Treatment of psychosis and substance misuse:development of the trial .


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Treatment of psychosis and substance misuse :development of the trial . Christine Barrowclough School of Psychological Sciences University of Manchester, UK christine.barrowclough@manchester.ac.uk. 2004 -2009. Medical Research Council/Department of Health funded.
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Treatment of psychosis and substance abuse :advancement of the trial Christine Barrowclough School of Psychological Sciences University of Manchester, UK christine.barrowclough@manchester.ac.uk

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2004 - 2009 Medical Research Council/Department of Health supported M otivational I ntervention for D floor covering and A lcohol use in S chizophrenia University of Manchester University of London Local NHS trusts

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Content of Presentation Briefly audit foundation and treatment writing Describe Manchester concentrate on Describe improvement of treatment model Outline MIDAS trial

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Acknowledgments MIDAS allow 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 group Ruth Johnson Gwen Alvey Sarah Jones Charlotte Hartley Laura Foster Anna Ruddle Karen Owens Alicia Picken

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Substance use in psychosis Prevalence : 30 - 60% past - year issue tranquilize or destructive liquor use in UK/US tests Correlates: Adverse effect on social working, emotional well-being, treatment results Clinical ramifications: Patient gathering displaying numerous difficulties to clinical groups

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Treatment approaches & assessment 1. Benefit assessment explore Integrating emotional well-being and substance utilize treatment conveyed simultaneously Focus on models of conveyance of various medicines in a pro administration Ingredients generally include: motivational mediations, self-assured effort, case administration, gather/singular treatment Mainly US concentrates however encouraging cases in UK eg COMPASS

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Treatment approaches & assessment 1. Benefit assessment explore cont\'d Evaluation methodologically troublesome: no confirmation that any treatment program is superior to anything treatment of course (surveys Drake et al 1998, Cochrane audit) KEY ISSUES HIGHLIGHTED: Emphasize significance of INTEGRATION of emotional wellness & substance utilize medicines And highlighted requirement for intercessions to MATCH STAGE OF CHANGE

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STAGES OF CHANGE (Prochaska & DiClimente ) Not considering it (Pre-thought) Relapse Thinking about change (Contemplation) Maintenance Change (Action) Getting prepared for change (Determination)

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Motivational Interviewing (Miller & Rollnick 2002) non judgemental, peaceful, intelligent, evoking style indecision is a typical focal wonder. it is imperative to comprehend the expenses and advantages - expect they are one of a kind to every person. the working through of indecision is a focal objective of Motivational Interviewing

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Treatment approaches & assessment: 2. Particular medicines :Brief mediations Focus on conveying a particular treatment bundle as an expansion to existing administration - less demanding to assess Treatments assessed - brief Motivational Interviewing/MI and Cognitive Behavior Therapy

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Treatment approaches & assessment: 2. Particular medicines :Brief motivational/MI in addition to CBT intercessions Kavanagh et al 2002 n = 25 psychosis inpatients - MI noteworthy diminishment substances But Kavenagh et al 2004 n = 86 MI/CBT 6 sessions - No effect on substances or side effects Baker et al, 2002 n = 160 psychiatric inpatients - One session of MI - Little effect Baker et al (in squeeze) N = 130 group psychosis test 10 sessions MI in addition to CBT-No effect substances or side effects

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Manchester think about Barrowclough et al, 2001, Haddock et al, 2004 Will a serious consolidated individual (MI in addition to CBT) and family treatment conveyed more than 9 months be useful for dually analyzed schizophrenia patients?

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Target test People with analysis of schizophrenia in contact with emotional wellness administrations Diagnosis of DSM IV substance abuse or reliance At minimum 10 hours contact with family or huge carer Random portion N= 36 Integrated treatment 9 months Treatment not surprisingly

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Treatment comprised of : - Motivational talking (initial 5 sessions and after that coordinated) - Individual CBT (20-24 sessions) - Family CBT (Between 10-16 sessions) - All conveyed more than 9 months Context: - Mental wellbeing administration treatment of course - Family bolster laborer

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General working Global appraisal working (GAF) at 0, 9, 12 and 18m (p = 0.001)

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Positive maniacal indications Mean PANSS constructive score at 0, 9, 12 and 18m (ns)

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Negative manifestations Mean PANSS contrary score at 0, 9, 12 & 18 (p = 0.028)

