Comorbidity of Mental Disorders With Alcohol and Other Drug Abuse

Latent class analysis of self-reported substance use during incarceration: Gender differences and associations with emotional distress and aggressiveness

INTRODUCTION

We know little about the prevalence and patterns of substance use during incarceration, and we know even less about comparative substance use patterns by gender. To address these gaps in the literature, this study used latent class analysis (LCA) to identify substance use subgroups of incarcerated men (n = 1118) and women (n = 207).

METHODS

The study drew data from six prisons in Spain. Participants completed a self-administered questionnaire with items probing for types of drugs used in the past three months, depression, anxiety, stress symptoms, aggressiveness, and perceived social support.

RESULTS

Substance use was common among incarcerated men and women, with tobacco, cannabis, and sedatives being most prevalent. LCA revealed different patterns of substance use by gender. Four- and two-class solutions best fitted the data for men and women, respectively. Aggressiveness and depression were associated with high depressant use membership for men. Among women, aggressiveness and anxiety symptoms were positively associated with high polydrug use membership.

CONCLUSIONS

The prevalent and patterned use of substances inside Spanish prisons and their association with aggressiveness and depression elevates the risk of harm during incarceration. In the interest of safety and wellness, correctional behavioral health services should include and expand the availability of gender-specific integrated mental health and substance use interventions that address maladaptive behaviors such as aggression.

Barriers for homeless with dual diagnosis: lessons learned from intensive mobile psychosocial assertive community treatment program

Purpose

Dual diagnosis is a term that describes the co-occurrence of mental health disorders or illness and substance use or abuse disorders. Because this co-occurrence results in multiple diseases, layers of treatment are often needed to successfully create positive change in the individual. The purpose of this study is to explore factors of treatment that could facilitate improvements in functionality and quality of life for those with a dual diagnosis.

Design/methodology/approach

A secondary data analysis, using both quantitative and qualitative data, was completed. Secondary analysis is an empirical exercise that applies the same basic research principles as studies using primary data and has steps to be followed, including the evaluative and procedural steps commonly associated with secondary data analysis. Documentation data from the intensive mobile psychosocial assertive community treatment program was gathered for this analysis; this program was used because of the intensive and community-based services provided to patients with a dual diagnosis.

Findings

The major findings from this secondary analysis suggested that significant barriers included “denial” (e.g. evasion, suspension or avoidance of internal awareness) of diagnoses, complicated treatment and other barriers related to housing. Ultimately, these findings provided greater insight into potential effective treatment interventions for people living with a dual diagnosis.

Originality/value

This study adds to the growing body of literature showing that patient-centered care allows for more effective treatment and ultimately, improved health outcomes.

The Impact of THC and CBD in Schizophrenia: A Systematic Review

Background: People with schizophrenia are more likely to develop cannabis use disorder (CUD) and experience worse outcomes with use. Yet as cannabis is legalized for medical and recreational use, there is interest in its therapeutic potential. Objectives: To conduct a systematic review summarizing the design and results of controlled trials using defined doses of THC and CBD in schizophrenia. Method: A keyword search of eight online literature databases identified 11 eligible reports. Results: One placebo controlled trial (13 stable patients without CUD) found that intravenous THC increased psychosis and worsened learning/recall. Two reports of a functional magnetic resonance (fMRI) study of smoked or oral THC in 12 abstinent patients with schizophrenia and CUD found no change in symptoms and cognition, and an amelioration of impaired resting state brain function in areas implicated in reward function and the default mode network. One 4 week trial in acutely psychotic inpatients without CUD (mean age 30 y) found 800 mg CBD to be similarly efficacious to amisupride in improving psychosis and cognition. Two 6 week studies of CBD augmentation of antipsychotics in stable outpatients reported mixed results: CBD 600 mg was not more effective than placebo; CBD 1,000 mg reduced symptoms in a sample that did not exclude cannabis use and CUD. A brain fMRI and proton magnetic resonance spectroscopy study of single dose CBD in a sample that did not exclude CUD and cannabis use found that CBD improved symptoms and brain function during a learning/recall task and was associated with increased hippocampal glutamate. Discussion: There is substantial heterogeneity across studies in dose, method of drug delivery, length of treatment, patient age, whether patients with cannabis use/CUD were included or excluded, and whether patients were using antipsychotic medication. Conclusion: There is insufficient evidence for an effect of THC or CBD on symptoms, cognition, and neuroimaging measures of brain function in schizophrenia. At this time, research does not support recommending medical cannabis (THC or CBD) for treating patients with schizophrenia. Further research should examine THC and CBD in schizophrenia with and without comorbid CUD and consider the role of CBD in mitigating symptom exacerbation from THC.

Relationships between Non-Suicidal Self-Injury and Other Maladaptive Behaviors: Beyond Difficulties in Emotion Regulation

Non-suicidal self-injury (NSSI) co-occurs with both other maladaptive behaviors (e.g., aggression) and emotion dysregulation. However, the extent to which these maladaptive behaviors are linked to NSSI independent of emotion dysregulation is unclear. The present study examined relationships between NSSI and six other maladaptive behaviors among university undergraduates. When controlling for demographic variables, emotion dysregulation, and other maladaptive behaviors, binge eating, purging, illicit drug use, and physical aggression were each related to lifetime NSSI history and/or severity. No maladaptive behaviors were significantly related to the presence of current diagnostic-level NSSI in these multivariate analyses. Results suggest that some maladaptive behaviors may relate uniquely to NSSI risk independent of emotion dysregulation, highlighting the importance of considering such behaviors in self-injury assessment and treatment.

Essential Elements of Forensic Assertive Community Treatment

LEARNING OBJECTIVE

After participating in this activity, learners should be better able to:• Assess characteristics of forensic assertive community treatment programs.

ABSTRACT

Forensic assertive community treatment (FACT) has emerged internationally as an intervention strategy for people with serious mental disorders who are involved with the criminal justice system. Studies to date have shown marked variability, however, in FACT program design and operation. Based upon a literature review and relevant experience, the authors present their perspective on the essential elements of FACT. Given that FACT is an adaptation of the evidence-based assertive community treatment (ACT) model, it is recommended that FACT programs maintain a high-fidelity ACT component. FACT programs should also have both mental health and criminal justice admission criteria because service recipients are involved in both service systems. For optimal effectiveness, FACT team clinicians must partner with criminal justice agencies that provide community-based supervision to their patients. Prospective FACT enrollees should receive a clear explanation of the program, including how their respective mental health and criminal justice service providers will work collaboratively with them to prevent incarceration. FACT programs should also use risk/need assessment to inform treatment planning, evidence-based mental health and community correctional practices to promote both wellness and public safety, and shared training to promote effective collaboration. Additional elements to consider include housing, medical care, and transitional services. These elements are presented and discussed, including a rationale and evidence to support each component. The article concludes with introduction of a FACT fidelity scale, the Rochester Forensic Assertive Community Treatment Scale (R-FACTS). By operationalizing essential FACT elements, the R-FACTS is designed to support FACT program development, implementation, and dissemination in a more consistent and measurable manner.

Evaluating hypothesized explanations for the Black-white depression paradox: A critical review of the extant evidence

The Black-white Depression paradox, the lower prevalence of major depression among non-Hispanic Black (relative to non-Hispanic white) individuals despite their greater exposure to major life stressors, is a phenomenon that remains unexplained. Despite a decade plus of research, there is little clarity as to whether the paradoxical observations are an invalid finding, spuriously produced by selection bias, information bias, or confounding, or are a valid finding, representative of a true racial patterning of depression in the population. Though both artefactual and etiologic mechanisms have been tested, a lack of synthesis of the extant evidence has contributed towards an unclear picture of the validity of the paradox and produced challenges for researchers in determining which proposed mechanisms show promise, which have been debunked, and which require further study. The objective of this critical review is to assess the state of the literature regarding explanations for the Black-white depression paradox by examining some of the more prominent hypothesized explanatory mechanisms that have been proposed and assessing the state of the evidence in support of them. Included mechanisms were selected for their perceived dominance in the literature and the existence of at least one, direct empirical test using DSM major depression as the outcome. This review highlights the very limited evidence in support of any of the extant putative mechanisms, suggesting that investigators should redirect efforts towards identifying novel mechanisms, and/or empirically testing those which show promise but to date have been relatively understudied. We conclude with a discussion of the broader implications of the evidence for well-accepted social theories and raise questions regarding the use of DSM major depression to assess mental health burden in Black communities.

Morbidity and mortality in schizophrenia with comorbid substance use disorders

OBJECTIVE

Schizophrenia is highly comorbid with substance use disorders (SUD) but large epidemiological cohorts exploring the prevalence and prognostic significance of SUD are lacking. Here, we investigated the prevalence of SUD in patients with schizophrenia in Finland and Sweden, and the effect of these co-occurring disorders on risks of psychiatric hospitalization and mortality.

METHODS

45,476 individuals with schizophrenia from two independent national cohort studies, aged <46 years at cohort entry, were followed during 22 (1996-2017, Finland) and 11 years (2006-2016, Sweden). We first assessed SUD prevalence (excluding smoking). Then, we performed Cox regression on risk of psychiatric hospitalization and all-cause and cause-specific mortality in SUD compared with those without SUD.

