BACKGROUND: Even low levels of substance misuse by people with a severe mental illness can have detrimental effects.
OBJECTIVES: To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care.
SEARCH METHODS: The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases.
SELECTION CRITERIA: We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness.
DATA COLLECTION AND ANALYSIS: Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison.
MAIN RESULTS: Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence).
AUTHORS' CONCLUSIONS: We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.
BACKGROUND: Intensive Case Management (ICM) is a community-based package of care aiming to provide long-term care for severely mentally ill people who do not require immediate admission. Intensive Case Management evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (fewer than 20) and high-intensity input.
OBJECTIVES: To assess the effects of ICM as a means of caring for severely mentally ill people in the community in comparison with non-ICM (caseload greater than 20) and with standard community care. We did not distinguish between models of ICM. In addition, to assess whether the effect of ICM on hospitalisation (mean number of days per month in hospital) is influenced by the intervention's fidelity to the ACT model and by the rate of hospital use in the setting where the trial was conducted (baseline level of hospital use).
SEARCH METHODS: We searched the Cochrane Schizophrenia Group's Trials Register (last update search 10 April 2015).
SELECTION CRITERIA: All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community care setting, where ICM is compared to non-ICM or standard care.
DATA COLLECTION AND ANALYSIS: At least two review authors independently selected trials, assessed quality, and extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated mean difference (MD) between groups and its 95% CI. We employed a random-effects model for analyses.We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect. We assessed overall quality for clinically important outcomes using the GRADE approach and investigated possible risk of bias within included trials.
MAIN RESULTS: The 2016 update included two more studies (n = 196) and more publications with additional data for four already included studies. The updated review therefore includes 7524 participants from 40 randomised controlled trials (RCTs). We found data relevant to two comparisons: ICM versus standard care, and ICM versus non-ICM. The majority of studies had a high risk of selective reporting. No studies provided data for relapse or important improvement in mental state.1. ICM versus standard careWhen ICM was compared with standard care for the outcome service use, ICM slightly reduced the number of days in hospital per month (n = 3595, 24 RCTs, MD -0.86, 95% CI -1.37 to -0.34,low-quality evidence). Similarly, for the outcome global state, ICM reduced the number of people leaving the trial early (n = 1798, 13 RCTs, RR 0.68, 95% CI 0.58 to 0.79, low-quality evidence). For the outcome adverse events, the evidence showed that ICM may make little or no difference in reducing death by suicide (n = 1456, 9 RCTs, RR 0.68, 95% CI 0.31 to 1.51, low-quality evidence). In addition, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment due to very low-quality evidence (n = 1129, 4 RCTs, RR 0.70, 95% CI 0.49 to 1.0, very low-quality evidence).2. ICM versus non-ICMWhen ICM was compared with non-ICM for the outcome service use, there was moderate-quality evidence that ICM probably makes little or no difference in the average number of days in hospital per month (n = 2220, 21 RCTs, MD -0.08, 95% CI -0.37 to 0.21, moderate-quality evidence) or in the average number of admissions (n = 678, 1 RCT, MD -0.18, 95% CI -0.41 to 0.05, moderate-quality evidence) compared to non-ICM. Similarly, the results showed that ICM may reduce the number of participants leaving the intervention early (n = 1970, 7 RCTs, RR 0.70, 95% CI 0.52 to 0.95,low-quality evidence) and that ICM may make little or no difference in reducing death by suicide (n = 1152, 3 RCTs, RR 0.88, 95% CI 0.27 to 2.84, low-quality evidence). Finally, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment as compared to non-ICM (n = 73, 1 RCT, RR 1.46, 95% CI 0.45 to 4.74, very low-quality evidence).3. Fidelity to ACTWithin the meta-regression we found that i.) the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36, 95% CI -0.66 to -0.07); and ii.) the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20, 95% CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but the 'baseline hospital use' result still significantly influences time in hospital (regression coefficient -0.18, 95% CI -0.29 to -0.07, P = 0.0027).
AUTHORS' CONCLUSIONS: Based on very low- to moderate-quality evidence, ICM is effective in ameliorating many outcomes relevant to people with severe mental illness. Compared to standard care, ICM may reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. Intensive Case Management is at least valuable to people with severe mental illnesses in the subgroup of those with a high level of hospitalisation (about four days per month in past two years). Intensive Case Management models with high fidelity to the original team organisation of ACT model were more effective at reducing time in hospital.However, it is unclear what overall gain ICM provides on top of a less formal non-ICM approach.We do not think that more trials comparing current ICM with standard care or non-ICM are justified, however we currently know of no review comparing non-ICM with standard care, and this should be undertaken.
