Research & Treatment of
Persons with SUDS &
Psychotic Disorders
Kim T. Mueser, Ph.D.
Professor of Psychiatry
Dartmouth Medical School
[email protected]
NIDA Blending Conference
April 22, 2010
Overview
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Comorbidity of substance use & severe psychiatric
disorders
Distinguishing features of psychotic disorders with
comorbid addiction
Understanding comorbidity: models of etiology &
treatment implications
Special treatment needs of psychotic & other severe
psychiatric disorders with comorbid addiction
Research reviews of integrated treatment for cooccurring disorders
New research on treatment of co-occurring disorders
Resources
Any Substance Use Disorder
Prevalence % of Substance Use
Disorder
60
50
40
30
20
10
0
Gen.Pop
Schiz
BPD
MD
OCD
Phobia
PD
Rates of Lifetime Substance Use Disorder (SUD) among Recently
Admitted Psychiatric Inpatients (N = 325)
(Mueser et al., 2000)
% of Clients with SUD
100
75
50
25
0
S ch iz oph re n ia
S ch iz oaffective Di sorder Bi pol ar Dis orde r
Major Depre ss i on
Prevalence of Mental Illness in
Alcohol Disorder Samples
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70
60
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50
40

30
20
In community, 24.4%
have mental illness
In institutions, 55% have
mental illness
In substance abuse
treatment, 65% have
mental illness
10
0
Community
SA
Treatme nt
Regier et al, JAMA 1990
Severe Mental Illnesses (SMI)
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Psychiatric disorder that has profound effect on:
–
–
–
–
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People often on disability due to mental illness (e.g., SSI, SSDI)
Common SMIs:
–
–
–
–
–
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Work or school
Parenting
Self-care
Social relationships
Schizophrenia & schizoaffective disorder
Bipolar disorder
Major depression
PTSD
Borderline personality disorder
Often present for treatment in psychiatric settings, but also
common in addiction treatment settings
Psychotic Disorders
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Psychosis = “Lack of contact with reality”
Common psychotic symptoms:
– Hallucinations
– Delusions
– Grandiosity
– Suspiciousness
– Bizarre behavior
– Formal thought disorder (disordered or disorganized speech)
– Conceptual disorganization
Psychotic symptoms common in schizophrenia, schizoaffective & bipolar
Psychotic symptoms relatively common in major depression & PTSD
Presence of psychotic symptoms associated with more severe mental
illness & greater co-occurring addiction
Understanding Comorbidity: Why are the
Rates of SMI/Psychotic Disorder so High?
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Self-medication
Other common motives for using
Super-sensitivity
Common factors for mental illness & substance
misuse
Self-Medication
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Many clients report using substance for at least some reasons
related to symptoms, BUT:
More symptomatic clients don’t use more than less symptomatic
ones
No relationship between symptoms & types of substances used
No relationship between psychiatric diagnosis and types of
substances used
Many clients report using DESPITE awareness it worsens
symptoms or triggers relapses
Strongest case for self-medication: alcohol use disorder in PTSD
frequently related to sleep problems
Self-medication/use for coping purposes is one of host of
motivations related to SMI for using substances, but doesn’t
explain all comorbidity
Other Common Motives for Using
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Socialization
Leisure & recreation
Dealing with stress
Escaping the stigma of mental illness
Lack of structured time
Lack of engagement in personally meaningful
roles (e.g., worker, student, parent)
Supersensitivity to Alcohol &
Drugs
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Biological sensitivity increases vulnerability to
effects of substances
Smaller amounts of substances result in
problems
“Normal” substance use is problematic for
clients with SMI but not in general population
Sensitivity to substances, rather than high
amounts of use, makes many clients with
mental illness different from general
population
Stress-Vulnerability Model
Medication
Substance
Abuse
Biological
Vulnerability
Severity
of SMI
Stress
Coping
Status of Moderate Drinkers with
Schizophrenia 4 - 7 Years Later (N=45)
100%
80%
60%
55.6
40%
20%
20.0
24.4
Moderate
Drinker
Alcohol
Use