RESULTS

The prevalence of SUD ranged from 26% (Finland) to 31% (Sweden). Multiple drug use (n = 4164, 48%, Finland; n = 3268, 67%, Sweden) and alcohol use disorders (n = 3846, 45%, Finland; n = 1002, 21%, Sweden) were the most prevalent SUD, followed by cannabis. Any SUD comorbidity, and particularly multiple drug use and alcohol use, were associated with 50% to 100% increase in hospitalization (aHR any SUD: 1.53, 95% CI = 1.46-1.61, Finland; 1.83, 1.72-1.96, Sweden) and mortality (aHR all-cause mortality: 1.65, 95% CI = 1.50-1.81, Finland; 2.17, 1.74-2.70, Sweden) compared to individuals without SUD. Elevated mortality risks were observed especially for suicides and other external causes. All results were similar across countries.

CONCLUSION

Co-occurring SUD, and particularly alcohol and multiple drug use, are associated with high rates of hospitalization and mortality in schizophrenia. Preventive interventions should prioritize detection and tailored treatments for these comorbidities, which often remain underdiagnosed and untreated.

Aripiprazole Lauroxil, a Novel Injectable Long-Acting Antipsychotic Treatment for Adults with Schizophrenia: A Comprehensive Review

PURPOSE OF REVIEW

This is a comprehensive review of the literature regarding the use of Aripiprazole lauroxil for schizophrenia. This review presents the background, evidence, and indications for using aripiprazole lauroxil to treat schizophrenia in the context of current theories on the development of schizophrenia.

RECENT FINDINGS

Schizophrenia is a chronic mental health disorder that currently affects approximately 3.3 million people in the United States. Its symptoms, which must be present for more than six months, are comprised of disorganized behavior and speech, a diminished capacity to comprehend reality, hearing voices unheard by others, seeing things unseen by others, delusions, decreased social commitment, and decreased motivation. The majority of these symptoms can be managed with antipsychotic medication. Aripiprazole lauroxil is a long-acting intramuscular injection that works as a combination of partial agonist activity at D2 and 5-HT1A receptors combined with antagonist activity at 5-HT2A receptors. It can be dosed as a 4-, 6-, or 8-week injection, depending on oral dosage. Aripiprazole lauroxil was FDA approved in October of 2015.

SUMMARY

Schizophrenia is a severe psychiatric disorder if left untreated. There are multiple medications to help treat schizophrenia. One antipsychotic agent, aripiprazole lauroxil, offers long duration injections that optimize and improve compliance. Known side effects include weight gain, akathisia, neuroleptic malignant syndrome, tardive dyskinesia, and orthostatic hypotension. Aripiprazole lauroxil is an FDA-approved drug that can be administered monthly, every six weeks, or every two months and has been shown to be both safe and effective.

Unmet Mental Health Care Needs and Illicit Drug Use During Pregnancy

OBJECTIVES

The prevalence of drug use is at alarmingly high levels in the United States. Of particular concern is prenatal drug use, which exposes the underdeveloped organ systems of the fetus to harsh chemicals. Identifying factors associated with illicit drug use during pregnancy is critical to identify and treat at-risk pregnant women and improve maternal and infant health outcomes. The goal of this study was to examine the association between unmet mental health care needs and substance use during pregnancy.

METHODS

The present cross-sectional study analyzed secondary data from the 2002 to 2014 National Survey on Drug Use and Health (n = 10,516). The main outcome of interest was self-reported illicit drug use in the last 30 days. The independent variable was unmet mental health care needs in the last 12 months.

RESULTS

Overall, 6.4% of the participants reported a history of unmet mental health care needs and 4.5% used a substance during pregnancy. The odds of illicit drug use during pregnancy were higher among women who had an unmet mental health care needs compared to women without a history of unmet mental health care needs, multivariable-adjusted odds ratio (95% CI) 4.06 (3.01 to 5.48; P < 0.001). The observed association between unmet mental health care needs and illicit drug use persisted in subgroup analyses by age, race/ethnicity and education.

CONCLUSION

In a nationally representative cross-sectional sample of pregnant women, having unmet mental health care needs was positively associated with illicit drug use during pregnancy after adjusting for potential confounders.

Environmental Risk Factors for Schizophrenia and Bipolar Disorder and Their Relationship to Genetic Risk: Current Knowledge and Future Directions

Schizophrenia (SZ) and bipolar disorder (BD) are severe psychiatric disorders which result from complex interplay between genetic and environmental factors. It is well-established that they are highly heritable disorders, and considerable progress has been made identifying their shared and distinct genetic risk factors. However, the 15-40% of risk that is derived from environmental sources is less definitively known. Environmental factors that have been repeatedly investigated and often associated with SZ include: obstetric complications, infections, winter or spring birth, migration, urban living, childhood adversity, and cannabis use. There is evidence that childhood adversity and some types of infections are also associated with BD. Evidence for other risk factors in BD is weaker due to fewer studies and often smaller sample sizes. Relatively few environmental exposures have ever been examined for SZ or BD, and additional ones likely remain to be discovered. A complete picture of how genetic and environmental risk factors confer risk for these disorders requires an understanding of how they interact. Early gene-by-environment interaction studies for both SZ and BD often involved candidate genes and were underpowered. Larger samples with genome-wide data and polygenic risk scores now offer enhanced prospects to reveal genetic interactions with environmental exposures that contribute to risk for these disorders. Overall, although some environmental risk factors have been identified for SZ, few have been for BD, and the extent to which these account for the total risk from environmental sources remains unknown. For both disorders, interactions between genetic and environmental risk factors are also not well understood and merit further investigation. Questions remain regarding the mechanisms by which risk factors exert their effects, and the ways in which environmental factors differ by sex. Concurrent investigations of environmental and genetic risk factors in SZ and BD are needed as we work toward a more comprehensive understanding of the ways in which these disorders arise.

Mental Health and Psychosocial Needs of Patients Being Treated for Opioid Use Disorder in a Primary Care Residency Clinic

Purpose: Primary care is an ideal setting to deliver efficacious treatments for opioid use disorder (OUD). Primary care providers need to be aware of other concerns patients with OUD might have in order to provide comprehensive care. This study describes the prevalence of mental health, comorbid substance use, and psychosocial concerns of patients seeking treatment for OUD in primary care and their relation to 6-month treatment retention. Methods: Patients (N = 100; M age = 34.9 years (SD = 10.8), 74% white, 46% female) with OUD who were starting treatment with buprenorphine at an academic family medicine residency clinic completed surveys of mental health concerns (depression, anxiety, trauma), psychosocial needs (food insecurity, income, transportation, employment), and demographic variables. Chart reviews were conducted to gather information on comorbid substance use, mental health diagnoses, and 6-month treatment retention. Results: Mental health symptoms were highly prevalent in this sample (44% screened positive for anxiety, 31% for depression, and 52% for posttraumatic stress disorder). Three-quarters reported use of illicit substances other than opioids. Many patients also had significant psychosocial concerns, including unemployment (54%), low income (75%), food insecurity (51%), and lacking reliable transportation (64%). Two-thirds (67%) of the sample were retained at 6 months; patients who previously used intravenous opioids were more likely to discontinue treatment (P = .003). Conclusions: Many patients receiving treatment for OUD have significant mental health problems, comorbid substance use, and psychosocial concerns; interestingly, none of these factors predicted treatment retention at 6 months. Primary care clinics would benefit from having appropriate resources, interventions, and referrals for these comorbid issues in order to enhance overall patient well-being and promote recovery.

The prevalence of hazardous and harmful drinking in the UK Police Service, and their co-occurrence with job strain and mental health problems

AIMS

Due to the stressful nature of policing, police employees are at risk of mental health problems and problematic alcohol use. We aim to determine the prevalence of hazardous and harmful alcohol use in the UK Police Service, and to explore the associations with job strain and mental health problems.

METHODS

Cross-sectional data from the Airwave Health Monitoring Study (N = 40 986) included measures of alcohol consumption (total units in past week), mental health (depression, anxiety and post-traumatic stress disorder [PTSD]) and job strain. The associations between mental health and job strain with alcohol consumption (i.e. abstinence, low-risk [<14 units per week, reference group], hazardous [>14 to 35 units for women, >14 to 50 units for men], harmful [>35 units for women, >50 units for men]), were analysed using multinomial logistic regressions, adjusting for potential confounders (i.e. age, gender, ethnicity, marital status, children under 18, income and smoking status).

RESULTS

A total of 32.6% of police employees reported hazardous drinking, with 3.0% drinking at harmful levels. Compared to those without a mental health problem, police employees with depression, anxiety or PTSD were twice as likely to be harmful drinkers and were also 1.3 times more likely to report abstinence. Those reporting low strain (reference group) were more likely to drink hazardously compared to those reporting high strain, which was statistically moderated by mental health. When the sample was stratified by mental health status, the association between low strain (compared to all other categories) and hazardous drinking, was significant only in those without a mental health problem.

