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.
Antecedentes: El manejo intensivo de casos (MCI) es un paquete comunitario de atención con el objetivo de brindar atención a largo plazo a personas con trastornos mentales graves que no requieren la admisión inmediata. El Manejo Intensivo de Casos evolucionó a partir de dos modelos originales de cuidado de la comunidad, el Tratamiento Asertivo Comunitario (ACT) y el Manejo de Casos (CM), donde ICM enfatiza la importancia del pequeño número de casos (menos de 20) y la entrada de alta intensidad. OBJETIVOS: Evaluar los efectos de la ICM como un medio para cuidar de personas con enfermedades mentales graves en la comunidad en comparación con los no-ICM (número de casos superior a 20) y con atención comunitaria estándar. No distinguimos entre modelos de ICM. Además, para evaluar si el efecto de la ICM en la hospitalización (número medio de días por mes en el hospital) está influenciado por la fidelidad de la intervención al modelo ACT y por la tasa de uso hospitalario en el lugar donde se realizó el ensayo (nivel basal Del uso hospitalario). Métodos de búsqueda: Se realizaron búsquedas en el Registro de Ensayos del Grupo Cochrane de Esquizofrenia (Cochrane Schizophrenia Group) (última actualización de búsqueda 10 de abril de 2015). CRITERIOS DE SELECCIÓN: Todos los ensayos clínicos aleatorios relevantes que se centran en las personas con enfermedad mental grave, de 18 a 65 años de edad y tratados en el entorno de atención comunitaria, donde se compara la ICM con la atención no-ICM o estándar. Recopilación y análisis de datos: Al menos dos revisores seleccionaron de forma independiente los ensayos, evaluaron la calidad y extrajeron los datos. Para los resultados binarios, se calculó la razón de riesgo (RR) y su intervalo de confianza del 95% (IC), en una intención de tratar la base. Para los datos continuos, se estimó la diferencia de medias (MD) entre los grupos y su IC del 95%. Se utilizó un modelo de efectos aleatorios para análisis. Se realizó un análisis de meta-regresión de efectos aleatorios para examinar la asociación de la fidelidad de la intervención al modelo ACT y la tasa de uso hospitalario en el entorno donde se realizó el ensayo con el efecto del tratamiento . Evaluamos la calidad general de los resultados clínicamente importantes usando el enfoque GRADE e investigamos el posible riesgo de sesgo dentro de los ensayos incluidos. La actualización de 2016 incluyó dos estudios más (n = 196) y más publicaciones con datos adicionales para cuatro estudios ya incluidos. La revisión actualizada, por lo tanto, incluye 7524 participantes de 40 ensayos controlados aleatorios (ECA). Encontramos datos relevantes para dos comparaciones: ICM versus atención estándar, y ICM versus no-ICM. La mayoría de los estudios tenían un alto riesgo de notificación selectiva. Ningún estudio proporcionó datos para la recaída o una mejora importante en el estado mental. ICM frente a la atención estándar Cuando se comparó la ICM con la atención estándar para el uso de servicios de resultado, ICM redujo ligeramente el número de días en el hospital por mes (n = 3595, 24 ECA, MD -0,86, IC 95% -1,37 a -0,34, Pruebas de calidad). Del mismo modo, para el estado global de resultados, la ICM redujo el número de personas que abandonaron el estudio con anticipación (n = 1798, 13 ECA, RR 0,68, IC del 95%: 0,58 a 0,79, evidencia de baja calidad). Para los eventos adversos de resultado, la evidencia mostró que ICM puede hacer poca o ninguna diferencia en la reducción de la muerte por suicidio (n = 1456, 9 ECA, RR 0,68, IC del 95%: 0,31 a 1,51, evidencia de baja calidad). Además, para el funcionamiento social del resultado, hubo incertidumbre sobre el efecto de la ICM en el desempleo debido a pruebas de muy baja calidad (n = 1129, 4 ECA, RR 0,70, IC del 95%: 0,49 a 1,0, evidencia de muy baja calidad) .2. ICM versus no ICM Cuando se comparó ICM con no-ICM para el uso del servicio de resultados, hubo