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Relapses* (No. of individuals backslid by gathering ) Relapse = manifestation worsening enduring > 2 weeks bringing about either hospitalization or change in administration eg increment pharmaceutical

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Results: medications and liquor (Time line take after back scores) The test aggregate had more % days abstinent from all substances over initial 12 months (p =0.03) No distinctions in forbearance rates in general between the gatherings at year and a half *Drug utilize: Cannabis (n = 22); Amphetamines (n = 10); Cocaine (n = 4); heroin (n = 4) *19 drug(s) + liquor 11 liquor just 6 drug(s) just

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Health economy results No critical cost contrasts amongst exploratory and control amasses notwithstanding when measurements of treatment represented Controls had more inpatient days Experimentals utilized more outpatient assets Support for \'cost-adequacy\'s (i.e. fetched little for noteworthy additions)

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Conclusions Positive: Intensive maintained treatment created empowering results from a methodologically thorough trial Low wearing down in a gathering characterized by rebelliousness (3 passings; 1 drop out from TAU) Limitations: Small example/low power Family status confined specimen Moderate effect on substance abuse

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Stages of Change Relapse Maintenance Action Determination Contemplation Pre-thought

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Many psychosis patients are unmotivated to change their substance utilize patients with low inspiration * to change at begin of study: 78% (n = 36) (Barrowclough et al, 2001) 70-49% (n = 106) (bring down inspiration, less utilize) (Baker et al, 2002) * precontemplative/scrutinizing

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Problems for the specialist Substance utilize may not show up on the issue list Patient might be extremely undecided about "issue" status of substance utilize "… an inability to concede to an issue list fates the treatment" Jacqueline Persons, p. 24

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Challenges for the advisor Chaotic ways of life and disappointment with administrations can make engagement dangerous Aspects of psychosis make substance utilize extremely utilitarian eg - improving adverse influences - getting to delight in setting of confined way of life Personal disservices less striking given have different complex issues and level of substances might be socially "ordinary" Low self regard/self adequacy for change

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Model of support of substance use in psychosis Availability& Endorsement By companions Learned anticipations of beneficial outcomes/Coping capacities + Negative Affects Beliefs Experiences Limited scope of option procedures psychosis Substance abuse + Internal stressors Medication non-adherence External stressors

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Integrated Motivational Interviewing/Cognitive Behavior Therapy Many patients won\'t recognize substance use as tricky Aims to encourage them making joins between key concerns & substance utilize Assumes this may regularly be a moderate procedure with starting spotlight on engagement RP needs to consider capacity of substances (eg CBT for manifestation administration) Intervention should be adequately adaptable to concentrate on other customer drove issues where introductory endeavors to build inspiration for substance diminishment unsuccessful

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Phases of incorporated MI/CBT 1. Inspiration building stage 1. Engagement 2. Inspire discuss concerns and life satisfactions 3 Elicit how substance utilize fits into life 4 Identify of how the psychosis fits into this picture 5 Share detailing of life worries with the client fitting together concerns/disease/substance utilize 6 Help spur/combine inspiration for the customer to achieve an activity phase of arranged substance diminishment

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2 Action Phase Committed To change Ambivalent Precontemplative Identify & create systems for substance lessening in view of the a common definition - change plan and CBT for RP including manifestation related issues where suitable Work on any part of the plan worthy to the customer & keep on using motivational methodologies to highlight/connect the substance use to the issue center

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Jack Aged 30, 6 year history of schizophrenia, lives alone (beforehand wedded, has week after week access for 2 little youngsters), rehashed affirmations and two genuine suicide endeavors Has been utilizing liquor consistently (more than 80 units for every week) for quite a while Regular cannabis utilize (12-20 cigs every week)

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KEY SYMPTOMS Believes that the police are after him since he conferred a murder. Hears voices letting him know he will be rebuffed. Extremely troubled by voices and fears of police. Dreadful to go out, invests most energy alone despite the fact that attempts to invest get to time with his youngsters.

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INITIAL CONCERNS (PROBLEM) LIST (Things that Jack sees as an issue) Difficulty going out/absence of social action Would get a kick out of the chance to accomplish more with kids Arguments with ex and his mom Fear of police/suspicion Keeping out of healing center Depression

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Initial Motivational Interviewing> scrutinizing Links liquor to some terrible outcomes - makes him discouraged the following day and going to bed

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