Transcript Five year follow-up study of female substance abusers in drug free

Five year follow-up study of female substance
abusers in drug free residential compulsory
treatment institution in Sweden
Rimini, October 2009
Mats Fridell, Johan Billsten, Iréne Jansson
Department of Psychology, Lund Universitet
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PUBLICATIONS

Jansson, I., Fridell, M., & Hesse, M. (2008). Personality Disorder
features as predictors of Symptoms five-year post treatment. The
American Journal on Addictions 17:172-175.

Jansson, I., Hesse, M., & Fridell, M. (2007). Validity of self-reported
criminal justice involvement in substance abusing women at five-year
follow-up. BMC Psychiatry 8:(2).

Jansson, I., Hesse, M., & Fridell, M. (2007). Influence of personality
disorder features on Social Functioning in Substance-abusing Women
five years after Compulsive Residential Treatment., European Addiction
Research 15: 25-31.

Fridell, M., Billsten, J., Jansson, & Amylon, R., (2009). Femårsuppföljning av kvinnor vårdade vid Lundens LVM- och LVU-hem.
Stockholm, Statens Institutionsstyrelse, SiS utvecklar och följer upp
2009:1. – GENERAL REPORT
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LUNDEN, RESIDENTIAL
DRUG FREE COMPULSORY CARE

A 21 bed inpatient residential treatment care unit, Lund
12 beds for adults and 9 for youth. Milieu therapeutic
organisation and psychosocial support and motivation
enhancement

Law on Compulsory Care for Substance Abusers (LVM, act
1988:870),

The Care of Young Persons Act (LVU, act 1990:5r2)

LVU and LVM acts are unrelated to penal code and laws of
psychiatric care.
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According to the LVU, “a care order is to be issued, if the
young person exposes his health or development to a
palpable risk of injury through the abuse of addictive
substances, criminal activities, or some other socially
degrading behavior” (LVU, act 1990:52, section 3).
Youths can also be taken into care under the LVU due to
neglect or chaotic circumstances in the home.
Under Section 4 of the LVM, a court can order
compulsory care for a person whose health is deemed to
be at risk, or who may be placing others at risk, and who
is considered to need assistance in order to discontinue
substance use. The LVM and 172 Downloaded By: [DNL]
At: 13:04 23 May 2008.
Sampling and Methodology

Sampling procedure: Consecutively admitted to compulsory treatment 1997-01-01 - 2000-12-31 at Lundens LVM/LVU-center for women in LUND

Cohort: N = 230 (138 LVM and 92 LVU)
Sample: 132 persons who were diagnosed and evaluated by
a number of psychological, neuropsychological and
psychiatric assessment procedures (60%)
All patients hade previously agreed to participate.
Study was approved by the ethics committe of the medical
faculty of Lund University Lund University
Written consent was in addition to previous consent
requested for each participant at the time of the interview.




