who use alcohol and other drugs. Frontline providers at two primary care clinics were surveyed using a 28-item instrument designed to assess their comfort and knowledge of behavioral health, including substance use. Two questions from the Integrated Behavioral Health Staff Perceptions Survey pertaining to confidence in clinics' ability to care for patients' behavioral health needs and comfort dealing with patients with behavioral health needs were used for the purposes of this report. Participants also self-reported their clinic role. Responses to these two items were assessed and then compared across roles. Chi square estimates and analysis of variance tests were used to examine relationships between clinic roles and comfort of substance use care delivery.RESULTS: Physicians, nurses/nurse practitioners, medical assistants, and other staff (N=59) participated. Forty-nine participants included substance use in their definition of behavioral health. Participants reported the least comfort caring for patients who use substances (M=3.5, SD=1.0) compared to those with mental health concerns (M=4.1, SD=0.7), chronic medical conditions (M=4.2, SD=0.7), and general health concerns (M=4.2, SD=0.7) (p<0.001). Physicians (M=3.0, SD=0.7) reported significantly lower levels of comfort than medical assistants (M=4.2, SD=0.9) (p<0.001) caring for patients who use substances.CONCLUSIONS: In a small sample of key stakeholders from two primary care clinics who participated in this survey, most considered substance use part of the broad umbrella of behavioral health. Compared to other conditions, primary care providers reported being less comfortable addressing patients' substance use. Level of comfort varied by role, where physicians were least comfortable, and medical assistants most comfortable.
View details for DOI 10.1186/s13722-020-00202-w
View details for PubMedID 32727589
Implementing Patient-Centred Behavioural Health Integration into Primary Care Using Model-Based Systems Engineering
SYSTEMS RESEARCH AND BEHAVIORAL SCIENCE
View details for DOI 10.1002/sres.2727
View details for Web of Science ID 000549763500001
Pre-implementation Evaluation of PARTNER-MH: A Mental Healthcare Disparity Intervention for Minority Veterans in the VHA.
Administration and policy in mental health
To design PARTNER-MH, a peer-led, patient navigation program for implementation in Veterans Health Administration (VHA) mental health care settings, we conducted a pre-implementation evaluation during intervention development to assess stakeholders' views of the intervention and to explore implementation factors critical to its future adoption. This is a convergent mixed-methods study that involved qualitative semi-structured interviews and survey data. Data collection was guided by the Consolidated Framework for Implementation Research (CFIR). We interviewed and administered the surveys to 23 peers and 10 supervisors from 12 midwestern VHA facilities. We used deductive and inductive approaches to analyze the qualitative data. We also conducted descriptive analysis and Fisher Exact Test to compare peers and supervisors' survey responses. We triangulated findings to refine the intervention. Overall, participants viewed PARTNER-MH favorably. However, they saw the intervention's focus on minority Veterans and social determinants of health framework as potential barriers, believing this could negatively affect the packaging of the intervention, complicate its delivery process, and impact its adoption. They also viewed clinic structures, available resources, and learning climate as potential barriers. Peers and supervisors' selections and discussions of CFIR items were similar. Our findings informed PARTNER-MH development and helped identify factors that could impact its implementation. This project is responsive to the increasing recognition of the need to incorporate implementation science in healthcare disparities research. Understanding the resistance to the intervention's focus on minority Veterans and the potential barriers presented by contextual factors positions us to adjust the intervention prior to testing, in an effort to maximize implementation success.
View details for DOI 10.1007/s10488-020-01048-9
View details for PubMedID 32399857
INTEGRATED BEHAVIORAL HEALTH: PATIENT AND PROVIDER PERSPECTIVES FROM TWO PRIMARY CARE CLINICS
OXFORD UNIV PRESS INC. 2020: S599
View details for Web of Science ID 000546262401421
ENHANCING INTEGRATED BEHAVIORAL HEALTH PRACTICES: EVALUATION AND MEASUREMENT OF REAL-WORLD IMPLEMENTATION
OXFORD UNIV PRESS INC. 2020: S5
View details for Web of Science ID 000546262400015
Advancing Evidence Synthesis from Effectiveness to Implementation: Integration of Implementation Measures into Evidence Reviews
SPRINGER. 2020: 1219–26
In order to close the gap between discoveries that could improve health, and widespread impact on routine health care practice, there is a need for greater attention to the factors that influence dissemination and implementation of evidence-based practices. Evidence synthesis projects (e.g., systematic reviews) could contribute to this effort by collecting and synthesizing data relevant to dissemination and implementation. Such an advance would facilitate the spread of high-value, effective, and sustainable interventions.The objective of this paper is to evaluate the feasibility of extracting factors related to implementation during evidence synthesis in order to enhance the replicability of successes of studies of interventions in health care settings.Drawing on the implementation science literature, we suggest 10 established implementation measures that should be considered when conducting evidence synthesis projects. We describe opportunities to assess these constructs in current literature and illustrate these methods through an example of a systematic review.Twenty-nine studies of interventions aimed at improving clinician-patient communication in clinical settings.We identified acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, intervention complexity, penetration, reach, and sustainability as factors that are feasible and appropriate to extract during an evidence synthesis project.To fully understand the potential value of a health care innovation, it is important to consider not only its effectiveness, but also the process, demands, and resource requirements involved in downstream implementation. While there is variation in the degree to which intervention studies currently report implementation factors, there is a growing demand for this information. Abstracting information about these factors may enhance the value of systematic reviews and other evidence synthesis efforts, improving the dissemination and adoption of interventions that are effective, feasible, and sustainable across different contexts.
View details for DOI 10.1007/s11606-019-05586-3
View details for Web of Science ID 000544932500033
View details for PubMedID 31848862
View details for PubMedCentralID PMC7174479
Implementing integrated services in routine behavioral health care: primary outcomes from a cluster randomized controlled trial.
BMC health services research
2019; 19 (1): 749
BACKGROUND: An estimated 8.2 million adults in the United States live with co-occurring mental health and substance use disorders. Although the benefits of integrated treatment services for persons with co-occurring disorders has been well-established, gaps in access to integrated care persist. Implementation research can address this gap. We evaluated if the Network for the Improvement of Addiction Treatment (NIATx) implementation strategy was effective in increasing integrated services capacity among organizations treating persons with co-occurring disorders.METHODS: This study employed a cluster randomized waitlist control group design. Forty-nine addiction treatment organizations from the State of Washington were randomized into one of two study arms: (1) NIATx strategy (active implementation strategy), or (2) waitlist (control). The primary outcome was a standardized organizational measure of integrated service capability: the Dual Diagnosis in Addiction Treatment (DDCAT) Index. Intent-to-treat analyses and per-protocol analyses were conducted to address the following questions: (1) Is NIATx effective in increasing integrated service capacity? and (2) Are there differences in organizations that actually use NIATx per-protocol versus those that do not?RESULTS: From baseline to one-year post active implementation, both the NIATx strategy and waitlist arms demonstrated improvements over time in DDCAT Index total and DDCAT dimension scores. In intent-to-treat analyses, a moderate but statistically significant difference in improvement between study arms was seen only in the Program Milieu dimension (p=0.020, Cohen's d=0.54). In per-protocol analyses, moderate-to-large effects in Program Milieu (p=0.002, Cohen's d=0.91) and Continuity of Care (p=0.026, Cohen's d=0.63) dimensions, and in total DDCAT Index (p=0.046, Cohen's d=0.51) were found.CONCLUSIONS: Overall, organizations in both study arms improved DDCAT Index scores over time. Organizations in the NIATx strategy arm with full adherence to the NIATx protocol had significantly greater improvements in the primary outcome measure of integrated service capacity for persons with co-occurring disorders.TRAIL REGISTRATION: ClinicalTrials.gov, NCT03007940 . Retrospectively registered January 2017.
View details for DOI 10.1186/s12913-019-4624-x
View details for PubMedID 31651302
Implementation of the hub and spoke model for opioid use disorders in California: Rationale, design and anticipated impact.
Journal of substance abuse treatment
As part of the State Targeted Response to the opioid epidemic, California has adopted the Hub and Spoke model to expand access to medications for opioid use disorder, particularly buprenorphine, throughout the state. By aligning opioid treatment programs as hubs with primary care, office-based practitioners, and other health care settings as spokes, a broader treatment model can reach more people with opioid use disorder, improve access to medications for opioid f specific activities and anticipated impact of the implementation plan in California's Hub and Spoke system. Training and technical assistance are designed to: increase the number and specific activities and anticipated impact of the implementation plan in California's Hub and Spoke system. Training and technical assistance are designed to: increase the number and capacity of waivered prescribers; enhance skills of prescribers and multidisciplinary teams; and create systems change. Activities include buprenorphine waiver trainings and provider support, a practice facilitator program, Project ECHO sessions, webinars, clinical skills trainings, and regional learning collaboratives. This overview highlights the steps California is taking to build treatment capacity to address the opioid epidemic.
View details for DOI 10.1016/j.jsat.2019.07.013
View details for PubMedID 31399272
"No more falling through the cracks": A qualitative study to inform measurement of integration of care of HIV and opioid use disorder.
Journal of substance abuse treatment
2019; 97: 28–40
INTRODUCTION: Integration of HIV- and opioid use disorder (OUD)-related care is associated with improved patient outcomes. Our goal was to develop a novel instrument for measuring quality of integration of HIV and OUD-related care that would be applicable across diverse care settings.METHODS: Grounded in community-based participatory research principles, we conducted a qualitative study from August through November 2017 to inform modification of the Behavioral Health Integration in Medical Care (BHIMC) instrument, a validated measure of quality of integration of behavioral health in primary care. We conducted semi-structured interviews of patients (n = 22), focus groups with clinical staff (n = 24), and semi-structured interviews of clinic leadership (n = 5) in two urban centers in Connecticut.RESULTS: We identified three themes that characterize optimal integration of HIV- and OUD-related care: (1) importance of mitigating mismatches in resources and knowledge, particularly resources to address social risks and knowledge gaps about evidence-based treatments for OUD; (2) need for patient-centered policies and inter-organization communication, and (3) importance of meeting people where they are, geographically and at their stage of change. These themes highlighted aspects of integrated care for HIV and OUD not captured in the original BHIMC.CONCLUSIONS: Patients, clinical staff, and organization leadership perceive that addressing social risks, communication across agencies, and meeting patients in their psychosocial and structural context are important for optimizing integration of HIV and OUD-related care. Our proposed, novel instrument is a step towards measuring and improving service delivery locally and nationally for this vulnerable population.