Disorder
0%
Abstinent
Source: Drake & Wallach (1993)
Common Factors for SMI & Addiction:
Conduct Disorder (CD) & Antisocial
Personality Disorder (ASPD)
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ASPD has highest addiction comorbidity of all
psychiatric disorders (60-70% in most estimates)
CD is powerful predictor of later onset of SUD
ASPD associated with earlier onset of addiction
CD & ASPD more common in SMI than general
population
CD/ASPD increase risk of addiction in SMI
CD/ASPD related to more severe addiction in cooccurring disorders
Estimated prevalence in co-occurring population: 2025%
CD, ASPD, and Recent SUD in Clients with SMI
(N = 293)
Alcohol Use Disorder
70%
60%
50%
40%
30%
20%
10%
Cannabis Use Disorder
63.2
60.0
60%
52.6
50%
41.7
36.0
40%
29.3
30%
20%
25.0
13.8
10%
0%
0%
Cocaine Use Disorder
40%
36.8
30%
CD Only
20%
Adult ASPD Only
12.5
10%
No ASPD/CD
4.9
8.0
Full ASPD
0%
Source: Mueser et. al. (1999)
Other Potential Common Factors
Leading to Increased Comorbidity
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Poverty/deprivation
Neurocognitive impairment
Trauma
Special Treatment Needs of CoOccurring SMI/Psychotic Disorder
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Integration of mental illness & substance use
disorder treatment
– Concurrent treatment
– Same treatment providers
– Integrated treatment of both disorders
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Minimization of treatment-related stress
Outreach & engagement
Close monitoring, especially for co-occurring
disorder clients with ASPD
Special Treatment Needs:
Motivational Enhancement
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Stages of change
Stages of treatment
– Engagement
– Persuasion
– Active treatment
– Relapse prevention
Adapted motivational interviewing
– Articulation of personal goals
– Active work towards goals
– Supportive self-efficacy for goal attainment &
substance reduction/abstinence
Motivational Enhancement (Con’d)
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Concept of recovery from mental illness
– Recovery defined by client, not in traditional
medical terms
– Recovery possible despite continued symptoms
– Instills hope
– Common themes: social relationships, role
functioning, community membership, respect for
self & from other
Special Treatment Needs:
Management of Cognitive Impairment
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Smaller “chunks” of information
Asking questions so client actively processes information
Frequent review of material
Shaping approach to reinforcing successive steps towards desired
goals
Patience & abundant reinforcement in light of small changes
Programming generalization of skills to natural environment by
– Home practice assignments
– Involvement of significant others in practicing skills
– Involvement of paraprofessionals in helping clients practice
skills
Special Treatment Needs:
Training in Illness Self-Management
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Information about mental illness & its treatment
Stress-vulnerability model
Involvement of family or significant other persons
Driven by personal goals
Principles of relapse prevention:
– Medication adherence
– Minimization of alcohol & drug use
– Stress reduction
– Meaningful but not over-demanding daily structure
– Coping & competence skills
– Social support
– Relapse prevention plan
Special Treatment Needs:
Psychiatric Rehabilitation
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Address motives underlying substance use
Skills training to address social motives, independent
living skills
Coping skills training/CBT for persistent symptoms
Targeted CBT to address primary or comorbid
depression, anxiety, PTSD symptoms
Supported employment/education for competitive work
or return to school
Family psychoeducation to reduce family stress &
burden, & facilitate management of co-occurring
disorders
Cognitive remediation for cognitive impairment
Supported housing for housing instability
Special Treatment Needs:
Psychiatric Medications
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Primary medications for schizophrenia-spectrum
disorders & bipolar disorder effective despite active
substance use
When in doubt, assume both disorders are primary &
pharmacologically treat psychiatric disorder
Medication non-adherence high
– Fear of interactions with substances despite rarity (main
exception: MAOIs)
– Denial/minimization of psychiatric disorder
