Services Research: Psychiatric Comorbidity in Drug Abuse

描述（由申请人提供）： 药物滥用治疗，包括足够剂量的每日美沙酮和每周咨询，通常是有效的管理阿片类药物依赖的普遍和破坏性的症状（例如，Simpson & Sells，1990）。超过二十年的治疗研究还表明，共病精神障碍的存在对这种治疗方式的总体有效性产生不利影响，至少对于这些不幸的患者中的许多人而言（King等人，2001; Rounsaville等人，1986年）。有希望解决这一严重健康问题的干预措施必须最终改变这样一个事实，即大多数这些患者未能接受任何精神病护理-即使是在药物滥用计划之外的普通精神病环境中。患者对精神病护理的依从性极差是一个主要的卫生服务问题，涉及患者、项目和国家（例如，Thompson等人，2000年）。一种有希望的办法是采取全面综合的服务提供办法，减少使这些药物滥用者因未经治疗的精神疾病而遭受不必要的高发病率的不良坚持情况。使用一个综合的护理模式，药物滥用者与共病障碍可以提供广泛的标准精神病服务与药物滥用计划。虽然从业者和研究人员颂扬药物滥用和精神病护理综合系统的优点，但令人惊讶的是，很少有对照研究来评估这种方法的有效性（例如，Drake等人，1996年，Ley等人，2001年）。更重要的是，这些研究中的大多数是在一般精神病与药物滥用项目中进行的，并且在药物滥用环境中进行的少数研究没有使用随机分配来评估现场服务与非现场服务对依从性或结果的影响;除了一项研究之外，所有这些研究（Saxon等人，1995年）提供的服务范围很窄。拟议的工作将是第一个已知的综合药物滥用和标准精神病治疗方法的有效性随机评估提供了一个药物滥用计划。研究参与者将是396名目前患有精神疾病的阿片类药物滥用者;所有人都将是成瘾服务治疗计划（ATS）的新入院者。使用两组析因设计，将受试者随机分配至综合药物滥用和精神病护理条件（ISAP-Integrated）或平行药物滥用和精神病护理条件（PSAP-平行）。ISAP条件的参与者将在ATS计划中获得标准的精神病护理;那些分配到PSAP条件的参与者将在位于同一校园的社区精神病学计划（CPP）中获得护理。各治疗中心（ATS和CPP）的标准精神科服务的范围和数量相同;所有药物滥用服务将在ATS项目中提供。参与者将在12个月内接受评估，并在一系列依从性和结局指标上进行比较：初次接受精神病护理的比率和对精神病服务的总体坚持率（治疗疗程和处方药物）、对预定药物滥用治疗服务的依从性以及一系列客观和自我报告的精神病和药物滥用治疗结果，包括高成本密集流动精神病护理、急性精神病住院治疗和因精神病或药物滥用问题而到急诊室就诊的使用率。本研究将产生及时和科学严谨的卫生服务研究数据，以了解药物滥用项目中综合精神病和药物滥用治疗的有效性;本研究的数据将为治疗领域以及地方和国家卫生保健讨论和决策提供信息和指导，这些讨论和决策将影响药物滥用和精神卫生服务的组织和资金。

DESCRIPTION (provided by applicant): Drug abuse treatment that incorporates adequate doses of daily methadone and weekly counseling is usually effective in managing the pervasive and devastating symptoms of opioid dependence (e.g., Simpson & Sells, 1990). Over two-decades of treatment research has also shown that the presence of a comorbid psychiatric disorder adversely impacts the overall effectiveness of this treatment modality, at least for many of these unfortunate patients (King et al., 2001; Rounsaville et al., 1986). Interventions with much hope of resolving this serious health problem must ultimately change the fact that most of these patients fail to receive any psychiatric care -- even when referred to general psychiatric settings outside of the drug abuse program. The extremely poor patient adherence to psychiatric care is a major health services problem that reaches across patients, programs and countries (e.g., Thompson et al., 2000). One promising approach to reducing the poor adherence that exposes these drug abusers to unnecessarily high levels of morbidity from untreated psychiatric disorders is a fully integrated service delivery approach. Using an integrated model of care, drug abusers with a comorbid disorder could be offered a broad range of standard psychiatric services with the drug abuse program. While practitioners and researchers extol the virtues of integrated systems of drug abuse and psychiatric care, amazingly few controlled studies have been done to evaluate the efficacy of this approach (e.g., Drake et al., 1996, Ley et al., 2001). More importantly, most of these studies were conducted in general psychiatric versus drug abuse programs, and the small number done in drug abuse settings did not use random assignment to evaluate the influence of on- versus off-site services on adherence or outcomes; and all but one of these studies (Saxon et al., 1995) offered a very narrow range of services. The proposed work will be the first known randomized evaluation of the effectiveness of an integrated drug abuse and standard psychiatric treatment approach delivered a drug abuse program. Study participants will be 396 opioid abusers with a current psychiatric disorder; all will be new admissions to the Addiction Services Treatment program (ATS). Using a two-group factorial design, participants will be randomly assigned to either the Integrated Substance Abuse and Psychiatric Care condition (ISAP-Integrated) or the Parallel Substance Abuse and Psychiatric Care condition (PSAP-Parallel). Participants in the ISAP condition will be offered standard psychiatric care in the ATS program; those assigned to the PSAP condition will be offered care in the Community Psychiatry Program (CPP), located on the same campus. The scope and amount of standard psychiatric services will be the same across treatment sites (ATS and CPP); all drug abuse services will be provided in the ATS program. Participants will be evaluated over a 12- month period and compared on a range of adherence and outcome measures: rates of initial engagement in psychiatric care and overall adherence to psychiatric services (therapy sessions and prescribed medications), adherence to scheduled drug abuse treatment services, and a range of objective and self-reported psychiatric and drug abuse treatment outcomes, including utilization rates of high cost intensive ambulatory psychiatric care, acute inpatient psychiatric hospitalization, and emergency room visits for psychiatric or drug abuse problems. This study will produce both timely and scientifically rigorous health services research data on the effectiveness of integrated psychiatric and drug abuse treatment in a drug abuse program; data from this study will inform and guide the treatment field and both local and national health care discussions and decisions that will impact the organization and funding of drug abuse and mental health services.