Psychiatric co-morbidity and substance use disorders: treatment in parallel systems or in one integrated system?

Coercion in psychiatry: the importance of extramural factors

BACKGROUND

Mechanical restraints and forced procedures in psychiatric wards are of major concern in Denmark and there is a desire to reduce these procedures to a minimum. So far, focus has primarily been on identifying and changing internal (intramural) factors when seeking to reduce coercion.

AIM

To identify possible external (extramural) factors that may increase the risk of coercion during admission to a closed psychiatric ward.

METHOD

Using a retrospective case-controlled design, 235 patients admitted to a closed ward during 2011-2013 were randomly selected. Coercion comprised belt restraint, physical restraint, and forced medication. The data source was the electronic patient records, which include statutory information on all forced measures. Multiple logistic regression analyses were applied to calculate the risk (odds ratio, OR (95% confidence interval)) of forced measures being used.

RESULTS

Out of the 235 patients, 66 (28%) were subject to coercion. The time of forced procedures was predominately during the first hours after admission. The risk of forced measures being applied was significantly higher if patients were involuntarily admitted (OR = 6.4 (3.4-11.9)), or were acutely intoxicated by substances at the time of admission (OR = 3.7 (1.7-8.2)).

CONCLUSION

Extramural factors should be included when mental health authorities plan efforts to reduce coercion during admission to psychiatric wards. A reduced threshold for admission and improved integrated effort between mental health services and treatment for substance abuse could improve the course of disease for this group of patients and reduce the need for involuntary admissions and subsequently coercion.

Professionals' perception on the management of patients with dual disorders

BACKGROUND

There is a need to evaluate the professionals' perception about the consequences of the lack of therapeutic adherence in the evolution of patients with co-occurring disorders.

METHODS

An online survey, released on the Socidrogalcohol [Spanish Scientific Society for Research on Alcohol, Alcoholism and other Drug Addictions] and Sociedad Española de Patología Dual [the Spanish Society of Dual Pathology] web pages, was answered by 250 professionals who work in different types of Spanish health centers where dual diagnosis patients are assisted.

RESULTS

Most professionals perceived the existence of noncompliance among dual diagnosis patients. Almost all of these professionals (99%) perceived that noncompliance leads to a worsening of the progression of the patient's disorder, in both the exacerbation of mental disorders and the consumption of addictive substances. Most of the professionals (69.2%) considered therapeutic alliance as the main aspect to take into account to improve the prognosis in this population. The primary purpose of treatment must be the improvement of psychotic-phase positive symptoms, followed by the control of behavior disorders, reduction of craving, improvement of social and personal performances, and reduction of psychotic-phase negative symptoms.

CONCLUSION

Most professionals perceived low adherence among dual diagnosis patients. This lack of adherence is associated with a worsening of their disease evolution, which is reflected in exacerbations of the psychopathology and relapse in substance use. Therefore, we propose to identify strategies to improve adherence.

Prevalence of comorbid substance use, anxiety and mood disorders in epidemiological surveys, 1990-2014: A systematic review and meta-analysis

BACKGROUND

Comorbidity is highly prevalent between substance use disorders (SUDs), mood and anxiety disorders. We conducted a systematic review and meta-analysis to determine the strength of association between SUDs, mood and anxiety disorders in population-based epidemiological surveys.

METHODS

A comprehensive literature search of Medline, EMBASE, CINAHL, PsychINFO, Web of Science, and Scopus was conducted from 1990 to 2014. Sources were chosen on the basis that they contained original research in non-clinical populations conducted in randomly selected adults living within defined boundaries. Prevalence of comorbid SUDs, mood and anxiety disorders and odds ratios (ORs) were extracted.

RESULTS

There were 115 articles identified by electronic searches that were reviewed in full text which yielded 22 unique epidemiological surveys to extract lifetime and 12-month prevalence data for psychiatric illness in respondents with an SUD. Meta-analysis indicated the strongest associations were between illicit drug use disorder and major depression (pooled OR 3.80, 95% CI 3.02-4.78), followed by illicit drug use and any anxiety disorder (OR 2.91, 95% CI 2.58-3.28), alcohol use disorders and major depression (OR 2.42, 95% CI 2.22-2.64) and alcohol use disorders and any anxiety disorder (OR 2.11, 95% CI 2.03-2.19). ORs for dependence were higher than those for abuse irrespective to diagnoses based on lifetime or 12-month prevalence.

