Where to practise evidence-based medicine?
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Decision Making↗
Biomedical subjects
N Siegfried
Publications and source records attributed to N Siegfried.
Improving services for people with a psychotic disorder and problematic substance use: a multifaceted approach to project evaluation.
OBJECTIVE: The objective of this study was to conduct a multifaceted formative evaluation of the Central Sydney Area Health Service (CSAHS) Psychosis and Substance Use Project. METHOD: Four evaluative methods were used: (i) description and interpretation of the Project's documented processes and outcomes; (ii) a benchmark comparison of the Project processes and outcomes against three of the 11 National Standards for Mental Health Services; (iii) a survey of the Project's key stakeholders; and (iv) interviews with 12 purposefully sampled key informants. RESULTS: The Project achieved its aim to develop a strategy to improve services for people with comorbid psychosis and problematic substance use. Three of the five Project objectives were fully achieved: examination of current clinical services, development of a clinical services plan, and development of a staff education programme. The Project partially achieved two objectives: development of an information system, and a research agenda. The Project and CSAHS performed well when measured against three of the National Mental Health Standards. Project participants perceived the Project to have been successful and worth continuing, identified some shortcomings and made recommendations for the second phase. CONCLUSIONS: The participatory approach to the Project and the evaluation was successful. With some improvements the Project is worth continuing into a second phase. A multifaceted approach and qualitative research methods are useful for formative evaluation of health service programmes.
Australia↗
Treatment programmes for people with both severe mental illness and substance misuse.
BACKGROUND: Substance misuse in the context of severe mental illness can have detrimental effects. A variety of treatments exist, but the drive has been to provide programmes integrating treatment of both substance misuse and severe mental illness. Such programmes require additional resources and may require radical redesign of service delivery systems. OBJECTIVES: To evaluate the effectiveness of treatment programmes within psychiatric care for people with problems of both substance misuse and serious mental illness. SEARCH STRATEGY: Biological Abstracts (1985-1998), CINAHL (1982-1998), The Cochrane Library (Issue 3, 1998), The Cochrane Schizophrenia Group's Register of trials (August 1998), EMBASE (1980-1998), MEDLINE (1966-1998), PsycLIT (1974-1998) and Sociofile (1974-1998) were comprehensively searched. Citations of all trials were searched and further studies sought from published trials and their authors. SELECTION CRITERIA: All randomised trials of any programme of substance misuse treatment for people with serious mental illness and current problems of substance misuse. DATA COLLECTION AND ANALYSIS: Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were also independently extracted. For homogeneous dichotomous data the Peto odds ratio (OR), and 95% confidence intervals (CI) were calculated on an intention-to-treat basis. MAIN RESULTS: Six relevant studies, four of which were small, were identified. In general, the quality of design and reporting was not high. Clinically important outcomes such as relapse of severe mental illness, violence to others, patient or carer satisfaction, social functioning and employment were not reported. There is no clear evidence supporting an advantage of any type of substance misuse programme for those with serious mental illness over the value of standard care. No one programme is clearly superior to another. REVIEWER'S CONCLUSIONS: The problems posed by substance misuse in the context of severe mental illness will not go away. The current momentum for integrated programmes is not based on good evidence. Implementation of new specialist substance misuse services for those with serious mental illnesses should be within the context of simple, well designed controlled clinical trials.
Comorbidity↗
Trauma and alcohol.
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Accidents, Traffic↗
Experience, knowledge and attitudes of mental health staff regarding patients' problematic drug and alcohol use.
