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

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

treatment institution in SwedenRimini, October 2009

Mats Fridell, Johan Billsten, Iréne Jansson

Department of Psychology, Lund Universitet

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PUBLICATIONSPUBLICATIONS

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). Femårsupp- följning 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 LUNDEN, RESIDENTIAL DRUG FREE COMPULSORY CARE 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 motivationenhancement

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.

According to the LVU, “a care order is to be issued, if the According to the LVU, “a care order is to be issued, if the young person exposes his health or development to a young person exposes his health or development to a palpable risk of injury through the abuse of addictive palpable risk of injury through the abuse of addictive substances, criminal activities, or some other socially substances, criminal activities, or some other socially degrading behavior” (LVU, act 1990:52, section 3).degrading behavior” (LVU, act 1990:52, section 3).

Youths can also be taken into care under the LVU due to Youths can also be taken into care under the LVU due to neglect or chaotic circumstances in neglect or chaotic circumstances in the home.the home.

Under Section 4 of the LVM, a court can order Under Section 4 of the LVM, a court can order compulsory care for a person whose health is deemed to compulsory care for a person whose health is deemed to be at risk, or who may be placing others at risk, and who be at risk, or who may be placing others at risk, and who is considered to need assistance in order to discontinue is considered to need assistance in order to discontinue

substance use. The LVM and substance use. The LVM and 172 172 Downloaded By: [DNL] Downloaded By: [DNL] At: 13:04 23 May 2008. At: 13:04 23 May 2008.

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Sampling and MethodologySampling and Methodology

Sampling procedure: Consecutively admitted to compul-sory 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 admissionWomen at index admission

Cohort design 1997 – 2000Cohort design 1997 – 2000

At which point in their carreers dothe women enter LVM-/LVU-treatment ?

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Abstinence treatment four years before andAbstinence treatment four years before andfour years after index admission, (register data n= 131)four years after index admission, (register data n= 131)

-4 -3 -2 -1 0 1 2 3 4

Year before and after admission to Lunden

-0,1

0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

Aver

age

num

ber o

f adm

issi

ons

per y

ear

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Inpatient treatment in Psychiatry four years before and Inpatient treatment in Psychiatry four years before and four years after index admission (register data, n=131)four years after index admission (register data, n=131)

Mean Mean and

95% confidence interval

-4 -3 -2 -1 0 1 2 3 4

Years before and after index admission

0,0

0,2

0,4

0,6

0,8

1,0

1,2

1,4

Aver

age

num

ber o

f adm

issi

ons

per y

ear

to p

sych

iatri

c tre

atm

ent

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Inpatient treatment in somatic hospital four years before Inpatient treatment in somatic hospital four years before and four years after index admission, and four years after index admission,

(register data, n= 131)(register data, n= 131)

Mean Mean and

95% confidence interval

-4 -3 -2 -1 0 1 2 3 4

Year before and after index admission

0,1

0,2

0,3

0,4

0,5

0,6

0,7

Aver

age

num

ber o

f adm

issi

ons

to s

omat

icho

spita

l per

yea

r

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BACKGROUND – baseline data (n=132)BACKGROUND – baseline data (n=132)

LVM LVU

Psychiatric problems in family 40% 29%of origin

Drug/alcohol abuse in family of 58% 46%origin

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 ADMISSIONDATA COLLECTED AT INDEX ADMISSION

Background data: DOK=ASI-equivalent docu-mentation

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 – PsychopathyNeuropsychological assessment Intelligence level (WAIS)

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Personality disorders at index (N=132) Personality disorders at index (N=132)

AXIS II diagnosis LVM (80) LVU (52)

Borderline 26% 17%

Anti-social PD 23% 0%

Conduct Disorder 1% 44%

ANY Person diagnosis 62% 69%

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PSYCHIATRIC DISORDERS (AXIS I) IN THE COHORT PSYCHIATRIC DISORDERS (AXIS I) IN THE COHORT (N=132) (N=132)

DIAGNOSISDIAGNOSIS LVM (80)LVM (80) LVU (52) LVU (52) AXIS IAXIS I PsychopathyPsychopathy 3% 3% 6% 6% Toxic psychosisToxic psychosis 17% 17% 15% 15% SchizophreniaSchizophrenia 0% 0% 5% 5%SociophobiaSociophobia 1% 1% 2% 2%Major Depression Major Depression 13% 13% 13% 13%Depressive disorders 13% Depressive disorders 13% 13% 13%DysthymiaDysthymia 3% 3% 0% 0%Anxiety, anyAnxiety, any 25% 25% 20% 20%

TOTALTOTAL 60% 60% 61% 61%

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TREATMENT LAST YEAR

LVM LVU

- Treatment in psychiatry 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-yearsPatients followed-up at five-years