CONCLUSIONS

This review confirms the strong association between SUDs, mood and anxiety disorders. The issue has now been recognised worldwide as a factor that affects the profile, course, patterns, severity and outcomes of these disorders.

Chronic light deprivation inhibits appetitive associative learning induced by ethanol and its respective c-Fos and pCREB expression

To address the role of mixed anxiety/mood disorder on appetitive associative learning, we verify whether previous chronic light deprivation changes ethanol-induced conditioned place preference and its respective expression of c-Fos and pCREB, markers of neuronal activity and plasticity. The experimental group was maintained in light deprivation for 24 h for a period of 4 wk. Subsequently, it was adapted to a standard light-dark cycle for 1 wk. As a control, some mice were maintained in standard cycle for a period of 4 wk (Naïve group). Then, all animals were submitted to behavioral tests to assess emotionality: elevated plus maze; open field; and forced swim. After that, they were submitted to ethanol-induced conditioned place preference. Ninety minutes after the place preference test, they were perfused, and their brains processed for c-Fos and pCREB immunohistochemistry. Light deprivation induced anxiety-like trait (elevated plus maze), despair (forced swim), and hyperlocomotion (open field), common features seen in other animal models of depression. Ethanol-induced conditioned place preference was accompanied by increases on c-Fos and pCREB in the hippocampus, prefrontal cortex and striatum. Interestingly, mice previously submitted to light deprivation did not develop either acquisition and/or expression of ethanol-induced conditioned place preference or increases in c-Fos and pCREB. Therefore, chronic light deprivation mimics several behavioral aspects of other animal models of depression. Furthermore, it could be useful to study the neurochemical mechanisms involved in the dual diagnosis. However, given its likely deleterious effects on appetitive associative memory, it should be used with caution to investigate the cognitive aspects related to the dual diagnosis.

Professionals' perceptions about healthcare resources for co-occuring disorders in Spain

BACKGROUND

Since provision of integrated services for patients with dual pathology or dual disorders (coexistence of an addictive disorder and other psychiatric disorders) constitutes an important challenge, this study compared the perceptions of health-care professionals with the existing, current state of specific resources for patients with dual pathology in Spain.

METHODS

Epidemiological, observational, cross-sectional, multicenter study with a large, representative sample of health care professionals attending patients with dual pathology in treatment resources throughout Spain. Participants completed a specifically designed ad-hoc on-line questionnaire about their perceptions on the existence of available resources and treatment needs for patients with dual pathology. To compare professionals' perceptions with existing available resources, the same on-line questionnaire was also completed by commissioners and managers responsible for national and regional healthcare plans on drug abuse.

RESULTS

A total of 659 professionals, mostly psychologists (43.40%) or psychiatrists (32.93%) agreed to participate in the study. The highest degree of concordance between the perceptions of professional and the actual situation was found regarding the existence of mental health and addiction networks (either separately or unified) (74.48%), followed by specific workshops (73.08%) and sub-acute inpatient units (67.38%), specific hospitalization units (66.26%), detoxification units (63.15%) and outpatient programs (60.73%). We detected a lower degree of agreement regarding specific occupational rehabilitation centers (59.34%) day hospitals (58.93%), day centers (57.88%), outpatient intermediate resources (48.87%), psychiatric acute admission units (46.54%) and therapeutic communities (43.77%). In addition, on average, health care professionals underestimated the number of resources present in their respective communities.

CONCLUSIONS

Relevant differences exist between the perceptions of professional and existing available resources for dual pathology patients in Spain, thus supporting the need of additional efforts and strategies to establish a registry and clearly inform about available resources for patients with dual diagnosis.

Health-related and legal interventions: A comparison of allegedly delinquent and convicted opioid addicts in Austria

