Loosening the Grip: a handbook of Alcohol Information 9th

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The Workplace

Akbar-Khanzadeh F. Exposure to environmental tobacco smoke in restaurants without separate ventilation systems for smoking and nonsmoking dining areas. Archives of Environmental Health 58(2): 97–103, 2003. (26 refs.)

In this study, the author examined (a) levels of airborne pollutants from environmental tobacco smoke in 8 restaurants, and (b) changes in urinary cotinine and nicotine levels among 97 nonsmoking subjects (i.e., 40 restaurant employees, 37 patrons, and 20 referents). Airborne pollutant levels were significantly lower in the control environments than in the nonsmoking dining rooms in which smoking was not permitted, and the levels were significantly lower in the dining rooms in which smoking was not permitted than in the dining rooms in which smoking was permitted. Levels of urinary cotinine and nicotine increased among subjects in the dining rooms in which smoking was permitted, and the increase was significantly greater in employees than patrons. There was a significant positive correlation between levels of urinary nicotine increase and the levels of airborne nicotine and solanesol. The results of this study support the restriction of smoking to designated areas that have separate ventilation systems, or the prohibition of smoking in restaurants. (Copyright 2003, Heldref Publications)

Arcury TA, Quandt SA, Preisser JS, Bernert JT, Norton D, Wang J. High levels of transdermal nicotine exposure produce green tobacco sickness in Latino farmworkers. Nicotine & Tobacco Research 5(3): 315–321, 2003. (27 refs.)

Green tobacco sickness (GTS) is an occupational illness that affects tobacco workers worldwide. This study tested whether GTS results from nicotine poisoning. Data collection was based on a prospective design in which 182 farmworkers were interviewed up to five times at biweekly intervals. A saliva sample was obtained at each interview. Examining four regression models in which salivary cotinine was evaluated as a mediator between behavioral risk factors and GTS, this analysis showed that nicotine causes GTS: 25 workers had 31 occurrences of GTS. Among nonsmokers, each increment increase in the natural log of cotinine increased the odds of GTS 2.11 times, adjusting for task and wet conditions. Treatment of GTS must address nicotine poisoning. GTS affects laborers with limited resources. Research must disclose the extent of this occupational illness and investigate ways to prevent it. (Copyright 2003, Carfax Publishing)

Cranford M. Drug testing and the right to privacy: Arguing the ethics of workplace drug testing. Journal of Business Ethics 17(16): 1805–1815, 1998.

As drug testing has become increasingly used to maximize corporate profits by minimizing the economic impact of employee substance abuse, numerous arguments have been advanced which draw the ethical justification for such testing into question, including the position that testing amounts to a violation of employee privacy by attempting to regulate an employee's behavior in her own home, outside the employer's legitimate sphere of control. This article first proposes that an employee's right to privacy is violated when personal information is collected or used by the employer in a way which is irrelevant to the terms of employment. This article then argues that drug testing is relevant and therefore ethically justified within the terms of the employment agreement, and therefore does not amount to a violation of an employee's right to privacy. Arguments to the contrary, including the aforementioned appeal to the employer's limited sphere of control, do not account for reasonable constraints on employee privacy which are intrinsic to the demands of the workplace and implicit in the terms of the employment contract. Copyright 1998, Kluwer Academic Publishers

Emener WG, Hutchison WS Jr., eds. Employee Assistance Programs: Wellness/Enhancement Programming Springfield IL: Charles C. Thomas 2003. (chapter refs)

This edited volume with xx chapter is organized into x parts. Part I deals with history and philosophy; Part II considers structure and the organization of programs; Part III reviews client characteristics and needed services; Part IV addresses program planning and evaluation; Part V reviews training and development, and Part VI, considers special issues such as legal concerns, ethics, and drug and alcohol testing.

French MT, Roebuck MC, Alexandre PK. To test or not to test. Do workplace drug testing programs discourage drug use? Social Science Research. 33: 45–65, 2003. (41 refs)

Workplace drug testing programs are often met with intense criticism. Despite resistance among labor and consumer groups and a lack of rigorous empirical evidence regarding effectiveness, drug testing programs have remained popular with employers throughout the 1990s and into the current century. The present study analyzed nationally representative data on over 15,000 US households to determine whether various types of workplace drug testing programs influenced the probability of drug use by workers. The study estimated several empirical specifications using both univariate and bivariate probit techniques. The specification tests favored the bivariate probit model over the univariate probit model. Estimated marginal effects of drug testing on any drug use were negative, significant, and relatively large, indicating that drug testing programs are achieving one of the desired effects. The results were similar when any drug use was replaced with chronic drug use in the models. These results have important policy implications regarding the effectiveness and economic viability of workplace anti-drug programs. Copyright 2004, Elsevier Science

Frone MR. Prevalence and distribution of alcohol use and impairment in the workplace: A US national survey. Journal of Studies on Alcohol 67(1): 147–156, 2006. (28 refs.)

Objective: Although much research has explored overall alcohol use in the workforce, little research has explored the extent of alcohol use and impairment in the workplace. This study explored the overall prevalence, frequency, and distribution of alcohol use and impairment during the workday. Method: Data were collected from a national probability sample of 2,805 employed adults using a random digit dialing telephone survey, Alcohol use within 2 hours of reporting to work, alcohol use during the workday, working under the influence of alcohol, and working with a hangover were assessed for the 12 months preceding the interview. Results: Workplace alcohol use and impairment directly affect an estimated 15% of the U.S. workforce (19.2 million workers). Specifically, an estimated 1.83% (2.3 million workers) drink before work, 7.06% (8.9 million workers) drink during the workday, 1.68% (2.1 million workers) work under the influence of alcohol, and 9.23% (11.6 million workers) work with a hangover. The results also suggest that most workplace alcohol use and impairment occur infrequently. The distribution of workplace alcohol use and impairment differs by gender, race, age, marital status, occupation, and work shift. Conclusion: Workplace alcohol use and impairment are prevalent enough that additional research should focus on their causes and impact on employee productivity. Moreover, clear policies should be in place regarding alcohol use and impairment at work. But despite management's responsibility for the development and enforcement of such policies, managers report elevated rates of consuming alcohol during the workday, working under the influence of alcohol, and working with a hangover. (Copyright 2006, Alcohol Research Documentation, Inc.)

Giannakoulas G, Katramados A, Melas N, Diamantopoulos I, Chimonas E. Acute effects of nicotine withdrawal syndrome in pilots during flight. Aviation, Space, and Environmental Medicine 74(3): 247–251, 2003. (74 refs.)