View details for PubMedID 30577897
Integration of care for HIV and opioid use disorder.
AIDS (London, England)
2019; 33 (5): 873–84
We sought to identify optimal strategies for integrating HIV- and opioid use disorder-(OUD) screening and treatment in diverse settings.Systematic review.We searched Ovid MEDLINE, PubMed, Embase, PsycINFO and preidentified websites. Studies were included if they were published in English on or after 2002 through May 2017, and evaluated interventions that integrated, at an organizational level, screening and/or treatment for HIV and OUD in any care setting in any country.Twenty-nine articles met criteria for inclusion, including 23 unique studies: six took place in HIV care settings, 12 in opioid treatment settings, and five elsewhere. Eight involved screening strategies, 22 involved treatment strategies, and seven involved strategies that encompassed screening and treatment. Randomized controlled studies demonstrated low-to-moderate risk of bias and observational studies demonstrated fair to good quality. Studies in HIV care settings (n = 6) identified HIV-related and OUD-related clinical benefits with the use of buprenorphine/naloxone for OUD. No studies in HIV care settings focused on screening for OUD. Studies in opioid treatment settings (n = 12) identified improving HIV screening uptake and clinical benefits with antiretroviral therapy when provided on-site. Counseling intensity for OUD medication adherence or HIV-related risk reduction was not associated with clinical benefits.Screening for HIV can be effectively delivered in opioid treatment settings, yet there is a need to identify optimal OUD screening strategies in HIV care settings. Strategies integrating the provision of medications for HIV and for OUD should be expanded and should not be contingent on resources available for behavioral interventions.A protocol for record eligibility was developed a priori and was registered in the PROSPERO database of systematic reviews (registration number CRD42017069314).
View details for PubMedID 30882491
Comparative Effectiveness of Cognitive Behavioral Therapy for Chronic Pain and Chronic Pain Self-Management within the Context of Voluntary Patient-Centered Prescription Opioid Tapering: The EMPOWER Study Protocol.
Pain medicine (Malden, Mass.)
Evidence to date, while sparse, suggests that patients taking long-term opioids require special considerations and protections to prevent potential iatrogenic harms from opioid de-prescribing, such as increased pain or suffering. Following this study protocol, the EMPOWER study seeks to address multiple unmet needs of patients with chronic pain who desire to reduce long-term opioid therapy, and provide the clinical evidence on effective methodology.EMPOWER applies patient-centered methods for voluntary prescription opioid reduction conducted within a comprehensive, multi-state, 3-arm randomized controlled comparative effectiveness study of three study arms (1) group cognitive behavioral therapy for chronic pain; (2) group chronic pain self-management; and (3) usual care (taper only). Specialized electronic data capture systems collect patient reported symptoms and satisfaction data weekly and monthly during the taper, with real-time clinical alerts and electronic feedback loops informing, documenting, and steering needed care actions.The EMPOWER study seeks to provide granular evidence on patient response to voluntary opioid tapering, and will provide evidence to inform clinical systems changes, clinical care, patient satisfaction, and patient outcomes for opioid reduction.
View details for DOI 10.1093/pm/pnz285
View details for PubMedID 31876947
Attitudes of primary care physicians toward prescribing buprenorphine: a narrative review.
BMC family practice
2019; 20 (1): 157
The opioid epidemic is a major public health issue associated with significant overdose deaths. Effective treatments exist, such as the medication buprenorphine, but are not widely available. This narrative review examines the attitudes of primary care providers (PCPs) toward prescribing buprenorphine.Narrative review of 20 articles published after the year 2000, using the Consolidated Framework for Implementation Research (CFIR) to organize the findings.Three of the five CFIR domains ("Intervention Characteristics," "Outer Setting," "Inner Setting") were strongly represented in our analysis. Providers were concerned about the clientele associated with buprenorphine, diversion, and their self-efficacy in prescribing the medication. Some believed that buprenorphine does not belong in the discipline of primary care. Other barriers included philosophical objections and stigma toward substance use disorders. Notably, two studies reported a shift in attitudes once physicians prescribed buprenorphine to actual patients.Negative attitudes toward buprenorphine encompassed multi-layered concerns, ranging from skepticism about the medication itself, the behaviors of patients with opioid use disorders, and beliefs regarding substance use disorders more generally. We speculate, however, that negative attitudes may be improved by tailoring support strategies that address providers' self-efficacy and level of knowledge.
View details for DOI 10.1186/s12875-019-1047-z
View details for PubMedID 31729957
Integration of care for HIV and opioid use disorder: a systematic review of interventions in clinical and community-based settings.
AIDS (London, England)
OBJECTIVE: We sought to identify optimal strategies for integrating HIV- and opioid use disorder-(OUD) screening and treatment in diverse settings.DESIGN: Systematic review.METHODS: We searched Ovid MEDLINE, PubMed, Embase, and PsycINFO and pre-identified websites. Studies were included if they were published in English on or after 2002 through May 2017, and evaluated interventions that integrated, at an organizational level, screening and/or treatment for HIV and OUD in any care setting in any country.RESULTS: Twenty-nine articles met criteria for inclusion, including 23 unique studies: six took place in HIV care settings, 12 in opioid treatment settings, and five elsewhere. Eight involved screening strategies, 22 involved treatment strategies, and seven involved strategies that encompassed screening and treatment. Randomized controlled studies demonstrated low to moderate risk of bias and observational studies demonstrated fair to good quality. Studies in HIV care settings (n = 6) identified HIV- and OUD-related clinical benefits with the use of buprenorphine/naloxone for OUD. No studies in HIV care settings focused on screening for OUD. Studies in opioid treatment settings (n = 12) identified improving HIV screening uptake and clinical benefits with antiretroviral therapy when provided on-site. Counseling intensity for OUD medication adherence or HIV-related risk reduction was not associated with clinical benefits.CONCLUSION: Screening for HIV can be effectively delivered in opioid treatment settings, yet there is a need to identify optimal OUD screening strategies in HIV care settings. Strategies integrating the provision of medications for HIV and for OUD should be expanded and should not be contingent on resources available for behavioral interventions.REGISTRATION: A protocol for record eligibility was developed a priori and was registered in the PROSPERO database of systematic reviews (registration number CRD42017069314).
View details for PubMedID 30585841
Is Integrated CBT Effective in Reducing PTSD Symptoms and Substance Use in Iraq and Afghanistan Veterans? Results from a Randomized Clinical Trial
COGNITIVE THERAPY AND RESEARCH
2018; 42 (6): 735–46
View details for DOI 10.1007/s10608-018-9931-8
View details for Web of Science ID 000448390900001
Using NIATx strategies to implement integrated services in routine care: a study protocol
BMC HEALTH SERVICES RESEARCH
2018; 18: 431
Access to integrated services for individuals with co-occurring substance use and mental health disorders is a long-standing public health issue. Receiving integrated treatment services are both more effective and preferred by patients and families versus parallel or fragmented care. National policy statements and expert consensus guidelines underscore the benefits of integrated treatment. Despite decades of awareness, adequate treatment for individuals with co-occurring substance use and mental health disorders occurs infrequently. The underlying disease burden associated with alcohol, illicit and prescription drug problems, as well as mental health disorders, such as depression, posttraumatic stress disorder and schizophrenia, is substantial.This cluster randomized controlled trial (RCT) is designed to determine if the multi-component Network for the Improvement of Addiction Treatment (NIATx) strategies are effective in implementing integrated services for persons with co-occurring substance use and mental health disorders. In this study, 50 behavioral health programs in Washington State will be recruited and then randomized into one of two intervention arms: 1) NIATx implementation strategies, including coaching and learning sessions over a 12-month intervention period to implement changes targeting integrated treatment services; or 2) wait-list control. Primary outcome measures include: 1) fidelity - a standardized organizational assessment of integrated services (Dual Diagnosis in Addiction Treatment [DDCAT] Index); and 2) penetration - proportion of patients screened and diagnosed with co-occurring disorders, proportion of eligible patients receiving substance use and mental health services, and psychotropic or substance use disorder medications. Barriers and facilitators, as determinants of implementation outcomes, will be assessed using the Consolidated Framework for Implementation Research (CFIR) Index. Fidelity to and participation in NIATx strategies will be assessed utilizing the NIATx Fidelity Scale and Stages of Implementation Completion (SIC).This study addresses an issue of substantial public health significance: the gap in access to an evidence-based practice for integrated treatment for individuals with co-occurring mental health and substance use disorders. The study utilizes rigorous and reproducible quantitative approaches to measuring implementation determinants and strategies, and may address a longstanding gap in the quality of care for persons with co-occurring disorders.ClinicalTrials.gov NCT03007940 . Registered 02 January 2017 - Retrospectively Registered.
View details for PubMedID 29884164
A Unified Model of Behavioral Health Integration in Primary Care.
Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry
2018; 42 (2): 265-268
View details for DOI 10.1007/s40596-018-0887-5
View details for PubMedID 29488173
Operationalizing the Consolidated Framework for Implementation Research into a mixed methods measure: the CFIR Index
BIOMED CENTRAL LTD. 2018
View details for Web of Science ID 000428652000122
A Unified Model of Behavioral Health Integration in Primary Care
View details for DOI 10.1007/s40596-018-0887-5
Trends in inequalities in child stunting in South Asia
Maternal & Child Nutrition 2017
2018; 14: 1-12
View details for DOI 10.1111/mcn.12517
Impact of age of onset of psychosis and engagement in higher education on duration of untreated psychosis
JOURNAL OF MENTAL HEALTH
2018; 27 (3): 257–62
The average age of onset of psychosis coincides with the age of college enrollment. Little is known about the impact of educational engagement on DUP in a college-aged population.To determine DUP, and the impact of educational engagement, for college-aged participants of the RAISE study (n = 404).We conducted secondary data analyses on the publicly available RAISE dataset. Subsamples were analyzed to determine the impact of age and educational engagement on DUP.DUP was significantly shorter (p < 0.02) for participants who were college-aged (18-22 years, n = 44) and engaged in post-secondary education (median = 12 weeks, mean = 29 weeks) compared with participants who were college-aged and not engaged in higher education (n = 92, median = 29 weeks, mean = 44 weeks).Educational engagement appears to be associated with a shorter DUP. This may be partially explained by the presence of on-site wellness centers in college settings. However, even among young people who engaged in post-secondary education DUP was still at, or beyond, the upper limit of WHO recommendations in this group. Future research exploring how colleges could improve their capacity to detect and refer at risk students for treatment at an earlier stage is recommended.