In Austria, judges can offer quasi-compulsory treatment options (in- and outpatient settings) as an alternative to imprisonment for drug-related delinquencies. A standard assessment of medical, psychological and legal data on the implementation of health-related and legal interventions in Austria was applied in 96 opioid-dependent individuals (10.4% female) undergoing quasi-compulsory treatment, receiving health-related measures. Additional data from the official prison registry were collected (data of 228 imprisoned individuals sentenced for drug-related crimes; 14.5% female) to gain comparable information to in- and outpatient health-related measure groups. Health-related measures were offered significantly more often to individuals charged with solely narcotics possession and/or trade, whereas imprisonment was filed significantly more often when concomitant property or violent crimes were committed in addition to drug possession/dealing (p < 0.001). Both cohorts had high prevalences of previous convictions (health-related measure 84.4%, prison 93.9%). The majority of patients in health-related measures suffered at the time of investigation from severe depression (62.5%), anxiety disorders (58.3%) and had a high loading of suicidal ideation (45.8%). Women showed a higher prevalence of affective disorders (p = 0.042), with higher administration rates of psychopharmacological medication (p = 0.045), whereas male offenders scored significantly higher in violent behaviour (p = 0.004). Inpatients showed a significantly higher burden of comorbid disorders compared to outpatients and reported a higher need for psychiatric treatment and legal counselling (all p < 0.001). The inpatient sample had a longer duration of opioid use (p = 0.024), a higher lifetime prevalence of intravenous drug use (p < 0.001) and a higher rate of hepatitis C infections (p = 0.012). Results confirm that imprisonment is sentenced to a vast extent for severe crimes, and health-related measure is well accepted among judges. However, based on patients’ high loading of previous convictions and alarmingly high burden of comorbidities, quality improvement and assurance in health-related measure are required when patients have their first contact with the criminal justice system. Continuous focus on applying diversion procedures is also required to reduce societal costs.

Dual diagnosis screening interview to identify psychiatric comorbidity in substance users: development and validation of a brief instrument

AIM

The objective of this study was to develop and validate a brief tool, the Dual Diagnosis Screening Instrument (DDSI), to screen psychiatric disorders in substance users in treatment and nontreatment-seeking samples.

METHODS

A total of 827 substance users (66.5% male, mean age 28.6±9.9 years) recruited in treatment (in- and outpatient) and nontreatment (substance user volunteers in university research studies) settings were assessed by trained interviewers using the DDSI and the Psychiatric Research Interview for Substance and Mental Disorders (PRISM) as the criterion standard. Both instruments were administered blind to the results of the other. Disorders obtained with the DDSI were compared to lifetime diagnoses obtained with the PRISM. Sensitivity, specificity, negative, and positive predictive values were estimated. Also test-retest reliability of the DDSI was assessed.

RESULTS

The DDSI showed a high sensitivity (≥80%) for identifying lifetime depression, mania, psychosis, panic, social phobia, and specific phobia disorders. Specificity was ≥82% for those diagnoses. Test-retest κ showed excellent agreement (range 81-95%). The mean duration of the DDSI administration was 16.8±2.5 min.

CONCLUSION

The DDSI is a valid and easy-to-administer screening tool to detect possible psychiatric comorbidity among substance users.

Non-fatal opioid overdose and major depression among street-recruited young heroin users

BACKGROUND/AIMS

Non-fatal opioid overdose (NFOO) and major depression (MD) are highly prevalent in heroin users. Many risk factors are known for NFOO, but studies in non-clinical samples on its relationship with MD are lacking. We aimed to examine this relationship in a street-recruited sample, controlling for potential well-known confounders.

METHODS

A cross-sectional study in 452 heroin users street-recruited by chain referral methods in three Spanish cities. Eligibility criteria were: age≤30 years, heroin use at least 12 days in the last year and at least once in the last 3 months. Depression was assessed using the Composite International Diagnostic Interview. A precise definition of NFOO was used. Adjusted odds ratios (AORs) for the NFOO predictors were obtained by logistic regression.

RESULTS

The prevalence of NFOO and MD in the last 12 months was 9.1 and 23.2%, respectively. After adjusting for potential confounders, NFOO and MD were significantly associated (AOR 2.2; 95% CI 1.01-4.74). Other associated factors were imprisonment (AOR 4.1; 95% CI 1.4-12.1), drug injection (AOR 6.7; 95% CI 2.4-18.4) and regular use of tranquillisers/sleeping pills (AOR 2.9; 95% CI 1.16-7).

CONCLUSIONS

Drug and mental health treatment facilities should consider the relationship between MD and NFOO when contacting and treating heroin users. Imprisonment, drug injection and use of tranquillisers/sleeping pills are also risk factors for NFOO.

Contingency management for patients with dual disorders in intensive outpatient treatment for addiction

OBJECTIVE

This quality improvement program evaluation investigated the effectiveness of contingency management for improving retention in treatment and positive outcomes among patients with dual disorders in intensive outpatient treatment for addiction.