CONCLUSIONS

These findings indicate that police employees may be an occupational group at risk of alcohol harm, with one-third drinking hazardously. The J-shaped relationship between mental health and alcohol use highlights a need for an integration of mental health and alcohol services, tailored for the UK Police Service.

A review of research-supported group treatments for drug use disorders

This paper reviews methodologically rigorous studies examining group treatments for interview-diagnosed drug use disorders. A total of 50 studies reporting on the efficacy of group drug use disorder treatments for adults met inclusion criteria. Studies examining group treatment for cocaine, methamphetamine, marijuana, opioid, mixed substance, and substance use disorder with co-occurring psychiatric conditions are discussed. The current review showed that cognitive behavioral therapy (CBT) group therapy and contingency management (CM) groups appear to be more effective at reducing cocaine use than treatment as usual (TAU) groups. CM also appeared to be effective at reducing methamphetamine use relative to standard group treatment. Relapse prevention support groups, motivational interviewing, and social support groups were all effective at reducing marijuana use relative to a delayed treatment control. Group therapy or group CBT plus pharmacotherapy are more effective at decreasing opioid use than pharmacotherapy alone. An HIV harm reduction program has also been shown to be effective for reducing illicit opioid use. Effective treatments for mixed substance use disorder include group CBT, CM, and women's recovery group. Behavioral skills group, group behavioral therapy plus CM, Seeking Safety, Dialectical behavior therapy groups, and CM were more effective at decreasing substance use and psychiatric symptoms relative to TAU, but group psychoeducation and group CBT were not. Given how often group formats are utilized to treat drug use disorders, the present review underscores the need to understand the extent to which evidence-based group therapies for drug use disorders are applied in treatment settings.

Smartphone addiction and associated factors among postgraduate students in an Arabic sample: a cross-sectional study

BACKGROUND

Smartphone addiction, as with other behavioral addictions, is associated with social, physical, and mental health issues. In this article, we investigated the prevalence of smartphone addiction among postgraduate students and evaluated its correlation with social demographics, depression, attention-deficit/hyperactivity disorder (ADHD), and nicotine dependence.

OBJECTIVES

The objective of this study was to investigate the prevalence of smartphone addiction among Middle Eastern postgraduate students, determine the factors associated with smartphone addiction, and estimate the incidence rate of major depressive disorder (MDD), ADHD, insomnia, and nicotine addiction among postgraduate students with smartphone addiction.

METHODS

As part of a cross-sectional online survey, participants were given a self-questionnaire divided into six sections: Socio-demographics, Smartphone Addiction Scale (SAS), Patient Health Questionnaire (PHQ9) for Depression, Athens Insomnia Scale (AIS), the Fagerström Test for Cigarette Dependence Questionnaire (FTCd), and the adult ADHD Self-Report Scale (ASRS-v1.1).

RESULTS

Of the 506 patients, 51.0% of the participants demonstrated smartphone addiction. A significant association was also observed between extensive smartphone use and MDD (P = 0.001). Of the smokers in this study, 41.5% were addicted to smartphones (P = 0.039). Smartphone addicts had approximately two times the chance of having insomnia (OR = 2.113) (P = 0.013). In addition, they showcased more ADHD symptoms (OR = 2.712) (P < 0.001).

CONCLUSIONS

We found a positive association among insomnia, depression, adult ADHD, and smartphone addiction, which confirms the findings reported in the previous studies. Therefore, we encourage the scientific community to further study the impacts of smartphone addiction on the mental health of postgraduate students.

Liver disease prevalence and severity in people with serious mental illness: a cross-sectional analysis using non-invasive diagnostic tools

BACKGROUND/PURPOSE OF THE STUDY

Little is known about all-cause liver disease in people with serious mental illness (SMI), despite heightened risk factors. We, therefore, prospectively assessed liver disease by etiology and severity in a cross-sectional cohort of people with SMI at a tertiary health service.

METHODS

We recruited 255 people with SMI between August 2019 and March 2020. Liver disease data were derived from structured interview, medical records, biochemical and BBV serological analyses, and vibration-controlled transient elastography (VCTE). Steatosis was determined using a threshold of ≥ 248 db/m via the controlled attenuation parameter (CAP) on VCTE. Liver disease prevalence was assessed descriptively, and predictors of metabolic-dysfunction associated fatty liver disease (MAFLD) analyzed using linear regression and multivariable analysis. Best fit modeling of non-invasive screening tests for MAFLD was also assessed.

RESULTS

Valid VCTE was obtained for 252 (98.9%) participants. Median age was 40 years (IQR 31-49) with male predominance (65.9%). Hepatitis C Virus (HCV) seroprevalence was 14.7% (37/252), with four new viremic cases identified. Hepatic steatosis was diagnosed in 61.5% (155/252) of participants, with MAFLD criteria met in 59.9% (151/252) of cases. Clozapine and paliperidone were associated with hepatic steatosis (CAP + 23.3 db/m, p 0.013 and CAP + 25.5, p 0.037, respectively). Advanced liver disease, defined by LSM ≥ 8.2 kPa, was identified in 26 individuals (10.3%). MAFLD compared to no MAFLD was associated with more advanced liver disease (5.3 kPa, 4.3-6.5 versus 4.9 kPa, 3.9-5.6, p < 0.001).

CONCLUSION

Liver disease is common in people with SMI and should be screened for as part of standard physical health assessment.

Relapse risk factors for patients with comorbid affective disorders and substance abuse disorders from an intensive treatment unit

BACKGROUND AND OBJECTIVES

The prevalence of substance use disorders (SUD), particularly involving opiates and benzodiazepines, has increased to the detriment of public health and the economy. Here, we evaluate relapse factors among the high-risk demographic of patients with SUD and comorbid affective disorders.

METHODS

A retrospective chart review of 76 patients discharged after detoxification and simultaneous psychiatric care for concomitant affective disorders and SUDs. Relapse was assessed by two independent evaluators via postdischarge chart review, which included state-wide healthcare utilization, by patient, through healthcare information exchange systems. A Cox Hazards analysis was performed to characterize relapse risk factors.

RESULTS

Benzodiazepine use, admission through the emergency department (ED) rather than direct admission, frequent ED use in the preceding year, and history of prior attendance at multiple detoxification programs were risk factors for shortened time-to-relapse. Polysubstance use and intravenous drug use prolonged time to relapse.

DISCUSSION AND CONCLUSIONS

Notable findings include the significant relapse risk associated with benzodiazepine abuse and frequent prior ED utilization. These risk factors could reflect a number of underlying mediators for relapse, including anxiety, disease burden, and malingering. Additionally, this study recapitulates the observation in other patient populations that the majority of health resource utilization is attributed to a small population of patients.

SCIENTIFIC SIGNIFICANCE

This study is the first to identify relapse predictors among dual-diagnosis affective disorder and SUD patients in survival analysis, and replicates the alarming and largely unknown effect that benzodiazepines have on increasing relapse risk.

Clozapine for Treatment-Refractory Aggressive Behavior

Emergency psychiatry has the main role of resolving suicidal behavior and aggression. These severe psychiatric symptoms can be found in many psychiatric disorders such as schizophrenia, bipolar disorder, major depression, personality disorders, cognitive disorders, intellectual disability and substance abuse. Although indications for the use of antipsychotics are limited to a specific group of diseases, they are frequently used as rescue medication in high-risk or nonresponsive cases. Clozapine, the gold standard for TRS (treatment resistant schizophrenia) is effective in controlling aggression. The aim of the research was to identify the use of clozapine for treatment-refractory aggressive behavior in psychiatric emergency. A retrospective study based on the paper files of patients admitted between 2010 and 2019 in the Clinical Hospital of Psychiatry and Neurology of Brasov, Romania. Were included all the patients admitted as a psychiatric emergency and treated with clozapine for aggressive behavior. The hospital is an academic institution with 150 beds for acute patients, serving an area of over 600,000 inhabitants. It is the main public institution where patients with psychiatric emergencies are hospitalized. Off 19,000 patients admitted during the study period, 504 patients (2,4%) with a diagnosis other than schizophrenia or schizoaffective disorder received clozapine for aggressiveness (89.5%). The first four diagnoses identified were bipolar disorder (n = 172), intellectual disability (n = 128), cognitive impairment (n = 112), and personality disorder (n = 92). Other disorders identified but with a smaller number of cases were major depressive disorder (n = 3), adjustment disorders (n = 2), delusional disorder (n = 2), obsessive compulsive disorder (n = 2) and postpartum psychosis (n = 1). Clozapine was used as 3rd or 4th choice. The dose was greater for manic patients (350.29 ± 98.01 mg/day) compared with all the other diagnoses. Clozapine was effective and safe in cases of patients with treatment-refractory aggressive behavior.

Severe drug-induced liver injury in patients under treatment with antipsychotic drugs: Data from the AMSP study

OBJECTIVES

Drug-induced liver injury (DILI) has been associated with various antipsychotic drugs (APDs). Comparative studies between individual APDs are largely not available.

METHODS

Antipsychotic drug utilisation data and reports of severe antipsychotic DILI were assessed by using data from an observational pharmacovigilance programme-Arzneimittelsicherheit in der Psychiatrie (AMSP)-during the period 1993-2016.