OBJECTIVE: The aim of this study was to assess the experience, knowledge and attitudes of mental health staff regarding patients' problematic drug and alcohol use in order to provide direction for planned drug and alcohol education. METHOD: A 47-item questionnaire was developed and individually posted to all mental health staff employed by Central Sydney Area Health Service (n = 536). RESULTS: Three hundred and thirty-eight (63%) staff members completed the questionnaire. Thirty-six percent of respondents had received drug and alcohol training and 41% had drug and alcohol work experience. Drug and alcohol training and work experience were associated with increased drug and alcohol knowledge. Respondents' perception of their knowledge and competence was positively correlated with their actual knowledge. Most staff reported having regular contact with patients with psychotic illnesses and drug and alcohol problems. The majority considered the management of this patient group difficult and currently inadequate. Seventy percent believed that as mental health professionals they had a role to play in the management of their patients' drug and alcohol problems. Almost all (95%) were willing to participate in further education and training in this area. CONCLUSIONS: Mental health staff are often confronted with drug and alcohol problems in patients with psychotic illnesses. They perceive a need for drug and alcohol education and training specific to the management of these patients. Future research will need to evaluate outcomes of education and training programs for both staff and patients.
Adult↗
A review of comorbidity: major mental illness and problematic substance use.
OBJECTIVE: The aim of this paper is to critically review the literature on major mental illness and problematic substance use in order to provide clinicians and policy-makers with evidence to support proposed directions for management of the above. METHOD: The available literature was accessed using computerised databases and manual searching. RESULTS: The predominantly North American-based literature is largely descriptive. Those studies which attempt empirical evaluation are limited by methodological weaknesses which include small sample sizes, short follow-up periods, inadequate measurement of substance use, lack of experimental design, and treatment drift over time. However, there is consensus among most studies regarding prevalence rates and treatment. CONCLUSIONS: Problematic substance use is the most common comorbid condition among people with a major mental illness and is associated with poorer patient outcomes. There is evidence to suggest that the integration of mental health and drug and alcohol services will result in improved detection, assessment and management of comorbidity. Integration refers to the provision of comprehensive services by a single service with staff who are competent in both mental health and drug and alcohol skills. A tolerant, non-confrontational approach to substance use is most appropriate for people with a major mental illness. Treatment programs need to recognise the longitudinal nature of substance abuse and dependence. More research needs to be conducted in this field in order to establish guidelines for effective management.
Australia↗
Profile of drinking behaviour and comparison of self-report with the CAGE questionnaire and carbohydrate-deficient transferrin in a rural Lesotho community.
This paper aims to: (1) profile the drinking behaviour of a rural Lesotho community facing relocation; (2) compare the following measures of hazardous drinking in this community: quantity/frequency self-report, the CAGE questionnaire and carbohydrate-deficient transferrin (CDT) levels; (3) describe community awareness of, and attitude towards, treatment services. As part of a larger baseline survey of community health status, households in 29 villages in Lesotho were randomly sampled. Consenting adults (n = 348) participated in a face-to-face interview about alcohol use, which included the CAGE. Blood was taken from participants for CDT determination. Fifty-three per cent of men (37/69) and 19% of women (53/279) reported drinking alcohol. Thirty-six per cent of men (25/69) and 9% of women (25/279) were classified as hazardous drinkers defined as drinking 350 g (males) or 225 g (females) of alcohol/week, or 'engaged in bouts of heavy drinking 1 to 2 days a month or more during the past 12 months'. Hazardous drinkers were significantly more likely to be male and older, but did not differ from the rest of the sample on marital status. Using hazardous drinking as the standard, CAGE (score > or = 2) had a positive predictive value (PPV) of 75% for men and 62% for women. The parameters for CDT must be interpreted with caution as the cut-offs for hazardous drinking, especially for women's drinking, were lower than the usual cut-offs in published CDT studies. However, the high specificities for CDT in men (100%; 19/19) and in women (77%; 110/142) are consistent with other studies, but the low PPV of 14% (5/37) for men and women combined suggests that CDT is not effective as a predictor of hazardous drinking in this population. There was high awareness of available treatment services among participants, and most believed treatment to be beneficial. Overall, the study provides a comprehensive baseline profile of drinking behaviour in this community, but did not show the CAGE questionnaire or CDT profile to be useful in in this community.
Adolescent↗