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Women at index admission
Cohort design 1997 – 2000
At which point in their carreers do
the women enter LVM-/LVU-treatment ?
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Abstinence treatment four years before and
four years after index admission, (register data n= 131)
Average number of admissions per year
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0,0
-0,1
-4
-3
-2
-1
0
1
2
3
4
Year before and after admission to Lunden
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Inpatient treatment in Psychiatry four years before and
four years after index admission (register data, n=131)
Average number of admissions per year
to psychiatric treatment
1,4
1,2
1,0
0,8
0,6
0,4
0,2
0,0
-4
-3
-2
-1
0
1
2
Years before and after index admission
3
4
Mean
Mean and
95% confidence interval
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Inpatient treatment in somatic hospital four years before
and four years after index admission,
(register data, n= 131)
Average number of admissions to somatic
hospital per year
0,7
0,6
0,5
0,4
0,3
0,2
0,1
-4
-3
-2
-1
0
1
2
Year before and after index admission
3
4
Mean
Mean and
95% confidence interval
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BACKGROUND – baseline data (n=132)
LVM
LVU
Psychiatric problems in family
of origin
40%
29%
Drug/alcohol abuse in family of
origin
58%
46%
At least one Suicidal attempt
48%
42%
Homeless at index admission
35%
54%
Prostitution as a source of income
41%
23%
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DATA COLLECTED AT INDEX ADMISSION
Background data: DOK=ASI-equivalent documentation
Test and rating scales:
 Personality inventories (BCT, CMPS),
 Psychiatric symptom scales (SCL-90)
 Global function (GAF),
 SCID I och SCID II, DSM-IV-diagnoses.
 PCL-R – Psychopathy
 Neuropsychological assessment
 Intelligence level (WAIS)
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Personality disorders at index (N=132)
AXIS II diagnosis
LVM (80)
LVU (52)
Borderline
26%
17%
Anti-social PD
23%
0%
1%
44%
62%
69%
Conduct Disorder
ANY Person diagnosis
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PSYCHIATRIC DISORDERS (AXIS I) IN THE COHORT
(N=132)
DIAGNOSIS
LVM (80)
AXIS I
Psychopathy
3%
Toxic psychosis
17%
Schizophrenia
0%
Sociophobia
1%
Major Depression
13%
Depressive disorders 13%
Dysthymia
3%
Anxiety, any
25%
TOTAL
60%
LVU (52)
6%
15%
5%
2%
13%
13%
0%
20%
61%
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TREATMENT LAST YEAR
LVM
- Treatment in psychiatry
LVU
61%
50%
-
Gynaecology
26%
17%
-
Dental treatment
59%
48%
-
Hepatitis B and/or C
57%
43%
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Patients followed-up at five-years
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TRIANGULATION APPROACH
Half structured face-to-face interview:
Background data, actual situation, diagnostics etc.
Standardized Psychological tests and rating scales
Register data from 1970-ties up to the present date:
a) Compulsory care,
b) Criminal records (BRÅ),
c) Hospital admissions all kinds (Epidemiological Center),
d) Causes of Death register (EPC), Death certificates
completed by forensic ortopsy reports.
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TEST AND RATING SCALES
Background data: DOK (LVM) & ADAD (LVU)
Time-Line-Follow-back over five years – DOC-variables
Test and rating scales:
AUDIT – level of problems related to Alcohol
Personality Inventory (BCT),
Psychiatric Rating Scales (SCL-90)
Global functioning (GAF),
Sense of Coherence (SOC)
Individual Schedule of Social Integration (ISSI)
SCID II - DSM-IV-diagnoses.
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INTERVIEWS
Face-to-face interview
106
Telephone interview
3
Deceased
8
in 32 different
communities
Outcome known (inkl deceased)
117 (88%) (83% itt)
Additional register data
130
(98%)
Independent Social workers
rating 2003 *
69
(84%)
*Stable abstinence (29%), definitely improved (23%), active
drug use (25%), diseased (7%), unknown (13%), Prison or
compulsory care LVM (3%)
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Abstinence at five-year follow-up
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70.0%
LVM (n=80)
LVU (n=52)
59.0%
60.0%
Linear (LVM (n=80))
54.0%
50.0%
44.0%
42.0%
39.0%
40.0%
37.0%
31.0%
30.0%
D
24.0%
19.0%
20.0%
17.0%
14%
13%
10.0%
10.0%
2.0%
0.0%
Diseased
Never abstinent
Abstinent last 30
days
Abstinent last 6
months
Abstinent last 12
months
Abstinent 2 yrs or
longer
Abstinent 5 years
Outcome at five year follow-up (ITT)
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80,0%
73,0%
70,0%
LVM
62,0%
Procent drogfria
60,0%
LVU
55,0%
49,0%
50,0%
47,0%
42,0%
36,0%
40,0%
28,0%
30,0%
17% 18%
20,0%
10,0%
0,0%
Drogfri
senaste 30
dgr
Drogfri
senaste
halvåret
Drogfri
senaste året.
Längd på drogfrihet
Drogfri
senaste två
åren eller
längre.
Drogfri sedan
utskrivning
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Cluster Analysis of continous trends for the
first three years after discharge from Lunden
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Time-line-diagrams demonstrating level of drug use
and abstinence until three years post treatment
Days of active drug use –
five categories
0 dgr
1-2 dgr
3-5 dgr
6-15 dgr
16-30 dgr
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--- not abstinent
--- Sporadicmbgrupp2
drug
,00use
1,00
__ Continous abstinence
2,00
Estimated Marginal Means
4,00
3,00
2,00
1,00
1
2
3
4
5
6
Six months intervals
Diagram 2. Drug use trends over three years after discharge from Lunden definied
by drug use the last 6 months before interview. Cluster analysis (Ward´s metod).
No of women = 101, Time-Line-Follow-Back-model (TLFB)
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CONCLUSIONS
Three different courses are discerned from discharge and
over the following three years: those who continues using
drugs regularily, those who improves but have relapses and
those who are abstinent almost from discharge and onwards.
Control for days in treatment three years past index, reveal
few differences even if number of days in treatment show a