RESULTS

Of the 333,175 patients treated with APDs, a total of 246 (0.07%) events of severe DILI were identified. Phenothiazines were associated with significantly higher rates of severe DILI (0.03%, 95% CI = 0.02-0.04) than thioxanthenes (0.01%, 95% CI = 0.00-0.02) or butyrophenones (0.01%, 95% CI = 0.00-0.01). Among individual drugs, olanzapine (0.12%, 95% CI = 0.10-0.16), perazine (0.09%, 95% CI = 0.05-0.15) and clozapine (0.09%, 95% CI = 0.10-0.12 ranked highest. In 78 cases (31.7%), combination therapies with antipsychotic and antidepressant drugs or with two or more APDs were considered responsible. Male sex and a diagnosis of mania were associated with significantly higher rates of severe DILI while older patients (≥65 years old) were significantly less often affected.

CONCLUSIONS

In the present analysis of a representative psychiatric inpatient cohort, olanzapine, perazine, and clozapine were the most common individual APDs associated with severe DILI.

Racial, Ethnic, and Socioeconomic Discrepancies in Opioid Prescriptions Among Older Patients With Cancer

PURPOSE

Minority race and lower socioeconomic status are associated with lower rates of opioid prescription and undertreatment of pain in multiple noncancer healthcare settings. It is not known whether these differences in opioid prescribing exist among patients undergoing cancer treatment.

METHODS AND MATERIALS

This observational cohort study involved 33,872 opioid-naive patients of age > 65 years undergoing definitive cancer treatment. We compared rates of new opioid prescriptions by race or ethnicity and socioeconomic status controlling for differences in baseline patient, cancer, and treatment factors. To evaluate downstream impacts of opioid prescribing and pain management, we also compared rates of persistent opioid use and pain-related emergency department (ED) visits.

RESULTS

Compared with non-Hispanic White patients, the covariate-adjusted odds of receiving an opioid prescription were 24.9% (95% CI, 16.0 to 33.9, P < .001) lower for non-Hispanic Blacks, 115.0% (84.7 to 150.3, P < .001) higher for Asian-Pacific Islanders, and not statistically different for Hispanics (-1.0 to 14.0, P = .06). There was no significant association between race or ethnicity and persistent opioid use or pain-related ED visits. Patients living in a high-poverty area had higher odds (53.9% [25.4 to 88.8, P < .001]) of developing persistent use and having a pain-related ED visit (39.4% [16.4 to 66.9, P < .001]).

CONCLUSION

For older patients with cancer, rates of opioid prescriptions and pain-related outcomes significantly differed by race and area-level poverty. Non-Hispanic Black patients were associated with a significantly decreased likelihood of receiving an opioid prescription. Patients from high-poverty areas were more likely to develop persistent opioid use and have a pain-related ED visit.

Prevalence and Demographic Correlates of Substance Use among Adults with Mental Illness in Eastern Cape, South Africa: A Cross-Sectional Study

This study reports on the prevalence and demographic correlates of substance use among individuals with mental illness in the Eastern Cape, South Africa. This cross-sectional study was conducted in the Outpatient Clinic of a large hospital in the Eastern Cape, South Africa. A pre-validated tool on alcohol and psychoactive drug use was administered to 390 individuals with mental illness. Multivariable logistic regression models were fitted to explore the demographic correlates of alcohol and psychoactive drug use. Of the total participants (N = 390), 64.4% and 33.3% reported lifetime (ever used) and past-year use of alcohol, respectively, but the prevalence of risky alcohol use was 18.5%. After adjusting for relevant covariates, only male sex, younger age, and rural residence remained significantly associated with risky alcohol use. The prevalence of ever-use and past-year use of psychoactive substances was 39.7% and 17.4%, respectively. The most common substance ever used was cannabis (37.4%). Male sex, younger age, owning a business, and being unemployed were significantly associated with higher odds of lifetime and past-year use of psychoactive substances. Findings highlight the need for dedicated infrastructure and staff training in the management of these dual diagnoses in the region.

High ethanol preference and dissociated memory are co-occurring phenotypes associated with hippocampal GABAAR-δ receptor levels

Alcohol use disorder (AUD) frequently co-occurs with dissociative disorders and disorders with dissociative symptoms, suggesting a common neurobiological basis. It has been proposed that facilitated information processing under the influence of alcohol, resulting in the formation of dissociated memories, might be an important factor controlling alcohol use. Access to such memories is facilitated under the effect of alcohol, thus further reinforcing alcohol use. To interrogate possible mechanisms associated with these phenotypes, we used a mouse model of dissociative amnesia, combined with a high-alcohol preferring (HAP) model of AUD. Dissociated memory was induced by activation of hippocampal extrasynaptic GABA type A receptor delta subunits (GABA_AR-δ), which control tonic inhibition and to which ethanol binds with high affinity. Increased ethanol preference was associated with increased propensity to form dissociated memories dependent on GABA_AR-δ in the dorsal hippocampus (DH). Furthermore, the DH level of GABA_AR-δ protein, but not mRNA, was increased in HAP mice, and was inversely correlated to the level of miR-365-3p, suggesting an miRNA-mediated post-transcriptional mechanism contributing to elevated GABA_AR-δ. The observed changes of DH GABA_AR-δ were associated with a severe reduction of excitatory projections stemming from GABA_AR-δ-containing pyramidal neurons in the subiculum and terminating in the mammillary body. These results suggest that both molecular and circuit dysfunction involving hippocampal GABA_AR-δ receptors might contribute to the co-occurrence of ethanol preference and dissociated information processing.

Association between perceived risk of harm and self-reported binge drinking, cigarette smoking, and marijuana smoking in young adults

OBJECTIVES

Evaluate the association between perceived risk of harm and self-reported binge drinking, cigarette smoking, and marijuana smoking among college students.

PARTICIPANTS

Participants were 599 students (ages 19-28) at a large Midwestern university recruited from October 2015 to December 2017.

METHODS

Hurdle regression was used to test the relationship between perceived risk of harm from substance use (i.e., binge drinking, cigarette smoking, and marijuana smoking), and self-reported use. Demographic characteristics were tested as moderators of this relationship.

RESULTS

Engagement in all three substance use behaviors was less likely when perceived risk was high. Age moderated the association between perceived risk and self-reported marijuana smoking with younger participants demonstrating a stronger relationship between perceived risk of smoking marijuana and self-reported marijuana smoking.

CONCLUSION

Intervention programs will be most effective when perceived risk of substance use is high. Therefore, intervention programs should aim to increase college students' perceived risk of substance use.

Explaining the Black-white depression paradox: Interrogating the Environmental Affordances Model

The Environmental Affordances (EA) model posits that Black Americans' engagement with unhealthy behaviors (i.e. smoking, alcohol use, eating calorie-dense foods) to cope with stressor exposure may simultaneously account for their observed greater risk of chronic physical illness, and their observed equal or lesser prevalence of depression, relative to white Americans - the so-called "Black-white depression paradox." However, the specific mechanisms through which such effects might arise have been theorized and analyzed inconsistently across studies, raising concerns regarding the appropriateness of existing empirical tests of the model as well as the validity of the conclusions. We specify the two mechanisms most consistent with the EA model - 'Mediation-only' and 'Mediation and Modification' - and derive a priori predictions based on each. We systematically test these pathways using a subset of 559 participants of the Child Health and Development Study who were included in an adult follow-up study between 2010 and 2012 and self-identified as Black or white. Results failed to support either of the two mechanisms derived from the EA model, challenging the validity and utility of the model for explaining racial differences in depression; efforts to develop alternative hypotheses to explain the paradox are needed.

Predicting Persistent Opioid Use, Abuse, and Toxicity Among Cancer Survivors

BACKGROUND

Although opioids play a critical role in the management of cancer pain, the ongoing opioid epidemic has raised concerns regarding their persistent use and abuse. We lack data-driven tools in oncology to understand the risk of adverse opioid-related outcomes. This project seeks to identify clinical risk factors and create a risk score to help identify patients at risk of persistent opioid use and abuse.

METHODS

Within a cohort of 106 732 military veteran cancer survivors diagnosed between 2000 and 2015, we determined rates of persistent posttreatment opioid use, diagnoses of opioid abuse or dependence, and admissions for opioid toxicity. A multivariable logistic regression model was used to identify patient, cancer, and treatment risk factors associated with adverse opioid-related outcomes. Predictive risk models were developed and validated using a least absolute shrinkage and selection operator regression technique.

RESULTS

The rate of persistent opioid use in cancer survivors was 8.3% (95% CI = 8.1% to 8.4%); the rate of opioid abuse or dependence was 2.9% (95% CI = 2.8% to 3.0%); and the rate of opioid-related admissions was 2.1% (95% CI = 2.0% to 2.2%). On multivariable analysis, several patient, demographic, and cancer and treatment factors were associated with risk of persistent opioid use. Predictive models showed a high level of discrimination when identifying individuals at risk of adverse opioid-related outcomes including persistent opioid use (area under the curve [AUC] = 0.85), future diagnoses of opioid abuse or dependence (AUC = 0.87), and admission for opioid abuse or toxicity (AUC = 0.78).

