Treatment of psychosis and substance misuse :development of the trial

1. 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

2. 2004 -2009 Medical Research Council/Department of Health funded Motivational Intervention forDrug and Alcohol use in Schizophrenia University of Manchester University of London Local NHS trusts

3. Content of Presentation • Briefly review background and • treatment literature • Describe Manchester study • Describe development of treatment model • Outline MIDAS trial

4. 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

5. 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

6. 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

7. 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

8. STAGES OF CHANGE (Prochaska & DiClimente) Not thinking about it (Pre-contemplation) Relapse Thinking about change (Contemplation) Maintenance Change (Action) Getting ready for change (Determination)

9. 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

10. 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

11. 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

12. Manchester studyBarrowclough 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?

13. 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

14. 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

15. General functioningGlobal assessment functioning (GAF) at 0, 9, 12 and 18m (p = 0.001)

16. Positive psychotic symptomsMean PANSS positive score at 0, 9, 12 and 18m (ns)

17. Negative symptomsMean PANSS negative score at 0, 9, 12 & 18 (p = 0.028)

18. Relapses*(No. of people relapsed by group) Relapse = symptom exacerbation lasting > 2 weeks resulting in either hospitalisation or change in management eg increase medication

19. 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 *Drug use: Cannabis (n = 22); Amphetamines (n = 10); Cocaine (n = 4); heroin (n = 4) *19 drug(s) + alcohol 11 alcohol only 6 drug(s) only

20. 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)

21. 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

22. Stages of Change Relapse Maintenance Action Determination Contemplation Pre-contemplation

23. 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

24. 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

25. 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

26. Model of maintenance of substance use in psychosis Availability& Endorsement By peers Learned expectancies of positive effects/ Coping functions + Negative Affects Beliefs Experiences Limited range of alternative strategies psychosis Substance misuse + Internal stressors Medication non- adherence External stressors

27. 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

28. 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

29. 2 Action Phase Committed To change Ambivalent Precontemplative Identify & develop strategies for substance reduction based on the a shared formulation - change plan and CBT for RP including symptom related problems where appropriate 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

30. 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)

31. 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.

32. 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

33. 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

34. 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

35. Going out /seeing children - next steps Challenging of paranoid beliefs Graded exposure in a hierarchy of public situations Behavioural “experiments” (eg distraction to prevent hyper-vigilance) With reduction in distress & increased confidence, planned reduction in alcohol

36. 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

37. Design Simple, two arm trial, random allocation of 400 patients : Participants meeting Inclusion criteria Treatment as usual Experimental intervention Plus TAU End of treatment Assessment (12 months) 6 monthly Substance use assessment 6 monthly Substance use assessment Follow up Assessment (24 months)

38. To date 160 patients randomised (Nov 05) Results…………………………..2009