Protocol Personality assessment as a support for referral and case-work in treatment for substance use disorders (PASRC-study)

1、 BMC PsychiatryBioMedCentralStudy protocolOpen AccessProtocol: Personality assessment as a support for referral and case-work in treatment for substance use disorders (PASRC-study)Morten Hesse* and Mads K PedersenAddress: University of Aarhus, Centre for Alcohol and Drug Research, Købmagergade

2、26E, 1150 Copenhagen C, DenmarkEmail: Morten Hesse* - mhcrf.au.dk; Mads K Pedersen - mkpcrf.au.dk* Corresponding author Published: 25 April 2008Received: 31 January 2008Accepted: 25 April 2008BMC Psychiatry 2008, 8:30doi:10.1186/1471-244X-8-30This article is available from: :/ biomedcentral /1471-24

3、4X/8/30© 2008 Hesse and Pedersen; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( ://licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided

4、the original work is properly cited.AbstractBackground: Assessment of co-morbid personality disorders in substance use disorders may leadto important insights concerning individual patients. However, little is known about the potentialvalue of routine personality disorder assessment in a clinical co

5、ntext.Methods: Patients are adults with past-year substance dependence seeking treatment at acentralized intake unit for substance abusers in the City of Copenhagen. A randomized controlledtrial of assessment of personality disorders and individual feedback vs. a general life situationinterview. Pat

6、ients are followed at 3 and 6 months post-treatmentDiscussion: If routine personality assessment improves outcomes of substance abuse treatment,the clinical implication is to increase the use of personality disorder assessment in substance abusetreatment settings.Trial registration: Current controll

7、ed trials ISRCTN39851689Backgroundpatients without personality disorders, and remain at alower level of functioning 7,8.Substance use disorders and personality disorders oftenco-occur 1,2. Patients with personality disorders arecommonly seen in treatment programs for substanceabuse, consume a dispro

8、portionate amount of staff time,and are more likely to drop out from substance abusetreatment interventions 3,4.Therefore, treatment that meets the needs of patients withsubstance abuse and personality disorders is needed.Recently, some studies have shown that integrated treat-ment for personality d

9、isorders and substance abuse maybe superior to treatment that focuses solely on substanceabuse treatment 9-11.At the same time, therapists and other professionals tendto react negatively to patients with personality disorders atan emotional level 5, this is especially the case with clus-ter B (drama

10、tic/erratic) personality disorders 6.This randomized experimental study is designed to assesswhether systematic assessment of personality disordersimproves outcomes, vs. assessment of Axis I disordersalone.Even if patients with personality disorders benefit fromtreatment, they often remain more symp

11、tomatic thanPage 1 of 9(page number not for citation purposes) BMC Psychiatry 2008, 8:30 :/ biomedcentral /1471-244X/8/30The objective of this study is to estimate the effect of rou-tine assessment of co-morbid axis II disorders in a central-ized intake unit for substance use disorders.The assessmen

12、t and feedback takes place in the first threeweeks of treatment.Table 1 gives an overview of the interviews and question-naires conducted at the different assessment times. Figure1 represents the research procedure schematically. Figure2 contains the expected participant flow.MethodDesignThe study i

13、s a randomized experimental trial comparingassessment of Axis I disorders alone with assessment ofboth Axis I disorders and Axis II disorders. For both treat-ment conditions, patients are given feedback about theresults of assessment and offered the opportunity to havetheir key-worker receive the sa

14、me feedback.Outcome criteriaThe main outcome criterion will be the following:Improvement in at least one of the following areas,described as a 30% decline in score, with no concurrentdeterioration in any area: global functioning, as measuredby the Work and Social Adjustment Scale 12; psychiatricsymp

15、toms, as measured by the Kessler 6+ 13,14; sub-stance use, as measured by the Opiate Treatment Indexdrug use indicator 15; treatment engagement, as meas-ured by treatment staff, using the treatment engagementscale from DATOS 16.Participants/settingParticipants are adults seeking treatment for a subs

16、tanceuse related disorder at the Central Intake Unit (CIU) inCopenhagen, Denmark (Købmagergade 26E, St., 1150Copenhagen C).Referral and recruitmentPatients are recruited by caseworkers. The management ofthe intake unit and the management of the centre haveinstructed all caseworkers to ask all n

17、ew referrals or thosereferred for a change in treatment to participate in thestudy.Secondary outcome criteria will be Retention in treatment, defined as being retained in thesame treatment that patients were first referred to aftertheir contact with the intake unit at 3 and 6 months fol-low-up, or h

18、aving completed that treatment as planned.Caseworkers inform patients that the study concernsassessment of psychological problems, behaviour andother disorders, and that patients will be randomlyassigned to one of two types of interviews. The primaryinterviewer later gives detailed information about

19、 thestudy procedure. Understanding of one's own personality and the impactthat personality has on others, as rated by an independentinterviewer 17. Readiness to change dysfunctional behaviour, work withemotional problems, change illicit drug use, and changealcohol use, as measured by brief 4-ite

