Evaluación de resultado e impacto clínico de los modelos de intervención en pacientes con patología dual

Abstract

The co-occurrence of substance use disorders with other mental disorders, known as psychiatric comorbidity or dual diagnosis, is well documented reality in psychiatric field. From a clinical point of view, patients with dual disorders present a greater impairment and poorer therapeutic outcomes than those patients without such comorbidity. However, regarding intervention of these patients, different review studies have shown that an adequate intervention program on these patients allows a significant improvement in their living conditions. In Andalusia, there is a Coordinated Protocol between Community Mental Health Units (CMHU) and Addiction Treatment Centers (ATC) for the attention of patients with dual diagnosis. This thesis is framed in this context, wich general objective is to analyze the effectiveness of the intervention of patients with dual pathology and the factors that contribute to psychopathological stability and disability in patients with dual diagnosis. For this aim, this thesis adopted a longitudinal observational design, with a baseline evaluation and follow-up at 6 months. The sample consisted of 182 patients diagnosed by dual disorders. Of these, 51 patients were treated exclusively in the CMHU, 62 patients in the ATC, and 69 patients were treated in a coordinated manner between the CMHU and the ATC. The instruments administered measured severity of dependence (SDSS), psychopathological stability (BSI-18), and functional disability (WHODAS 2.0). On the first study, the clinical utility of WHODAS 2.0 to detect reliable change in these patients was analyzed. To do that, two psychometrics approaches were used: Classical Test Theory (CTT) and Item Response Theory (IRT). Reliability estimated by Cronbach's alpha provided acceptable values for all domains. The IRT model revealed an adequate precision of the item parameters, and an adequate capacity to discriminate between people with high and low disability in terms of the total scores, but not in the domains. As a consequence, the kappa coefficients are low to detect the reliable change in most domains, but adequate for the total score. In conclusions, the use of total WHODAS 2.0 scores may be useful from a clinical perspective. However, more evidence is required for domain scores in order to support its usefulness. The decision to use the CTT or the IRT makes difference in terms of calculating clinically reliable change. The second study analyze and compare the profile of dual patients treated in CMHU or ATC services with patients using both. The results show that a higher prevalence of patients with a cocaine and heroin dependence profile was observed in the patients treated in ATC (35.9%, as opposed to 2% in CMHU and 16.4% in the coordinated service). For those patients treated in CMHU there was a higher prevalence of profiles related to cannabis dependence (41.2%, as opposed to 9.4% in the ADH and 16.4% in the coordinated service). The odds ratio for hypomanic episodes was 2.879 (p <0.05) for patients in ATC compared with the other two services. The odds ratio observed for manic episodes was 0.483 (p <0.05) in ATC patients, whilst for patients in CMHU there was a higher prevalence of comorbid psychotic disorders in comparison with those using ATC services (66% as opposed to 37.5%). As conclusions, the differences in profiles identified should be taken into account when planning the attention on the different services. The third study analyze the progress of patients diagnosed with dual pathology, comparing the outcomes of those who exclusively attend either ATC or CMHU with those patients who follow a program in which the two services are coordinated. In general, the results show no statistically significant differences between baseline and follow up in WHODAS and BSI-18 scores. More cocaine use was found in three groups after intervention, but was statistically significant in patients attended by ATC and CMHU. Higher percentages of abandonment were found in patients attending coordinate services. In terms of reliable change, there were higher percentages of ATC and CMHU patients who showed a deterioration in WHODAS 2.0. Among those receiving the coordinated treatment, there were more patients who showed improvements in the WHODAS 2.0 dimensions, with the exception of the self-care dimension. The results show that the coordinated service is related with more abandonment. As conclusions, the inconvenience caused by going to different treatment networks may partially explain these results. However, patients who remain in treatment in coordinated services, show lower functionality deterioration than patients in other modalities.