Effectiveness of psychosocial interventions for adults with substance use disorder that have a co-occurring mental health disorder: an umbrella review and illustrative cost-effectiveness analysis.

内容摘要

To systematically review evidence of the clinical effectiveness of psychosocial interventions for adults with substance use disorder that have a co-occurring common mental health disorder or borderline personality disorder. To identify papers that estimate the cost-effectiveness of interventions for patients with substance use disorder and common mental health disorder or borderline personality disorder. An umbrella review (a systematic review of systematic reviews) for clinical effectiveness was conducted. Systematic database searches [MEDLINE, EMBASE, PsycInfo® (American Psychological Association, Washington, DC, USA), Cochrane Database of Systematic Reviews, and Web of Science] were carried out in February 2024. Inclusion criteria: Adults with substance use disorder and common mental health disorder or borderline personality disorder; psychosocial interventions (with or without pharmacological therapies); comparators psychosocial treatments, treatment as usual, waitlist/no treatment; systematic reviews of randomised controlled trials. Data, including critical appraisal, were extracted into a standardised form by one reviewer, and checked by another. Data were discussed in a narrative review. A literature review of MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and EconLit were undertaken to identify cost-effectiveness papers. An illustrative model was constructed to show how cost-effectiveness could be calculated if data were available. Of 5420 unique records, 30 systematic reviews were included in the clinical review. The methodological quality of the reviews was generally good. Most of the interventions and many of the active comparators studied resulted in some improvement for patients. Most reviews focused on depression, anxiety or post-traumatic stress disorder; there were some looking at mixed common mental health disorder or borderline personality disorder. There was much heterogeneity both between reviews, and between the randomised controlled trials within the reviews. The results suggested integrated treatment for co-occurring diagnosis patients may be better for common mental health disorder outcomes than treatment as usual of parallel uncoordinated services. One study was identified that met the cost-effectiveness criteria. However, this reported results alongside a clinical study and was not a modelling paper. The illustrative model should aid future researchers. Heterogeneity made it difficult to reach an overall conclusion about which therapies were best. Most reviews stated the results were not generalisable across all populations or settings. There were few reviews of borderline personality disorder; or of common mental health disorder other than anxiety/depression/post-traumatic stress disorder. Future research comparing integrated with parallel or sequential treatment, with follow-up of 6 months or longer, and sample size large enough to encompass dropout, may be beneficial. No implications for current practice could be recommended due to heterogeneity of reviews/randomised controlled trials within reviews. This study is registered as PROSPERO CRD42024515813. This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR166951) and is published in full in Health Technology Assessment; Vol. 30, No. 49. See the NIHR Funding and Awards website for further award information. People with substance use disorders (alcohol or drug) can have a co-occurring (comorbid) mental health disorder. The National Institute for Health and Care Excellence has produced guidance on treating people with co-occurring substance use and serious mental health disorder; however, this does not cover people with less severe mental health difficulties. This project aimed to identify evidence on the effectiveness (how well treatments worked) of psychosocial interventions (talking therapies or services designed to reduce substance use and lessen the symptoms of mental health disorders) for adults with substance use disorders and co-occurring common mental health disorders or borderline personality disorder. Therapies or services relevant to UK practice were investigated. Systematic literature reviews of randomised controlled trials (studies comparing two or more treatments allocated randomly) were sought. This project included 30 reviews of clinical effectiveness. Most reviews investigated depression, anxiety or post-traumatic stress disorder. Most therapies studied improved mental health and reduced substance use; as did some of the comparators (treatment as usual). The trials included in the reviews differed in the people treated, therapies, and the way outcomes of substance use, or mental health, were assessed. This made it difficult to draw conclusions about which therapies were best. Treating both substance use and mental health using a co-ordinated approach to co-occurring disorders (integrated treatment) was usually better than treating one condition alone, and sometimes better than two separate (parallel) treatments at the same time. There was limited evidence looking at treating one condition then the other (sequential), but evidence suggested it was similarly effective to integrated treatment. There was not much research on whether these treatments are cost-effective (good value for money). However, an example was developed to show how the cost-effectiveness of a promising therapy could be estimated.