20、m questions,adapted from the smoking cessation literature 18.Inclusion criteriaTo be eligible for the study, patients must satisfy the fol-lowing criteria:Outcome criteria will be assessed at 3 and 6 months fol-low-up. Be at least 18 years of age. Not currently be psychotic or have a known diagnosis

21、 ofschizophrenia excluding patients from treatment at theintake unit.Intake procedureAt intake to the CIU, patients undergo a routine intakeinterview with a key-worker that includes the AddictionSeverity Index 19. After the completion of the intakeinterview, patients are informed by the caseworker o

22、f thefact that a study of psychopathology is ongoing at theunit. If the patient agrees to receive further information, aresearcher is contacted, which immediately comes to theoffice of the key-worker to meet the patient and schedulesan intake interview. Not currently be involved in an ongoing treatm

23、ent for adrug or alcohol problem. Patients who are currentlyinvolved in treatment for alcohol or drug abuse will, how-ever, not be referred to the CIU. Have past-year substance dependence, as indicated by ascore on the SDS of 3 or more for either alcohol or drugs.Baseline interview Speak Danish or E

24、nglish fluently. Give informed consent.At the baseline interview, the interviewer informs thepatient of the study, and explains that the study focuses ofpsychological and behavioural problems that people withsubstance abuse regularly encounter. He then explainsPage 2 of 9(page number not for citatio

25、n purposes) BMC Psychiatry 2008, 8:30 :/ biomedcentral /1471-244X/8/30Information after intake interviewat central intake unitWeek 1. Intake screening and axisI assessment. Introduction tofollow-up interviewerExclusion: Does notsatisfy criteria forsubstance dependenceRandomizationPersonality disorde

26、r assessmentClient-driven interviewIndividual feedback about axis Iand II disordersIndividual feedback about axis IdisordersFeedback with patient and caseworker if patient agreesMonth 3: First follow-up assessmentMonth 6: Second follow-up assessmentFlowchartFigure 1 of the process from information t

27、o follow-upFlowchart of the process from information to follow-up.that there are two different interviews, and that patientswill be randomly assigned to one of two types. If asked, hewill explain that he does not yet know what kind of inter-view he will conduct the second time they meet, but hewill

28、give a further explanation at their second appoint-ment. If the patient gives consent to participate in thestudy, a brief structured assessment of axis I disorders isconducted. The assessment is kept brief, in order to reduceassessment reactivity, i.e., the effects that assessment canhave on treatme

29、nt outcomes 20.The instruments used are therefore chosen to be brief, buthave strong indications of validity:Page 3 of 9(page number not for citation purposes) BMC Psychiatry 2008, 8:30 :/ biomedcentral /1471-244X/8/30Approached: (n= )Refused: (n= )Accepted, but contact notestablished: (n= )Intake s

30、creening and axis Iassessment. Introduction tofollow-up interviewerExclusion: Does notsatisfy criteria forsubstance dependence (n=)RandomizationAllocated to personalityAllocated to personalityclient-driven interview (n= )Did not show up for secondinterview (n= )disorder assessment (n= )Did not show

31、up for secondinterview (n= )AllocationDid not complete feedback(n= )Did not complete feedback(n= )Refused feedback tocaseworker (n= )Refused feedback tocaseworker (n= )Lost to follow-up (n= )For reasonLost to follow-up (n= )For reasonFollow-upAnalysisAnalyzed (n= )Lost to follow-up (n= )For reasonAn

32、alyzed (n= )Lost to follow-up (n= )For reasonFlowchartFigure 2 of participantsFlowchart of participants.Page 4 of 9(page number not for citation purposes) BMC Psychiatry 2008, 8:30 :/ biomedcentral /1471-244X/8/30Table 1: Instruments at different assessment momentsSecond interview experimental condi

33、tionIf the patient is randomized to the experimental condi-tion, the second interview will be an assessment of axis IIdisorders. The patient will first receive a brief descriptionof what personality disorders is, and be given a briefdescription of personality disorders as inflexible, mala-daptive pa

34、tterns of behaviour that cause significant prob-lems or distress for themselves or others.BaselineFollow-upFollow-upInterview:SAPAS 22, 23ASRS 14K6 32*OTI 15SDS alcohol 21SDS drugs 21WAI 29Ratings of the feedbackprocedure VASClinician rated:CGI-externalizing 23CGI-substance use 23GAF 23The interview

35、 will consist of the following elements: The Alcohol Use Disorder and Associated DisordersInterview Schedule (AUDADIS) section for avoidant,dependent, obsessive-compulsive, paranoid, schizoid andhistrionic personality disorder 24. Added items takenfrom the Parker Personality inventory will be taken