View details for PubMedID 29707996
Individual Placement and Support (IPS) for Methadone Maintenance Therapy Patients: A Pilot Randomized Controlled Trial.
Administration and policy in mental health
Individual Placement and Support (IPS) is an evidence-based employment model for people with severe mental illness, but it has not been evaluated for clients enrolled in substance abuse treatment programs. This study evaluated the effectiveness of IPS for people with opioid use disorders enrolled in an opioid treatment program. Within a randomized controlled experiment, 45 patients receiving methadone maintenance therapy were assigned to either IPS or a 6-month waitlist. The waitlist group received IPS after 6 months. The primary outcome assessed over 1 year compared the attainment of a job for the IPS condition to the waitlist comparison group. During the first 6 months after enrollment, 11 (50%) active IPS participants gained competitive employment compared to 1 (5%) waitlist participant (Χ (2) = 12.0, p < 0.001). Over 12 months of enrollment, 11 (50%) IPS participants gained competitive employment compared to 5 (22%) waitlist participants (Χ (2) = 3.92, p = 0.07). We conclude that IPS holds promise as an employment intervention for people with opioid use disorders in methadone maintenance treatment, but larger trials with longer follow-up are needed.
View details for DOI 10.1007/s10488-017-0793-2
View details for PubMedID 28213673
The influence of family and social problems on treatment outcomes of persons with co-occurring substance use disorders and PTSD
JOURNAL OF SUBSTANCE USE
2016; 21 (3): 237-243
Family and social problems may contribute to negative recovery outcomes in patients with co-occurring substance use and psychiatric disorders, yet few studies have empirically examined this relationship. This study investigates the impact of family and social problems on treatment outcomes among patients with co-occurring substance use and posttraumatic stress disorder (PTSD).A secondary analysis was conducted using data collected from a randomized controlled trial of an integrated therapy for patients with co-occurring substance use and PTSD. Substance use, psychiatric symptoms, and social problems were assessed. Longitudinal outcomes were analyzed using generalized estimating equations (GEE) and multiple linear regression.At baseline, increased family and social problems were associated with more severe substance use and psychiatric symptoms. Over time, all participants had comparable decreases in substance use and psychiatric problem severity. However, changes in family and social problem severity were predictive of PTSD symptom severity, alcohol use, and psychiatric severity at follow-up.For patients with co-occurring substance use and PTSD, family and social problem severity is associated with substance use and psychiatric problem severity at baseline and over time. Targeted treatment for social and family problems may be optimal.
View details for DOI 10.3109/14659891.2015.1005184
View details for Web of Science ID 000375171700004
View details for PubMedID 27182200
View details for PubMedCentralID PMC4864012
Using a Learning Collaborative Strategy With Office-based Practices to Increase Access and Improve Quality of Care for Patients With Opioid Use Disorders
JOURNAL OF ADDICTION MEDICINE
2016; 10 (2): 117-123
Rapidly escalating rates of heroin and prescription opioid use have been widely observed in rural areas across the United States. Although US Food and Drug Administration-approved medications for opioid use disorders exist, they are not routinely accessible to patients. One medication, buprenorphine, can be prescribed by waivered physicians in office-based practice settings, but practice patterns vary widely. This study explored the use of a learning collaborative method to improve the provision of buprenorphine in the state of Vermont.We initiated a learning collaborative with 4 cohorts of physician practices (28 total practices). The learning collaborative consisted of a series of 4 face-to-face and 5 teleconference sessions over 9 months. Practices collected and reported on 8 quality-improvement data measures, which included the number of patients prescribed buprenorphine, and the percent of unstable patients seen weekly. Changes from baseline to 8 months were examined using a p-chart and logistic regression methodology.Physician engagement in the learning collaborative was favorable across all 4 cohorts (85.7%). On 6 of the 7 quality-improvement measures, there were improvements from baseline to 8 months. On 4 measures, these improvements were statistically significant (P < 0.001). Importantly, practice variation decreased over time on all measures. The number of patients receiving medication increased only slightly (3.4%).Results support the effectiveness of a learning collaborative approach to engage physicians, modestly improve patient access, and significantly reduce practice variation. The strategy is potentially generalizable to other systems and regions struggling with this important public health problem.
View details for DOI 10.1097/ADM.0000000000000200
View details for Web of Science ID 000374748800007
View details for PubMedID 26900669
View details for PubMedCentralID PMC4865252
- Responding to the opioid epidemic: Vermont’s hub and spoke model as a system of care. American Psychological Association Division 50 Addictions Newletter. 2016 ; Addictions Newsletter (2): 32–34
The Impact of Addiction Medications on Treatment Outcomes for Persons With Co-Occurring PTSD and Opioid Use Disorders
AMERICAN JOURNAL ON ADDICTIONS
2015; 24 (8): 722-731
Previous research has been inconclusive about whether adding psychosocial treatment to medication assisted treatment (MAT) improves outcomes for patients with co-occurring psychiatric and opioid use disorders. This study evaluated the impact of MAT and psychosocial therapies on treatment outcomes for patients with co-occurring opioid use disorders and PTSD.Patients meeting criteria for PTSD and substance use disorders were randomly assigned to one of three treatment conditions: Standard Care (SC) alone, Integrated Cognitive Behavioral Therapy (ICBT) plus SC, or Individual Addiction Counseling (IAC) plus SC. Substance use and psychiatric symptoms were assessed at baseline and 6 months. Only patients with opioid use disorders were included in the present analyses (n = 126). Two-way ANOVAS and logistic regression analyses were used to examine associations between treatment conditions and MAT, for substance use and psychiatric outcomes.MAT patients receiving ICBT had significantly decreased odds of a positive urine drug screen, compared to non-MAT patients receiving SC alone (OR = .07, 95% CI = .01, .81, p = .03). For PTSD symptoms, a significant MAT by psychosocial treatment condition interaction demonstrated that MAT patients had comparable declines in PTSD symptoms regardless of psychosocial treatment type (F(2, 88) = 4.74, p = .011). Non-MAT patients in ICBT had significantly larger reductions in PTSD.For patients with co-occurring opioid use disorders and PTSD, MAT plus ICBT is associated with more significant improvement in substance use. For non-MAT patients, ICBT is most beneficial for PTSD symptoms.
View details for DOI 10.1111/ajad.12292
View details for Web of Science ID 000368506100005
View details for PubMedID 26388539
View details for PubMedCentralID PMC4866634
Adherence and competence in two manual-guided therapies for co-occurring substance use and posttraumatic stress disorders: clinician factors and patient outcomes
AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE
2015; 41 (6): 527-534
The challenges of implementing and sustaining evidence-based therapies into routine practice have been well-documented.This study examines the relationship among clinician factors, quality of therapy delivery, and patient outcomes.Within a randomized controlled trial, 121 patients with current co-occurring substance use and posttraumatic stress disorders were allocated to receive either manualized Integrated Cognitive Behavioral Therapy (ICBT) or Individual Addiction Counseling (IAC). Twenty-two clinicians from seven addiction treatment programs were trained and supervised to deliver both therapies. Clinician characteristics were assessed at baseline; clinician adherence and competence were assessed over the course of delivering both therapies; and patient outcomes were measured at baseline and 6-month follow-up.Although ICBT was delivered at acceptable levels, clinicians were significantly more adherent to IAC (p < 0.05). At session 1, clinical female gender (p < 0.05) and lower education level (p < 0.05) were predictive of increased clinician adherence and competence across both therapies. Adherence and competence at session 1 in either therapy were significantly predictive of positive patient outcomes. ICBT adherence (p < 0.05) and competence (p < 0.01) were predictive of PTSD symptom reduction, whereas IAC adherence (p < 0.01) and competence (p < 0.01) were associated with decreased drug problem severity.The differential impact of adherence and competence for both therapy types is consistent with their purported primary target: ICBT for PTSD and IAC for substance use. These findings also suggest the benefits of considering clinician factors when implementing manual-guided therapies. Future research should focus on diverse clinician samples, randomization of clinicians to therapy type, and prospective designs to evaluate models of supervision and quality monitoring.
View details for DOI 10.3109/00952990.2015.1062894
View details for Web of Science ID 000364408700007
View details for PubMedID 26286351
View details for PubMedCentralID PMC4698972
A randomized controlled trial of treatments for co-occurring substance use disorders and post-traumatic stress disorder
2015; 110 (7): 1194-1204
Post-traumatic stress disorder (PTSD) is common among people with substance use disorders, and the comorbidity is associated with negative outcomes. We report on a randomized controlled trial comparing the effect of integrated cognitive-behavioral therapy (ICBT) plus standard care, individual addiction counseling plus standard care and standard care alone on substance use and PTSD symptoms.Three-group, multi-site randomized controlled trial.Seven addiction treatment programs in Vermont and New Hampshire, USA.Recruitment took place between December 2010 and January 2013. In this single-blind study, 221 participants were randomized to one of three conditions: ICBT plus standard care (SC) (n = 73), individual addiction counseling (IAC) plus SC (n = 75) or SC only (n = 73). One hundred and seventy-two patients were assessed at 6-month follow-up (58 ICBT; 61 IAC; 53 SC). Intervention and comparators: ICBT is a manual-guided therapy focused on PTSD and substance use symptom reduction with three main components: patient education, mindful relaxation and flexible thinking. IAC is a manual-guided therapy focused exclusively on substance use and recovery with modules organized in a stage-based approach: treatment initiation, early abstinence, maintaining abstinence and recovery. SC are intensive out-patient program services that include 9-12 hours of face-to-face contact per week over 2-4 days of group and individual therapies plus medication management.Primary outcomes were PTSD severity and substance use severity at 6 months. Secondary outcomes were therapy retention.PTSD symptoms reduced in all conditions with no difference between them. In analyses of covariance, ICBT produced more favorable outcomes on toxicology than IAC or SC [comparison with IAC, parameter estimate: 1.10; confidence interval (CI) = 0.17-2.04; comparison with SC, parameter estimate: 1.13; CI = 0.18-2.08] and had a greater reduction in reported drug use than SC (parameter estimate: -9.92; CI = -18.14 to -1.70). ICBT patients had better therapy continuation versus IAC (P<0.001). There were no unexpected or study-related adverse events.Integrated cognitive behavioral therapy may improve drug-related outcomes in post-traumatic stress disorder sufferers with substance use disorder more than drug-focused counseling, but probably not by reducing post-traumatic stress disorder symptoms to a greater extent.