BACKGROUND: Current guidance suggests that we should monitor the physical health of people with serious mental illness, and there has been a significant financial investment over recent years to provide this.
OBJECTIVES: To assess the effectiveness of physical health monitoring, compared with standard care for people with serious mental illness.
SEARCH METHODS: We searched the Cochrane Schizophrenia Group Trials Register (October 2009, update in October 2012), which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO.
SELECTION CRITERIA: All randomised clinical trials focusing on physical health monitoring versus standard care, or comparing i) self monitoring versus monitoring by a healthcare professional; ii) simple versus complex monitoring; iii) specific versus non-specific checks; iv) once only versus regular checks; or v) different guidance materials.
DATA COLLECTION AND ANALYSIS: Initially, review authors (GT, AC, SM) independently screened the search results and identified three studies as possibly fulfilling the review's criteria. On examination, however, all three were subsequently excluded. Forty-two additional citations were identified in October 2012 and screened by two review authors (JX and MW), 11 of which underwent full screening.
MAIN RESULTS: No relevant randomised trials which assess the effectiveness of physical health monitoring in people with serious mental illness have been completed. We identified one ongoing study.
AUTHORS' CONCLUSIONS: There is still no evidence from randomised trials to support or refute current guidance and practice. Guidance and practice are based on expert consensus, clinical experience and good intentions rather than high quality evidence.
BACKGROUND: There is currently much focus on provision of general physical health advice to people with serious mental illness and there has been increasing pressure for services to take responsibility for providing this.
OBJECTIVES: To review the effects of general physical healthcare advice for people with serious mental illness.
SEARCH METHODS: We searched the Cochrane Schizophrenia Group's Trials Register (last update search October 2012) which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO and registries of Clinical Trials. There is no language, date, document type, or publication status limitations for inclusion of records in the register.
SELECTION CRITERIA: All randomised clinical trials focusing on general physical health advice for people with serious mental illness..
DATA COLLECTION AND ANALYSIS: We extracted data independently. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. We employed a fixed-effect model for analyses. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE.
MAIN RESULTS: Seven studies are now included in this review. For the comparison of physical healthcare advice versus standard care we identified six studies (total n = 964) of limited quality. For measures of quality of life one trial found no difference (n = 54, 1 RCT, MD Lehman scale 0.20, CI -0.47 to 0.87, very low quality of evidence) but another two did for the Quality of Life Medical Outcomes Scale - mental component (n = 487, 2 RCTs, MD 3.70, CI 1.76 to 5.64). There was no difference between groups for the outcome of death (n = 487, 2 RCTs, RR 0.98, CI 0.27 to 3.56, low quality of evidence). For service use two studies presented favourable results for health advice, uptake of ill-health prevention services was significantly greater in the advice group (n = 363, 1 RCT, MD 36.90, CI 33.07 to 40.73) and service use: one or more primary care visit was significantly higher in the advice group (n = 80, 1 RCT, RR 1.77, CI 1.09 to 2.85). Economic data were equivocal. Attrition was large (> 30%) but similar for both groups (n = 964, 6 RCTs, RR 1.11, CI 0.92 to 1.35). Comparisons of one type of physical healthcare advice with another were grossly underpowered and equivocal.
AUTHORS' CONCLUSIONS: General physical health could lead to people with serious mental illness accessing more health services which, in turn, could mean they see longer-term benefits such as reduced mortality or morbidity. On the other hand, it is possible clinicians are expending much effort, time and financial resources on giving ineffective advice. The main results in this review are based on low or very low quality data. There is some limited and poor quality evidence that the provision of general physical healthcare advice can improve health-related quality of life in the mental component but not the physical component, but this evidence is based on data from one study only. This is an important area for good research reporting outcome of interest to carers and people with serious illnesses as well as researchers and fundholders.
OBJECTIVE: To present a systematic review of the evaluation of randomized interventions directed toward improving somatic health for patients with severe mental illness (SMI).
METHOD: A systematic search in PubMed, Embase, Cinahl, and PsycInfo was performed. The scope of the search was prospective studies for patients aged 18-70, published from January 2000 till June 2011. Randomized interventions directed toward improving somatic health for patients with SMI were selected. We excluded studies on elderly, children, and studies performed before 2000. Information on population, type of intervention, follow-up, outcome measures, and on authors' conclusions were drawn from the original articles.
RESULTS: Twenty-two original studies were included, presenting four types of interventions: health education (n = 9), exercise (n = 6), smoking cessation (n = 5), and changes in health care organization (n = 2). To evaluate the effect of these studies 93 different outcome measures were used in 16 categories.