Background: Pilots who smoke are occasionally obliged to abstain from nicotine intake during flight and may during this period exhibit certain symptoms leading to performance decrement. Methods: We studied 20 healthy male aviators, who were regular smokers, (mean age 33.7 +/- 1.4 yr) operating military fixed- and rotary-wing aircraft (C-47 Dakota, F-16, A. Bell 205). All pilots were subjected to a 12-h abstinence from cigarette smoking, during which time they performed flight duties. After landing, we studied the intensity of the nicotine withdrawal syndrome, as well as its effect on physiological parameters, psychological functions, and cognitive tasks. This was achieved by the completion of a questionnaire, measurement of BP and heart rate, and the execution of certain computerized performance assessment tests. These tests measure mental arithmetic, visual vigilance, and image free-recall. In a subsequent flight performed under similar conditions, every pilot repeated the procedure without smoking deprivation. Thus, each subject served as his own control. The Wilcoxon non-parametric test was applied for statistical analysis. Results: The most frequent symptoms reported during nicotine deprivation were nervousness, craving for tobacco, tens ion-anxiety, fatigue, difficulty in concentration, decrease in alertness, disorders of fine adjustments, prolonged reaction times, anger-irritability, drowsiness, increase in appetite, and impairment of judgement. Systolic BP and heart rate tended to decrease and diastolic BP tended to rise during withdrawal, although the differences were not statistically significant. Finally, all tests recorded an impairment of cognitive functions during abstinence. Conclusion: Abrupt cessation of smoking may be detrimental to flight safety and the smoking withdrawal syndrome may influence flying parameters. Copyright 2003, Aerospace Medical Association)

Halpern MT, Dirani R, Schmier JK. Impacts of a smoking cessation benefit among employed populations. Journal of Occupational and Environmental Medicine 49(1): 11–21, 2007. (32 refs.)

Objective: The objective of this study was to project the health and economic impacts of providing a workplace smoking cessation benefit. Methods: The authors conducted an update of a previously published outcomes model using recently published data and clinical trial results. Results: In four example workplace types evaluated, coverage of a cessation benefit resulted in greater numbers of successful cessations and decreased rates of smoking-related diseases. Total savings from benefit coverage (decreased healthcare and workplace costs) exceeded costs of the benefit within 4 years. Total savings per smoker ranged from $350 to $582 at 10 years and $1152 to $1743 at 20 years. Internal rate of return ranged from 39% to 60% at 10 years. Conclusion: Providing a workplace smoking cessation benefit results in substantial health and economic benefits with economic savings exceeding the cost of the benefit within a relatively short period. Clinical Significance: Providing a workplace smoking cessation benefit is projected to increase the rate of smoking cessation as well as decrease the incidence of smoking-related conditions and healthcare costs. In addition, workplace cessation benefits can result in decreased absenteeism, increased productivity, and net cost savings within 4 years. (Copyright 2007, Lippincott, Williams & Wilkins)

National Collegiate Athletic Association. NCAA Study of Substance Abuse of College Student Athletes. Indianapolis IN: NCAA, January 2006.

Ong MK, Glantz SA. Free nicotine replacement therapy programs vs implementing smoke-free workplaces: A cost-effectiveness comparison. American Journal of Public Health 95(6): 969–975, 2005. (41 refs.)
We compared the cost-effectiveness of a free nicotine replacement therapy (NRT) program with a state-wide smoke-free workplace policy in Minnesota. We conducted 1-year simulations of costs and benefits. The number of individuals who quit smoking and the quality-adjusted life years (QALYs) were the measures of benefits. After 1 year, a NRT program generated 18500 quitters at a cost of $7020 per quitter ($4440 per QALY), and a smoke-free workplace policy generated 10400 quitters at a cost of $799 per quitter ($506 per QALY). Smoke-free workplace policies are about 9 times more cost-effective per new nonsmoker than free NRT programs are. Smoke-free workplace policies should be a public health funding priority, even when the primary goal is to promote individual smoking cessation. (Copyright 2005, American Public Health Association

Osinubi OYO, Sinha S, Rovner E, Perez-Lugo M, Jain NJ, Demissie K, Goldman M. Efficacy of tobacco dependence treatment in the context of a “smoke-free grounds” worksite policy: A case study. American Journal of Industrial Medicine 46(2): 180–187, 2004. (19 refs.)

Background: Smoking restrictions provide opportunities to modify smoking behavior. A large insurance company implemented a smoke-free grounds policy at two of their office complexes in January, 2000. Methods: This cohort study evaluated the impact of the smoke-free grounds policy on abstinence among 128 employees who participated in a tobacco dependence treatment program. Results The overall quit rate at 6 months was 44.5%. The larger complex showed a trend for higher quit rates compared to the smaller complex (46.5 vs. 28.6%). Post-ban participants had higher quit rates than pre-ban participants (52.4 vs. 43.0%). The probability of abstinence at 6 months follow-up was higher for post-ban compared to pre-ban participants (P = 0.03). Post-ban participants were 80% less likely to relapse than pre-ban participants. Non-quitters decreased their consumption by 6.6 cigarettes/day (39.1% decrease). Conclusions: A "smoke-free grounds" policy encourages abstinence and may play a significant role in harm reduction among continuing tobacco users. Copyright 2004, Wiley-Liss

Ozminkowski RJ, Mark TL, Goetzel RZ, Blank D, Walsh JM, Cangianelli L. Relationships between urinalysis testing for substance use, medical expenditures, and the occurrence of injuries at a large manufacturing firm. American Journal of Drug and Alcohol Abuse 29(1): 151–167, 2003. (25 refs.)

Drug use among employees continues to be a serious concern for American employers. Over 80% of the large employers in the United States use some form of testing to detect drug use, but this practice is controversial and the cost-effectiveness of drug testing remains largely unknown. This study begins an empirical investigation of the consequences of drug testing by estimating its impact on medical care expenditures and injury rates at a large manufacturing firm in 1996-1999. Multiple regression analyses of a pooled cross-sectional time-series data set were used to separate the impact of drug testing from other factors and to help find the optimal level of testing that was associated with minimum medical expenditures. Results indicated that medical expenditures would be minimized when 42% of the employees in a calendar quarter were drug tested. This implies that, on average, employees should be tested 1.68 times a year. The results also indicated that doubling the testing rate would reduce the odds of incurring any injuries on the job by over half, but the injury rate was already so low that this impact was very small. Hopefully the results of this study will inform the policy debate over drug testing by focusing on real data, as opposed to supposition or political considerations that seem to dominate many discussions. Copyright 2003, Marcel Dekker, Inc.

Siegel M, Skeer M. Exposure to secondhand smoke and excess lung cancer mortality risk among workers in the “5 B’s”: Bars, bowling alleys, billiard halls, betting establishments, and bingo parlours. Tobacco Control 12(3): 333–338, 2004. (42 refs.)