View details for DOI 10.1111/add.12943
View details for Web of Science ID 000356808500023
View details for PubMedID 25846251
View details for PubMedCentralID PMC4478141
The Prevalence of Posttraumatic Stress Disorder Symptoms among Addiction Treatment Patients with Cocaine Use Disorders
JOURNAL OF PSYCHOACTIVE DRUGS
2015; 47 (1): 42-50
Co-occurring cocaine use and posttraumatic stress disorders are prevalent and associated with negative treatment, health and societal consequences. This study examined the relationships among PTSD symptoms, gender, and cocaine use problems. Within a cross-sectional design, we gathered archival point prevalence data on new admissions (n = 573) to three addiction treatment agencies. Demographic, substance use, and PTSD symptom information were collected across the three agencies. Logistic regression analyses revealed that patients with cocaine use disorders had a two-fold increased odds for a probable PTSD diagnosis, compared to patients without a cocaine use disorder (OR = 2.19, 95% CI = 1.49-3.22, p < 0.001). Among females with cocaine use disorder, multinomial regression yielded a significant increase in the risk of moderate (RRR = 2.12, 95% CI = 1.10-4.10, p < 0.05) and severe (RRR = 2.87, 95% CI = 1.33-6.21, p < 0.01) PTSD symptoms. Males with cocaine use disorders had a two-fold increase in the risk of moderate PTSD symptoms (RRR = 2.13, 95% CI = 1.23-3.68, p < 0.01), but had no increased risk of developing severe PTSD symptoms (RRR = 1.93, 95% CI = 0.85-4.39, p = 0.117). Cocaine use appears to impact the risk of PTSD symptoms, especially in females. Future research should explore the generalizability of these findings to more racially and ethnically diverse samples, as well as among persons with this comorbidity who are not engaged in treatment services.
View details for DOI 10.1080/02791072.2014.977501
View details for Web of Science ID 000349897500006
View details for PubMedID 25715071
View details for PubMedCentralID PMC4876862
Co-occurring prescription opioid use problems and posttraumatic stress disorder symptom severity
AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE
2014; 40 (4): 304-311
Prescription opioids are the most rapidly growing category of abused substances, and result in significant morbidity, mortality and healthcare costs. Co-occurring with psychiatric disorders, persons with prescription opioid problems have negative treatment outcomes. Data are needed on the prevalence of co-occurring prescription opioid abuse and specific disorders, such as posttraumatic stress disorder (PTSD), to better inform clinical practice.To determine prevalence rates of current co-occurring prescription opioid use problems and PTSD symptom severity among patients in community addiction treatment settings.We abstracted administrative and chart information on 573 new admissions to three addictive treatment agencies during 2011. Systematic data were collected on PTSD symptoms, substance use, and patient demographics.Prescription opioid use was significantly associated with co-occurring PTSD symptom severity (OR: 1.42, p < 0.05). Use of prescription opioids in combination with sedatives (OR: 3.81, p < 0.01) or cocaine (OR: 2.24, p < 0.001) also were associated with PTSD severity. The odds of having co-occurring PTSD symptoms and prescription opioid use problem were nearly three times greater among females versus males (OR: 2.63, p < 0.001). Younger patients (18-34 years old) also were at higher risk (OR: 1.86, p < 0.01).Prescription opioid use problems are a risk factor for co-occurring PTSD symptom severity. Being female or younger increase the likelihood of this co-morbidity. Further research is needed to confirm these finding, particularly using more rigorous diagnostic procedures. These data suggest that patients with prescription opioid use problems should be carefully evaluated for PTSD symptoms.
View details for DOI 10.3109/00952990.2014.910519
View details for Web of Science ID 000338194000008
View details for PubMedID 24809229
View details for PubMedCentralID PMC4883674
Dual Diagnosis Capability in Mental Health and Addiction Treatment Services: An Assessment of Programs Across Multiple State Systems
ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH
2014; 41 (2): 205-214
Despite increased awareness of the benefits of integrated services for persons with co-occurring substance use and psychiatric disorders, estimates of the availability of integrated services vary widely. The present study utilized standardized measures of program capacity to address co-occurring disorders, the dual diagnosis capability in addiction treatment and dual diagnosis capability in mental health treatment indexes, and sampled 256 programs across the United States. Approximately 18 % of addiction treatment and 9 % of mental health programs met criteria for dual diagnosis capable services. This is the first report on public access to integrated services using objective measures.
View details for DOI 10.1007/s10488-012-0449-1
View details for Web of Science ID 000331200300006
View details for PubMedID 23183873
View details for PubMedCentralID PMC3594447
Integrated Cognitive Behavioral Therapy (ICBT) For PTSD and Substance Use in Iraq and Afghanistan Veterans: A Feasibility Study.
Journal of Traumatic Stress Disorders & Treatment
2014; 3 (4)
Co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) is prevalent in military Veterans and is associated with poorer outcomes than either disorder alone. The current pilot study examines the feasibility of delivering integrated cognitive behavioral therapy (ICBT) for co-occurring PTSD-SUD to Veterans who served in Iraq and Afghanistan. Our primary aims were testing the feasibility of engaging and retaining Veterans with a complex clinical presentation in a 12-week structured therapy. We focused on two feasibility outcomes: 1) acceptability; and 2) tolerability. We also examined clinically meaningful change in PTSD and depressive symptoms as a secondary aim. Over the course of the study, we recruited 12 eligible Veterans, 6 of whom completed ICBT. We encountered challenges related to engaging and retaining Veterans in treatment and discuss adaptations and refinements of ICBT or other integrated treatments for returning Veterans with co-occurring PTSD-SUD to increase feasibility with military Veterans.
View details for PubMedID 25580442
View details for PubMedCentralID PMC4288018
- A manual-guided therapy for co-occurring substance use and psychiatric disorders delivered by community addiction counselors: Are outcomes different from psychotherapy delivered by mental health professionals? Journal of Addictive Behaviors, Therapy and Rehabilitation 2014; 3 (3)
Assessing the Co-occurring Capability of Mental Health Treatment Programs: the Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) Index
JOURNAL OF BEHAVIORAL HEALTH SERVICES & RESEARCH
2013; 40 (2): 234-241
The Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) Index was developed to assess the capability of mental health programs to provide substance abuse and co-occurring treatment services. The DDCMHT is an objective scale rated following a site visit that includes semi-structured interviews with staff at all levels, review of program documents and client charts, and ethnographic observation of the milieu and setting. Using data from 67 mental health programs across six states, this study found that the DDCMHT had excellent total score reliability, variable subscale reliability, high inter-rater reliability (n = 18), and moderate construct validity (n = 22). Results also suggest that many mental health programs are at a relatively low level of capability for the delivery of care to individuals with co-occurring disorders. Results from this important new benchmark measure, the DDCMHT, can be used with programs in implementation planning and with treatment systems, states, or national organizations to guide policy change.
View details for DOI 10.1007/s11414-012-9317-8
View details for Web of Science ID 000318518100009
View details for PubMedID 23334656
Substance abuse treatment implementation research
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2013; 44 (1): 1-3
View details for DOI 10.1016/j.jsat.2012.09.006
View details for Web of Science ID 000312050500001
View details for PubMedID 23083972
View details for PubMedCentralID PMC3718484
Organizational Capacity to Address Co-occurring Substance Use and Psychiatric Disorders: Assessing Variation by Level of Care
JOURNAL OF ADDICTION MEDICINE
2013; 7 (1): 25-32
There is widespread recognition that services to persons with co-occurring substance use and psychiatric disorders should be accessible, yet most persons with these disorders do not receive care for both problems. Estimates of available services vary widely and have not examined potential variation by level of care.The present study samples 180 community addiction treatment programs and utilizes a standardized observational assessment of these programs using the dual diagnosis capability of addiction treatment (DDCAT) index. By level of care, the sample consisted of 53 outpatient programs, 50 intensive outpatient programs, and 77 residential programs.Overall, approximately 81.1% of programs across levels of care offered addiction-only services, 18.3% dual diagnosis capable services, and less than 1% dual diagnosis enhanced services. Relative to residential and intensive outpatient programs, outpatient programs were more likely to have greater dual diagnosis capability (dual diagnosis capable services). Outpatient programs scored significantly higher on the DDCAT dimensions associated with program policies and continuity of care. Specific DDCAT benchmark items revealing detailed differences were found in these dimensions and specific assessment and treatment practices. Access to physician-prescriber or to psychotropic medications did not differ by level of care.The findings suggest that across levels of care, addiction-treatment systems and programs must continue to improve capacity for patients with co-occurring disorders. The application of a standardized, objective, and observational instrument may be useful to guide and measure the effectiveness of these efforts.
View details for DOI 10.1097/ADM.0b013e318276e7a4
View details for Web of Science ID 000314825100004
View details for PubMedID 23188042
Measuring Organizational Capacity to Treat Co-Occurring Psychiatric and Substance Use Disorders.
Journal of dual diagnosis
2013; 9 (2): 165-170
View details for PubMedID 24072988
View details for PubMedCentralID PMC3780454
Development and initial feasibility of an organizational measure of behavioral health integration in medical care settings
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2012; 43 (4): 402-409
In the advent of health care reform, models are sought to integrate behavioral health and routine medical care services. Historically, the behavioral health specialty has not itself been integrated, but instead bifurcated by substance use and mental health across treatment systems, care providers and even research. With the present opportunity to transform the health care delivery system, it is incumbent upon policymakers, researchers and clinicians to avoid repeating this historical error, and provide integrated behavioral health services in medical contexts. An organizational measure designed to assess this capacity is described: the Dual Diagnosis Capability in Health Care Settings (DDCHCS). The DDCHCS was used to assess a sample of federally-qualified health centers (N=13) on the degree of behavioral health integration. The measure was found to be feasible and sensitive to detecting variation in integrated behavioral health services capacity. Three of the 13 agencies were dual diagnosis capable, with significant variation in DDCHCS dimensions measuring staffing, treatment practices and program milieu. In general, mental health services were more integrated than substance use. Future research should consider a revised version of the measure, a larger and more representative sample, and linking organizational capacity with patient outcomes.
