The UCSF Department of Psychiatry will use a $7.9 million grant to study creative ways to treat complex, substance abusing patients in community settings, such as hospital emergency rooms and mental health programs.
The grant, awarded by the National Institutes of Health, spans over five years and will focus on four areas. The study is unique in that it deals with patients who are doubly diagnosed, such as someone who is mentally ill and also smokes or a person who is HIV positive and addicted to heroin, said principal investigator Sharon Hall, PhD, professor of psychiatry and vice-chair of the UCSF Department of Psychiatry.
"Not a lot of research is done with this complicated population, " she said. "And when it is done, it's not in community settings."
Hall's research involves working on a computer-based intervention program for smokers who are also depressed and seeking treatment for that disorder. The computer program is built around the "stages of change" theory: pre-contemplation, contemplation, preparation, action and maintenance. The program is designed to encourage people to think about what stage they're in and gives them indications of what things to think about in order to move onto the next stage until they reach the action stage, when they do something concrete to quit smoking such as buy a nicotine patch.
Hall is recruiting 400 people who come to UCSF's Langley Porter Psychiatric Institute for treatment of depression. They will be tracked for 18 months. Many people who are at risk for depression are also nicotine addicted, she said, and people who have come in for counseling might be an ideal population to work with to quit smoking.
"These are people who have started to make a major change in their life, so perhaps this is a good time to help change their behaviors," she said. "What we want to see is a decrease in smoking rates."
Another area of study will look at the effectiveness of linking heroin addicts who come into San Francisco General Hospital Medical Center's emergency room to methadone maintenance treatments by either assigning them to a case manager who will move them into treatment or by giving them a voucher good for six months at an area methadone clinic. This isn't treatment as usual: doctors or nurses noticing needle marks on a patient's arms, treating them and giving them a referral to a treatment program, said James Sorensen, PhD, adjunct professor of psychiatry and co- principal investigator who is based at the UCSF-affiliated San Francisco General Hospital Medical Center.
"This kind of outreach isn't usually done," he said. "Usually, treatment programs wait for the patients to come to them."
The goal is to get addicts into treatment right away, he said. "The emergency room is a great place to catch them," Sorensen said. "Otherwise, they are out there living on the streets and in parks and we never see them. It's a way we can have access to this group of people who would be better off if we got them into treatment."
The study will enroll 120 participants who will be followed for a year and a half to see if they go into methadone treatment, what other kinds of services they use and what kinds of problems were they having with their addiction.
Sorenson also is overseeing another study that will test voucher based incentives to encourage HIV/AIDS positive patients enrolled in San Francisco General's methadone program to take their medicine on schedule and stay drug free. Patients can receive vouchers redeemable for goods and services, such as groceries, if their urine samples turn out drug free or if they take their medicine. Doctors can tell if patients have been taking their medication by having information downloaded off a computer chip placed on the cap of the medicine bottle that indicates when and how often the bottle has been opened.
The grant will also be used to train case managers on how to treat their client's drug abuse-while meeting all of their basic needs such as finding them shelter, food and making sure they are safe. The case managers work in mental health programs run by the City and County of San Francisco. After receiving the training, the case managers will teach their clients (people suffering from serious mental illnesses such as schizophrenia) how to cope with stress and other social skills in an effort to get them off drugs. Increasingly, more mentally ill people are also drug addicted and this can exacerbate their condition, said co-principal investigator Barbara Havassy, PhD, adjunct professor of psychiatry based at San Francisco General Hospital Medical Center. For example, drugs can cause patients to forget to take their medicine.
"Missing a dose or two means you are in a lot of trouble," Havassy said. "Whatever stability you have has been destroyed."
Havassy is recruiting 300 patients for treatment for six months and will follow them for a year after that. "This study not only meets scientific criteria in that it is a well designed trial. It will also yield a lot of information that could influence how services are being organized and lead to policy decisions," she said. "It's part of the larger issue of we have people who are mentally ill and drug addicted. Where and how is the best way to take care of them."