Objective: To review existing data on exposure to secondhand smoke in bars, bowling alleys, billiard halls, betting establishments, and bingo parlours (the "5 B's") as assessed by ambient nicotine air concentration measurements and to estimate the excess lung cancer mortality risk associated with this exposure. Data sources: Using the Medline, Toxline, and Toxnet databases, the internet, and bibliographies of relevant articles, we identified studies that reported measurements of ambient nicotine concentrations in the 5 B's. Study selection: Studies were included if they reported a mean concentration of ambient nicotine measured in at least one of the 5 B's. Data extraction: We calculated a weighted average of nicotine concentrations in each of the 5 B's. We then estimated the working lifetime excess lung cancer mortality risk associated with this exposure, as well as with exposure at the upper and lower limits of the range of mean exposures reported in all of the studies in each establishment category. Data synthesis: Nicotine concentrations in the 5 B's were 2.4 to 18.5 times higher than in offices or residences, and 1.5 to 11.7 times higher than in restaurants. At these exposure levels, estimated working lifetime excess lung cancer mortality risk from secondhand smoke exposure for workers in the 5 B's is between 1.0-4.1/1000, which greatly exceeds the typical de manifestis risk level of 0.3/1000.Conclusions: Workers in the 5 B's have high levels of occupational exposure to secondhand smoke and must be included in workplace smoking regulations. Copyright 2003, BMJ Publishing Group

Skeer M, Cheng DM, Rigotti NA, Siegel M. Secondhand smoke exposure in the workplace. American Journal of Preventive Medicine 28(4): 331–337, 2005. (42 refs.)

Objective: To review existing data on exposure to secondhand smoke in bars, bowling alleys, billiard halls, betting establishments, and bingo parlours (the "5 B's") as assessed by ambient nicotine air concentration measurements and to estimate the excess lung cancer mortality risk associated with this exposure. Data sources: Using the Medline, Toxline, and Toxnet databases, the internet, and bibliographies of relevant articles, we identified studies that reported measurements of ambient nicotine concentrations in the 5 B's. Study selection: Studies were included if they reported a mean concentration of ambient nicotine measured in at least one of the 5 B's. Data extraction: We calculated a weighted average of nicotine concentrations in each of the 5 B's. We then estimated the working lifetime excess lung cancer mortality risk associated with this exposure, as well as with exposure at the upper and lower limits of the range of mean exposures reported in all of the studies in each establishment category. Data synthesis: Nicotine concentrations in the 5 B's were 2.4 to 18.5 times higher than in offices or residences, and 1.5 to 11.7 times higher than in restaurants. At these exposure levels, estimated working lifetime excess lung cancer mortality risk from secondhand smoke exposure for workers in the 5 B's is between 1.0-4.1/1000, which greatly exceeds the typical risk level of 0.3/1000. Conclusions: Workers in the 5 B's have high levels of occupational exposure to secondhand smoke and must be included in workplace smoking regulations. Copyright 2003, BMJ Publishing Group

Substance Abuse and Mental Health Services Administration Office of Applied Studies, Zhang Z, Huang LX, Brittingham AM. Worker Drug Use and Workplace Policies and Programs: Results from the 1994 and 1997 NHSDA. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1999.

This report begins with a summary of the report highlights. Among the findings noted are that while the rate of drug use is higher among the unemployed, most drug users are employed (70% of users between the ages of 18 and 49. In the general population, about 7.7% of full-time workers reported current illicit drug use (any drug use in the past month) and 7.6 percent reported heavy alcohol use , i.e. 5 or more drinks per occasion on five or more days in the past month. Among full-time workers between the ages of 18 and 49, there were 6.3 million current illicit drug users and 6.2 million heavy drinkers. These figures include the 1.6 million persons who fit both definitions. Between 1994 and 1997, the proportion of full-time workers in this age group who reported present illicit drug use or reported was essentially the same. Those who reported heavy drinking or illicit drug use were more likely to have worked for three or more employers in the past year, to have voluntarily left a job, or to have missed work because of their substance use. There was a significant increase in the numbers of persons who reported there being drug testing at work, either as part of hiring, randomly, or post-accident. Particularly in large worksites, there was almost a 50% increase in drug testing at the point of hiring. Similarly random drug testing virtually doubled. This report is organized into seven chapters: (1) Introduction; (2) Current illicit drug use and heavy alcohol use: Demographic, and workplace characteristics; (3) Current illicit drug use and heavy alcohol use and their associations with workplace outcomes; (4) Workplace information, policies, and programs concerning drug and alcohol use; (5) Workplace drug testing programs; (6) Multivariate models of current illicit drug use and current heavy alcohol use among full-time workers; (7) Conclusions which address the trend from 1994 to 1997, differences between workers in that period in terms of drug use and heavy alcohol use, and the relationship to establishment size, and occupational types, plus other factors. There are three appendices that provide details of the methodology and instruments used to survey the workforce populations. The data is summarized in 21 tables and 17 figures.

Walters ST, Neighbors C. Feedback interventions for college alcohol misuse: What, why and for whom? Addictive Behaviors 30(6): 1168–1182, 2005. (55 refs.)

In response to the persistent problem of college drinking, universities have instituted a range of alcohol intervention programs for students. Motivational feedback is one intervention that has garnered support in the literature and been adopted on college campuses. This article reviews published outcome studies that have utilized feedback as a major component of an alcohol intervention for college students. Overall, 11 of the 13 reviewed studies (77%) found a significant reduction in drinking as compared to a control or comparison group. While the studies varied widely in terms of population, follow-up period, and feedback content, it appears that feedback can be effective whether delivered by mail, the Internet, or via a face-to-face motivational interview. Feedback seems to change normative perceptions of drinking and may be more effective among students who drink for social reasons. The addition of a group or individual counseling session does not appear to increase the short-term impact of the feedback. Copyright 2005, Elsevier Science

White T. Drug testing at work: Issues and perspectives. Substance Use & Misuse 38(11/13): 1891–1902, 2003.

Over the past two decades there has been a significant rise in the number of employers requiring their staff or prospective staff members to undergo testing to determine whether they have been taking illicit drugs. Such testing usually takes place within the framework of broad employee-assistance programs and is underpinned by the wish to ensure public safety and corporate security, as well as achieving a "drug-free workplace" by helping staff who have drug-use-related problems. By whatever means these tests are conducted, though, issues of privacy raise a question mark against whether this is truly an area in which the interests of collective security should always override individual civil liberties. Copyright 2003, Marcel Dekker, Inc.

Zarkin GA, Bray JW, Karuntzos GT, Demiralp B. The effect of an enhanced employee assistance program (EAP) intervention on EAP utilization. Journal of Studies on Alcohol 62(3): 351–358, 2001. (24 refs.)

Chapter 12 Other Psychiatric Considerations

Brady K, Verduin M. Pharmacotherapy of comorbid mood, anxiety, and substance use disorders (review). Substance Use & Misuse 40(13/14): 2021–2041, 2005. (103 refs.)