– Forgetting to take medication: behavioral tailoring to integrate
into daily routine
– Simplify medication regimen complexity
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Promote dialogue between client & prescriber
Special Treatment Needs:
Medications for Alcoholism
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Naltrexone established efficacy for alcoholism
in SMI
Disulfirim effective in SMI, but psychiatrists
reluctant to prescribe it
Research Reviews of Treatment
of Co-Occurring Disorders
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Drake et al. (1998): 36 studies, including pre-post, quasiexperimental, and RCTs
Brunette et al. (2004): 10 quasi-exp or RCTs of residential
programs for DD
Drake et al. (2004): 26 recent studies, quasi-exp or RCTs (19942004)
Donald et al. (2005): 10 RCTs
Mueser et al. (2005): 30 studies of specific interventions, including
pre-post, quasi-exp, & RCTs
Kavanagh & Mueser (2007): 17 RCTs
Cleary et al. (2008): 25 RCTs
Drake et al. (2008): 22 RCTs, 23 quasi-exp
Summary of Research on Treating
Co-Occurring Disorders in SMI
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Limited impact of brief interventions
– Primary purpose is to engage in treatment
– Useful for enhancing follow through for mental
illness & substance misuse treatment
Limited gain from providing more intensive case
management, such as Assertive Community Treatment
But, effects of intensity of service may interact with
client characteristics, such as ASPD
Study Design (Essock et al., 2006)
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198 clients with SMI
2 sites in Connecticut: Hartford & Bridgeport
3 year follow-up period with assessments every
6 months
Randomized to ACT (N = 99) or SCM (N = 99)
Everyone received integrated treatment for cooccurring disorders
SATS Predicted and Actual Means
8
Site 1 ACT
Site 1 STD
Site 2 ACT
Site 2 STD
SATS Mean
7
6
5
4
3
2
1
0
6
12
18
Study Months
Essock, Mueser, Drake et al. Psychiatr Serv. 2006
24
30
36
Mean Number of Days Spent in Hospital
Total Psychiatric Hospital Days During
Entire Study Period
50
45
40
35
30
25
20
15
10
5
0
ACT
Standard
41(60)
32(91)
23(68)
26(48)
15(27)
12(28)
MWU=3971, p=.12
MWU=1043, p=.35
MWU=713, p=.002*
Total
Site 1
Site 2
Essock, Mueser, Drake et al. Psychiatr Serv. 2006
Did Clients with ASPD Benefit
from ACT Treatment More?
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Secondary data analysis (Frisman et al., 2009)
Focused on most extreme subgroups: Full ASPD (N =
36) or No CD/ASPD (N = 88)
Outcomes = AUS, DUS, days alcohol use, days drug
use, SATS, BPRS, hospital days, homeless days, jail
days
Statistical analyses: mixed effects linear modeling with
time, treatment group, and ASPD group, with test of
primary interest being the 3-way interaction
Significant interactions 2 variables: AUS and days in
jail
Figure 1. Mixed effect results: estimated and observed (obs) mean
value for alcohol consensus rating over time by ASPD and treatment
groups
ASPD group
alcohol consensus rating
5.00
4.50
4.00
ACT
TAU
3.50
3.00
ACT-O
2.50
TAU-O
2.00
1.50
1.00
0 1 2 3 4 5 6
Time
Figure 1. Mixed effect results: estimated and observed (obs) mean
value for alcohol consensus rating over time by ASPD and treatment
groups
alcohol consensus rating
No ASPD group
5.00
4.50
4.00
3.50
3.00
2.50
2.00
1.50
1.00
0
1
2
3
Time
4
5
6
Figure 2. Estimated percentage of any jail time by ASPD group
% jail
ASPD group
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
ACT
TAU
ACT-Obs
TAU-Obs
0
1
2
3
Time
4
5
6
Figure 2. Estimated percentage of any jail time by ASPD group
No ASPD group
1.00
0.90
0.80
% jail
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
0
1
2
3
Time
4
5
6
Summary of Research on Treating
Co-Occurring Disorders in SMI
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Co-occurring treatment associated with better
substance abuse & psychiatric outcomes
Strongest effects for group counseling,
contingency management, & residential
treatment
Group counseling most studied treatment
modality
Integrated Group Therapy (IGT) for
BPD & SUD (Weiss et al., 2007)
• Supported by NIDA Behavioral Therapies Development
Program
• Goal: to develop & test an integrated group therapy for clients
with bipolar disorder & substance misuse
• 20 sessions that have 12 repeating topics, “rolling admissions”
• Identifies thoughts & behavior patterns common to recovery
from & relapse/recurrence to substance use and psychiatric
symptoms
• Evaluated in RCT comparing IGT with Group Drug