View details for DOI 10.1016/j.jsat.2012.08.013
View details for Web of Science ID 000311063000005
View details for PubMedID 22999813
An intervention to increase alcohol treatment engagement: A pilot trial
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2012; 43 (2): 161-167
Previous research has documented the difficulty individuals with alcohol use disorders have initiating alcohol treatment. This study assessed the feasibility of a brief, cognitive-behavioral intervention designed to increase treatment initiation among individuals with alcohol use disorders.This randomized controlled trial included 196 participants who screened positive for a possible alcohol use disorder on the alcohol use disorders identification test. Randomly assigned intervention participants were administered a brief cognitive-behaviorally-based intervention by telephone designed to modify beliefs that may interfere with treatment-seeking behavior. Beliefs about treatment and treatment-seeking behavior were assessed postintervention.Participants receiving the intervention had significantly improved their attitudes toward addiction treatment (p < .002) and increased their reported intention-to-seek treatment (p < .000) postintervention. Further, intervention participants were almost three times more likely to attend treatment within a 3-month period (odds ratio = 2.60, p < .025) than participants in the control group.A brief, cognitive-behavioral intervention delivered by telephone and focused on modifying treatment-interfering beliefs holds promise for increasing alcohol treatment seeking among individuals in need.
View details for DOI 10.1016/j.jsat.2011.10.028
View details for Web of Science ID 000307207100003
View details for PubMedID 22138200
View details for PubMedCentralID PMC3297732
Journal of Substance Abuse Treatment: Tradition, change and opportunity
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2012; 42 (1): 1-3
View details for DOI 10.1016/j.jsat.2011.10.006
View details for Web of Science ID 000297956900001
View details for PubMedID 22117543
Co-occurring Substance Use and Posttraumatic Stress Disorders: Reasons for Hope
JOURNAL OF DUAL DIAGNOSIS
2011; 7 (4): 187-193
View details for DOI 10.1080/15504263.2011.620419
View details for Web of Science ID 000300007600001
The boundaries of addiction treatment services research
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2011; 40 (1): 1-2
View details for DOI 10.1016/j.jsat.2010.10.003
View details for Web of Science ID 000285371900001
View details for PubMedID 21051176
A Randomized Controlled Trial Comparing Integrated Cognitive Behavioral Therapy Versus Individual Addiction Counseling for Co-occurring Substance Use and Posttraumatic Stress Disorders
JOURNAL OF DUAL DIAGNOSIS
2011; 7 (4): 207-227
OBJECTIVE: Co-occurring posttraumatic stress (PTSD) and substance use disorders provide clinical challenges to addiction treatment providers. Interventions are needed that are effective, well-tolerated by patients, and capable of being delivered by typical clinicians in community settings. This is a randomized controlled trial of integrated cognitive behavioral therapy for co-occurring PTSD and substance use disorders. METHODS: Fifty-three participants sampled from seven community addiction treatment programs were randomized to integrated cognitive behavioral therapy plus standard care or individual addiction counseling plus standard care. Fourteen community therapists employed by these programs delivered both manual-guided therapies. Primary outcomes were PTSD symptoms, substance use symptoms and therapy retention. Participants were assessed at baseline, 3- and 6-month follow-up. RESULTS: Integrated cognitive behavioral therapy was more effective than individual addiction counseling in reducing PTSD re-experiencing symptoms and PTSD diagnosis. Individual addiction counseling was comparably effective to integrated cognitive behavioral therapy in substance use outcomes and on other measures of psychiatric symptom severity. Participants assigned to individual addiction counseling with severe PTSD were less likely to initiate and engage in the therapy than those assigned to integrated cognitive behavioral therapy. In general, participants with severe PTSD were more likely to benefit from integrated cognitive behavioral therapy. CONCLUSIONS: The findings support the promise of efficacy of integrated cognitive behavioral therapy in improving outcomes for persons in addiction treatment with PTSD. Community counselors delivered both interventions with satisfactory adherence and competence. Despite several limitations to this research, a larger randomized controlled trial of integrated cognitive behavioral therapy appears warranted.
View details for DOI 10.1080/15504263.2011.620425
View details for Web of Science ID 000300007600003
View details for PubMedID 22383864
View details for PubMedCentralID PMC3289146
Co-Occurring Medical, Psychiatric, and Alcohol-Related Disorders Among Veterans Returning From Iraq and Afghanistan
2010; 51 (6): 503-507
Soldiers often return from war with a variety of combat-related mental health conditions, including posttraumatic stress disorder, depression, and substance-use disorders.The authors investigated common co-occurring medical and psychiatric conditions and patterns of conditions among returning Iraq/Afghanistan veterans using the Veterans Administration (VA) healthcare systems.Common clusters of ICD-9 diagnostic-related conditions among returning soldiers (N=293,861) were extracted from the VA data center.Diagnoses involving pain are extremely common among returning veterans seeking health care at the VA. In addition to pain-related conditions, psychiatric disorders rank second most prevalent. Psychiatric disorders, and in particular the multimorbid triad of pain, posttraumatic stress disorder, and depression frequently overlap.As more veterans return from war, there will be greater need for effective services. Given the findings of high rates of comorbidity and multimorbidity, VA services should be reorganized so as to co-locate psychiatric staff in pain centers, simultaneously targeting pain and psychiatric disorders.
View details for Web of Science ID 000283851800008
View details for PubMedID 21051682
Improving the Dual Diagnosis Capability of Addiction and Mental Health Treatment Services: Implementation Factors Associated With Program Level Changes
JOURNAL OF DUAL DIAGNOSIS
2010; 6 (3-4): 237-250
View details for DOI 10.1080/15504263.2010.537221
View details for Web of Science ID 000285514600007
- Co-occurring substance abuse and psychiatric disorders. The Robert Wood Johnson Foundation, Substance Abuse Policy Research Program. http://www.saprp.org/knowledgeassets/Knowledge.cfm. 2010
A cognitive behavioral therapy for co-occurring substance use and posttraumatic stress disorders
2009; 34 (10): 892-897
Co-occurring posttraumatic stress disorder (PTSD) is prevalent in addiction treatment programs and a risk factor for negative outcomes. Although interventions have been developed to address substance use and PTSD, treatment options are needed that are effective, well tolerated by patients, and potentially integrated with existing program services. This paper describes a cognitive behavioral therapy (CBT) for PTSD that was adapted from a treatment for persons with severe mental illnesses and PTSD in community mental health settings. The new adaptation is for patients in community addiction treatment with co-occurring PTSD and substance use disorders. In this study, 5 community therapists delivered the CBT for PTSD. Outcome data are available on 11 patients who were assessed at baseline, post-CBT treatment, and at a 3-month follow-up post-treatment. Primary outcomes were substance use, PTSD severity, and retention, of which all were favorable for patients receiving the CBT for PTSD.
View details for DOI 10.1016/j.addbeh.2009.03.009
View details for Web of Science ID 000269170300015
View details for PubMedID 19395179
View details for PubMedCentralID PMC2720425
Racial/Ethnic Disparities in Mental Health Treatment in Six Medicaid Programs
JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED
2009; 20 (1): 165-176
Little is known about ethnic and racial disparities in mental health care among Medicaid beneficiaries. The association between ethnicity and race and the utilization of mental health care was explored in six Medicaid programs. The analysis distinguished between different settings of care, including community-based, outpatient hospital, inpatient, and emergency departments (EDs). Racial and ethnic disparities in mental health care were observed across state Medicaid programs. Hispanic and African American beneficiaries with mental illness were much less likely than Whites to be treated in community-based settings. African Americans were more likely to receive mental health treatment in inpatient, ED, and outpatient hospital settings in some states. The implications of these findings and possible initiatives to enhance community-based mental health care among African American and Hispanic Medicaid beneficiaries are discussed.
View details for Web of Science ID 000263480000017
View details for PubMedID 19202255
Impact of Substance Disorders on Medical Expenditures for Medicaid Beneficiaries With Behavioral Health Disorders
2009; 60 (1): 35-42
This study measured the impact of substance use disorders on Medicaid expenditures for behavioral and physical health care among beneficiaries with behavioral health disorders.Claims for Medicaid beneficiaries with behavioral health diagnoses in 1999 from Arkansas, Colorado, Georgia, Indiana, New Jersey, and Washington were analyzed. Behavioral health and general medical expenditures for individuals with diagnoses of substance use disorders were compared with expenditures for those without such diagnoses. States were analyzed separately with adjustment for confounders.A total of 148,457 beneficiaries met selection criteria, and 43,457 (29.3%) had a substance use diagnosis. Compared with other beneficiaries with behavioral health disorders, individuals with diagnoses of substance use disorders had significantly higher expenditures for physical health problems in five of six states. Approximately half of the additional care and expenditures were for treatment of physical conditions. Differences declined but remained statistically significant after adjustment for higher overall disease burden among beneficiaries with addictions. Medical expenditures for individuals with diagnoses of substance use disorders increased significantly with age in five of six states, whereas behavioral health expenditures were stable or declined. Hospital admissions for psychiatric and general medical reasons were higher for those with diagnoses of substance use disorders.The impact of addiction on Medicaid populations with behavioral health disorders is greater than the direct cost of mental health and addictions treatment. Higher medical expenditures can be partly attributed to greater prevalence of co-occurring physical disorders, but expenditures remained higher after adjustment for disease burden. Spending estimates based only on behavioral health diagnoses may significantly underestimate addictions-related costs, particularly for older adults.