CONCLUSION

This study demonstrates the potential to predict adverse opioid-related outcomes among cancer survivors. With further validation, personalized risk-stratification approaches could guide management when prescribing opioids in cancer patients.

Psychiatric Comorbidity and Associated Professional Mental Health Utilization among Students in Recovery from Addiction in Southern Collegiate Recovery Communities

OBJECTIVES

This pilot study explores the additional psychiatric problems and their associated professional mental health utilization by students in recovery from addiction in collegiate recovery communities (CRCs) across the US South. The article has three goals: introduce CRCs to a broad medical audience; identify coexisting psychiatric concerns among students in CRC programs; and determine these students' type, rate, and location of professional mental health services.

METHODS

During the 2014-2015 academic year, this study recruited participants through e-mail to all known CRC directors, who had the option of forwarding a survey link to its participants.

RESULTS

Fourteen percent of students in 13 known southern CRCs completed the survey. Seventy-four percent of them reported at least one coexisting psychiatric issue. The most common issue was depression, followed by anxiety. Other reported disorders included attention-deficit/hyperactivity disorder, eating disorder, bipolar disorder, posttraumatic stress disorder, psychotic disorder, and obsessive-compulsive disorder. Most of the students in southern CRCs worked with psychiatrists and other therapists off-campus on their psychiatric problems.

CONCLUSIONS

This pilot study suggests that a significant number of students in southern CRCs have additional psychiatric problems that require professional mental health services.

Comorbidity between depressive symptoms and substance use in-patients hospitalized for non-psychiatric diseases

INTRODUCTION

Epidemiological studies have shown a high prevalence and concurrence between depression and substance use. This is known as "dual diagnosis" and is associated with a worse prognosis for patients.

OBJECTIVE

To establish the comorbidity between depressive symptoms and substance abuse in patients admitted with acute or chronic diseases to a public hospital.

METHODS

A descriptive, cross-sectional study of prevalence which included 296 patients aged 18-65, to whom the PHQ-9 and ASSIST 3.0 scales were applied to determine the prevalence of depressive symptoms and substance abuse. Other clinical and sociodemographic variables were also taken into account.

RESULTS

50.7% were women with a median age of 41 and an interquartile range of 27 years. Moderate-to-severe depressive symptoms were found in 27.4% of the patients. Alcohol was the substance with the highest consumption in the previous 3 months with 53.7%, followed by cigarettes (47.6%), marijuana (26.7%) and cocaine (14.5%). A significant association was found between severe depressive symptoms PHQ-9 ≥ 20 and problematic use of alcohol, marijuana and cocaine (ASSIST score >26); alcohol (RP 27.30, 95% CI [2.37-314.16], P = 0.01); marijuana (RP 15.00, 95% CI [3.46-64.96], P = 0.001) and cocaine (RP 10.65, 95% CI [2.23-51.10], P = 0.01).

DISCUSSION

A high prevalence of depressive symptoms and substance use was found in patients hospitalised for non-psychiatric medical conditions, which worsens the prognosis of the underlying medical condition.

CONCLUSIONS

To provide better hospital care for patients, we need to give visibility to the problem of dual pathology. This could be achieved by conducting more related research in these clinical scenarios.

Food addiction comorbid to mental disorders: A nationwide survey and register-based study

OBJECTIVE

Substance use disorder is highly prevalent among individuals with mental disorders. However, it remains largely unknown whether this is also the case for "food addiction"-a phenotype characterized by an addiction-like attraction to predominantly highly processed foods with a high content of refined carbohydrates and fat. Therefore, the primary aim of this study was to estimate the weighted prevalence of food addiction among individuals with mental disorders.

METHOD

A total of 5,000 individuals aged 18-62 were randomly drawn from eight categories of major mental disorders from the Danish Psychiatric Central Research Register and invited to participate in an online questionnaire-based survey, which included the Yale Food Addiction Scale 2.0. Data on health care and sociodemographics from the Danish registers were linked to all invitees-enabling comprehensive attrition analysis and calculation of the weighted prevalence of food addiction.

RESULTS

A total of 1,394 (27.9%) invitees participated in the survey. Across all diagnostic categories, 23.7% met the criteria for food addiction. The weighted prevalence of food addiction was highest among individuals with eating disorders (47.7%, 95%CI: 41.2-54.2), followed by affective disorders (29.4%, 95%CI: 22.9-36.0) and personality disorders (29.0%, 95%CI: 22.2-35.9). When stratifying on sex, the prevalence of food addiction was higher among women in most diagnostic categories.

DISCUSSION

Food addiction is highly prevalent among individuals with mental disorders, especially in those with eating disorders, affective disorders and personality disorders. Food addiction may be an important target for efforts aimed at reducing obesity among individuals with mental disorders.

Evidence for Use of Cannabinoids in Mood Disorders, Anxiety Disorders, and PTSD: A Systematic Review

OBJECTIVE

Two primary compounds of the cannabis plant (Cannabis sativa), delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), differentially and dose-dependently affect mood and anxiety. In this systematic review, the authors summarize the design and results of controlled trials assessing the effects of THC and CBD on affective disorders, anxiety disorders, and posttraumatic stress disorder (PTSD).

METHODS

A keyword search of eight online literature databases identified eight randomized controlled trials of defined CBD or THC doses for the target populations.

RESULTS

A 1-month trial of daily THC (up to 3 mg per day) for DSM-II anxiety disorder reduced anxiety symptoms, but symptoms were very low throughout the study. Another trial of sequential, single-day, low-dose THC in social anxiety disorder found no symptom changes. Two studies reported that single-dose CBD pretreatment reduced anxiety in laboratory paradigms among individuals with social anxiety disorder. A study of daily CBD for 4 weeks among adolescents with social anxiety disorder indicated modest symptom improvements. One crossover trial involving 10 patients with PTSD showed that THC added to standard pharmacotherapy reduced self-reported nightmares. Two small studies of THC for hospitalized patients with unipolar or bipolar depression found no improvement of depression; instead, anxiety and psychotic symptoms emerged in >50% of patients.

CONCLUSIONS

With only eight very small studies, insufficient evidence was found for efficacy of CBD and THC to manage affective disorders, anxiety disorders, or PTSD. Therefore, medical cannabis should not be recommended for treating patients with these disorders. Further research should investigate the safety and efficacy of managing psychiatric disorders with cannabinoids.

Alcohol use in Tanzanians with chronic psychotic disorders and poor medication adherence

Background

The burden of chronic psychotic disorders (CPDs) in sub-Saharan Africa (SSA) is significant. Poorly medically adherent patients are more likely to have worse outcomes and require more resources. However, factors impacting effective treatment of CPD in this population are unclear.

Aim

Examine the relationship between alcohol use and disease management and compare alcohol risk stratification between the Alcohol Use Disorders Identification Test (AUDIT) and Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in poorly medication adherent Tanzanians with CPD.

Setting

Muhimbili National Hospital and ambulatory clinics in Dar es Salaam, Tanzania.

Methods

100 Tanzanians with CPDs and suboptimal medication adherence were dichotomized into low and moderate-to-high risk alcohol use based on AUDIT scores and compared regarding medication attitudes, adherence and psychiatric symptoms. Patients completed the ASSIST for comparison to AUDIT risk stratification.

Results

Moderate-to-high risk alcohol users had worse medication attitudes (p < 0.01), medication adherence (previous week, p = 0.01; previous month, p < 0.001), and psychiatric symptoms (p = 0.03). They were younger, predominately male and more likely to have a family history of alcohol abuse. A logistic regression analysis found age, gender and family history of abuse as significant predictors of hazardous alcohol use (p = 0.02, 0.02, < 0.01, respectively). Risk stratification between AUDIT and ASSIST aligned in 85% of participants.

Conclusion

Alcohol use is an important consideration in treating poorly adherent Tanzanians with CPD. The ASSIST was comparable to the AUDIT in stratifying risky alcohol use with the additional benefit of screening for other substances.

Prognostic plasma exosomal microRNA biomarkers in patients with substance use disorders presenting comorbid with anxiety and depression

Psychiatric disorders such as anxiety and depression precipitated by substance use occurred during both use and withdrawal. Exosomes play significant roles in biological functions and regulate numerous physiological and pathological processes in various diseases, in particular substance use disorders (SUDs) and other psychiatric disorders. To better understand the role of exosomal miRNAs in the pathology of symptoms of anxiety and depression in patients with SUDs, we first isolated circulating exosomes from heroin-dependent patients (HDPs) and methamphetamine-dependent patients (MDPs) and identified exosomal miRNAs that were differentially expressed between patients and healthy controls (HCs). Furthermore, the correlations between exosomal DE-miRNAs and symptoms of anxiety and depression which were measured using Hamilton-Anxiety (HAM-A)/Hamilton-Depression (HAM-D) Rating Scales in the participants. Notably, the expression level of exosomal hsa-miR-16-5p, hsa-miR-129-5p, hsa-miR-363-3p, and hsa-miR-92a-3p showed significantly negative correlations with HAM-A scores in both HDPs and MDPs. But all of the 4 DE-miRNAs lost significant correlations with HAM-D scores in HDPs. Functional annotation analyses showed that the target genes of the DE-miRNAs were mainly enriched for “synapse”, “cell adhesion”, “focal adhesion” and “MHC class II protein complex”. Our study suggests that a set of circulating exosomal miRNAs were associated with anxiety and depression in SUD patients and may have clinical utility as diagnostic and prognostic biomarkers.