36、in toreflect schizotypal personality disorder and narcissisticpersonality disorder 25.*WAI 29Notes:SAPAS: Standardised Assessment of Personality AbbreviatedScale.ASRS: Adult ADHD Self-Report Scale.K6: Kessler 6.OTI:Opiate Treatment Index.SDS: Severity of Dependence Scale.WAI:Working Alliance Invento

37、ry. VAS: Visual analogue scales. CGI: ClinicalGlobal Impression. GAF: Global Assessment of Functioning. The NPI-16 will be added as a measure of narcissism26. The Psychiatric Research Interview for Substance andMental Disorders (PRISM) 27,28 will be used to assessborderline and antisocial personalit

38、y disorder. Anxiety/depression is assessed with The Kessler 6 inter-view 14. Attention Deficit/Hyperactivity Disorder is assessed withthe Adult ADHD Self-Report Scale 14.Following this, patients will be asked if they have anyquestions, and thereafter the interviewer will proceed withthe interview. T

39、he interview will contain the followingelements. Illicit substance dependence and alcohol dependenceare both assessed by means of the Opiate Treatment Indexsubstance use items 15.The interviewer will be trained through role-plays inadministering the interview package. For the PRISM,taped interviews

40、will be co-rated to assess the inter-raterreliability of coding. Severity of alcohol and illicit drug dependence will beassessed by the Severity of Dependence Scale SDS 21. Personality disorder severity is assessed with the Struc-tured Assessment of Personality Abbreviated ScaleSAPAS 22,23.Second in

41、terview: control conditionThe control condition will contain an interview of up toone hour, where the patient chooses focus based on a listof items (substance use problems; family; friends; work/education; etc). The interview is client-driven and followsan ethnographic approach.If the patient does n

42、ot speak Danish or English well, doesnot screen positive for substance dependence as indicatedby an SDS score of 3 or more for either alcohol or drugs,a feedback session is scheduled, and the patient isinformed that based on his data, we wish to give him indi-vidual feedback on the next session.Thes

43、e interviews are taped and used as the basis for a con-densed summary in the feedbackRandomization and blindingIf the patient satisfies inclusion criteria (speaks Danish orEnglish; SDS > 3; gives informed consent), a second inter-view is scheduled. The interviewer will also schedule ameeting with

44、 the researcher conducting follow-up inter-views.Randomization will be conducted by means of a prede-fined list of random numbers, stratified by predefinedcharacteristics, which will not be disclosed at this point toreduce risk of breaking of blind. Randomization is exe-cuted according to a list, th

45、e allocation sequence of whichwas computer-generated by one of the researchers (MH).The interviewer will be blinded to randomization at thebaseline interview.The patient is then randomized to either experimental orcontrol conditions.Page 5 of 9(page number not for citation purposes) BMC Psychiatry 2

46、008, 8:30 :/ biomedcentral /1471-244X/8/30The follow-up interviewers will be introduced to thepatients at the baseline interview, to assure blinded fol-low-up assessments.Follow-up procedureTrained interviewers will make contact with study partici-pants before randomization, but after intake intervi

47、ew.Interviewers will be blinded to randomization status. Thefollow-up interview will contain the same elements as thebaseline interview (i.e., the K6, the ASRS, the WSAS, theOTI, and the SDS). Also, patients will be asked to rate thevalue of the feedback procedure on visual analogue scalesrepresenti

48、ng the skills of the interviewer (on a line rangingfrom "extremely unskilled" to "extremely skilled"), hisknowledge (from very little knowledge, to highly knowl-edgeable), his degree of interest in the patient, his under-standing of the patient, the value of the feedback for thet

49、reatment, the value of the treatment for the patient, howmuch thought the patient has given the feedback, andhow much work he has done in regard to the issues dis-cussed in the feedback.WithdrawalA participant can withdraw from the trial at any point,although information already given to caseworkers

50、 can-not be withdrawn. Participants who withdraw from thetrial treatment will not be asked to attend the follow-upappointments, and will be deleted from all files.Feedback and psychoeducation procedurePatients will receive individual feedback first. The feed-back is inspired by psychoeducation proce

51、dures 17. Foreach diagnosis for which a positive result is found,patients are first prompted about their knowledge of thedisorder, and then given their test results. Test results willinvolve diagnoses and possible treatment options andimplications (e.g., psychotherapy and/or medication foranxiety/de

52、pression; skills training and/or medication forattention deficit/hyperactivity disorder). For personalitydisorders, treatment implications, resources and relevanttreatment options are summarized in Table 2.Finally, the patient is asked to rate his alliance with thecaseworker using the Working allian

53、ce inventory, patientversion 29.Table 2: Treatment implications, personal resources, and relevant treatment options for each of the ten personality disordersPersonalitydisorderImplicationsResourcesTreatment optionsParanoidSchizoidProblems dealing with high expressed emotion; needs Careful, able to cope inCounselling; inpatient treatment in smallwards with great flexibility; notexploratory psychotherapy 10Counselling; possibly inpatient treatmentin small wards with great flexibility 10time to build trust; needs great pati