View details for Web of Science ID 000262049600007
View details for PubMedID 19114568
The status of addiction treatment research with co-occurring substance use and psychiatric disorders
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2008; 34 (1): 1-2
View details for DOI 10.1016/j.jsat.2007.03.007
View details for Web of Science ID 000252002900001
View details for PubMedID 17574797
Co-occurring psychiatric and substance use disorders: A multistate feasibility study of the quadrant model
2007; 58 (7): 949-954
The quadrant model was developed to organize the heterogeneous group of persons with co-occurring psychiatric and substance use disorders and to anticipate differential use of systems of care. The purpose of the study presented here was to test the feasibility of applying the model to classify persons with co-occurring disorders, examine the reliability of quadrant prevalence and distribution, and test the validity of differential service use by quadrant.Medicaid claims data from 1999 from six states were analyzed, and 22,912 individuals with co-occurring disorders were classified into quadrants, by severity of substance use and psychiatric disorders. Distribution by quadrant and the utilization of emergency and inpatient services were analyzed.A majority of cases were classified in quadrant IV (52.5%) (high severity of psychiatric and substance use disorders), and fewest were classified in quadrant I (8.2%) (low severity of psychiatric and substance use disorders). There was equivalence in distribution for quadrant III (19.8%) (high severity of substance use disorders and low severity of psychiatric disorders) and quadrant II (19.4%) (high severity of psychiatric disorders and low severity of substance use disorders). Distribution was consistent across states, and service utilization was most associated with quadrant IV. Persons with the more severe psychiatric problems (quadrants II and IV) were more likely to be female, to be older, and to have been hospitalized or to have visited an emergency department. Another important finding is the high rate of persons with substance dependence disorders (quadrants III and IV).The feasibility of applying the quadrant model was supported. The quadrant model has been well adopted conceptually by community providers and policy makers. The consistency of the findings across six state Medicaid systems supports the potential utility of the model to articulate patient characteristics and service use patterns. Further application and research with this model is proposed.
View details for Web of Science ID 000253360400010
View details for PubMedID 17602011
Treatment for co-occurring mental and substance use disorders in five state Medicaid programs
2007; 58 (7): 942-948
This study described the locations and patterns of psychiatric and substance abuse treatment for Medicaid beneficiaries with co-occurring mental and substance use disorders in five states.Medicaid beneficiaries aged 21 to 65 with psychiatric or substance use disorders were identified with claims and encounter records. Groups were further divided into those with and those without a diagnosed substance use disorder. Adjusted odds of treatment in community-based settings, inpatient facilities, emergency departments, and hospital outpatient departments were calculated.A total of 92,355 persons had a psychiatric disorder, 34,158 had a substance use disorder, and 14,256 had co-occurring psychiatric and substance use disorders. In all five states, beneficiaries with severe mental illness (schizophrenia, bipolar disorder, or major depression) and a substance use disorder had higher odds of inpatient, emergency department, and hospital-based outpatient psychiatric treatment, compared with those with severe mental illness alone. In four of five states, both severe and less severe mental illness and a co-occurring substance use disorder were associated with lower odds of community-based treatment compared with those with the respective mental illness alone. Compared with those with less severe mental illness alone, individuals with less severe psychiatric disorders and a co-occurring substance use disorder had higher odds of inpatient treatment in all states and of emergency department use in three of five states. Odds of inpatient and outpatient hospital use and emergency department use for substance abuse treatment were higher for persons with severe mental illness and a co-occurring substance use disorder in most states, compared with odds for those with a substance use disorder alone.Heavy inpatient and emergency department use by Medicaid beneficiaries with co-occurring substance use disorders is a consistent cross-state problem. Co-occurring disorders may decrease the likelihood of community-based treatment for those with less severe mental disorders and for those with severe mental illness, suggesting that policies focusing only on these settings may miss a significant proportion of people with these co-occurring disorders.
View details for Web of Science ID 000253360400009
View details for PubMedID 17602010
Addiction treatment services and co-occurring disorders: The ASAM-PPC-2R taxonomy of program dual diagnosis capability
JOURNAL OF ADDICTIVE DISEASES
2007; 26 (3): 27-37
The ASAM-PPC-2R taxonomy of addiction treatment program dual diagnosis capability provides a conceptual model of services for persons with co-occurring substance use and psychiatric disorders. However, no objective study of this model has been conducted.This paper describes a survey of addiction treatment providers (n = 453) who were asked to identify their program as Addiction Only Services (AOS), Dual Diagnosis Capable (DDC) or Dual Diagnosis Enhanced (DDE). The survey also queried providers on prevalence estimates, clinical practices, and perceived barriers to treating persons with co-occurring substance use and psychiatric disorders.With brief definitions available to respondents, 92.9% of providers surveyed categorized their program as: AOS (23.0%), DDC (65.3%) or DDE (11.6%). Patient characteristics, clinical practices, and barriers to effective treatments varied by program dual diagnosis capability.The findings support the utility of the ASAM dual diagnosis capability taxonomy, and suggest specific avenues for system and program assessment and future research.
View details for DOI 10.1300/J069v26n03_04
View details for Web of Science ID 000248992800004
View details for PubMedID 18018806
Addiction treatment services and co-occurring disorders: Prevalence estimates, treatment practices, and barriers
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2006; 31 (3): 267-275
As the model for treating co-occurring disorders in addiction treatment settings becomes articulated, service systems need data on prevalence, current practice, and barriers to the implementation of evidence-based practices. A self-report survey was administered to 453 addiction treatment providers (43 agency directors, 110 clinical supervisors, and 300 clinicians) from a single state system of care. Data on prevalence estimates, treatment practices, and barriers to implementing services for co-occurring disorders were obtained. The three groups estimated that several co-occurring disorders were extremely common: mood disorders (40%-42%), anxiety disorders (24%-27%), posttraumatic stress disorder (24%-27%), severe mental illnesses (16%-21%), antisocial personality disorder (18%-20%), and borderline personality disorder (17%-18%). Practice patterns for patients with these co-occurring disorders differed widely, from referral to mental health programs to provision of integrated treatment. Common barriers to providing services to persons with co-occurring disorders were lack of psychiatric personnel and resources. Comprehensive surveys of an addiction treatment service system can rapidly and economically produce estimates of prevalence, current practices, and barriers to evidence-based practices. This objective information is critical for systems intending to enhance services to persons with co-occurring disorders.
View details for DOI 10.1016/j.jsat.2006.05.003
View details for Web of Science ID 000241215900006
View details for PubMedID 16996389
A systematic analysis of college substance use policies
JOURNAL OF AMERICAN COLLEGE HEALTH
2005; 54 (3): 169-176
College substance use policies provide guidelines for student behavior and influence campus culture. Although they are the primary environmental strategy to address campus substance use, policies have not been systematically compared and studied. We constructed a systematic review method to examine the accessibility, comprehensiveness, enforcement procedures, and clarity of college substance use policies. We developed an objective evaluation scheme for each of these 4 dimensions and then applied it to documented substance use policies from a sample of colleges and universities (N = 24). Policies were found to vary considerably but tended to specify compliance with local laws and emphasize student health and well-being. The next stage of campus policy review should examine actual implementation, evaluate potential differentiating factors among institutions, and assess the influence of policy on campus climate and student outcomes.
View details for Web of Science ID 000233811500006
View details for PubMedID 16335317
Relapse of substance use disorder and its prevention among persons with co-occurring disorders
2005; 56 (10): 1270-1273
This article summarizes the scientific literature on the relapse process, describes the basic principles of relapse prevention treatment, highlights the major empirical studies, and offers suggestions for future research and application, especially in terms of ongoing care for persons with co-occurring disorders. Relapse prevention treatments have a well-established efficacy and effectiveness for persons with substance use disorders. Key ingredients include reducing exposure to substances, fostering motivation for abstinence, self-monitoring, recognizing and coping with cravings and negative affect, identifying thought processes with relapse potential, and deploying, if necessary, a crisis plan. Relapse prevention approaches may be best suited for persons in the action of maintenance stages of treatment or recovery. Further research is needed to examine relapse prevention therapies as a key component to continuing care for persons with co-occurring substance use and psychiatric disorders.
View details for Web of Science ID 000232470100013
View details for PubMedID 16215194
Future directions in preventing relapse to substance abuse among clients with severe mental illnesses
2005; 56 (10): 1297-1302
The authors review the literature on substance use disorders among persons with severe mental illnesses, including the other papers in this special section on relapse prevention, and suggest future directions. Although prevention of relapse to substance abuse has a well-developed theoretical and empirical base, this perspective has rarely been applied to persons with co-occurring severe mental illness. Research indicates that clients with co-occurring disorders are highly prone to relapse to substance abuse, even after they have attained full remission. Their risk factors include exacerbations of mental illness, social pressures within drug-using networks, lack of meaningful activities and social supports for recovery, independent housing in high-risk neighborhoods, and lack of substance abuse or dual diagnosis treatments. The evidence in hand suggests several steps: developing healthy and protective environments that are experienced as nurturing of recovery; helping people make fundamental changes in their lives, such as finding satisfying jobs, abstinent friends, networks of people who are in the process of recovery, and a sense of meaning; providing specific and individualized treatments for mental illnesses, substance use disorders, and other co-occurring problems; and developing longitudinal research on understanding and preventing relapse that addresses social context as well as biological vulnerabilities and cognitive strategies.
View details for Web of Science ID 000232470100018
View details for PubMedID 16215199
Physicians and nurses with substance use disorders
JOURNAL OF ADVANCED NURSING
2004; 47 (5): 561-571
The literature addressing substance use patterns among medical professionals suggests that specialty, gender, age, familial substance abuse, and access/familiarity with prescription drugs are associated with particular chemical dependencies. These studies have rarely compared nurses and physicians directly, thereby making if difficult to tailor interventions to the potentially unique needs of each group.This paper reports a study to compare the initial clinical presentations, service utilization patterns, and post-treatment functioning of nurses and physicians who received services in an addiction treatment programme.This exploratory study combined data collected through retrospective record reviews and prospective questionnaires. There were three types of dependent variables: initial clinical characteristics, treatment utilization patterns, and post-treatment functioning. The independent variable was membership of either professional group. Time both in treatment and between discharge and follow-up were covariates.Nurses and physicians showed comparable results in most domains. Among the statistically significant differences between groups, a subset was particularly noteworthy. Prior to participating in the programme nurses showed significantly less personality disturbance than physicians, although they tended to work and live in environments with more triggers to relapse, such as other substance users. After the index hospitalization, nurses received less primary treatment, worked longer hours, and were more symptomatic than physicians. Furthermore, nurses reported more frequent and severe work-related sanctions as a consequence of their behavioural disorders.In most areas of study, nurses and physicians demonstrated comparable results; however, a series of statistically significant differences suggest that these groups may have unique clinical needs. The policy implications of these findings are discussed.