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TRIANGULATION APPROACHTRIANGULATION 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 SCALESTEST 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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INTERVIEWSINTERVIEWS

Face-to-face interview 106 in 32 different communities

Telephone interview 3

Deceased 8

Outcome known (inkl deceased) 117 (88%) (83% itt)

Additional register data 130 (98%)

Independent Social workers 69 (84%)rating 2003 *

*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-upAbstinence at five-year follow-up

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DD

Outcome at five year follow-up (ITT)

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73,0%

55,0%

47,0%

28,0%

17% 18%

36,0%

42,0%

49,0%

62,0%

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

70,0%

80,0%

Drogfrisenaste 30

dgr

Drogfrisenastehalvåret

Drogfrisenaste året.

Drogfrisenaste tvååren eller

längre.

Drogfri sedanutskrivning

Längd på drogfrihet

Pro

cent

dro

gfri

a

LVM

LVU

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Cluster Analysis of continous trends for theCluster Analysis of continous trends for the

first three years after discharge from Lundenfirst three years after discharge from Lunden

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Time-line-diagrams demonstrating level of drug use Time-line-diagrams demonstrating level of drug use and abstinence until three years post treatmentand abstinence until three years post treatment

Days of active drug use –Days of active drug use – 0 dgr0 dgr five categories five categories 1-2 dgr1-2 dgr

3-5 dgr3-5 dgr6-15 dgr6-15 dgr

16-30 dgr 16-30 dgr

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Diagram 2. Drug use trends over three years after discharge from Lunden definiedby 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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Six months intervals

4,00

3,00

2,00

1,00

Est

ima

ted

Mar

gin

al M

ean

s 2,001,00,00

mbgrupp2

--- --- not abstinentnot abstinent

--- --- Sporadic drug useSporadic drug use

__ Continous abstinence

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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 Control for days in treatment three years past index, reveal few differences even if number of days in treatment show afew differences even if number of days in treatment show atendency to decrease over time F(1;99)=7,167); p < .009). tendency to decrease over time F(1;99)=7,167); p < .009).

More women in active substance use have many treatmentMore women in active substance use have many treatmentoccasions F=4,431; p < .0,04) compared to those abstinent. occasions F=4,431; p < .0,04) compared to those abstinent.

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Diagram 3. Trends in criminal activity over three years pasttreatment in two clusters past discharge (n=101). TLFB-model.

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Mätpunkt

0,80

0,60

0,40

0,20

0,00

Kri

m

Missbrukar

Missbrukar inte

Two levels of drug useover three years pasttreatment

___ ___ not abstinentnot abstinent

_____ abstinent_____ abstinent

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CONCLUSIONSCONCLUSIONS

Already in the first year, those who still use drugs, Already in the first year, those who still use drugs, (group 2 and 3) continue to have a higher number (group 2 and 3) continue to have a higher number of offences brought to justice in the Criminal of offences brought to justice in the Criminal Justice data-base (BRÅ) F(1,99)=9.062; p<0.003. Justice data-base (BRÅ) F(1,99)=9.062; p<0.003.

There is a significantly decreasing trend among There is a significantly decreasing trend among those abstinent, which does not exsist in the group those abstinent, which does not exsist in the group still using drugs.still using drugs.

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Aggregated measures of social adjustment over Aggregated measures of social adjustment over the three years past discharge (n=101)the three years past discharge (n=101)

Halvår efter utskrivning

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Sjä

lvra

pport

erade so

cial fö

rhållande

2,00

1,75

1,50

1,25

1,00

0,75

Inte drogfriDrogfri

Två missbruksgrupper baserade på 6 mån innan

uppföljning

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CONCLUSIONSCONCLUSIONS

In the abstinent group (Group 1) there is an increase In the abstinent group (Group 1) there is an increase in legal income, number of non drug friends, social in legal income, number of non drug friends, social relations to family, more stable living etc. F(1,99( = relations to family, more stable living etc. F(1,99( =

4.30, p < .04).4.30, p < .04).

There is a simliar trend for the first year after There is a simliar trend for the first year after discharge for the drug abusing group, but it does not discharge for the drug abusing group, but it does not continue and the interaction between the two groups continue and the interaction between the two groups

is significant, F (1;99) = 6,37, p < .013), F (1;99) = is significant, F (1;99) = 6,37, p < .013), F (1;99) = 11,168), p < .001).11,168), p < .001).

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Mortality and causes of deathMortality and causes of death8 diseased in the sample8 diseased in the sample

11 in the comparison group11 in the comparison group

All but one women had a drug related death,All but one women had a drug related death,two suicides. 3 died from somatic illnesses. two suicides. 3 died from somatic illnesses.