Health-related quality of life among patients with bipolar disorder in rural southwestern Uganda: a hospital based cross sectional study

BACKGROUND

Bipolar disorder is a psychiatric disorder that alters mood and affects over 55 million people globally with an estimated lifetime prevalence of approximately 0.8-1.1%. In Africa, the lifetime prevalence of the bipolar spectrum disorders is slightly lower at 0.1-0.6%. Bipolar disorder is ranked the sixth leading cause of disability with high rates of morbidity and mortality and negatively impacts quality of life of those affected.

METHODS

The aim of the study was to determine the health-related quality of life of patients with bipolar disorder attending a mental health clinic in south western Uganda. We enrolled a consecutive sample of 169 participants and evaluated their health-related quality of life using the medical outcomes health survey short form-36 (SF-36) scale. We used bivariate and multivariable logistic regression to determine associations between quality of life, sociodemographic and clinical factors setting the physical and mental component categories of quality life scale as the main outcome variables.

RESULTS

The mean age of the participants was 37.23 (12.83) and slightly over half (54.4%) were females. More than half (66.86%) of the participants had poor physical component summary (mean = 45.06, SD = 8.44) while 81% of the participants had poor mental component summary (mean = 41.95, SD = 8.45). Poor physical quality of life had a statistically significant association with history of suicidal thoughts (OR = 2.75, 95% CI = 1.14-6.63, P = 0.02), while poor mental quality of life had a statistically significant association with history of suicidal thoughts (OR = 3.94, CI = 1.22-12.71, P = 0.02) and history of psychotic symptoms (OR = 2.46, CI = 1.07-5.64, P = 0.03).

CONCLUSION

The mental and physical quality of life of our participants was poor and history of suicidal thoughts and psychotic symptoms were associated with poor quality of life. There is need to address psychotic symptoms and suicidal thoughts in the management of patients with bipolar disorder to improve health related outcomes and quality of life.

Researcher perspectives on including people who use drugs in clinical research

Background: People who use drugs are commonly excluded from clinical research despite being disproportionately impacted by numerous health conditions. Recent work indicates that community-recruited individuals report low support of research inclusion for persons reporting substance use.Objective: This study conducted a mixed-method assessment of researchers' attitudes on including persons reporting substance use in clinical research.Methods: Respondents (N = 168; 58% female; 58% psychologists) recruited via scientific society listservs and Twitter completed a survey containing two hypothetical research vignettes. Quantitative items evaluated respondents' endorsement of research participation by healthy adults, people who use drugs, and vulnerable populations. Qualitative items included open-ended questions asking reasons why people who use drugs should and should not participate in research.Results: Respondents reported significantly lower support for research participation by people who use drugs compared to healthy adults (p <.001). Open-ended responses concerning the inclusion of people who use drugs included themes relevant to the Belmont Principles (e.g., capacity to consent) and data quality (e.g., "bad data," poor compliance).Conclusion: Although lower support for research participation by people who use drugs was observed compared to healthy adults, the magnitude of this difference was smaller than reported for prior community-recruited respondents. These findings emphasize salient factors that may serve as both protections for and barriers to inclusion of people who use drugs in research. Initiatives including adoption of person-first language, addressing stereotyping of people who use drugs, and emphasizing the benefits of including these populations in clinical research should be explored to reduce bias while retaining needed protections.

[Differential diagnostic distinction between substance-induced and primary psychoses: : Recommendations for general psychiatric and forensic practice]

Substanzinduzierte psychotische Störungen (SIPS) sind häufig und für ca. 25 % der ersten Einweisungen in eine psychiatrische Klinik verantwortlich. Aus klinischer Sicht ist aufgrund ähnlicher psychopathologischer Phänomene die diagnostische Unterscheidung zwischen SIPS und primären (genuinen oder kryptogenen) psychotischen Störungen oft eine Herausforderung. Dieser Umstand wird dadurch erschwert, dass SIPS im Zusammenhang mit Cannabis, Halluzinogenen und Amphetaminen ein erhebliches Risiko des Übergangs in eine primäre psychotische Störung (z. B. Schizophrenie) haben. Im ersten Abschnitt dieser Arbeit werden zunächst zwei exemplarische Fallvignetten aus der allgemeinpsychiatrischen und forensischen Praxis vorgestellt. Danach wird im Sinne einer selektiven Literaturübersicht die Relevanz der differenzialdiagnostischen Unterscheidung beider Störungsbilder aus der Sicht der allgemeinen und forensischen Psychiatrie in Bezug auf Therapie, Prognose und richterliche Entscheidung bezüglich der Unterbringung im Maßregelvollzug (§ 63 vs. § 64 StGB) beleuchtet. Der letzte Abschnitt hat das Ziel, ein strukturiertes Vorgehen zur differenzialdiagnostischen Unterscheidung zwischen SIPS und primären psychotischen Störungen zu erarbeiten. Die in dieser Arbeit dargestellten und diskutierten Konzepte und Befunde sollen klinisch tätigen Psychiatern und Psychologen die Diagnosestellung im allgemeinen und forensischen Kontext erleichtern.

Effects of aripiprazole long-acting injectable antipsychotic on hospitalization in recent-onset schizophrenia

OBJECTIVE

Recent-onset schizophrenia (ROS) represents a critical period that can greatly influence the clinical course of schizophrenia. The use of long-acting injectable antipsychotics (LAIs) in this period is increasingly being considered as a first-line treatment option. Aripiprazole LAI (ALAI) is the newest of all LAI's available on the market, with limited data on its effects on hospitalization rates after first episode of schizophrenia. It was our goal to evaluate whether ALAI has an effect on hospitalization rates, number of bed days and clinical improvement in patients with ROS.

METHODS

This mirror-image study included 138 inpatients suffering from schizophrenia. We collected sociodemographic data on all individuals, number of hospitalization days, hospitalization rates as well as Clinical Global Impression Scale-severity of illness (CGI-S) and Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS) scores at the initiation of ALAI and at the end of a 1 year follow up.

RESULTS

Mean number of hospitalizations and hospitalization days in the year after starting ALAI significantly decreased compared to the year before (p = 0.005 and p < 0.001). Mean scores on both CGI and CRDPSS also significantly decreased after initiating ALAI (p < 0.001).

CONCLUSION

Results suggest that ALAI is an important therapeutic option in patients with ROS. It leads to reduced usage of hospital services, potentially reducing the socio-economic healthcare burden.

Effects of psychotherapy on comorbid bipolar disorder and substance use disorder: A systematic review

OBJECTIVES

This review aim was to examine whether psychotherapy is more or less effective in patients with SUD, compared to those without; whether there is a differential effect of a particular psychotherapy in patients with SUD.

METHODS

A quantitative systematic review following the Cochrane Handbook of Systematic Reviews was used.

RESULTS

Five studies of psychotherapy for BD and two studies of an integrated psychotherapy for comorbid BD and SUD were included in the review. Five studies provided a sub-analysis of the effect of SUD on overall outcomes with only one finding an overall detrimental effect. The results indicated equal, if not better outcomes for individuals with comorbid BD and SUD.

CONCLUSION

There was little evidence that interventions targeted at both BD and SUD may be more efficacious. Further research in to psychotherapeutic treatment for BD should include individuals with comorbid SUD, and analyse substance use as an outcome. Additionally, research into treatments specifically developed for these commonly comorbid disorders is indicated.

Identification of Domestic Violence Service Needs Among Child Welfare-Involved Parents With Substance Use Disorders: A Gender-Stratified Analysis

The current study examined the prevalence and associations of a need for domestic violence services among child welfare-involved mothers and fathers with substance use disorders. Data were drawn from 2,231 child welfare-involved parents in Illinois with an identified substance use disorder. Approximately 42% of mothers and 33% of fathers with a substance use disorder had a concurrent need for domestic violence services. The sample was stratified by gender and logistic regression models were fit to determine the adjusted odds of an identified need for domestic violence services. For both mothers and fathers, the strongest association was an additional need for mental health services. Age, education status, alcohol use, marijuana use, and a reported history of physical violence victimization were also associated with a need for domestic violence services among mothers, while race, age, marital status, annual income, alcohol use, cocaine use, and a reported history of physical violence perpetration were associated with a need for domestic violence services among fathers. The findings of this study make clear that domestic violence is a commonly co-occurring service need for child welfare-involved parents with identified substance use disorders, and that associations with this need vary by gender.