Counseling (GDC)
Days of Substance Use/Month
by Treatment Over Time (p<.001)
Days used
15
12
9
6
IGT
3
GDC
0
Baseline
1
2
3
4
Month
5
6
7
8
Time to First Abstinent Month
by Treatment (p<.03)
Abstinent (%)
100
80
60
40
IGT
20
GDC
0
Baseline 1
2
3
4
5
Month
6
7
8
Summary of Research on
Integrated Treatment for SMI
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Cognitive-behavioral therapy (CBT) approaches
appear promising than supportive, educational,
or 12-step approaches
Program fidelity to principles of integrated
treatment contributes to better outcomes
Fidelity to IDDT Model Improves
Outcome (McHugo et al., 1999)
Efforts to Provide Integrated
Treatment of Anxiety Disorders &
Substance Abuse
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RCTs of integrated treatment for panic disorder &
social phobia indicate improvement in anxiety &
substance misuse for both integrated & substance
treatment groups
No trials of integrated treatment for GAD or OCD
Limited success thus far with integrated PTSD
treatment, but new developments under way
Integrated Treatments for PTSD &
Addiction
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Substance Dependence PTSD Therapy (Triffleman,
1999)
• Exposure-based, 40 sessions, no RCTs
Concurrent Treatment of PTSD & Cocaine
Dependence (Brady et al, 2001)
• Exposure-based, high dropout rate (62%), no
RCTs
Transcend (Donovan et al, 2001)
• Broad-based, residential, 60 session, no RCTs
Seeking Safety (Najavits, 2003; Hien et al, 2004)
• Ecclectic, moderate dropout rate (35-40%), RCTs
don’t support treatment over standard substance
abuse treatment
Cognitive Restructuring for PTSD
in Vulnerable Populations
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12-16 week standardized treatment program for PTSD
developed by Mueser et al. (2009)
Core components: breathing retraining, education
about PTSD, cognitive restructuring
Feasibility established in SMI, addiction, adolescents,
ethnic/cultural minorities, disaster/mass violence
survivors
RCTs completed on SMI (Mueser et al., 2008) &
addiction (McGovern et al., in pres) populations
STAGE I Phase II.a: Feasibility Study
Main Outcomes (McGovern et al.)
PTS D Diagnosis
Clinician Administered PTS D S cale (CAPS )
Mean CAPS Score
75
50
25
0
Baseline
PostTreatment
Mean number of days
Number of days using in past 3 months
30
25
20
15
10
5
0
PostTreatment
60
40
20
0
Baseline
PostTreatment
Addiction S everity Index
Alcohol
Baseline
80
3 Month
Follow-up
Drug
3 Month
Follow-up
Mean ASI Composite
% PTSD Positive
100
3 Month
Follow-up
(AS I) Composite
0.500
0.400
0.300
Alcohol
0.200
Drug
0.100
0.000
Baseline
PostTreatment
3 Month
Follow-up
Clinical Resources
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Bellack, A. S., Bennet, M. E., & Gearon, J. S. (2007). Behavioral Treatment for Substance Abuse in People with Serious
and Persistent Mental Illness. New York: Taylor and Francis.
Center for Substance Abuse Treatment. (2005). Substance Abuse Treatment for Persons With Co-Occurring Disorders.
(Vol. DHHS Publication No. (SMA) 05-3922). Rockville, MD: Substance Abuse and Mental Health Services Administration.
Centre for Addiction and Mental Health. (2001). Best Practices: Concurrent Mental Health and Substance Use Disorders.
Ottowa: Health Canada.
IDDT Toolkit: http://www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/default.asp
Graham, H. L., Copello, A., Birchwood, M. J., & Mueser, K. T. (Eds.). (2003). Substance Misuse in Psychosis: Approaches
to Treatment and Service Delivery. Chichester, England: Wiley.
Graham, H. L., Copello, A., Birchwood, M. J., Mueser, K. T., Orford, J., McGovern, D., Atkinson, E., Maslin, J., Preece, M.
M., Tobin, D., & Georgion, G. (2004). Cognitive-Behavioural Integrated Treatment (C-BIT): A Treatment Manual for
Substance Misuse in People with Severe Mental Health Problems. Chichester, England: John Wiley & Sons.
Mercer-McFadden, C., Drake, R. E., Clark, R. E., Verven, N., Noordsy, D. L., & Fox, T. S. (1998). Substance Abuse
Treatment for People with Severe Mental Disorders: A Program Manager's Guide. Concord, NH: New HampshireDartmouth Psychiatric Research Center.
Mueser, K. T., & Gingerich, S. (2006). The Complete Family Guide to Schizophrenia: Helping Your Loved One Get the
Most Out of Life. New York: Guilford Press.
Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003). Integrated Treatment for Dual Disorders: A Guide to Effective
Practice. New York: Guilford Press.