Mood and anxiety disorders commonly co-occur with substance use disorders. Exploration of the neurobiology of substance use disorders and mood and anxiety disorders have found that the neural circuitry in mood, anxiety, and substance use disorders is clearly overlapping. These discoveries have encouraged the exploration of a number of pharmacotherapeutic agents in the treatment of co-occurring mood, anxiety, and substance use disorders. In this article, recent data on the pharmacotherapeutic treatment of mood and anxiety disorders in individuals with substance use disorders are reviewed. Some of the barriers to the use of pharmacotherapy in individuals with substance use disorders are discussed. Copyright 2005, Marcel Dekker

Crawford V, Crome IB, Clancy C. Co-existing problems of mental health and substance misuse (dual diagnosis): A literature review. Drugs: Education, Prevention and Policy 10 (Supplement): S1–S74, 2003. (138 refs.)

This review looks at ten years of literature relating to substance use and psychiatric disorders. The aim is to introduce the reader to the themes within the literature. These range from assessment and screening, substance-specific research, specific common psychiatric conditions, childhood, women, violence and suicide through to treatment. Copyright 2003, Carfax Publishing Co

Drake RE, Mueser KT, Brunette MF, McHugo GJ. A review of treatments for people with severe mental illnesses and cooccurring substance use disorders (review). Psychiatric Rehabilitation Journal 27(4): 360–374, 2004. (93 refs.)

Several interventions for people with co-occurring severe mental illnesses and substance use disorders have emerged since the early 1980s. This paper reviews 26 controlled studies of psychosocial interventions published or reported in the last 10 years (1994-2003). Though most studies have methodological weaknesses, the cumulative evidence from experimental and quasi-experimental research supports integrating outpatient mental health and substance abuse treatments into a single, cohesive package. Effective treatments are also individualized to address personal factors and stage of motivation, e.g., engaging people in services, helping them to develop motivation, and helping them to develop skills and supports for recovery. Accumulating evidence from quasi-experimental studies also suggests that integrated residential treatment, especially long-term (one year or more) treatment, is helpful for individuals who do not respond to outpatient dual disorders interventions. Current research aims to refine and test individual components and combinations of integrated treatments. Copyright 2004, Center for P

Frye MA, Salloum IM. Bipolar disorder and comorbid alcoholism: Prevalence rate and treatment considerations (review). Bipolar Disorders 8(6): 677–685, 2006. (63 refs.)

Classic Kraepelian observations and contemporary epidemiological studies have noted a high prevalence rate between bipolar disorder and alcoholism. The extent to which these two illnesses are comorbid (i.e., two distinct disease processes each with an independent course of illness), genetically linked, or different phenotypic expressions of bipolar illness itself continues to be investigated. It is increasingly clear that co-occurring alcohol abuse or dependence in bipolar disorder phenomenologically changes the illness presentation with higher rates of mixed or dysphoric mania, rapid cycling, increased symptom severity, and higher levels of novelty seeking, suicidality, aggressivity, and impulsivity. It is very encouraging that interest and efforts at evaluating pharmacotherapeutic compounds has substantially increased over the past few years in this difficult-to-treat patient population. This article will review the clinical studies that have evaluated the effectiveness of conventional mood stabilizers (lithium, carbamazepine, divalproex, and atypical antipsychotics) in the treatment of alcohol withdrawal and relapse prevention in patients with alcoholism and in the treatment of bipolar disorder with comorbid alcoholism. A number of add-on, adjunctive medications, such as naltrexone, acamprosate, topiramate, and the atypical antipsychotics quetiapine and clozapine, may be candidates for further testing. Copyright 2006, Blackwell Publishing

Goldstein BI, Diamantouros A, Schaffer A, Naranjo CA. Pharmacotherapy of alcoholism in patients with co-morbid psychiatric disorders (review). Drugs 66(9): 1229–1237, 2006. (64 refs.)

There has been an exponential increase in recent years of literature pertaining to the treatment of individuals with alcohol use disorders and co-morbid psychiatric disorders. Patients with mood and anxiety disorders in particular have a very high prevalence of alcoholism. Alcoholism confers significant morbid risks to patients with psychiatric disorders, and vice versa, including markedly increased risk of suicide. Only recently have studies examined the impact of various psychiatric medications on alcohol use among patients with these disorders. Evidence supporting the benefits of antidepressants for co-morbid alcoholism and depression continues to mount. Although these studies have demonstrated benefits in terms of quantitative decreases in the volume and frequency of consumption, the benefits in terms of remission from alcoholism have yet to be shown conclusively. The first randomised, controlled trial involving subjects with co-morbid alcoholism and bipolar disorder was recently conducted, yielding promising results for valproate in this population. The literature regarding co-morbid alcoholism and anxiety disorders has also seen recent progress, particularly in the study of post-traumatic stress disorder (PTSD). A placebo-controlled study of sertraline suggests some benefit in terms of alcohol use among individuals with early-onset PTSD and less severe alcohol dependence. Atypical antipsychotics such as olanzapine and quetipaine have been examined in several open studies of subjects with alcoholism co-morbid with a variety of psychiatric conditions including bipolar disorder, PTSD and schizophrenia. This paper selectively reviews the evidence that is currently available for the pharmacological management of alcoholism among persons with co-morbid psychiatric illness. Effectiveness, safety and tolerability are considered, and directions for future study are discussed. Copyright 2006, Adis International Ltd.

Jane-Llopis E, Matytsina I. Mental health and alcohol, drugs and tobacco: A review of the comorbidity between mental disorders and the use of alcohol, tobacco and illicit drugs (review). Drug and Alcohol Review 25(6): 515–536, 2006. (80 refs.)

This paper reviews some major epidemiological studies undertaken in high-income countries during the last 15 years which have reported the prevalence of mental disorders and substance use disorders and their relationship. Comorbidity between mental and substance use disorders is highly prevalent across countries. In general, people with a substance use disorder had higher comorbid rates of mental disorders than vice versa, and people with illicit drug disorders had the highest rates of comorbid mental disorders. There is a strong direct association between the magnitude of comorbidity and the severity of substance use disorders. While causal pathways differ across substances and disorders, there is evidence that alcohol is a casual factor for depression, in some European countries up to 10% of male depression. Policies that reduce the use of substances are likely to reduce the prevalence of mental disorders. Treatment should be available in an integrated fashion for both mental and substance use disorders. There is a need to expand the evidence base on comorbidity, particularly in low-income countries. Copyright 2006, Taylor & Francis

Johnson J. Cost-effectiveness of mental health services for persons with a dual diagnosis: A literature review and the CCMHCP. Journal of Substance Abuse Treatment 18(2): 119–127, 2000. (95 refs.)

