Patients in substance use disorder treatment: Motivation for behavioural change, co-occurring disorders and problem domains

Abstract

Denne avhandlingen undersøker kliniske karakteristika og faktorer ved pasientene som var i døgnbehandling for rusmiddelavhengighet.

Det empiriske materialet er basert på to bekvemmelighetsutvalg innsamlet på rusbehandlingsinstitusjoner i Midt-Norge. Materialet fra det første utvalget (N=95) er spørreskjemadata kombinert med deler av et strukturert intervju av pasienter på vei inn i behandling, og inkluderer oppfølging etter tre måned. Det andre (N=85) er et kryss-seksjonelt utvalg og data er fra spørreskjema besvart av pasienter i ferd med å avslutte sitt døgnopphold i rusbehandlingsinstitusjoner og av behandler fra institusjonen.

I denne studien fant vi ikke støtte for at instrumentet “University of Rhode Island Change Assessment (URICA)” er egnet til predikasjon av motivasjon til atferdsendring fra rusmiddelavhengighet i denne populasjonen, og konkluderer med at URICA derfor bør benyttes med varsomhet.

Motsatt konkluderer vi at “Symptom Check List 90-Revised (SCL-90-R)” er egnet til å undersøke symptomtrykk på psykiske lidelser på pasienter i rusbehandling. Og videre at komposittskåren fra “Global Severity Index (GSI)” er en egnet global indeks. Pasienter i ferd med å avslutte sitt behandlingsopphold hadde høyere gjennomsnittlig GSI-skåre enn et utvalg fra normalpopulasjonen.

Sammenligning av pasient og behandler rapportering om pasientens psykiske lidelser viste sammenfall i 72 prosent av tilfellene, til tross forskjeller i 24 av 85 av disse rapportene. Denne forskjellen var statistisk signifikant for affektive lidelser (p =.05) og personlighetsforstyrrelser (p =.02). Behandlerne vurderte alvorlighetsgraden av pasientenes mentale helse og rusmiddelbruk ved å anvende Kvadrantmodellen. De fleste pasientene (70%) ble vurdert til å ha høy alvorlighetsgrad i rusmiddelbruk og lav i psykiske problemer. En av fem pasienter ble imidlertid vurdert til å ha høy grad av alvorlighet i både rusmiddelbruk og psykiske problemer.

Rusbehandlingsinstitusjoner tilbyr hjelp på mange ulike problemområder. Det var også noen ulikheter i problemområder, opplevd utbytte av behandling og behandlingsintervensjoner mellom pasienter med og uten psykiske lidelser. Pasientene rapporterte at de var fornøyd med behandlingen de hadde mottatt.

Denne avhandlingen støtter viktigheten av at behandling for pasienter med rusmiddelavhengighet er multimodal, med individuelle tilpasninger der det er nødvendig.

The main purpose of the present thesis was to investigate factors associated with individuals in substance use disorder in-patient treatment and the treatment they received. The chosen factors were motivation and its predictive abilities related to the change of substance use behaviour, mental health, differences between self-reports and reports from treatment personnel related to substance use and psychiatric disorders, help with problem domains and treatment interventions in substance use disorder treatment, and perceived benefit from treatment. The results from this thesis are based on two convenient samples from substance use disorder clinics in Central Norway. Sample 1 (N = 95) is a sample where data are collected through a survey combined with an interview of patients about to enter substance use disorder treatment, with a follow-up three months after baseline. Sample 2 (N = 85) is a sample where a cross-sectional survey was carried out among patients about to end their inpatient stay at substance use disorder clinic and their treatment personnel. Sample 1 was used in paper I, while paper II-IV applied sample 2. Treating substance use disorder is challenging because patients often have many additional problems. Motivation is believed to be important to make individuals seek and stay in treatment. In paper I the University of Rhode Island Change Assessment (URICA) instrument was used to investigate whether motivation predicted if patients remained in treatment three months after baseline. The Readiness To Change (RTC) and Committed Action (CA) composite scores were used in order to explore this relation. The study did not find any evidence of a relationship between motivation measured with the use of RTC and CA and whether patients remained in treatment three months after baseline. The paper questions if the URICA instrument should be used as a measure of motivation among patients with substance use disorders. Many patients with a substance use disorder have co-occurring mental health problems. The research reported in paper II explored whether the Symptom Check List 90-Revised (SCL-90- R) instrument was suitable for assessing this pattern of comorbidity. No evidence was found to support the original nine-factor structure of the SCL-90-R. The instrument appears to have a uni-dimensional structure and using the Global Severity Index (GSI) appears to be a reasonable solution. Mean GSI scores were also used to investigate whether patients had more mental health problems than a sample from the general population in Norway. Participants who were about to end an in-patient treatment stay for substance use disorders had higher mean GSI scores than the general population, indicating that there were more psychiatric symptoms in this clinical substance use sample. The scores of GSI was also associated with self-reported psychiatric disorders and prescribed medication for mental illness, which also supports the discriminant validity of GSI on the SCL-90-R. Reports from patients and treatment personnel about psychiatric disorders and substance use and discrepancies between their reports were investigated in paper III. The study showed discrepancies between patients’ and treatment personnel’s assessments of patient’s mental health in 24 out of 85 patients. The discrepancy was statistically significant for affective and personality disorders. There was no significant discrepancy found between self-reported substance use and substance use disorders reported from treatment personnel. The treatment personnel were also asked to assess the severity of all patients’ mental health and substance use problems using the quadrant model. This model consists of four quadrants where individuals are categorized depending on the considered level (high or low) of severity in substance use and mental health. Most patients were assessed as having severe substance use problems and less severe mental health problems. However, one in five patients had severe mental health problems in addition to severe substance use problems. Paper IV explored the interventions used in in-patient treatment for substance use disorders, the problem domains for which patients received help, and in which problem domains they felt they had benefited from treatment. The most common interventions according to treatment personnel were interventions targeted to improve relationships with family and important others, applied relaxation techniques, psychodynamic therapy, cognitive behavioural therapy and motivational interviewing. Patients reported receiving most help in the domains of relapse prevention, physical health, daily functioning, relationships with others, psychological health and self-esteem. The patients reported benefiting most from physical activities, support from co-patients, group therapy, counseling, and assessment and treatment of psychological health problems. There were differences between patients with and without co-occurring disorders on several measures. Patients with co-occurring disorders were given more motivational interviewing and cognitive behavioural therapy interventions. They also reported receiving more help with their self-esteem and coping with psychiatric symptoms, and benefiting most from treatment of psychological health problems, acute help, and help with social situations than those without comorbid problems. In summary, findings in this thesis support that several psychological aspects are important in understanding and treating substance use disorders and co-occurring mental health problems. Among the variables of importance are general distress, psychological and physical health, and social support. Motivation is also perceived to be of importance, but the relation between motivation and change in substance use behaviour got inconclusive support when assessed by the URICA in this thesis. Patients with co-occurring disorders received some differential treatment. This thesis supports the significance of targeting multiple problem domains to all patients, with individual adjustments when necessary. The findings from this thesis support the important of implementing the national guideline for assessment, treatment and rehabilitation of persons with co-occurring substance use disorders and psychiatric disorders.