Services Research: Psychiatric Comorbidity in Drug Abuse

描述(由申请人提供)： 药物滥用治疗包括每日适量的美沙酮和每周的咨询，在控制阿片类药物依赖的普遍和破坏性症状方面通常是有效的(例如，Simpson&Sales，1990)。二十多年的治疗研究也表明，至少对许多不幸的患者来说，共病精神障碍的存在对这种治疗方式的整体有效性产生了不利影响(King等人，2001年；Rounaville等人，1986年)。对解决这一严重健康问题抱有很大希望的干预措施，最终必须改变这样一个事实，即这些患者中的大多数人没有得到任何精神护理--即使是在药物滥用计划之外的普通精神科环境中也是如此。极差的患者对精神护理的依从性是一个跨患者、跨项目和跨国家的主要卫生服务问题(例如，Thompson等人，2000)。减少这些吸毒者因未经治疗的精神障碍而不必要地高发病率而导致依从性差的一个有希望的办法是完全综合的服务提供办法。使用综合护理模式，患有共病障碍的吸毒者可以通过药物滥用计划获得广泛的标准精神科服务。虽然实践者和研究人员称赞药物滥用和精神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，Ley等人，2001)。更重要的是，这些研究中的大多数都是在一般精神科与药物滥用方案中进行的，少数在药物滥用环境中进行的研究没有使用随机分配来评估现场与非现场服务对依从性或结果的影响；除了一项研究(Saxon等人，1995年)外，所有这些研究都提供的服务范围非常窄。这项拟议的工作将是已知的第一次对药物滥用和标准精神治疗方案提供的综合药物滥用和精神治疗方法的有效性进行随机评估。研究参与者将是396名目前有精神障碍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。采用两组析因设计，参与者将被随机分配到综合药物滥用和精神治疗条件(ISAP-集成)或平行物质滥用和精神治疗条件(PSAP-并行)。ISAP病症的参与者将在ATS计划中获得标准的精神护理；那些被分配到PSAP病症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。标准精神科服务的范围和数量将在不同的治疗地点(ATS和CPP)相同；所有药物滥用服务都将在ATS计划中提供。参与者将在12个月的时间内接受评估，并在一系列遵守和结果衡量标准上进行比较：最初接受精神治疗的比率和对精神服务(治疗过程和处方药)的总体坚持程度，坚持定期药物滥用治疗服务的比率，以及一系列客观和自我报告的精神和药物滥用治疗结果，包括高成本强化门诊精神治疗、急性住院精神疾病住院和因精神或药物滥用问题而前往急诊室就诊的使用率。这项研究将及时和科学地提供关于药物滥用计划中精神和药物滥用综合治疗有效性的卫生服务研究数据；这项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定提供信息和指导，这些讨论和决定将影响药物滥用和精神健康服务的组织和资金。

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.