View details for Web of Science ID 000223281600012
View details for PubMedID 15312119
A survey of clinical practices and readiness to adopt evidence-based practices: Dissemination research in an addiction treatment system
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2004; 26 (4): 305-312
Addiction research is challenged to disseminate evidence-based practices into routine clinical settings. The successful adoption of innovation must consider issues of fit, such as the characteristics, readiness, and attitudes of clinicians in the community. We constructed a survey to assess clinical practices and readiness to adopt certain evidence-based practices in addiction treatment programs. The instrument was administered to directors (n = 21) and clinicians (n = 89) from 24 public addiction treatment programs in New Hampshire (USA). Clinicians are more motivated to adopt some evidence-based practices (twelve-step facilitation, cognitive behavioral therapy, motivational interviewing, relapse prevention therapy) than others (contingency management, behavioral couples therapy, pharmacotherapies). Translational strategies for treatment development and research dissemination are discussed.
View details for DOI 10.1016/j.jsat.2004.03.003
View details for Web of Science ID 000222018400008
View details for PubMedID 15182895
Evidence-based practices for substance use disorders
PSYCHIATRIC CLINICS OF NORTH AMERICA
2003; 26 (4): 991-?
There are inherent complexities in evaluating EBPs for substance use disorders: the heterogeneity of the disorder itself, the variability in people who suffer from them, the range of settings in which services are provided, and multiple lines of research development. This article outlined four models for evaluating the evidence for interventions for substance use disorders, and presented brief descriptions of pharmacological, behavioral/psychosocial, and treatment services that have a clearly defined intervention (chemical agent or manual-guided therapy) and a documented record of objective evaluation. Although substantial work is underway to evaluate effectiveness in the real world, clinicians and individuals with substance use disorders and their families should be cognizant of the burgeoning array of effective treatment alternatives that are available.
View details for DOI 10.1016/S0193-953X(03)00073-X
View details for Web of Science ID 000187528500013
View details for PubMedID 14711132
View details for PubMedCentralID PMC3678283
Gender of physicians with substance use disorders: Clinical characteristics, treatment utilization, and post-treatment functioning
SUBSTANCE USE & MISUSE
2003; 38 (7): 993-1001
Gender has emerged as an important variable in both the course and treatment of substance-use disorders. This study examines the role of gender in a sample of physicians (n = 73) treated for substance-use disorders. Pilot data gathered on physicians treated during 1995 to 1997, included initial pretreatment characteristics, service utilization, and posttreatment functioning. Although there were many similarities, important differences emerged among the groups. These differences have implications for physician education and training and warrant more systematic clinical research.
View details for DOI 10.1081/JA-120017620
View details for Web of Science ID 000183310300009
View details for PubMedID 12801152
Psychiatric comorbidity and physicians with substance use disorders: A comparison between the 1980s and 1990s
JOURNAL OF ADDICTIVE DISEASES
2003; 22 (3): 79-87
The assessment and treatment of physicians with substance use disorders has been of considerable interest over the past twenty years. This study compares two cohorts of addicted physicians treated at a single program. Data from 101 physicians treated during 1985 to 1987 were compared with 73 physicians treated from 1995 to 1997. Although the cohorts were similar on demographic, physician specialty, and drug of choice variables, psychiatric comorbidity was significantly more prevalent in the later sample.
View details for DOI 10.1300/J069v22n03_07
View details for Web of Science ID 000186710000007
View details for PubMedID 14621346
- Psychiatric comorbidity and physicians with substance use disorders: Clinical characteristics, treatment experiences, and post-treatment functioning. Addictive Disorders & Their Treatment 2002; 1 (3): 89-98
Characteristics of physicians presenting for assessment at a behavioral health center
JOURNAL OF ADDICTIVE DISEASES
2000; 19 (2): 59-73
Physician health and impairment have been of considerable interest in recent years. This study contributes detailed clinical data to the existing body of knowledge, by drawing from a sample of physicians assessed at a behavioral health center over a two year time frame. Demographic, referral, and clinical data were gathered using a systematic medical record review procedure, based on 108 physicians who were evaluated within an intensive multidisciplinary assessment program. The majority suffered from active substance use disorders (52.8%), with other psychiatric disorders (29.6%), and substance use disorders in remission (17.6%) the other largest categories. Of those with an active substance use disorder, primary drugs of choice were alcohol and prescription opiates. Over half had comorbid psychiatric disorders (Axis I, II, or both). Significant relationship, employment, and emotional problems were found in all three groups. The significant increase in presentation and/or detection of psychiatric and behavioral problems, both comorbid with and not substance use related, confirms the need for a revision and expansion of views about physicians' behavioral health concerns.
View details for Web of Science ID 000086601700005
View details for PubMedID 10809520
Training in substance use disorders assessment and intervention: Design and implementation of a model within a traditional mental health clinic
PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE
1999; 30 (4): 411-414
View details for Web of Science ID 000081608300014
Diagnosis and treatment of psychiatric comorbidity in alcoholics and drug addicts
1998; 28 (12): 705-?
View details for Web of Science ID 000077513400006
Female physicians and substance abuse - Comparisons with male physicians presenting for assessment
JOURNAL OF SUBSTANCE ABUSE TREATMENT
1998; 15 (6): 525-533
As with women in general, the vicissitudes of the female physician who suffers from a substance use disorder have been understudied, and such persons remain underrepresented in treatment. The purpose of the present study is to describe the similarities and differences between female and male physicians presenting for assessment; 108 physicians in total were included in the study, 10 of whom were female. Demographically, we found that the female physicians were more likely to be single and younger than their male counterparts. On clinical indices, females showed less impairment on legal and medical functioning, and better capability in sustaining abstinence and eliminating environmental cues to relapse. Of the women with substance use disorders, higher rates of comorbidity were found than with males. Although there were no significant differences in overall severity, males were more likely to be recommended to more intensive levels of care for either substance use or psychiatric disorders. The female physicians were recommended to a level of care of a lower intensity, but more often to a treatment with a dual-diagnosis focus. These findings are discussed in terms of the vulnerabilities of the female physician, barriers to treatment, tailoring treatment to female needs, and opportunities for prevention and further research.
View details for Web of Science ID 000077210000006
View details for PubMedID 9845866
Differential therapeutics and the impaired physician: Patient-treatment matching by specificity and intensity
JOURNAL OF ADDICTIVE DISEASES
1998; 17 (2): 93-107
The objective of this study was to determine the nature and degree of patient to treatment matching for a sample of physicians based on differential problem type and severity. Methods included a single assessment of variables using retrospective chart review. Subjects included 108 physicians (98 men and 10 women), who were sampled consecutively from assessments performed over a 2-year period. They represented a variety of specialties, and most were third-party referred, predominantly by state medical societies. Main outcome measures included demographic information, DSM-IV multiaxial diagnoses, the Severity of Substance-Related Disorder scale, and the type and intensity of recommended treatment. It was found that the physicians presented with a variety of conditions that were clustered into three categories: active substance use disorders (52.8%), substance use disorders in remission (17.6%), and psychiatric/behavioral problems (29.6%). An analysis of the appropriateness of matching types of treatment to these problem categories appeared to support a differential assignment process. A range in severity was also found within problem categories and was subsequently tested for correspondence with the range in intensity of recommended treatment. It was found that severity correlated strongly with recommended treatment intensity for all groups. In addition, multiple regression analyses showed that two factors, ability to sustain abstinence and emotional disturbance, were predictive of treatment intensity for the two substance use disorder subgroups (64% of variance accounted for). In the psychiatric/behavioral problem subgroup, such analysis demonstrated that the severity of difficulties with one's significant other was predictive of treatment intensity (89% of variance accounted for).
View details for Web of Science ID 000073093900007
View details for PubMedID 9567228
- Triaging the impaired physician: Patient-treatment matching by specificity and intensity. Epikrisis 1998; 9 (6): 1-2
Treatment matching and the impaired physician: Assessment of substance use, psychiatric, and behavioral problems
ROUTLEDGE JOURNALS, TAYLOR & FRANCIS LTD. 1997: A1–A1
View details for Web of Science ID A1997WP06400009
Utility of the chemical use, abuse, and dependence scale in screening patients with severe mental illness
1996; 47 (6): 647-649
The Chemical Use, Abuse, and Dependence (CUAD) Scale was administered with other scales to 100 consecutive admissions to a psychiatric hospital. Moderately high correlations with other measures of drug and alcohol use were obtained. Although more research with the CUAD is necessary, it may be potentially useful in screening for substance use among severely mentally ill patients.
View details for Web of Science ID A1996UN31900018
View details for PubMedID 8726496
OBJECT RELATIONS AND SOCIAL FUNCTIONING OF SCHIZOPHRENIC AND BORDERLINE PATIENTS - A CROSS-SECTIONAL DEVELOPMENTAL PERSPECTIVE
JOURNAL OF CLINICAL PSYCHOLOGY
1993; 49 (3): 319-326
Using a cross-sectional design, this study compared patients with schizophrenic and borderline personality disorders on measures of object relations and social functioning. Although we found that on measures of object relations the borderline group remained less impaired than the schizophrenics, during the course of the lifespan the schizophrenic patients appeared to surpass the borderlines on social functioning. These results are integrated with the literature that compares the long-term course and outcomes for these disorders and are discussed within the context of differential adaptive capacities, change mechanisms, and treatment interventions.
View details for Web of Science ID A1993LE86300002
View details for PubMedID 8315032
PROBLEM SEVERITY AND SYMPTOMATOLOGY AMONG SUBSTANCE MISUSERS - DIFFERENCES BETWEEN AFRICAN-AMERICANS AND CAUCASIANS
INTERNATIONAL JOURNAL OF THE ADDICTIONS
1993; 28 (9): 909-922
Using data collected on 348 patients presenting to a hospital-based substance misuse treatment program, the present study compares psychiatric symptomatology and severity of substance misuse among African-American and Caucasian alcohol and drug misusers. African-Americans had a higher overall severity of substance misuse and reported using more substances than Caucasians. African-Americans also had higher levels of somatization, interpersonal problems, depression, hostility, obsessive/compulsive behavior, phobia, paranoia, and psychoticism than Caucasians. African-Americans exhibited higher levels of psychosocial stress and lower levels of global functioning than did Caucasians. The implications of the findings are discussed.
