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

1. 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

2. 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). Femårsupp- följning av kvinnor vårdade vid Lundens LVM- och LVU-hem. Stockholm, Statens Institutionsstyrelse, SiS utvecklar och följer upp 2009:1. – GENERAL REPORT

3. 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.

4. 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.

5. Sampling 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.

6. Women at index admissionCohort design 1997 – 2000At which point in their carreers dothe women enter LVM-/LVU-treatment ?

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

8. Inpatienttreatment in Psychiatryfouryearsbefore and fouryears after index admission (register data, n=131)

9. Inpatienttreatment in somatic hospital fouryearsbefore and fouryears after index admission, (register data, n= 131)

10. BACKGROUND – baseline data (n=132) LVMLVU 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%

11. DATA 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 – Psychopathy • Neuropsychological assessment • Intelligence level (WAIS)

12. 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%

13. PSYCHIATRIC DISORDERS (AXIS I) IN THE COHORT (N=132) DIAGNOSIS LVM (80) LVU (52) AXIS I Psychopathy 3% 6% Toxic psychosis 17% 15% Schizophrenia 0% 5% Sociophobia 1% 2% Major Depression 13% 13%Depressive disorders 13% 13% Dysthymia 3% 0% Anxiety, any 25% 20%TOTAL 60% 61%

14. TREATMENT LAST YEAR LVM LVU - Treatment in psychiatry 61% 50% Gynaecology 26% 17% Dental treatment 59% 48% Hepatitis B and/or C 57% 43%

15. Patients followed-up at five-years

16. 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.

17. 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.

18. INTERVIEWS 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%)

19. Abstinence at five-year follow-up

20. D Outcome at five year follow-up (ITT)

22. Cluster Analysis of continous trends for thefirst threeyears after discharge from Lunden

23. Time-line-diagrams demonstrating level of drug use and abstinence until three years post treatmentDays of active drug use – 0 dgr five categories 1-2 dgr 3-5 dgr 6-15 dgr 16-30 dgr

24. mbgrupp2 4,00 ,00 1,00 2,00 3,00 Estimated Marginal Means 2,00 1,00 1 2 3 4 5 6 Six months intervals --- not abstinent --- Sporadicdruguse __ Continousabstinence 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)

25. 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.

26. Twolevels of druguse over threeyearspast treatment 0,80 Missbrukar inte Missbrukar 0,60 0,40 Krim 0,20 0,00 1 2 3 4 5 6 Mätpunkt ___ not abstinent _____ abstinent Diagram 3. Trends in criminal activity over three years past treatment in two clusters past discharge (n=101). TLFB- model.

27. CONCLUSIONSAlready 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.

28. Aggregatedmeasures of social adjustment over the threeyearspast discharge (n=101)

29. CONCLUSIONS In the abstinent group (Group 1) there is an increase in legal income, number of non drug friends, social relations to family, morestableliving etc. F(1,99( = 4.30, p < .04). There is a simliar trend for the first year after discharge for the drugabusing group, but it does not continue and the interaction between the twogroups is significant, F (1;99) = 6,37, p < .013), F (1;99) = 11,168), p < .001).

30. Mortality and causes of death8 diseased in the sample11 in the comparison groupAll but one women had a drug related death,two suicides. 3 died from somatic illnesses. 12 Overdoses and 3 fatal poisoningsSubstance problems were a contributing factor in all. SMR=9,07

31. PSYCHIATRIC SYMPTOMS

32. Två missbruksgrupperbaserade på 6 mån innan uppföljning ___ Fortsatt missbruk ___Drogfria 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)

33. CONCLUSIONSSymptoms higher on all scales in groups with non-abstinentwomen F(2, 99)= 4,445; p < .038).The maindifference is in the earlyphases of the threeyear period.

35. 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

36. Anti-social Personality disorder and Conductdisorder have a significantly negative impact ondrugabuse, criminalbehaviour, social adaptationNo otherpersonality disorder reveal this !!!

37. SUMMARY1. It is a surprisingly positive outcome for many2. 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 intervention7. NOTE that 15% leave Lunden with no or minor relapses.

39. METHODSettingThe 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, 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 generalpractitioner. Within eight days after report, an assessment of need for treatment must be completed, and court hearings can thenproceed.Care orders are implemented in specially certified LVM and LVU homes, under the authority of the National Board forInstitutional 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