pruebas de calidad moderada que ICM probablemente hace poca o ninguna diferencia en el número promedio de días en el hospital por mes (n = 2220, 21 ECA, MD -0,08, IC del 95%: -0,37 a 0,21, evidencia de calidad moderada) o en el número promedio de admisiones (n = 678, 1 RCT, MD -0,18, IC del 95%: -0,41 a 0,05, A no-ICM. Del mismo modo, los resultados mostraron que la ICM puede reducir el número de participantes que abandonan la intervención tempranamente (n = 1970, 7 ECA, RR 0,70, IC del 95%: 0,52 a 0,95, evidencia de baja calidad) y que ICM puede hacer poca o ninguna diferencia en Reduciendo la muerte por suicidio (n = 1152, 3 ECA, RR 0,88, IC del 95%: 0,27 a 2,84, evidencia de baja calidad). Por último, para el funcionamiento social de los resultados, hubo incertidumbre sobre el efecto de la ICM sobre el desempleo en comparación con los no ICM (n = 73, 1 ECA, RR 1,46, IC del 95% 0,45 a 4,74, evidencia de muy baja calidad) . La fidelidad a la ACT en la meta-regresión encontró que i.) Cuanto más ICM es adherente al modelo de ACT, mejor es en la disminución del tiempo en el hospital (coeficiente de la "fidelidad de la organización" -0.36, IC del 95% -0.66 a -0.07 ); Y ii.) Cuanto mayor es el uso hospitalario de referencia en la población, mejor ICM se encuentra en la disminución del tiempo en el hospital (coeficiente variable de "uso hospitalario de referencia" -0.20; IC del 95%: -0.32 a -0.10). Al combinar ambas variables dentro del modelo, la "fidelidad de la organización" ya no es significativa, pero el resultado del "uso básico del hospital" todavía influye significativamente en el tiempo en el hospital (coeficiente de regresión -0,18; IC del 95%: -0,29 a -0,07; P = 0,0027) . CONCLUSIONES DE LOS AUTORES: Basado en evidencia de muy baja a moderada calidad, la MCI es eficaz para mejorar muchos resultados relevantes para las personas con enfermedad mental severa. En comparación con la atención estándar, ICM puede reducir la hospitalización y aumentar la retención en la atención. También mejoró globalmente el funcionamiento social, aunque el efecto de ICM sobre el estado mental y la calidad de vida sigue siendo poco claro. El manejo intensivo de casos es al menos valioso para las personas con enfermedades mentales severas en el subgrupo de aquellos con un alto nivel de hospitalización (alrededor de cuatro días al mes en los últimos dos años). Los modelos de gestión de casos intensivos con alta fidelidad a la organización original del equipo de ACT fueron más eficaces en la reducción del tiempo en el hospital. Sin embargo, no está claro qué ganancia general ICM proporciona encima de un enfoque menos formal de no ICM. Se justifican más ensayos que comparen ICM actual con atención estándar o sin ICM, sin embargo actualmente no conocemos ninguna revisión comparando la ICM con la atención estándar, y esto debería ser realizado.
Revisamos la literatura sobre gestión estándar de casos (SCM), gestión de casos intensiva (ICM), el tratamiento asertivo comunitario (ACT), y la intervención momento crítico (CTI) para los adultos sin hogar. Se realizaron búsquedas en bases de datos para artículos en inglés revisados por pares publicados desde 1985 hasta 2011 y encontramos 21 ensayos controlados aleatorios o estudios cuasi-experimentales que comparan la administración de casos a otros servicios. Encontramos poca evidencia de la efectividad de la ICM. SMC mejoró estabilidad de la vivienda, reduce el consumo de sustancias, y elimina las barreras de empleo para los usuarios de sustancias. ACT mejoró la estabilidad de vivienda y era rentable para las personas con enfermedades mentales y con diagnóstico dual. CTI mostró promesa para la vivienda, la psicopatología, y el uso de sustancias y era formentally personas con enfermedades rentables. Se necesita más investigación sobre cómo el manejo de casos puede apoyar más efectivamente enfoques rápido realojamiento de las personas sin hogar.
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.