METHODS

The effect of contingency management was explored among a group of 160 patients exposed to contingency management (n = 88) and not exposed to contingency management (no contingency management, n = 72) in a six-week partial hospitalization program. Patients referred to the partial hospitalization program for treatment of substance use and comorbid psychiatric disorders received diagnoses from psychiatrists and specialist clinicians according to the Diagnostic and Statistical Manual of the American Psychiatric Association. A unique application of the contingency management "fishbowl" method was used to improve the consistency of attendance at treatment sessions, which patients attended 5 days a week. Days attending treatment and drug-free days were the main outcome variables. Other outcomes of interest were depression, anxiety and psychological stress, coping ability, and intensity of drug cravings.

RESULTS

Patients in the contingency management group attended more treatment days compared to patients in the no contingency management group; M = 16.2 days (SD = 10.0) versus M = 9.9 days (SD = 8.5), respectively; t = 4.2, df = 158, p <.001. No difference was found between the treatment groups on number of drug-free days. Psychological stress and drug craving were inversely associated with drug-free days in bivariate testing (r = -.18, p <.02; r = -.31, p <.001, respectively). Treatment days attended and drug craving were associated with drug-free days in multivariate testing (B =.05, SE =.01, β =.39, t = 4.9, p <.001; B = -.47; SE =.12, β = -.30, t = -3.9, p <.001, respectively; Adj. R(2) =.21). Days attending treatment partially mediated the relationship between exposure to contingency management and self-reported drug-free days.

CONCLUSIONS

Contingency management is a valuable adjunct for increasing retention in treatment among patients with dual disorders in partial hospitalization treatment. Exposure to contingency management increases retention in treatment, which in turn contributes to increased drug-free days. Interventions for coping with psychological stress and drug cravings should be emphasized in intensive dual diagnosis group therapy.

Differentiating Army suicide attempters from psychologically treated and untreated soldiers: a demographic, psychological and stress-reaction characterization

BACKGROUND

Suicide is the leading cause of death in most armies during peace-time. The recent dramatic rise in suicides in the US Army further focuses attention on the causes of suicidal behavior in the military.

METHODS

This study investigated demographic characteristics, psychological profile and stress-related risk factors associated with suicide attempts in Israelis aged 18-21 years, who served in the Army in 2009. Soldiers who attempted suicide (N=60) were compared to soldiers treated by a mental health professional, but reported no suicidal behavior (N=58), and to controls (N=50).

RESULTS

Suicide attempters had lower socioeconomic status and less cognitive ability compared with treated soldiers and untreated control soldiers. Only 25% of the suicide attempters had received mental healthcare prior to the attempt. The majority of the attempts were non-lethal (86.2%), and only 5.2% used firearms. Attempters had more previous suicide attempts (37.9%) and deliberate selfharm incidents (19.3%), compared to almost no such behaviors in the other two groups. Following the suicide attempt, 77% were diagnosed with moderate to severe mental disorders, 44.8% personality disorders and 8.6% mood disorders. Attempters reported higher levels of general stress compared to their peers in the other two groups. Being away from home and obeying authority were especially more stressful in attempters.

CONCLUSIONS

Young soldiers are less prone to seek mental health assistance, despite suffering from higher levels of stress. Screening is required to detect soldiers at risk for suicidal behavior and preventive intervention will require active outreach.

Psychiatric morbidity is linked to problem drinking in midlife among alcohol-dependent men: a co-twin control study

OBJECTIVE

Prior research on predictors of problem drinking has been limited because of an inability to attribute an unambiguous environmental explanation to observed findings. Using a prospective co-twin control design, we examined the extent to which a history of psychiatric symptoms exerts an environmental influence on problem drinking in midlife that is unconfounded by genetic underpinnings.

METHOD

Participants were 367 complete male twin pairs (208 monozygotic, 159 dizygotic) from the Vietnam Era Twin Registry who were assessed in midlife as part of the Family Twin Study (Mage = 51.4 years, SD = 2.8). Twin pairs who were concordant for a lifetime diagnosis of an alcohol use disorder (AUD) in 1992 were selected for participation and were reinterviewed in 2001 to measure symptoms of AUD (i.e., problem drinking) since the prior assessment (past 10 years).

RESULTS

Within-pair differences in lifetime symptom counts of several psychiatric disorders measured in 1992 (i.e., major depression, dysthymia, generalized anxiety disorder, panic disorder, antisocial personality, mania, and posttraumatic stress disorder) were significantly associated with within-pair differences in AUD symptoms in the subsequent 10 years.

CONCLUSIONS

A history of psychiatric problems, particularly one marked by internalizing symptoms, appears to be linked to problem drinking in midlife above and beyond the confounding influence of genetic effects and underscores the potential value of integrated interventions for comorbidity to address problem drinking among individuals during this period of the life course.