Electroconvulsive Therapy in Mania: A Review of 80 Years of Clinical Experience

Resistance to pharmacological agents is commonly encountered in the treatment of acute episodes of mania. In contemporary practice guidelines, electroconvulsive therapy (ECT), once a widely used standalone intervention for mania, is no longer considered a first-line treatment. Stigma, logistics, and ethical factors constrain ECT administration in this condition and lead to its underutilization. However, the past three decades have produced promising research regarding the use of ECT in mania. Randomized controlled trials, albeit in limited numbers, the adoption of ultrabrief ECT, examination of the safety and efficacy of combining ECT with pharmacological agents, including lithium, and use of ECT as a maintenance strategy have enhanced our understanding of how and when to utilize this intervention in mania. In this comprehensive review, the authors summarize the evidence regarding the efficacy and safety of ECT in mania, including related syndromes, such as delirious mania and mixed affective states. The impact of technical parameters, particularly the choice of treatment frequency, electrode placements, and pulse width, are discussed in the light of recent evidence.

A Gender Perspective of Addictive Disorders

Purpose of Review

Substance use disorders (SUD) affect differentially women and men. Although the prevalence has been reported higher in men, those women with addictive disorders present a more vulnerable profile and are less likely to enter treatment than men. The aim of this paper is to present an overview of how sex and gender may influence epidemiology, clinical manifestations, social impact, and the neurobiological basis of these differences of women with SUD, based on human research.

Recent Findings

The differences in prevalence rates between genders are getting narrower; also, women tend to increase the amount of consumption more rapidly than men, showing an accelerated onset of the SUD (telescoping effect). In respect to clinical features, the most important differences are related to the risk of experience psychiatric comorbidity, the exposure to intimate partner violence, and the associated high risks in sexual and reproductive health; and those who are mothers and addicted to substances are at risk of losing the custody of children accumulating more adverse life events. Some of these differences can be based on neurobiological differences: pharmacokinetic response to substances, sensitivity to gonadal hormones, differences in neurobiological systems as glutamate, endocannabinoids, and genetic differences.

Summary

Specific research in women who use drugs is very scarce and treatments are not gender-sensitive oriented. For these reasons, it is important to guarantee access to the appropriate treatment of women who use drugs and a need for a gender perspective in the treatment and research of substance use disorders.

Developmental trajectories in psychiatric disorders: does substance/alcohol use moderate the effects of affective temperaments as moderators of age at onset? A study in post-acute, hospitalized patients with psychotic or DSM-5 bipolar or major depressive disorders

BACKGROUND

Age-at-onset (AAO) affects psychiatric disorder outcome; substance (SUDs) or alcohol use disorders (AUDs) may influence their onset. Affective temperaments may affect early AAO and drug-use proneness. Objectives: To investigate whether SUD/AUD moderated temperamental effects in determining AAO of mental disorders. Methods: We included 300 post-acute inpatients with schizophrenia-spectrum and other psychotic (SSOPDs), major depressive (MDD) or bipolar (BD) disorders (168 men; mean age, 40.63 years ± 11.82 men, 43.21 years ± 12.69 women) with (N = 110) or without (N = 190) SUD/AUD. Patients completed cross-sectionally TEMPS-A. We carried moderation analysis with each regression-significant TEMPS temperament as independent variable, SUD/AUD presence/absence as dichotomous moderator, and AAO as dependent variable. Significance was set at p < 0.05. Results: AAO was lower in patients with SUD/AUD diagnosis than in patients without (23.74 ± 10.09 vs. 27.73 ± 10.35, respectively, p = 0.001, η2 = 0.034). SUD/AUD patients scored higher on the hyperthymic (10.22 ± 4.08, p < 0.001, η2 = 0.069) and irritable (8.26 ± 4.69, p < 0.01, η2 = 0.026) temperaments than nonSUD/AUD patients. Moderation analysis showed only direct effects of irritable (β = -0.55, p < 0.005) and hyperthymic (β = -0.95, p < 0.001) temperaments on AAO and no significant SUD/AUD and interaction effects. Limitations. Cross-sectional design. Conclusions: When irritable and hyperthymic traits prevail over other temperaments, AAO is earlier in SSOPDs, MDD, and BD. SUD/AUD presence/absence does not moderate the relationship between temperament and AAO.

Comorbid Cannabis Use Disorder with Major Depression and Generalized Anxiety Disorder: A Systematic Review with Meta-analysis of Nationally Representative Epidemiological Surveys

BACKGROUND

Studies have shown a high degree of comorbidity between cannabis use disorder (CUD) and other mental illnesses. However, there is a paucity of research on the comorbidity between CUD with major depression (MD) and generalized anxiety disorder (GAD). This systematic review with meta-analysis aimed to assess the prevalence and strength of association between co-morbid CUD with MD and GAD.

METHODS

An extensive search of Medline, CINAHL, PsycINFO, EMBASE, and grey literature were conducted to cover articles published between January 1^st, 1980, and July 31^st, 2020. Inclusion criteria were publications in English Language, original research, nationally representative samples, and non-clinical randomly selected adult populations. A systematic review and meta-analysis for the prevalence and ORs for comorbid CUD with MD or GAD were done.

RESULTS

A total of 67 articles were identified by the electronic searches. A full-text review yielded 8 publications on nationally representative epidemiological surveys. 12-month and lifetime comorbidity estimates were extracted and used for the meta-analysis. CUD was strongly associated with MDE (OR 3.22; 2.31 - 4.49) and with GAD (OR 2.99; 2.14 - 4.16).

LIMITATIONS

Limitations of this study include the heterogeneity observed due to the combination of studies from different geographic regions with different modifications of diagnostic criteria and varied response rates. This was addressed with a random-effects model.

CONCLUSION

This review confirms the evidence of high prevalence and a 3-fold comorbid association between CUD with MD and CUD with GAD. Implementation of evidence-based policy interventions with effective, integrated management of comorbid CUDs with psychiatric disorders may contribute to positive patient outcomes.

A randomized, double-blind, placebo-controlled proof-of-concept study of ondansetron for bipolar and related disorders and alcohol use disorder

Bipolar disorder is associated with high rates of alcohol use disorder. However, little is known about the treatment of this dual diagnosis population. Previous studies suggest that ondansetron decreases alcohol use, particularly in people with specific single nucleotide polymorphism (SNP) alleles. A 12-week, randomized, double-blind, placebo-controlled trial of ondansetron was conducted in 70 outpatients with bipolar spectrum disorders and early onset alcohol use disorder. Outcome measures included alcohol use, assessed with the Timeline Followback method, Penn Alcohol Craving Scale (PACS), Hamilton Rating Scale for Depression (HRSD), Inventory of Depressive Symptomatology-Self-report, and Young Mania Rating Scale. SNPs rs1042173, rs1176713 and rs1150226 were explored as predictors of response. Participants had a mean age of 44.9 ± 9.4 years, were mostly men (60.0%), and African American (51.4%). Mean ondansetron exit dose was 3.23 ± 2.64 mg. No significant between-group differences in alcohol use measures were observed. However, a significant reduction in HRSD scores was observed (p = 0.045). Inclusion of SNPs increased effect sizes for some alcohol-related outcomes and the HRSD. Ondansetron was well tolerated. This proof-of-concept study is the first report on ondansetron in bipolar people with bipolar disorders and alcohol use disorder. Alcohol use did not demonstrate a significant between-group difference. However, the findings suggest that ondansetron may be associated with reduction in depressive symptom severity in persons with bipolar illnesses and alcohol use disorder. A larger trial is needed to examine the effects of ondansetron on bipolar depression.

Outpatient prescribing of opioids to adults diagnosed with mental disorders in the United States

BACKGROUND

Adults with mood and anxiety disorders have an increased likelihood of being prescribed opioids. The influence of other mental disorders, such as psychotic and attention disorders, on opioid prescribing patterns is less known.

METHODS

We studied a population-representative sample of 166,927 outpatient visits for adults with painful conditions from the 2002-2016 National Ambulatory Medical Care Survey and the 2002-2011 National Hospital Ambulatory Medical Care Survey. Logistic regression analyses examined the likelihood of opioid prescription among visits with specific mental disorder diagnoses (anxiety, attention, mood, psychotic, post-traumatic stress disorder (PTSD), opioid use, and non-opioid substance use), adjusted for covariates and weighted for the complex survey design. Secondary analyses stratified results by whether opioids were newly initiated or continued.

RESULTS

Opioids were prescribed at 16.8 % of visits. Mood, anxiety, and non-opioid substance use disorders were associated with higher likelihoods of opioid prescriptions, particularly for continued rather than first-time prescriptions. Psychotic disorders were strongly negatively associated with opioid prescriptions (adjusted odds ratio 0.44, 95 % CI 0.22-0.86). Diagnoses of PTSD and attention disorders were not associated with opioid prescribing.

CONCLUSIONS

Outpatient physicians are more likely to prescribe and refill opioids for adults with pain who present with mood, anxiety, and non-opioid substance use disorders, but not for those who present with PTSD or attention disorders. Patients with psychotic disorders and pain are markedly less likely to be prescribed opioids.

Individualized prediction of 2-year risk of relapse as indexed by psychiatric hospitalization following psychosis onset: Model development in two first episode samples

BACKGROUND

Although most patients with psychotic disorders experience relapse, it is not possible to predict whether or when an individual patient is going to relapse. We aimed to develop a multifactorial risk prediction algorithm for predicting risk of relapse in first episode psychosis (FEP).