12 Overdoses and 3 fatal poisonings12 Overdoses and 3 fatal poisonings

Substance problems were a contributing Substance problems were a contributing factor in all. SMR=9,07factor in all. SMR=9,07

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PSYCHIATRIC SYMPTOMS

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Diagram 6. The course of psychiatric symptoms like depression, anxiety and aggressive behavour is more negative among the persons still having a substance abuse compared to abstinent persons.(F(2,99)=4,445: p < .038.) (n=101)

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factor1

1,40

1,20

1,00

0,80

0,60

Es

tim

ate

d M

arg

ina

l M

ea

ns

2,00

Missbrukar inte

Två missbruksgrupperbaserade på 6 mån

innan uppföljning

Estimated Marginal Means of MEASURE_1

Två missbruksgrupper baserade på 6 mån innan uppföljning

___ Fortsatt missbruk

______ DrogfriaDrogfria

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CONCLUSIONSCONCLUSIONS

Symptoms higher on all scales in groups with Symptoms higher on all scales in groups with non-abstinent women F(2, 99)= 4,445; p < .038).non-abstinent women F(2, 99)= 4,445; p < .038).

The main difference is in the early phases of the The main difference is in the early phases of the three year period.three year period.

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Patients becoming abstinent have significantly:Patients becoming abstinent have significantly:

- A Higher SOC (KASAM) than others- A Higher SOC (KASAM) than others- Have lower scores of symptoms (SCL-90)- Have lower scores of symptoms (SCL-90)- A higher level of social integration (ISSI)- A higher level of social integration (ISSI)- Show personality changes (BCT) - Show personality changes (BCT) - Have lower levels of criminal activity- Have lower levels of criminal activity

Anti-social Personality disorder and ConductAnti-social Personality disorder and Conductdisorder have a significantly negative impact ondisorder have a significantly negative impact on

drug abuse, criminal behaviour, social adaptationdrug abuse, criminal behaviour, social adaptation

No other personality disorder reveal this !!!No other personality disorder reveal this !!!

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SUMMARYSUMMARY1. It is a surprisingly positive outcome for many1. It is a surprisingly positive outcome for many2. The immediate consequences on short sight 2. The immediate consequences on short sight

following discharge are very important also following discharge are very important also for long-term outcome.for long-term outcome.

3. When substance problems decreases, so do 3. When substance problems decreases, so do problems in social functioning, criminality etc, problems in social functioning, criminality etc, 4. Improvement in drug patterns give important 4. Improvement in drug patterns give important

gains .gains .5. The assessment of quality show that most 5. The assessment of quality show that most

patients are satisfied with the interventionpatients are satisfied with the intervention7. 7. NOTE that 15% leave Lunden with no or minor NOTE that 15% leave Lunden with no or minor

relapses.relapses.

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METHODMETHOD

SettingSettingThe setting was a 21-bed inpatient compulsory care residential care unit, Lunden, in Lund, Sweden. The institutionThe setting was a 21-bed inpatient compulsory care residential care unit, Lunden, in Lund, Sweden. The institutionhas 12 beds for adults and 9 for youths. The unit staff includes psychologists, psychiatrist, nurses, social workers, 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 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 Abusers (LVM, act 1988:870) or The Care of Young Persons Act (LVU, act 1990:52).1990:52).

According to the LVU, “a care order is to be issued, if the young person exposes his health or development to a 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 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 behavior” (LVU, act 1990:52, section 3). Youths can also be taken into care under the LVU due to neglect or chaotic circumstances in circumstances in the home.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 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. who may be placing others at risk, and who is considered to need assistance in order to discontinue substance use. The LVM and The LVM and 172 172 Downloaded By: [DNL] At: 13:04 23 May 2008. LVU acts are unrelated to penal code and laws of Downloaded By: [DNL] At: 13:04 23 May 2008. LVU acts are unrelated to penal code and laws of psychiatric psychiatric care.care.

Patients are usually reported to courts by social welfare, or, more rarely, police, their family members, or generalPatients are usually reported to courts by social welfare, or, more rarely, police, their family members, or generalpractitioner. Within eight days after report, an assessment of need for treatment must be completed, and court practitioner. Within eight days after report, an assessment of need for treatment must be completed, and court hearings can hearings can then proceed.then proceed.

Care orders are implemented in specially certified LVM and LVU homes, under the authority of the National Board forCare orders are implemented in specially certified LVM and LVU homes, under the authority of the National Board forInstitutional Care. Institutional Care. The number of adults undergoing compulsory care was 1,029 persons in 2003, of which 301 were 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 girlswomen, and the number of youths was 1073, of which 373 were girls

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