CONCLUSION: Many interventions directed toward improving somatic health for patients with SMI have been started. These studies did not apply similar evaluations, and did not use uniform outcome measures of the effect of their interventions. Valuable comparisons on effectiveness are therefore almost impossible.
OBJECTIVES: Individuals with serious mental illness (SMI) have excess mortality from cardiovascular disease (CVD) and high rates of CVD risk factors such as diabetes, obesity, and hyperlipidemia. We conducted a systematic review to evaluate interventions to improve CVD risk factors in adults with SMI.
DATA SOURCES: We searched PubMed(®), Embase(®), PsycINFO(®), and the Cochrane Database of Systematic Reviews for English-language trials published since 1980 that evaluated patient-focused behavioral interventions, peer or family support interventions, pharmacological treatments, and multicondition lifestyle interventions, or their combination, that targeted weight control, glucose levels, lipid levels, or CVD risk profile among adults with SMI at elevated risk of CVD.
REVIEW METHODS: Two investigators screened each abstract and full-text article for inclusion, abstracted data, and performed quality ratings, efficacy–effectiveness ratings, and evidence grading. Qualitative and quantitative methods, using random-effects models, were used to summarize results.
RESULTS: Of 35 eligible studies, most enrolled patients with schizophrenia who were prescribed antipsychotics. Most studies were designed to control weight (n=28); one study specifically addressed diabetes management, none targeted hyperlipidemia, and three were multicondition interventions. Most studies were efficacy trials comparing behavioral interventions with control; none evaluated peer and family support. There were few direct comparisons of active interventions; effects on overall CVD risk, physical functioning, or cardiovascular events were reported rarely. Compared with controls, behavioral interventions (mean difference [MD] −3.13 kg; 95% CI, −4.21 to −2.05), metformin (MD −4.13 kg; CI, −6.58 to −1.68), the anticonvulsive medications topiramate and zonisamide (MD −5.11kg; CI, −9.48 to −0.74), and adjunctive or antipsychotic switching to aripiprazole improved weight control. However, aripiprazole switching may be associated with higher rates of treatment failure. Nizatidine did not improve any outcome. The evidence was insufficient for all other interventions and effects on glucose and lipid control.
CONCLUSIONS: Few studies have evaluated interventions to address one or more CVD risk factors in patients with SMI. Comparative effectiveness studies are needed to test multimodal strategies, agents known to be effective in non-SMI populations, and antipsychotic-management strategies.
OBJECTIVE: To evaluate the efficacy of non-pharmacological interventions for antipsychotic-associated weight gain.
METHODS: Systematic literature search and meta-analysis of randomized controlled trials comparing behavioral interventions with control groups to ameliorate antipsychotic-associated weight gain.
RESULTS: Across 17 studies (n=810, mean age: 38.8 years, 52.7% male, 40.8% White, 85.6% with schizophrenia-spectrum disorders), non-pharmacological interventions led to a significant reduction in weight (-3.12 kg; CI: -4.03, -2.21, p<0.0001) and body mass index (BMI) (-0.94 kg/m²; CI: -1.45, -0.43, p=0.0003) compared with control groups. Intervention benefits extended to all secondary outcomes, except for high density-lipoprotein-cholesterol and systolic blood pressure. Compared to controls, intervention patients experienced significant decreases in waist circumference (WMD=-3.58 cm, CI: -5.51, -1.66, p=0.03), percent body fat (WMD=-2.82%, CI: -5.35, -0.30, p=0.03), glucose (WMD=-5.79 mg/dL, CI: -9.73, -1.86, p=0.004), insulin (WMD=-4.93 uIU/mL, CI: -7.64, -2.23, p=0.0004), total cholesterol (WMD=-20.98 mg/dL, CI: -33.78, -8.19; p=0.001), low density-lipoprotein-cholesterol (WMD=-22.06 mg/dL, CI: -37.80, -6.32, p=0.006) and triglycerides (WMD=-61.68 mg/dL, CI: -92.77, -30.59, p=0.0001), and less weight gain >7% (29.7% vs. 61.3%; RR=-0.52, CI: -0.35, -0.78, p=0.002; number-needed-to-treat=4). Up to 12 months after the intervention ended (mean=3.6 months), benefits endured regarding weight (WMD=-3.48 kg, CI: -6.37, -0.58, p=0.02), but not BMI (p=0.40). Subgroup analyses showed superiority of non-pharmacological interventions irrespective of treatment duration, individual or group, cognitive behavioral or nutritional interventions, or prevention versus intervention trials. However, weight and BMI were significantly improved only in outpatient trials (p<0.0001), but not in inpatient or mixed samples (p=0.09-0.96).