METHODS

Data from two prospectively collected cohorts of FEP patients (N = 1803) were used to develop three multiple logistic prediction models to predict risk of relapse (defined as hospitalization) within the first 2 years of onset of psychosis. Model 1 (M1_S1) used data obtained from clinical notes (Sample 1) while model 2 (M2_S2) applied the same set of predictors using data obtained from research interviews (Sample 2). The final model (Sample 2: M3_S2) used the same predictors plus additional detailed information on predictors. Model performance was evaluated employing measures of overall accuracy, calibration, discrimination and internal validation.

RESULTS

In both samples, the 2-year probability of psychiatric hospitalization was 37%. Of all the models, discrimination accuracy was lowest when limited information (such as socio-demographic and clinical parameters) was included in the prediction model. Model M3_S2 using additional information (descriptors of pattern of cannabis, nicotine, alcohol and other illicit drug use) obtained from research interview had the best discrimination accuracy (Harrell's C index 0.749).

CONCLUSIONS

The measures that contributed most to predicting hospitalization are readily accessible in routine clinical practice, suggesting that a risk prediction tool based on these models would be clinically practicable following validation in independent samples and permit a personalized approach to relapse prevention in psychosis.

Polysubstance use among adolescents in Malaysia: Findings from the National Health and Morbidity Survey 2017

BACKGROUND

Polysubstance use is defined as the use of more than one non-prescribed licit or illicit substance either concurrently or simultaneously. This study aimed to determine the prevalence of single substance users and polysubstance users and 'their associated factors among adolescents in Malaysia.

METHODS

This study was a secondary data analysis from the National Health and Morbidity Survey (NHMS) 2017, a cross-sectional survey conducted among Malaysian school-going adolescents aged 13 to 17. The NHMS utilised a two-stage stratified cluster sampling. Multivariate Multinomial Logistic Regression analysis was applied.

RESULTS

The overall prevalence of single substance use and polysubstance use among adolescents were 17.2% and 5.1% respectively. The multinomial model showed a higher likelihood of being single or polysubstance user among male (single user OR = 3.0, poly user OR = 4.6), others Bumiputeras vs Malay (single user OR = 1.7, poly user OR = 5.3), those who live with a single parent (single user OR = 1.2, poly user OR = 1.4), involved in truancy (single user OR = 1.7, poly user OR = 3.6) and being bullied (single user OR = 1.3, poly user OR = 3.4), those who had lack of peer support (single user OR = 1.3, poly user OR = 1.4), poor parental bonding (single user OR = 1.4, poly user OR = 1.8), depression (single user OR = 1.4, poly user OR = 3.2) and those who had no close friend (single user OR = 1.3, poly user OR = 2.7).

CONCLUSION

Our study highlighted multiple significant associated factors of single and polysubstance use among adolescents in Malaysia. This result can assist in the development of specific intervention and prevention programs targeting high-risk groups.

Subjective response to alcohol: Associated alcohol use and orbitofrontal gray matter volume in bipolar disorder

BACKGROUND

Alcohol use disorders (AUDs) are highly prevalent in bipolar disorder, however the developmental etiology of this comorbidity remains unknown. Structural differences in the orbitofrontal cortex (OFC) have been linked to problematic drinking in bipolar disorder and typically developing youth, with evidence implicating variations in OFC in differential subjective response to alcohol in typical development.

METHODS

Subjective response to alcohol, recent alcohol use, impulsivity, and variation in OFC gray matter volume were investigated in 48 emerging adults (24 with bipolar disorder, 24 typically developing). On average 1.5 years later, drinking patterns were reassessed and relations between subjective response and changes in alcohol use were explored.

RESULTS

Groups did not differ in baseline alcohol use or subjective response. At baseline, decreased subjective response to alcohol was associated with increased alcohol use in both groups. Lower gray matter volume in medial OFC in bipolar disorder was associated with increased subjective response to alcohol, whereas lower gray matter volume in OFC in typically developing participants was associated with decreased subjective response to alcohol. Increase in alcohol use (baseline to follow-up) was associated with increased baseline subjective response to alcohol in bipolar disorder, and decreased baseline subjective response in the typically developing group.

LIMITATIONS

Preliminary study with a small sample size.

CONCLUSION

Underlying OFC biology may contribute to differences in alcohol sensitivity in bipolar disorder which may also relate to prospective changes in alcohol use patterns. Future studies are needed to examine how these factors prospectively relate to development of AUDs in bipolar disorder.

Epidemiology and prognostic implications of panic disorder and generalized anxiety disorder in patients with coronary artery disease: rationale and design for a longitudinal cohort study

Background

Anxiety is associated with poorer prognosis in patients with coronary artery disease (CAD). Due to their severity and chronic course, anxiety disorders, particularly generalized anxiety disorder (GAD) and panic disorder (PD), are of considerable interest and clinical importance in this population. This study has two main objectives: (1) to estimate the prevalence and incidence of GAD and PD in patients with CAD over a 2-year period and (2) to prospectively assess the association between PD or GAD and adverse cardiac events, treatment adherence, CAD-related health behaviors, quality of life and psychological distress.

Design/Method

This is a longitudinal cohort study in which 3610 participants will be recruited following a CAD-related revascularization procedure. They will complete an interview and questionnaires at 5 time points over a 2-year period (baseline and follow-ups after 3, 6, 12 and 24 months). The presence of PD or GAD, adherence to recommended treatments, health behaviors, quality of life and psychological distress will be assessed at each time point. Data regarding mortality and adverse cardiac events will be collected with a combination of interviews and review of medical files.

Discussion

This study will provide essential information on the prevalence and incidence of anxiety disorders in patients with CAD and on the consequences of these comorbidities. Such data is necessary in order to develop clear clinical recommendations for the management of PD and GAD in patients with CAD. This will help improve the prognosis of patients suffering from both conditions.

Theories of change for e-health interventions targeting HIV/STIs and sexual risk, substance use and mental ill health amongst men who have sex with men: systematic review and synthesis

BACKGROUND

Sexual risk, substance use, and mental ill health constitute a syndemic of co-occurring, mutually reinforcing epidemics amongst men who have sex with men (MSM). Developed since 1995, e-health interventions offer accessible, anonymous support and can be effective in addressing these outcomes, suggesting the potential value of developing e-health interventions that address these simultaneously amongst MSM. We conducted a systematic review of e-health interventions addressing one or more of these outcomes amongst MSM and in this paper describe the theories of change underpinning relevant interventions, what these offer and how they might complement each other.

METHODS

We identified eligible reports via expert requests, reference-checking and database and Google searches. Results were screened for reports published in 1995 or later; focused on MSM; reporting on e-health interventions providing ongoing support to prevent HIV/STIs, sexual risk behaviour, substance use, anxiety or depression; and describing intervention theories of change. Reviewers assessed report quality, extracted intervention and theory of change data, and developed a novel method of synthesis using diagrammatic representations of theories of change.

RESULTS

Thirty-three reports on 22 intervention theories of change were included, largely of low/medium-quality. Inductively grouping these theories according to their core constructs, we identified three distinct groupings of theorised pathways. In the largest, the 'cognitive/skills' grouping, interventions provide information and activities which are theorised to influence behaviour via motivation/intention and self-efficacy/perceived control. In the 'self-monitoring' grouping, interventions are theorised to trigger reflection, self-reward/critique and self-regulation. In the 'cognitive therapy' grouping, the theory of change is rooted in cognitive therapy techniques, aiming to reframe negative emotions to improve mental health.

CONCLUSIONS

The synthesised theories of change provide a framework for developing e-health interventions that might holistically address syndemic health problems amongst MSM. Improving reporting on theories of change in primary studies of e-health interventions would enable a better understanding of how they are intended to work and the evidence supporting this. The novel diagrammatic method of theory of change synthesis used here could be used for future reviews where interventions are driven by existing well-defined behaviour and behaviour change theories.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018110317.

Multidimensional Structure of the Alcohol Use Disorders Identification Test: Factorial Validity and Reliability in Patients With Anxiety and Mood Disorders in Lithuania

AIMS

The current study aimed to evaluate the factorial structure of the Lithuanian version of the Alcohol Use Disorders Identification Test (AUDIT) in patients with anxiety and mood disorders (AMD).

METHODS

The AUDIT was completed by 199 consecutive outpatients with AMD (21% men, mean age 39 ± 12 years), as defined by AMD criteria in DSM-5. The MINI International Neuropsychiatric Interview was used for current diagnosis of alcohol use disorder (AUD). Sociodemographic and clinical data were also collected.

RESULTS

In patients with AMD, the AUDIT showed high internal consistency (Cronbach's alpha = 0.88) and good psychometric characteristics for identifying current AUD at a cut-off value of ≥9 (positive predictive value = 83.7%, sensitivity = 94.7%, specificity = 95.7%). The confirmatory factor analysis suggested a three-factor ('consumption', 'dependence' and 'related consequences') structure and indicated adequate fit to the model (comparative fit index = 0.966, normed fit index = 0.936, root mean square error of approximation = 0.072).

CONCLUSIONS

The findings are in line with increasing evidence suggesting that the AUDIT measures three separate factors related to alcohol misuse level of consumption, dependence and alcohol-related consequences and support the utility of AUDIT as a screening instrument for AUD in AMD patients in Lithuania.