People suffering from comorbid mental illness and substance abuse disorders (the dually diagnosed) are thought to constitute large portions of clients treated as outpatients by public-sector community-based mental health providers. These providers dispense units of ambulatory mental health services and treatments incrementally to maintain clients in the community and out of psychiatric hospitals. Community maintenance is one step, albeit critical, toward quitting drugs and eventual abstinence. Thus, there is a need for information that compares the effectiveness and cost of such services on dually diagnosed clients to identify appropriate low-cost high-yield treatment and service options and packages. This article provides a review of the literature on the effectiveness of ambulatory mental health services and recent emergent reports of cost-effectiveness of programs for the dually diagnosed, paying special attention to the gray areas and gaps. This article also describes a new project; an inexpensive add-on to an existing community mental health center. The project will be examining over 4 years of data to compare influence and cost of different ambulatory mental health services and treatments delivered to a matched pair group of clients with dual disorders and those with only mental illness. The intention of this project is not only to address gray areas and gaps in the literature, but also to inform a more rational deployment of mental health services. Copyright 2000, Pergamon Press

Kalbag A, Levin F. Adult ADHD and substance abuse: Diagnostic and treatment issues (review). Substance Use & Misuse 40(13/14): 955–1981, 2005. (125 refs.)

Attention deficit hyperactivity disorder (ADHD) is a neurobehavioral, developmental disorder most often diagnosed during childhood, marked by the core symptoms of inattention, hyperactivity, and impulsivity that results in social, academic, and occupational underachievement. Although the disorder has a prevalence of 3-9% in the general childhood population and 1-5% in the general adult population, it affects between 11 and 35% of "substance-abusing" adults, oftentimes complicating treatment response. The present review discusses diagnostic assessment issues, prevalence, comorbidity, pharmacotherapy, and psychological interventions in substance-abusing adults with ADHD. Copyright 2005, Marcel Dekker

Moore B. Empirically supported family and peer interventions for dual disorders. Research on Social Work Practice 15(4): 231–245, 2005. (61 refs.)

Objective: This article selectively reviews evidence-based family and peer interventions for co-occurring mental illness and substance use disorders. Although few researchers have specifically investigated family interventions for dual disorders, considerable empirical evidence exists for the effectiveness of such interventions in treating each of the two disorders separately. Method: Quality of supporting research is examined and implications for dual disorders are explored. Results: Findings from multiple studies are that inclusion of families in treatment helps to engage treatment-resistant individuals, promotes treatment adherence and psychiatric stability, reduces relapse, reduces alcohol and illicit drug use, and improves well-being of clients and family members. Conclusions: Research and treatment implications are discussed with suggestions for integration of approaches derived from the two historically separate fields. Copyright 2005, Sage Publications, Inc.

Moore THM, Zammit S, Lingford-Hughes A, Barnes TRE, Jones PB, Burke M, Lewis G. Cannabis use and risk of psychotic or affective mental health outcomes: A systematic review (review). Lancet 370(9584): 319–328, 2007. (69 refs.)

Background: Whether cannabis can cause psychotic or affective symptoms that persist beyond transient intoxication is unclear. We systematically reviewed the evidence pertaining to cannabis use and occurrence of psychotic or affective mental health outcomes. Methods We searched Medline, Embase, CINAHL, PsycINFO, ISI Web of Knowledge, ISI Proceedings, ZETOC, BIOSIS, LILACS, and MEDCARIB from their inception to September, 2006, searched reference lists of studies selected for inclusion, and contacted experts. Studies were included if longitudinal and population based. 35 studies from 4804 references were included. Data extraction and quality assessment were done independently and in duplicate. Findings: There was an increased risk of any psychotic outcome in individuals who had ever used cannabis (pooled adjusted odds ratio=1.41, 95% Cl 1.20-1.65). Findings were consistent with a dose-response effect, with greater risk in people who used cannabis most frequently (2.09, 1.54-2.84). Results of analyses restricted to studies of more clinically relevant psychotic disorders were similar. Depression, suicidal thoughts, and anxiety outcomes were examined separately. Findings for these outcomes were less consistent, and fewer attempts were made to address non-causal explanations, than for psychosis. A substantial confounding effect was present for both psychotic and affective outcomes. Interpretation: The evidence is consistent with the view that cannabis increases risk of psychotic outcomes independently of confounding and transient intoxication effects, although evidence for affective outcomes is less strong. The uncertainty about whether cannabis causes psychosis is unlikely to be resolved by further longitudinal studies such as those reviewed here. However, we conclude that there is now sufficient evidence to warn young people that using cannabis could increase their risk of developing a psychotic illness later in life. Copyright 2007, Lancet Ltd.

Mueser KT, Torrey WC, Lynde D, Singer P, Drake RE. Implementing evidence-based practices for people with severe mental illness (review). Behavior Modification 27(3): 387–411, 2003. (114 refs.)

Persons with severe mental illnesses (SMI) often lack access to effective treatments. The authors describe the Implementing Evidence-Based Practices (EBPs) Project, designed to increase access for people with SMI to empirically supported interventions. The EBP Project aims to improve access through development of standardized implementation packages, created in collaboration with different stakeholders, including clinicians, consumers, family members, clinical supervisors, program leaders, and mental health authorities. The background and philosophy of the EBP Project are described, including the six EBPs identified for initial package development: collaborative psychopharmacology, assertive community treatment, family psychoeducation, supported employment, illness management and recovery skills, and integrated dual disorders treatment. The components of the implementation packages are described as well as the planned phases of the project. Improving access to EBPs for consumers with SMI may enhance outcomes in a cost-effective manner, helping them pursue their personal recovery goals with the support of professionals, family, and friends. Copyright 2003, Sage Publications, Inc.

Nunes EV, Levin FR. Treatment of depression in patients with alcohol or other drug dependence: A meta-analysis (review). Journal of the American Medical Association 291(15): 1887–1896, 2004. (83 refs.)

