The prevalence and course of alcohol and drug use were examined in a longitudinal, retrospective study of 100 schizophrenic outpatients. During the 18 month study period, problem substance use (abuse and dependence) was not associated with differential attrition from outpatient treatment. Thirty to forty percent of subjects were using drugs or alcohol during any evaluation period. The overall level of substance use and problem use of alcohol, marijuana, and other drugs remained stable, while problem use of cocaine and multiple substances increased over time. Problem substance use was associated with lower functional status and the detrimental effect of problem substance use appeared to increase with time. These findings underscore the need to address substance use problems in the context of outpatient schizophrenia treatment.
Objective
To test the hypotheses that: 1) Clinical case management integrated with Problem Solving Therapy (CM-PST) is more effective than clinical case management alone (CM) in improving functional outcomes in disabled, impoverished patients and 2) Improvement in depression, self-efficacy and problem solving skills mediates improvement of disability.
Design
RCT with a parallel design, allocating participants to CM or CM-PST at 1:1 ratio. Raters were blind to patients’ assignments.
Setting
Participants’ homes.
Participants
271 individuals were screened and 171 were randomized. Participants were ≥60 years with major depression, had at least 1 disability, were eligible for home-based meals services, and had income ≤30% of their counties’ median.
Interventions
12 weekly sessions of either CM or CM-PST.
Main Outcome Measure
WHO Disability Assessment Scale (WHODAS).
Results
Both interventions resulted in improved functioning by 12 weeks (t=4.28, df=554, p=0.001), which was maintained until 24 weeks. Contrary to hypothesis, CM was non-inferior to CM-PST (one-sided p=0.0003, t=−3.5, df=558). Change in disability was not affected by baseline depression severity, cognitive function or number of unmet social service needs. Improvements in self efficacy (t=−2.45, df = 672, p=0.021), problem solving skill (t=−2.44, df=546, p=0.015), depression symptoms (t=2.25, df = 672, p=.025) by week 9 predicted improvement in function across groups by week 12.
Conclusions
Case management is non-inferior to case management augmented with PST for late-life depression in low-income populations. The effect of these interventions occur early, with benefits in functional status being maintained as long as 24 weeks after treatment initiation.
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