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IAC 09-055 – HSR&D Study

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IAC 09-055
Dual Diagnosis Inpatients: Telephone Monitoring RCT to Improve Outcomes
Christine Timko PhD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: October 2010 - March 2015

BACKGROUND/RATIONALE:
Substance use disorders (SUDs) are highly prevalent among Veteran psychiatry inpatients. Dual substance use and psychiatric disorders are related to poor outcomes and rehospitalizations, which are quite costly. However, relatively little is known about how to effectively help dually diagnosed psychiatry inpatients. Telephone Monitoring (TM) is effective among SUD patients at increasing SUD continuing care and self-help utilization and improving SUD outcomes. This study builds on these findings and contributes important new clinical knowledge by determining whether TM is similarly effective when adapted for dually diagnosed Veteran psychiatry inpatients. It is evaluating the effectiveness of a manual-guided TM intervention.

OBJECTIVE(S):
Primary hypotheses are that patients in the TM condition, compared to patients in usual care (UC), will attend more SUD continuing care sessions and 12-step group meetings, and have better SUD and psychiatric outcomes. Secondary hypotheses are that TM patients will have fewer and delayed rehospitalizations, and their better outcomes will be mediated by SUD outpatient treatment and 12-step group participation.

METHODS:
This study took place at two VAs: Palo Alto (VISN 21) and Ann Arbor (VISN 11). Dually diagnosed patients in psychiatry inpatient treatment were randomly assigned to UC or TM. Patients in the TM condition received an in-person session while in treatment, followed by monitoring over the telephone for three months after discharge. The intervention incorporated motivational interviewing to monitor patients' substance use, facilitate entry into outpatient treatment if a relapse occurred, and encourage 12-step self-help group participation. Patients were assessed at baseline, end-of-intervention (three months post-baseline), and six months and one-year post-intervention for primary and secondary outcomes and non-VA health care; VA health care is being assessed with VA databases. GLMM analyses will be conducted to compare the UC and TM groups on course of primary and secondary outcomes over time; Cox regression models will compare groups on time to rehospitalization; and sequential regression analyses will examine whether outcomes associated with TM are mediated by more SUD continuing care and 12-step group participation.

FINDINGS/RESULTS:
We have completed data set up and merging for the baseline and 3-month follow-up assessments. At baseline (N=406), participants were mainly male (91.4%), White (63.2%), unemployed (53.6%), and housed (86.6%); on average they were 45.3 years old (SD=12.9) and had 13.5 years of education (SD=2.0). Prior to baseline, participants were high utilizers of addiction and other mental health services, e.g., on average, they had five previous episodes of inpatient psychiatric treatment. At the 3-month follow-up (82% followed), with baseline values of outcomes controlled, participants assigned to TM, compared to those assigned to UC, had more family/social support on the Addiction Severity Index (ASI) composite (p<.05); they also had more self-efficacy to reduce substance use (Brief Situational Confidence Questionnaire), rated additional treatment for alcohol problems as more important (ASI), and had greater readiness to attend both outpatient addiction treatment and 12-step group meetings (Readiness Ruler). We are setting up and merging the 9- and 15-month follow-up data, and planning analyses to examine associations between TM "dose" (number of phone calls) and outcomes.

IMPACT:
Given (a) the high prevalence of SUDs among psychiatry inpatients, (b) the established relationship of dual diagnoses with poorer outcomes and higher risks of rehospitalization, and (c) the high costs of hospital stays, psychiatry inpatient programs need to develop and implement successful strategies for treating dually diagnosed patients. Inpatient psychiatry treatment provides a unique opportunity to intervene to improve dually diagnosed patients' utilization of SUD services, participation in 12-step mutual-help groups, and SUD outcomes. However, for the most part, transitions to SUD treatment and mutual-help, which have been demonstrated to be effective for dually diagnosed patients, are not being successfully accomplished by inpatient psychiatry programs. This project adapted an intervention demonstrated to be effective for SUD patients to improve care transitions and outcomes among dually diagnosed veterans receiving inpatient psychiatry treatment. Its expected impact is to improve outcomes for dually diagnosed psychiatry inpatients as the follow-up data are analyzed and results are disseminated.

PUBLICATIONS:

Journal Articles

  1. Timko C, Ilgen M, Haverfield M, Shelley A, Breland JY. Polysubstance use by psychiatry inpatients with co-occurring mental health and substance use disorders. Drug and Alcohol Dependence. 2017 Nov 1; 180:319-322.
  2. Timko C, Bonn-Miller MO, McKellar JD, Ilgen MA. Detoxification history and two-year outcomes of substance use disorder treatment and mutual-help group participation. Journal of drug issues. 2014 Jan 1; 44(1):4-21.
  3. Woodhead E, Cowden Hindash A, Timko C. Dual Diagnosis, Mutual-Help Use, and Outcomes: A Naturalistic Follow-Up. Journal of Dual Diagnosis. 2013 May 3; 9(2):158-164.
  4. Timko C, Cronkite RC, McKellar J, Zemore S, Moos RH. Dually diagnosed patients' benefits of mutual-help groups and the role of social anxiety. Journal of substance abuse treatment. 2013 Feb 1; 44(2):216-23.
Conference Presentations

  1. Halvorson M, Ahmed U, Ilgen MA, Sonnicksen S, Kong C, Cronkite RC, Timko C. Telephone Monitoring Linked to Lower Rates of Drinking and Suicide in Early Results from a Randomized Controlled Trial of Dual Diagnosis Inpatients. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 9; San Diego, CA.
  2. Ahmed U, Halvorson MK, Sonnicken SD, Kong C, Bui L, Cronkite RC, Ilgen MA, Timko C. Telephone Monitoring for Dually Diagnosed Psychiatry Inpatients Improves Alcohol-Related Outcomes. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 8; San Diego, CA.
  3. Halvorson MK, Ahmed U, Ilgen MA, Sonnicksen SD, Kong C, Bui L, Cronkite RC, Timko C. Telephone Monitoring for Dual Diagnosis Inpatients Reduced Drinking and Suicidality. Poster session presented at: Association for Psychological Science Annual Convention; 2014 May 23; San Francisco, CA.
  4. Lin SL, Timko C, Cowden Hindash AH. Benefits of Mutual-Help Groups for Dually Diagnosed Patients. Poster session presented at: Research Society on Alcoholism Annual Scientific Meeting; 2012 Jun 23; San Francisco, CA.


DRA: Mental, Cognitive and Behavioral Disorders, Substance Abuse and Addiction, Health Systems
DRE: Treatment - Observational
Keywords: Bipolar Disorder, Depression, PTSD, Substance Use and Abuse, Telemedicine/Telehealth
MeSH Terms: none