Context: Depression and substance abuse are common and costly disorders that frequently-co-occur, but controversy about effective treatment for patients with both disorders persists. Objective: To conduct a systematic review and meta-analysis to quantify the efficacy of antidepressant medications for treatment of combined depression and substance use disorders.Data Sources PubMed, MEDLINE, and Cochrane database search (1970-2003), using the keywords antidepressant treatment or treatment depressed in conjunction with each of the following alcohol dependence, benzodiazepine dependence, opiate dependence, cocaine dependence, marijuana dependence, and methadone; a search of bibliographies; and consultation with experts in the field.Study Selection Among inclusion criteria used for study selection were prospective, parallel group, double-blind, controlled clinical trials with random assignment to an antidepressant medication or placebo for which trial patients met standard diagnostic criteria for current alcohol or other drug use and a current unipolar depressive disorder. Of the more than 300 citations extracted, 44 were placebo-controlled clinical trials, 14 of which were selected for this analysis and included 848 patients: 5 studies of tricyclic antidepressants, 7 of selective serotonin re-uptake inhibitors, and 2 from other classesData Extraction We independently screened the titles and abstracts of each citation, identified placebo-controlled trials of patients with both substance dependence and depression, applied the inclusion criteria, and reached consensus. Data on study methods, sample characteristics, and depression and substance use outcomes were extracted. The principal measure of effect size was the standardized difference between means on the Hamilton Depression Scale (HDS).Data Synthesis For the HDS score, the pooled effect size from the random-effects model was 0.38 (95% confidence interval, 0.18-0.58). Heterogeneity of effect on HDS across studies was significant (P <.02), and studies with low placebo response showed larger effects. Moderator analysis suggested that diagnostic methods and concurrent psychosocial interventions influenced outcome. Studies with larger depression effect sizes (>0.5) demonstrated favorable effects of medication on measures of quantity of substance use, but rates of sustained abstinence were low. Conclusions Antidepressant medication exerts a modest beneficial effect for patients with combined depressive- and substance-use disorders. It is not a stand-alone treatment, and concurrent therapy directly targeting the addiction is also indicated. More research is needed to understand variations in the strength of the effect, but the data suggest that care be exercised in the diagnosis of depression-either by observing depression to persist during at least a brief period of abstinence or through efforts by clinical history to screen out substance-related depressive symptoms. Copyright 2004, American Medical Association

Pirkola SP, Suominen K, Isometsa ET. Suicide in alcohol-dependent individuals: Epidemiology and management (review). CNS Drugs 18(7): 423–436, 2004. (138 refs.)

The association of alcohol dependence with suicidal behaviour is well established although complex. On the basis of epidemiological and clinical evidence, alcohol dependence is known to increase the risk for suicidal ideation, suicide attempts and completed suicide. However, this risk is modulated by a wide variety of factors including sociodemographic, clinical, treatment-related and life situational characteristics as well as current drinking status and the effect of inebriation. Treatment and management of patients with alcohol dependence and concomitant suicidal communication or suicide attempts is crucial, as is the recognition of these patients in emergency and other healthcare service contacts. The treatment strategies cannot be based on evidence derived from randomised clinical trials as such data do not exist. They must rather be based on current knowledge of risk factors for suicidal behaviour, efficacy of treatment for alcohol dependence or relevant co-morbid conditions and problems known to be common in treatment settings. In this article, we review the essential literature on the epidemiological and clinical research in the areas of alcohol dependence and suicidal behaviour. On the basis of current data and clinical experience, we suggest the following principles be followed in the management of alcohol-dependent individuals: (i) suicidal threats or communication by alcohol-dependent individuals in emergency and other contacts should be taken seriously; (ii) other mental disorders should be well evaluated, a consequent treatment plan initiated and follow-up arranged; (iii) appropriate and up-to-date pharmacological treatment should focus on both reducing the amount of drinking and treating symptoms of other mental disorders; (iv) psychotherapeutic efforts should be focused on emerging symptoms of both alcohol use and other mental disorders; and (v) known epidemiological and clinical risk factors, adverse life events in particular, should be recognised and taken into account. Copyright 2004, Adis International Ltd

Sacks S, Ries RK. Substance Abuse Treatment for Persons with Co- Occurring Disorder. A Treatment Improvement Protocol, No. 42. Rockville, MD: Center for Substance Abuse Treatment, 2005.

This Treatment Improvement Protocol (TIP) dealing with co-occurring disorders is a revision of TIP 9. This revision provides state-of-the-art treatment guidelines for counselors and others working in the field of co-occurring substance use and mental disorders. It is organized into nine chapters: Chapter 1: Introduction. Following a discussion of the evolving field of co-occurring disorders, this chapter addresses the developments that led to this TIP, the scope of the TIP, its intended audience, and the basic approach that has guided the selection of strategies, techniques, and models highlighted in the text. Chapter 2: Definitions, Terms, and Classification Systems for Co-Occurring Disorders. This chapter reviews terminology and classifications related to substance use, clients, treatment, programs, and systems for clients with COD. Chapter 3: Keys to Successful Programming. Readers are provided with a review of guiding principles in treatment of clients with COD and key challenges to establishing services in substance abuse treatment settings (including a system for classifying substance abuse treatment programs to determine an appropriate level of services and care). The chapter describes some service delivery issues including access, assessment, integrated treatment, comprehensive services, and continuity of care. Finally, critical issues in workforce development are discussed. Chapter 4: Assessment. This discussion of assessment includes key principles of assessment, selected assessment instruments, and 12 steps in the assessment process. The specific relationship of assessment to treatment planning also is addressed. Chapter 5: Strategies for Working with Clients With Co-Occurring Disorders. This chapter presents guidelines for developing a successful therapeutic relationship with individuals who have COD. It describes specific counseling techniques that appear to be the most successful in treating clients with COD and introduces guidelines that are important for the successful use of all these strategies. Chapter 6. Traditional Settings and Models. A discussion of traditional settings includes essential programming for clients with COD that can readily be offered in most substance abuse treatment settings. Practices are highlighted that have proven effective for the treatment of persons with COD in outpatient and residential settings. The chapter also highlights several distinctive models. Chapter 7. Special Settings and Specific Populations. Information about special settings includes issues related to providing treatment to clients with COD in acute care and other medical settings, as well as the need to sustain these programs. Several dual recovery mutual self-help groups that address the specific concerns of clients with COD are described, as are other resources. Finally, the importance of addressing the particular needs of people with COD within three key populations -- homeless persons, criminal justice populations, and women -- is discussed. Chapter 8: A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues. This chapter updates material that was presented on the major disorders covered in TIP 9 (i.e., personality disorders, mood disorders, anxiety disorders, and psychotic disorders) and adds other mental disorders with particular relevance to COD that were not covered (i.e., attention deficit/hyperactivity disorder, posttraumatic stress disorder, eating disorders, and pathological gambling). Suicidality and nicotine dependency are presented as cross-cutting issues. Chapter 9: Substance-Induced Disorders. Information on mental disorder symptoms caused by the use of substances is described. The toxic effect of substances is outlined and an overview of substance-induced symptoms that can mimic mental disorders is presented. There are a series of appendices that deal with commonly used medications; screening and assessment instruments; resources for training; dual recovery mutual self-help programs and other resources for consumers and providers; and confidentiality. Copyright 2005, Project Cork

Schubiner H. Substance abuse in patients with attention-deficit hyperactivity disorder: Therapeutic implications (review). CNS Drugs 19(8): 643–655, 2005. (102 refs.)