CONCLUSION: Behavioral interventions effectively prevented and reduced antipsychotic-associated weight gain and cardiometabolic perturbations, at least in outpatients agreeing to participate in trials aimed at improving physical health. Effective treatments ranged from nutritional interventions to cognitive behavioral therapy.
BACKGROUND: There is a high prevalence of overweight and obesity in persons with severe mental disorders and this has serious implications on the short and long term health outcomes of these patients. The aim of this review was to evaluate the effectiveness of lifestyle interventions targeting physical activity and eating habits in persons with severe mental disorders. Special attention was given if any of the included studies in the review also examined the cost-effectiveness of these health promotion interventions.
METHODS: A systematic search through the electronic databases Medline, Web of Science, CINAHL and Cohrane Library was conducted, and by hand-searching the reference lists of the retrieved articles from the electronic databases. Studies were included if they examined effectiveness and/or cost-effectiveness of lifestyle interventions targeting physical activity and eating habits in persons with severe mental disorders, with primary outcome changes in Body Mass Index and body weight.
RESULTS: Fourteen studies met the inclusion criteria. Weight loss and Body Mass Index decrease were observed in intervention groups in 11 studies. The difference in weight change between intervention and control groups was statistically significant in nine studies. Differences in mean Body Mass Index between intervention and control groups were statistically significant in eight studies. Five studies reported improvements in quality of life and general health. In none of the studies cost-effectiveness of lifestyle interventions was examined.
CONCLUSION: Further research on both effectiveness and cost-effectiveness of lifestyle interventions targeting physical activity and eating habits in persons with severe mental disorders is required to assist in the development of new health promotion interventions in this population.
Objective: The promotion of healthy lifestyles among persons with serious mental illness is an integral part of their recovery. The aims of this systematic literature review were to rate the methodological quality of lifestyle intervention outcome studies for persons with serious mental illness, summarize intervention strategies, examine physical health outcomes, and evaluate the inclusion of racial and ethnic minority groups in these studies. Methods: Electronic bibliographic database searches were performed to locate studies conducted in the United States. Articles written in English and published in peer-reviewed journals between 1980 and 2009 were included. The authors used a standardized instrument to rate studies' methodological quality. Results: Twenty-three articles were reviewed. Based on studies' methodological quality, three levels of evidence were found: single-group reports, quasi-experimental studies, and randomized controlled trials. Most interventions used behavioral techniques to improve dietary habits and increase physical activity. Twelve studies reported significant improvements in either weight loss or metabolic syndrome risk factors associated with receiving a lifestyle intervention. Persons from racial and ethnic minority groups were underrepresented, especially Hispanics and Asian Americans. Only one study included non-English-speaking participants. Conclusions: Lifestyle interventions adapted to persons with serious mental illness show promise in reducing weight loss and some risk factors for metabolic syndrome. The underrepresentation of persons from racial or ethnic minority groups in this literature limits its generalizability. Implications for research and practice are discussed.
BACKGROUND: Antipsychotic medication is the cornerstone of schizophrenia treatment. The impact of long-term exposure to antipsychotics on life-expectancy has recently received some attention, partly because awareness is increasing of the differential mortality of people with schizophrenia and the general population.
METHODS: A systematic review of studies assessing the association between antipsychotic exposure and mortality in persons with schizophrenia was undertaken.
RESULTS: In total, 12 studies met the inclusion criteria. Three out of five studies examining antipsychotic dosage and higher mortality showed a significant association for one or more antipsychotics. Two out of four found negative effects of antipsychotic polypharmacy on life-expectancy. Some studies found a lower cardiovascular mortality risk with higher treatment intensity or when comparing current versus past or non-use of antipsychotics. Others established a stable correlation between antipsychotic exposure and an increase in cardiovascular mortality. Evidence for differential effects on mortality in favor of second generation (SGA) compared to first generation antipsychotics was inconsistent. No study of SGA drugs had a sufficient follow-up time. A major confounding factor may be a higher risk factor load for somatic disorders in the most severely mentally ill.
CONCLUSION: There is some evidence that long-term exposure to antipsychotics increases mortality in schizophrenia. More rigorously designed, prospective studies are urgently needed.
Even low levels of substance misuse by people with a severe mental illness can have detrimental effects.
OBJECTIVES:
To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care.
SEARCH METHODS:
The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases.
SELECTION CRITERIA:
We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness.
DATA COLLECTION AND ANALYSIS:
Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison.
MAIN RESULTS:
Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence).
AUTHORS' CONCLUSIONS:
We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.
