Transcript Slide 1

Treatment of psychosis and
substance misuse:development
of the
trial
Christine Barrowclough
School of Psychological Sciences
University of Manchester, UK
[email protected]
2004 -2009
Motivational
Intervention
for Drug
and Alcohol use
in Schizophrenia
Medical Research
Council/Department
of Health funded
University of Manchester
University of London
Local NHS trusts
Content of Presentation
•Briefly review background and
treatment literature
•Describe Manchester study
•Describe development of treatment model
•Outline MIDAS trial
Acknowledgements
MIDAS grant holders:
Christine Barrowclough
Gillian Haddock
Nick Tarrier
Til Wykes
Jan Moring
Graham Dunn
Linda Davies
Tom Craig
John Strang
Collaborators
Patricia Conrad
Ian Lowens
MIIDAS Therapists
Rory Allot
Richard Craven
Paul Earnshaw
Sarah Nothard
Mike Fitzsimmons
MIIDAS Research team
Ruth Johnson
Gwen Alvey
Sarah Jones Charlotte Hartley
Laura Foster Anna Ruddle
Karen Owens
Alicia Picken
Substance use in psychosis
Prevalence :
30 - 60% past -year problem drug or
harmful alcohol use in UK/US samples
Correlates:
Adverse impact on social functioning,
mental health, treatment outcomes
Clinical implications:
Patient group presenting many
challenges to clinical teams
Treatment approaches & evaluation
1. Service evaluation research

Integrating mental health and substance
use treatment delivered concurrently

Focus on models of delivery of multiple
treatments in a specialist service

Ingredients usually include: motivational
interventions, assertive outreach, case
management, group/individual therapy

Mainly US studies but promising examples
in UK eg COMPASS
Treatment approaches & evaluation
1. Service evaluation research cont’d

Evaluation methodologically difficult: no
evidence that any treatment programme is
better than treatment as usual (reviews
Drake et al 1998, Cochrane review)
KEY ISSUES HIGHLIGHTED:

Emphasise importance of INTEGRATION of
mental health & substance use treatments

And highlighted need for interventions to
MATCH STAGE OF CHANGE
STAGES OF CHANGE (Prochaska & DiClimente)
Not thinking about it
(Pre-contemplation)
Relapse
Thinking about
change
Maintenance
(Contemplation)
Change
(Action)
Getting ready for
change
(Determination)
Motivational Interviewing
(Miller & Rollnick 2002)
 non judgemental, quiet, reflective, eliciting style
 ambivalence is a normal central phenomenon.
 it is important to understand the costs and
benefits - assume they are unique to each
individual.
 the working through of ambivalence is a central
goal of Motivational Interviewing
Treatment approaches & evaluation:
2. Specific treatments :Brief interventions
 Focus on delivering a specific treatment package
as an addition to existing service - easier to
evaluate
 Treatments evaluated - brief Motivational
Interviewing / MI and Cognitive Behaviour
Therapy
Treatment approaches & evaluation:
2. Specific treatments :Brief
motivational/MI plus CBT interventions
 Kavanagh et al 2002 n = 25 psychosis inpatients MI significant reduction substances
 But Kavenagh et al 2004 n = 86 MI/CBT 6
sessions - No impact on substances or
symptoms
 Baker et al, 2002 n = 160 psychiatric inpatients One session of MI - Little impact
 Baker et al (in press) N = 130 community
psychosis sample 10 sessions MI plus CBT- No
impact substances or symptoms
Manchester study
Barrowclough et al, 2001, Haddock et al, 2004
Will an intensive combined individual (MI
plus CBT) and family treatment
delivered over 9 months be efficacious
for dually diagnosed schizophrenia
patients?
Target sample
 People with diagnosis of schizophrenia in touch
with mental health services
 Diagnosis of DSM IV substance misuse or
dependence
 At least 10 hours contact with family or significant
carer
Random allocation N= 36
Integrated
treatment
9 months
Treatment as
usual
Treatment
Treatment consisted of :
- Motivational interviewing (first 5 sessions and then
integrated)
- Individual CBT (20-24 sessions)
- Family CBT (Between 10-16 sessions)
- All delivered over 9 months
Context:
- Mental health service treatment as usual
- Family support worker
General functioning
Global assessment functioning (GAF)
at 0, 9, 12 and 18m (p = 0.001)
62
60
58
56
CBT
N=15
54
52
Control
N=14
50
48
46
0m
9m
12m
18m
Positive psychotic symptoms
Mean PANSS positive score at 0, 9, 12
and 18m (ns)
18
17
16
15
CBT
N=15
14
Control
N=14
13
12
0m
9m
12m
18m
Negative symptoms
Mean PANSS negative score at 0, 9,
12 & 18 (p = 0.028)
17
16
15
14
CBT
N=15
13
Control
N=14
12
11
10
0m
9m
12m
18m
Relapses*
(No. of people relapsed by group)
9
12
18
months months months
CBT
5
Control 11
6
7
12
12
Relapse = symptom exacerbation lasting > 2 weeks
resulting in either hospitalisation or change in management
eg increase medication
Results: drugs and alcohol
(Time line follow back scores)
 The experimental group had more % days
abstinent from all substances over first 12
months (p =0.03)
 No differences in abstinence rates overall
between the groups at 18 months
*19
11
6
drug(s) + alcohol
alcohol only
drug(s) only
*Drug use: Cannabis (n = 22);
Amphetamines (n = 10);
Cocaine (n = 4); heroin (n = 4)
Health economy outcomes
 No significant cost differences between
experimental and control groups even when dose
of therapy accounted for
 Controls had more inpatient days
 Experimentals used more outpatient resources
 Support for ‘cost-effectiveness’ (i.e. cost small for significant
gains)
Conclusions
Positive:
 Intensive sustained treatment produced
encouraging outcomes from a
methodologically rigorous trial
 Low attrition in a group defined by
noncompliance (3 deaths; 1 drop out from
TAU)
Limitations:
 Small sample / low power
 Family status restricted sample
 Moderate impact on substance misuse
Stages of Change
Relapse
Maintenance
Action
Determination
Contemplation
Pre-contemplation
Many psychosis patients are
unmotivated to change their substance
use
patients with low motivation* to
change at start of study:
• 78% (n = 36) (Barrowclough et al,
2001)
•70- 49% (n = 106) (lower motivation,
less use) (Baker et al, 2002)
*precontemplative/contemplative
Problems for the therapist
Substance use may not appear on the problem list
Patient may be very ambivalent about “problem”
status of substance use
“…a failure to agree on a problem list dooms the
treatment”
Jacqueline Persons, p. 24
Challenges for the therapist
•Chaotic lifestyles and dissatisfaction with services
can make engagement problematic
•Aspects of psychosis make substance use very
functional eg
-ameliorating negative affects
-accessing pleasure in context of restricted life style
•Personal disadvantages less salient given have
multiple complex problems and level of substances
may be culturally “normal”
•Low self esteem/self efficacy for change
Model of maintenance of substance use in
psychosis
Availability&
Endorsement
By peers
psychosis
Medication
non- adherence
+
Learned
expectancies
of positive effects/
Coping functions
Negative
Affects
Beliefs
Experiences
+
External
stressors
Limited
range of
alternative
strategies
Internal
stressors
Substance
misuse
Integrated Motivational Interviewing
/Cognitive Behaviour Therapy