View details for Web of Science ID A1993LP99400007
View details for PubMedID 8359947
- The clinician factor in addiction treatment: Implications for differential practices. Alcoholism and Drug Research 1992; 3 (3): 10
THE CHEMICAL USE, ABUSE, AND DEPENDENCE SCALE (CUAD) - RATIONALE, RELIABILITY, AND VALIDITY
JOURNAL OF SUBSTANCE ABUSE TREATMENT
1992; 9 (1): 27-38
This article describes the rationale for the development of the Chemical Use, Abuse, and Dependence Scale (CUAD). The instrument is in a semistructured interview format; it derives both substance use severity scores and DSM-III-R substance use disorder diagnoses and can be administered in a short period with minimal training. The reliability and validity of the CUAD are reported and appear satisfactory. The CUAD is recommended for use as a detection, diagnostic, and treatment selection index in clinical, research, and program evaluation contexts.
View details for Web of Science ID A1992HR00500005
View details for PubMedID 1317464
- Psychiatric symptomatology among alcoholics: Comparisons between African-Americans and Caucasians. Psychology of Addictive Behaviors 1992; 6 (4): 219-224
CAPITATION PAYMENT SYSTEMS AND PUBLIC MENTAL-HEALTH-CARE - IMPLICATIONS FOR PSYCHOTHERAPY WITH THE SERIOUSLY MENTALLY-ILL
AMERICAN JOURNAL OF ORTHOPSYCHIATRY
1990; 60 (2): 298-304
The evolution, rationale, and implications of capitation payment systems in public mental health are discussed. These systems will unify the clinical, administrative, and fiscal structures of state and community mental health providers. Psychotherapeutic practice may shift to more action-oriented, problem-focused, brief and crisis interventions. The diminishing prospects for long-term intensive psychotherapy and the need to demonstrate its clinical efficacy and economic feasibility are discussed.
View details for Web of Science ID A1990DC17500016
View details for PubMedID 2111638
- Capitation payment systems and public mental health care: Implications for psychotherapy with the chronic and severely disturbed. American Journal of Orthopsychiatry 1990; 60 (2): 298-304
- Decision-making in the emergency room: A reply American Journal of Psychiatry 1989; 146 (2): 291-292
- The relationship between years of psychotherapy experience and conceptualizations, interventions, and treatment plan costs. Professional Psychology 1989; 29: 59-61
- Co-existing serious mental illness and substance abuse: Impact on hospital length of stay, re-hospitalization, and aftercare linkage. Hospital and Community Psychiatry 1989; 40: 1067-1069
EVALUATING TRAINEES RELATIVE TO THEIR SUPERVISORS DURING THE PSYCHOLOGY INTERNSHIP
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
1988; 56 (5): 659-665
View details for Web of Science ID A1988Q401700003
View details for PubMedID 3057003
PSYCHIATRIC DECISION-MAKING IN THE EMERGENCY ROOM - A RESEARCH OVERVIEW
AMERICAN JOURNAL OF PSYCHIATRY
1988; 145 (8): 918-925
In an overview of the research on psychiatric decision making in the emergency room, the authors discuss studies done between 1963 and 1977, which suffered from an overreliance on univariate statistical techniques, problems with the reliability and validity of the instruments used for data collection, and the lack of alternatives to hospitalization for emergency room patients. More recent studies of emergency room decision making are then reviewed, with particular attention to those that had multivariate statistical designs. The article concludes with a synthesis of the research findings to date and recommends multivariate approaches and choices of variables for future studies.
View details for Web of Science ID A1988P500800002
View details for PubMedID 3293473
- Evaluating the conceptualizations and treatment plans of interns and supervisors during a psychology internship. Journal of Consulting and Clinical Psychology 1988; 56 (5): 659-665
PSYCHIATRIC CHRONICITY - A SINGLE SYSTEM MODEL
ADMINISTRATION AND POLICY IN MENTAL HEALTH
1988; 16 (2): 79-84
View details for Web of Science ID A1988AE97700003
- On the integration of state hospital and community-based services for the chronic mentally ill: A systemic case study. Hospital and Community Psychiatry 1988; 39 (5): 553-555
- The implementation of a single system model for psychiatric chronicity: The initial stage and its analysis Administration and Policy in Mental Health 1988; 16 (2): 79-87
SIMPLE MEASURES OF CASE MIX IN MENTAL-HEALTH-SERVICES
EVALUATION AND PROGRAM PLANNING
1987; 10 (3): 197-200
The concept of Case Mix in community mental health service program evaluation can be useful in mental health program evaluation if the definition of case mix is expanded beyond Diagnostic Related Groups (DRG), where DRG is solely based upon diagnosis and length of hospitalization stay. A case mix definition based upon two principal characteristics is offered. One characteristic is clinical status defined in terms of diagnostic signs and symptoms, level of functioning, and age. The other characteristic is typical treatment strategy for a given period of time (e.g., 13 weeks). Two cases mixes typical of services designed for the chronically mentally ill are discussed.
View details for Web of Science ID A1987J916300003
View details for PubMedID 10312179
- The role of academic psychiatry in public mental health. Contemporary Psychiatry 1987; 6 (2): 73-76
- Emergency psychiatry comes of age. Contemporary Psychiatry 1987; 6 (4): 238-239
METATHEORETICAL ASSUMPTIONS AND PSYCHOTHERAPY ORIENTATION - CLINICIAN ATTRIBUTIONS OF PATIENTS PROBLEM CAUSALITY AND RESPONSIBILITY FOR TREATMENT OUTCOME
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
1986; 54 (4): 476-481
View details for Web of Science ID A1986D465500011
View details for PubMedID 3745600
PSYCHOTHERAPEUTIC ORIENTATIONS - A COMPARISON OF CONCEPTUALIZATIONS, INTERVENTIONS, AND TREATMENT PLAN COSTS
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
1986; 54 (3): 369-374
View details for Web of Science ID A1986C428900017
View details for PubMedID 3088077
- Medical versus social treatment of alcohol withdrawal. Digest of Alcoholism Theory and Application 1984; 4 (1): 60-68
COMPARATIVE-EVALUATION OF MEDICAL VS SOCIAL TREATMENT OF ALCOHOL WITHDRAWAL SYNDROME
JOURNAL OF CLINICAL PSYCHOLOGY
1983; 39 (5): 791-803
Compared medical and social setting detoxification treatments of alcohol withdrawal syndrome on the degree to which each involved alcoholics in ongoing rehabilitative efforts. Two hundred patients were selected randomly from both treatments and administered the Physical Problem Inventory, Short Michigan Alcoholism Screening Test, Assessment of Life Experience, and Level of Motivation scales. Analysis of covariance with multiple covariates was employed to assess the effect of the treatment model on willingness to continue rehabilitation as measured by the dependent variable, ongoing referral status. The difference between detoxification treatment models was highly significant, and none of the covariates, which controlled for pretest differences and the assignment process, was significant. Results are discussed in the context of current notions of pharmacotherapy, learning, and physiological models of withdrawal treatment. In addition, expectancies, in terms of perceived responsibility for outcome, are discussed as important factors that contribute to the discrepancy between medical vs. social models in the treatment of alcoholism.
View details for Web of Science ID A1983RH79000026
View details for PubMedID 6630559
A MULTIPLE PERSPECTIVE ANALYSIS OF SCHIZOPHRENICS SYMPTOMS AND COMMUNITY FUNCTIONING
AMERICAN JOURNAL OF COMMUNITY PSYCHOLOGY
1983; 11 (5): 593-607
The present investigation examined the extent of agreement among schizophrenic clients, hospital clinicians, and independent evaluators' views of the client's symptoms and community functioning status using the Symptom Checklist-90, the Denver Community Mental Health Questionnaire, and the Personal Adjustment and Role Skills Inventory. The results suggest there is significant agreement among viewpoints and that this finding is generalizable across community assessment instruments. The average shared variance among the three perspectives across the three instruments was .68. The estimates of shared variance between the SCL-90, the DCMHQ, and the PARS ranged from .54 to .85, indicating these outcome instruments measure a common phenomenon or share significant method variance. The previously assumed necessity of multiple perspective assessment as the only valid approach is challenged.
View details for Web of Science ID A1983RK46900008
View details for PubMedID 6650463
OUTCOME PREDICTION OF INPATIENT ALCOHOL DETOXIFICATION
1983; 8 (2): 167-171
A wide range of patient characteristics was assessed to determine their relative contribution upon alcohol detoxification treatment outcome. The outcome criteria were length of stay and commitment to ongoing rehabilitation, of which 17% and 24% of respective variance was accounted for by the predictor variables. The Internal-External Locus of Control scale was the most significant predictor, with internals tending toward successful treatment outcomes. The measures which tapped degree of socio-economic life satisfaction and physiological complications due to alcohol abuse, were inversely related to positive outcomes.
View details for Web of Science ID A1983QX55000010
View details for PubMedID 6613715
- A multiple perspective analysis of schizophrenics' symptoms and community functioning. American Journal of Community Psychology 1983; 11 (5): 593–607
A naturalistic assessment of partial-hospital treatment.
International journal of partial hospitalization
1982; 1 (4): 311-326
Three hundred fifty-eight consecutive admissions to 13 partial hospitals were evaluated over an 8-month period. The design of the study focused on an unobstrusive measurement process involving clinical judgment of outcome. Analyses revealed that the clinical judgment process generated data which were both reliable and valid. The results of the study indicate that partial-hospital treatment is most effective for chronic and acute schizophrenic conditions, paranoid schizophrenia, and affective disorders and least so far patients diagnosed as adjustment disorders. Patients in the organic and neurotic diagnostic categories tended to remain stable. As in previous research, the pretreatment levels of the dependent variables were the best predictors of improvement, but the present study also reveals that progressive amounts of partial-hospital treatment lead to a greater improvement in patient functioning.
View details for PubMedID 10260152
ALCOHOLISM IN SOUTHEAST-ASIA PREVALENCE AND TREATMENT
INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY
1982; 28 (1): 36-44
A pilot, field investigation of the prevalence and treatment of alcoholism in Southeast Asia (Singapore, Indonesia, Malaysia, Burma, and Thailand) and conducted. The methodology combined an informant study, interviewing leading alcohol and drug abuse authorities; utilising existing data; and clinical and naturalistic observation. The effects of modernisation, multiracial culture, and the unilateral focus on opiates are discussed; recommendations on treatment, education, and research are presented.
View details for Web of Science ID A1982ND10000005
View details for PubMedID 6980858
- Developing an integrated behavioral health system using engineering design. Industrial and Systems Engineering Conference 2017