Attention-deficit hyperactivity disorder (ADHD) is a common, disorder in children that frequently persists into adulthood. Studies have found that substance use disorders (SUD) are seen more commonly in those with ADHD than the general population.; Although treatment with stimulant medications has been shown to be effective for individuals with ADHD, concern about the use of these, agents in this population persists. This review article highlights the research in this area with a focus on the treatment of individuals who present with concomitant ADHD and SUD. Although stimulants can be abused, studies have shown that adolescents who are prescribed stimulants for ADHD have lower rates of SUD than those who are not treated with stimulants. It may be particularly difficult to evaluate adults for the diagnosis of ADHD when, SUD is a co-morbid factor. Studies show that 20-30% of adults presenting with SUD have concomitant ADHD and approximately 20-40% of adults with ADHD have histories of SUD. Therefore, it is critical-to perform careful diagnostic interviews to discern if patients have either or both of these disorders. Many clinical experts suggest that adults with ADHD and active SUD be treated for the SUD until a period of sobriety persists prior to initiation of specific treatment for ADHD. Since individuals with ADHD and active SUD are more likely to have more-severe SUD and a worse prognosis, this approach may not serve many patients, as they relapse prior to, obtaining ADHD treatment. Therefore, research. has been directed towards determining if the treatment of ADHD with stimulant medications can be safe and effective for the individual with active SUD and concomitant ADHD. An initial trial of methylphenidate in a population of adults with active cocaine dependence and ADHD. indicates that this is. the case. Individuals with ADHD and SUD can present difficult diagnostic and therapeutic challenges. It appears that the most effective treatment option is to create a programme that uses the most effective treatment modalities available, including both behavioural and medical therapies, along with close supervision and, monitoring. Newer medical treatment options of long-acting stimulants. and non-stimulants (e.g. atomoxetine) offer effective. treatment with a lower risk, of abuse potential. Copyright 2005, Adis International Ltd.

Schuckit MA. Comorbidity between substance use disorders and psychiatric conditions. Addiction 101(Supplement 1): 76–88, 2006. (138 refs.)

Aims: To review information relevant to the question of whether substance-induced mental disorders exist and their implications. Design and method: This paper utilized a systematic review of manuscripts published in the English language since approximately 1970 dealing with comorbid psychiatric and substance use disorders. Findings: The results of any specific study depended on the definitions of comorbidity, the methods of operationalizing diagnostic criteria, the interview and protocol invoked several additional methodological issues. The results generally support the conclusion that substance use mental disorders exist, especially regarding stimulant or cannabinoid-induced psychoses, substance-induced mood disorders, as well as substance-induced anxiety conditions. Conclusions: The material reviewed indicates that induced disorders are prevalent enough to contribute significantly to rates of comorbidity between substance use disorders and psychiatric conditions, and that their recognition has important treatment implications. The current literature review underscores the heterogeneous nature of comorbidity. Copyright 2006, Society for the Study of Addiction to Alcohol and Other Drugs

Sher L. Alcoholism and suicidal behavior: A clinical overview. Acta Psychiatrica Scandinavica 113(1): 13–22, 2006. (86 refs.)

Objective: The purpose of this paper was to provide a clinical review of the literature on the relation of alcoholism to suicidal behavior. Method: Studies of alcoholism and suicidal behavior available in MEDLINE. Institute for Scientific Information Databases (Science Citation Index Expanded., Social Sciences Citation Index, and Arts & Humanities Citation Index), EMBASE, and Cochrane Library were identified and reviewed. Results: Alcoholism is associated with a considerable risk of suicidal behavior. Individuals with alcoholism who attempt or complete suicide are characterized by major depressive episodes, stressful life events, particularly interpersonal difficulties, poor social support, living alone, high aggression/impulsivity, negative affect, hopelessness, severe alcoholism. comorbid substance, especially cocaine abuse, serious medical illness, suicidal communication, and prior suicidal behavior. Partner-relationship disruptions are strongly associated with suicidal behavior in individuals with alcoholism. Conclusion: All individuals with alcoholism should receive a suicide risk assessment based on known risk factors. Copyright 2006, Blackwell Publishing

Stahl SM. Essential Psychopharmacology: Neuroscientific Basis and Practical Applications, Second Edition. Cambridge, UK: Cambridge University Press, 2000.

Covers the actions and uses of all psychotropic medications, with excellent illustrative cartoons.

Sullivan LE, Fiellin DA, O’Connor PG. The prevalence and impact of alcohol problems in major depression: A systematic review (review). American Journal of Medicine 118(4): 330–341, 2005. (77 refs.)

Major depression and alcohol problems are common in primary care, yet little is known about the prevalence of alcohol problems in patients with depression or alcohol's effect on depression outcomes. We strove to answer the following questions: How common are alcohol problems in patients with depression? Does alcohol affect the course of depression, response to antidepressant therapy, risk of suicide/death, social functioning and health care utilization? In which alcohol categories and treatment settings have patients with depression and alcohol problems been evaluated? English language studies from MEDLINE, PsychINFO, and Cochrane Controlled Trial Registry were reviewed. Studies were selected using predefined criteria if they reported on the prevalence or effects of alcohol problems in depression. Thirty-five studies met criteria and revealed a median prevalence of current or lifetime alcohol problems in depression of 16% (range 5-67%) and 30% (range 10-60%), respectively. This compares with 7% for current and 16-24% for lifetime alcohol problems in the general population. There is evidence that antidepressants improve depression outcomes in persons with alcohol dependence. Alcohol problems are associated with worse outcomes with respect to depression course, suicide/death risk, social functioning, and health care utilization. The majority of the studies, 34 of 35 (97%), evaluated alcohol abuse and dependence, and 25 of 35 (71%) were conducted in psychiatric inpatients. We conclude that alcohol problems are more common in depression than in the general population, are associated with adverse clinical and health care utilization outcomes, and that antidepressants can be effective in the presence of alcohol dependence. In addition, the literature focuses almost exclusively on patients with alcohol abuse or dependence in psychiatric inpatient settings, and excludes patients with less severe alcohol problems and primary care outpatient settings. Copyright 2005, Excerpta Medica, Inc. Used with permission

Tiet QQ, Mausbach B. Treatments for patients with dual diagnosis: A review (review). Alcoholism: Clinical and Experimental Research 31(4): 513–536, 2007. (96 refs.)

Background: Comorbid substance use and mental illness is prevalent and often results in serious consequences. However, little is known about the efficacy of treatments for patients with dual diagnosis. Methods: This paper reviews both the psychosocial and medication treatments for those diagnosed with a substance-related disorder and one of the following disorders: (a) depression, (b) anxiety disorder, (c) schizophrenia, (d) bipolar disorder, (e) severe mental illness, and (f) nonspecific mental illness. We made no restriction of study design to include all published studies, due to the dearth of studies on treatments of patients with dual diagnosis. Results: Fifty-nine studies were identified (36 randomized-controlled trials; RCT). Limited number of studies, especially RCTs, have been conducted within each comorbid category. This review did not find treatments that had been replicated and consistently showed clear advantages over comparison condition for both substance-related and other psychiatric outcomes. Conclusions: Although no treatment was identified as efficacious for both psychiatric disorders and substance-related disorder, this review finds: (1) existing efficacious treatments for reducing psychiatric symptoms also tend to work in dual-diagnosis patients, (2) existing efficacious treatments for reducing substance use also decrease substance use in dually diagnosed patients, and (3) the efficacy of integrated treatment is still unclear. This review provides a critique of the current state of the literature, identifies the directions for future research on treatment of dual-diagnosis individuals, and calls for urgent attention by researchers and funding agencies to conduct more and more methodologically rigorous research in this area. Copyright 2007, Research Society on Alcoholism

Townsend AL, Biegel DE, Ishler KJ, Wieder B, Rini A. Families of persons with substance use and mental disorders: A literature review and conceptual framework (review). Family Relations 55(4): 473–486, 2006. (104 refs.)