Many patients won’t identify substance use as
problematic

Aims to facilitate them making links between
key concerns & substance use

Assumes this may often be a slow process
with initial focus on engagement

RP needs to take account function of
substances (eg CBT for symptom management)

Intervention needs to be sufficiently flexible to
focus on other client led issues where initial
attempts to increase motivation for substance
reduction unsuccessful
Phases of integrated MI/CBT
1. Motivation building phase
1. Engagement
2. Elicit talk about concerns and life satisfactions
3
Elicit how substance use fits into life
4
Identify of how the psychosis fits into this picture
5 Share formulation of life concerns with the client
fitting together concerns/illness/substance use
6 Help motivate/consolidate motivation for the
client to reach an action stage of planned substance reduction
2 Action Phase
Committed
To change
Identify & develop
strategies for substance
reduction based on the
a shared formulation change plan and CBT
for RP including
symptom related
problems where
appropriate
Ambivalent
Precontemplative
Work on any aspect of
the formulation
acceptable to the client
& continue to use
motivational strategies
to highlight/link the
substance use to the
problem focus
Jack
 Aged 30, 6 year history of schizophrenia,
lives alone (previously married, has weekly
access for 2 small children), repeated
admissions and two serious suicide attempts
 Has been using alcohol regularly (over 80
units per week) for several years
 Regular cannabis use (12-20 cigs per week)
KEY SYMPTOMS
 Believes that the police are after him
because he committed a murder.
 Hears voices telling him he will be
punished.
 Very distressed by voices and fears of
police. Fearful to go out, spends most
time alone although does attempt to
spend access time with his children.
INITIAL CONCERNS (PROBLEM) LIST
(Things that Jack sees as a problem)






Difficulty going out / lack of social activity
Would like to do more with children
Arguments with ex wife and his mother
Fear of police / paranoia
Keeping out of hospital
Depression
Initial Motivational Interviewing>
contemplative
 Links alcohol to some bad consequences - makes
him depressed the next day and going to bed
makes him feel useless.
 Very ambivalent about cannabis - bad effects
(paranoia, fear of police attention) outweigh the
good (initial feelings of well-being, sharing with
friends) but lacks self efficacy for change.
 Fears that giving up drink will leave him with no
ways to cope with intense fears
Some willingness (discrepancy) , very low self
efficacy, substance reduction not the
highest priority
Highest priority - Going out /seeing children Primary Intervention focus
 Analysis of problems when out identified his fears
(paranoid delusions) as central
 Monitoring of fears highlighted relationship of fear
intensity to cannabis use
 Substance reduction linked to the highest priority
 Jack elected on a change plan for reduction in use
Going out /seeing children - next
steps
 Challenging of paranoid beliefs
 Graded exposure in a hierarchy of public situations
 Behavioural “experiments”
prevent hyper-vigilance)
(eg
distraction
to
 With reduction in distress & increased confidence,
planned reduction in alcohol
Intervention
 Integrated motivational interviewing & CBT
(lack of family not exclusion)
 26 sessions over 1year (anticipate variable
takeup > analyses of “dose” effects)
 Assertive outreach approach to appointment
scheduling – home based therapy
Design
Simple, two arm trial, random allocation of
400 patients :
Participants meeting
Inclusion criteria
Experimental intervention
Plus TAU
Treatment as usual
End of treatment
Assessment (12 months)
6 monthly
Substance use
assessment
Follow up
Assessment (24 months)
6 monthly
Substance use
assessment
To date 160 patients randomised (Nov 05)
Results…………………………..2009