Mueser, K. T., Rosenberg, S. D., & Rosenberg, H. J. (2009). Treatment of Posttraumatic Stress Disorder in Special
Populations: A Cognitive Restructuring Program. Washington, DC: American Psychological Association.
Roberts, L. J., Shaner, A., & Eckman, T. A. (1999). Overcoming Addictions: Skills Training for People with Schizophrenia.
New York: W.W. Norton.
Weiss, R. D., Griffin, M. L., Jaffee, W. B., Bender, R. E., Graff, F. S., Gallop, R. J., & Fitzmaurice, G. M. (2009). A
community-friendly version of Integrated Group Therapy for patients with bipolar disorder and substance dependence:
A randomized controlled trial. Drug and Alcohol Dependence, 104, 212-219.
Research
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Brunette, M. F., Mueser, K. T., & Drake, R. E. (2004). A review of research on residential programs for people with severe
mental illness and co-occurring substance use disorders. Drug and Alcohol Review, 23, 471-481.
Cleary, M., Hunt, G., Matheson, S., Siegfried, N., & Walter, G. (2008). Psychosocial interventions for people with both
severe mental illness and substance misuse (Review). Cochrane Database of Systematic Reviews, Issue 1. Art. No.:
CD001088. DOI: 10.1002/14651858.CD001088.pub2.
Donald, M., Dower, J., & Kavanagh, D. J. (2005). Integrated versus non-integrated management and care for clients with
co-occurring mental health and substance use disorders: A qualitative systematic review of randomised controlled
trials. Social Science & Medicine, 60, 1371-1383.
Drake, R. E., Mercer-McFadden, C., Mueser, K. T., McHugo, G. J., & Bond, G. R. (1998). Review of integrated mental
health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin, 24, 589-608.
Drake, R. E., Mueser, K. T., Brunette, M. F., & McHugo, G. J. (2004). A review of treatments for clients with severe mental
illness and co-occurring substance use disorder. Psychiatric Rehabilitation Journal, 27, 360-374.
Drake, R. E., O'Neal, E., & Wallach, M. A. (2008). A systematic review of psychosocial interventions for people with cooccurring severe mental and substance use disorders. Journal of Substance Abuse Treatment, 34, 123-138.
Frisman, L. K., Mueser, K. T., Covell, N. H., Lin, H.-J., Crocker, A., Drake, R. E., & Essock, S. M. (2009). Use of integrated
dual disorder treatment via assertive comunity treatment versus clinical case management for persons with cooccurring disorders and antisocial personality disorder. Journal of Nervous and Mental Disease, 197, 822-828.
Green, A. I., Noordsy, D. L., Brunette, M. F., & O'Keefe, C. D. (2008). Substance abuse and schizophrenia:
Pharmacotherapeutic intervention. Journal of Substance Abuse Treatment, 34, 61-71.
Kavanagh, D. J., & Mueser, K. T. (2007). Current evidence on integrated treatment for serious mental disorder and
substance misuse. Journal of the Norwegian Psychological Association, 5, 618-637.
McGovern, M. P., Lambert-Harris, C., Acquilano, S., Weiss, R. D., & Xie, H. (2009). A cognitive behavioral therapy for cooccurring substance use and posttraumaticstress disorders. Addictive Behaviors, 34, 892-897.
Mueser, K. T., Drake, R. E., Sigmon, S. C., & Brunette, M. F. (2005). Psychosocial interventions for adults with severe
mental illnesses and co-occurring substance use disorders: A review of specific interventions. Journal of Dual
Diagnosis, 1, 57-82.
Mueser, K. T., Kavanagh, D. J., & Brunette, M. F. (2007). Implications of research on comorbidity for the nature and
management of substance misuse. In P. M. Miller & D. J. Kavanagh (Eds.), Translation of Addictions Science into
Practice (pp. 277-320). Amsterdam: Elsevier.
Mueser, K. T., Noordsy, D. L., Fox, L., & Wolfe, R. (2003). Disulfiram treatment for alcoholism in severe mental illness.
American Journal on Addictions, 12, 242-252.
Weiss, R. D., Griffin, M. L., Kolodziej, M. E., Greenfield, S. F., Najavits, L. M., Daley, D. C., Doreau, H. R., & Hennnen, J. A.
(2007). A randomized trial of integrated group therapy versus group drug counseling for patients with bipolar disorder
and substance dependence. American Journal of Psychiatry, 164, 100-107.
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Research & Treatment of Persons with Substance Use & Psychotic