There are significant knowledge gaps concerning the experiences of families of persons with co-occurring substance and mental disorders and the impact of families on treatment of individuals with these disorders. This paper presents a conceptual framework for examining family involvement of adults in treatment for co-occurring substance and mental disorders. An overview of the characteristics, problems, and needs of these individuals and their family members is presented. The extant literature pertaining to our conceptual framework is reviewed with focus on predictors of family involvement with clients, predictors of family member involvement in clients' treatment, and consequences of family involvement for client treatment outcomes. Gaps in the research literature and implications for future research and practice are discussed. Copyright 2006, National Council on Family Relations

van den Bosch LMC, Verheul R. Patients with addiction and personality disorder: Treatment outcomes and clinical implications (review). Current Opinion in Psychiatry 20(1): 67–71, 2007. (36 refs.)

Purpose of review: The present review examines the outcomes of treatments focusing on substance abuse, on personality disorders, and on both the foci simultaneously. Clinical guidelines for the treatment of dually diagnosed patients are described. Recent findings: Recent studies continued the tradition of examining the importance of factors such as the chronicity of substance abuse and the impact of sex with regard to the prognosis of the treatment of substance abuse and the development of effective treatment programs. Overall, the multifaceted and risky nature of dual problems is stressed, and as a logical consequence, an early detection of dual problems is promoted. Several studies show the risk of suicidal and harmful behavior associated with this population, even when the treatment for substance abuse has been successful. For the first time, the issue of dropout is studied from the client's perspective. Summary: Knowledge about the effectiveness of dually focused treatments is emerging. Results show that the treatment of dually diagnosed patients with severe problems needs to include both the foci because it leads to enormous gains for the patients when personality disorders are also addressed. Yet, integrated treatment programs are lacking and research is still too limited. Copyright 2007, Lippincott, Williams & Wilkins

Watkins KE, Hunter SB, Burnam MA, Pincus HA, Nicholson G. Review of treatment recommendations for persons with a co-occurring affective or anxiety and substance use disorder. Psychiatric Services 56(8): 913–926, 2005. (64 refs.)

Objective: The authors review and evaluate the literature and guidelines on care for individuals with a co-occurring affective or anxiety disorder and substance use disorder. Methods: MEDLINE and PsycINFO computerized searches of the English language literature were conducted for the period 1990-2002. These articles were supplemented with searches of the Cochrane Database of Systematic Reviews (1990 to 2002) and with articles that were sent to the authors by experts in the field to review. Bibliographies of selected papers were hand searched for additional articles. From these searches a total of 219 articles were found, of which 127 were selected for review. Results and discussion: The literature shows that, over the past several decades, treatment for co-occurring disorders has undergone a broad shift in approach, from treating substance abuse before providing mental health care to providing simultaneous treatment for each disorder, regardless of the status of the comorbid condition. Many treatment recommendations are supported by a broad consensus. However, despite this broad agreement, recommendations are often not specific enough to guide clinical care. Most recommendations with specificity are for acute pharmacotherapy, but even specific recommendations lag behind current clinical practice. Although the use of psychotropic medication for mental illness is encouraged, experts disagree as to whether it is necessary to wait for abstinence before beginning pharmacotherapy. In addition, most diagnosis-specific guidelines are silent as to whether the specific treatment recommendation applies to co-occurring disorders. Finally, empirical evidence is lacking for most recommendations. The authors conclude that the mental health and substance abuse treatment fields need to consider its research priorities and how to address the multitude of potential combinations of disorders. Copyright 2005, American Psychiatric Association

Wilens TE, Faraone SV, Biederman J, Gunawardene S. Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature (review). Pediatrics 111(1): 179–185, 2003. (56 refs.)

Objective. Concerns exist that stimulant therapy of youths with attention-deficit/hyperactivity disorder (ADHD) may result in an increased risk for subsequent substance use disorders (SUD). We investigated all long-term studies in which pharmacologically treated and untreated youths with ADHD were examined for later SUD outcomes. Methods. A search of all available prospective and retrospective studies of children, adolescents, and adults with ADHD that had information relating childhood exposure to stimulant therapy and later SUD outcome in adolescence or adulthood was conducted through PubMed supplemented with data from scientific presentations. Meta-analysis was used to evaluate the relationship between stimulant therapy and subsequent SUD in youths with ADHD in general while addressing specifically differential effects on alcohol use disorders or drug use disorders and the potential effects of covariates. Results. Six studies-2 with follow-up in adolescence and 4 in young adulthood-were included and comprised 674 medicated subjects and 360 unmedicated subjects who were followed at least 4 years. The pooled estimate of the odds ratio indicated a 1.9-fold reduction in risk for SUD in youths who were treated with stimulants compared with youths who did not receive pharmacotherapy for ADHD (z = 2.1; 95% confidence interval for odds ratio [OR]: 1.1-3.6). We found similar reductions in risk for later drug and alcohol use disorders (z = 1.1). Studies that reported follow-up into adolescence showed a greater protective effect on the development of SUD (OR: 5.8) than studies that followed subjects into adulthood (OR: 1.4). Additional analyses showed that the results could not be accounted for by any single study or by publication bias. Conclusion. Our results suggest that stimulant therapy in childhood is associated with a reduction in the risk for subsequent drug and alcohol use disorders. Copyright 2003, American Academy of Pediatrics

Williams JM, Ziedonis D. Addressing tobacco among individuals with a mental illness or an addiction (review). Addictive Behaviors 29(6): 1067–1083, 2004. (109 refs.)

Tobacco dependence among individuals with a mental illness or an addiction is a tremendous problem that goes largely ignored. Studies of genetics, neuroimaging, and nicotinic receptors support a neurobiological link between tobacco use and alcohol dependence, drug dependence, schizophrenia, depression, attention-deficit hyperactivity disorder (ADHD), and anxiety disorders. This paper summarizes the recent literature on this topic and discusses how treatment for tobacco can no longer be ignored in mental-health and addiction-treatment settings. More research is needed as well as a national organized effort to address tobacco in this large segment of smokers. Copyright 2004, Elsevier Science Ltd.

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