tendency to decrease over time F(1;99)=7,167); p < .009).
More women in active substance use have many treatment
occasions F=4,431; p < .0,04) compared to those abstinent.
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Two levels of drug use
over three years past
treatment
0,80
Missbrukar inte
___ not abstinent
Missbrukar
_____ abstinent
0,60
Krim
0,40
0,20
0,00
1
2
3
4
5
6
Mätpunkt
Diagram 3. Trends in criminal activity over three years past
treatment in two clusters past discharge (n=101). TLFBmodel.
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CONCLUSIONS
Already in the first year, those who still use drugs,
(group 2 and 3) continue to have a higher number
of offences brought to justice in the Criminal
Justice data-base (BRÅ) F(1,99)=9.062; p<0.003.
There is a significantly decreasing trend among
those abstinent, which does not exsist in the group
still using drugs.
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Aggregated measures of social adjustment over
the three years past discharge (n=101)
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CONCLUSIONS
In the abstinent group (Group 1) there is an increase
in legal income, number of non drug friends, social
relations to family, more stable living etc. F(1,99( =
4.30, p < .04).
There is a simliar trend for the first year after
discharge for the drug abusing group, but it does not
continue and the interaction between the two groups
is significant, F (1;99) = 6,37, p < .013), F (1;99) =
11,168), p < .001).
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Mortality and causes of death
8 diseased in the sample
11 in the comparison group
All but one women had a drug related death,
two suicides. 3 died from somatic illnesses.
12 Overdoses and 3 fatal poisonings
Substance problems were a contributing
factor in all. SMR=9,07
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PSYCHIATRIC SYMPTOMS
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Estimated Marginal Means of MEASURE_1
Två missbruksgrupper
baserade
Två missbruksgrup
på 6 mån innan
uppföljning
baserade
på 6 må
Estimated Marginal Means
1,40
innan uppföljning
___ Fortsatt
missbruk
Missbrukar inte
___ Drogfria 2,00
1,20
1,00
0,80
0,60
1
2
3
4
5
6
Diagram 6. The course of psychiatric
symptoms like depression, anxiety and
factor1
aggressive behavour is more negative among the persons still having a substance
abuse compared to abstinent persons.(F(2,99)=4,445: p < .038.)
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(n=101)
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CONCLUSIONS
Symptoms higher on all scales in groups with
non-abstinent women F(2, 99)= 4,445; p < .038).
The main difference is in the early phases of the
three year period.
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SCL-90-scores for patients with drug dependence at five years follow up (n=90) on three
levels of abstinence
100
Non stable abstinence (n=38)
Abstinence from 6 months to 2 years (n=12)
90
Stable abstinence (2 years or more) (n=40)
70
***
***
***
***
***
***
**
***
***
***
***
60
50
40
Positive Symptom
Distress Index
Psychoticism
Paranoid ideation
Global Severity Index
SCL-90
Fobic Anxiety
Aggressive-ness
Anxiety
Depression
Interpersonal
sensitivity
Obsessive-compulsive
30
Somatization
Mean
80
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Patients becoming abstinent have significantly:
- A Higher SOC (KASAM) than others
- Have lower scores of symptoms (SCL-90)
- A higher level of social integration (ISSI)
- Show personality changes (BCT)
- Have lower levels of criminal activity
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Anti-social Personality disorder and Conduct
disorder have a significantly negative impact on
drug abuse, criminal behaviour, social adaptation
No other personality disorder reveal this !!!
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SUMMARY
1. It is a surprisingly positive outcome for many
2. The immediate consequences on short sight
following discharge are very important also
for long-term outcome.
3. When substance problems decreases, so do
problems in social functioning, criminality etc,
4. Improvement in drug patterns give important
gains .
5. The assessment of quality show that most
patients are satisfied with the intervention
7. NOTE that 15% leave Lunden with no or minor
relapses.
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METHOD
Setting
The setting was a 21-bed inpatient compulsory care residential care unit, Lunden, in Lund, Sweden. The institution
has 12 beds for adults and 9 for youths. The unit staff includes psychologists, psychiatrist, nurses, social workers,
treatment attendants, and administration. Women are treated under the Law on Compulsory Care for Substance
Abusers (LVM, act 1988:870) or The Care of Young Persons Act (LVU, act 1990:52).
According to the LVU, “a care order is to be issued, if the young person exposes his health or development to a
palpable risk of injury through the abuse of addictive substances, criminal activities, or some other socially degrading
behavior” (LVU, act 1990:52, section 3). Youths can also be taken into care under the LVU due to neglect or chaotic
circumstances in the home.
Under Section 4 of the LVM, a court can order compulsory care for a person whose health is deemed to be at risk, or
who may be placing others at risk, and who is considered to need assistance in order to discontinue substance use.
The LVM and 172 Downloaded By: [DNL] At: 13:04 23 May 2008. LVU acts are unrelated to penal code and laws of
psychiatric care.
Patients are usually reported to courts by social welfare, or, more rarely, police, their family members, or general
practitioner. Within eight days after report, an assessment of need for treatment must be completed, and court
hearings can then proceed.
Care orders are implemented in specially certified LVM and LVU homes, under the authority of the National Board for
Institutional Care. The number of adults undergoing compulsory care was 1,029 persons in 2003, of which 301 were
women, and the number of youths was 1073, of which 373 were girls
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