Magazine article Clinical Psychiatry News

Substance Abuse and SPMI Patients

Magazine article Clinical Psychiatry News

Substance Abuse and SPMI Patients

Article excerpt

The Problem

You have a patient who has been diagnosed with a severe and persistent mental illness and alcohol dependence. This patient has been treated in a state hospital after being found not guilty of a crime by reason of insanity, and he is now being discharged to the outpatient setting. A court order mandates his participation in Alcoholics Anonymous.

The Question

Are substance abuse treatment programs efficacious for patients with severe and persistent mental illness?

The Analysis

We performed a search of the Cochrane Library ( for the phrase "mental illness and substance."

The Evidence

Those patients who have severe and persistent mental illnesses (SPMIs), such as schizophrenia with comorbid substance abuse, are at higher risk than those with SPMI alone for poor treatment compliance, homelessness, medical complications, poor money management, and violence (Schizophr. Res. 1999;35 [suppl.]:93-100).

Given those important sequelae, reducing the effects of substance abuse is high on the list of priorities. But are psychocial programs that are currently available for people with SPMI efficacious in treating comorbid substance abuse disorders?

Our search strategy located a Cochrane Review pertinent to the posed question (Cochrane Database Syst. Rev. 2000;4:CD001088). The Cochrane Group reviewed all randomized trials of any program of substance abuse treatment for patients with SPMI (schizophrenia or bipolar disorder) and comorbid substance abuse.

Data from studies in which dropout rates were greater than 50% were not used because of the increased likelihood of bias. Outcomes were divided into 6, 12, 18, and greater than 24 months, and were evaluated by instruments described in peer-reviewed journals. Ultimately, six randomized controlled trials were included.

Only one study mentioned blinded raters. Most study designs were similar: Community-based patients were referred by their treating clinicians and randomly allocated to one of two treatment conditions. No two trials used the same interventions, and all trials occurred in the United States.

In one of the many comparisons conducted, the efficacy of any substance abuse treatment program within psychiatric care was compared with psychiatric care alone. Analyses by those conducting the trials indicated no statistically significant difference between integrated programs and psychiatric care alone on measures of substance use, mental status, or days hospitalized. …

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