Comorbid Addiction and Major Mental Illness in Europe: A Narrative Review

Which Factors Are Associated With Comorbid Psychiatric Conditions in Patients Affected by Substance Use Disorders? The Impact of COVID-19 Pandemic on Dual-Diagnosis Subjects

OBJECTIVE

To investigate demographic/cinical variables associated to dual diagnosis and the psychological reaction of dual-diagnosis patients to COVID-19 pandemic.

METHODS

Information was collected at the Addiction Service of Monza, Italy. The Impact of Event Scale-Revised (IES-R), a self-report questionnaire measuring the subjective response to a traumatic event, was administered. Univariate analyses and binary logistic regression were performed. IES-R scores were compared between groups defined by qualitative variables through one-way analyses of variance (ANOVA).

RESULTS

118 outpatients were included, 48.3% with dual diagnosis. Alcohol use disorder and being female were associated to dual diagnosis. IES-R scores were significantly higher in the dual-diagnosis group, especially for personality disorders (PDs). IES-R scores were higher in patients taking treatment for substance use disorder (SUD).

CONCLUSIONS

Females and alcohol abusers were at-risk subjects for dual diagnosis. Patients with SUD and PDs may benefit from additional support, especially when traumatic life events occur.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04694482.

Substance use and its association with mental health among Swiss medical students: A cross-sectional study

BACKGROUND

Studies on mental health and substance use among medical students indicated worrying prevalence but have been mainly descriptive.

AIM

To evaluate the prevalence of substance use in a sample of medical students and investigate whether mental health variables have an influence on substance use.

METHODS

The data were collected as part of the first wave of the ETMED-L, an ongoing longitudinal open cohort study surveying medical students at the University of Lausanne (Switzerland). N = 886 students were included and completed an online survey including measures of mental health (depression, suicidal ideation, anxiety, stress, and burnout) and use of and risk related with several substances (tobacco, alcohol, cannabis, cocaine, stimulants, sedatives, hallucinogens, opioids, nonmedical prescription drugs, and neuroenhancement drugs). We evaluated the prevalence of use of each substance and then tested the association between mental health and substance use in an Exploratory Structural Equation Modeling framework.

RESULTS

Statistical indices indicated a four-factor solution for mental health and a three-factor solution for substance use. A factor comprising risk level for alcohol, tobacco, and cannabis use - which were the most prevalent substances - was significantly associated with a burnout factor and a factor related to financial situation and side job stress. There was a significant association between a factor comprising depression, anxiety, and suicidal ideation and a factor related to the use of sedatives, nonmedical prescription drugs and neuroenhancement drugs. Although their use was less prevalent, a factor comprising the risk level of stimulants and cocaine use was significantly but more mildly related to the burnout factor. A factor comprising stress related to studies and work/life balance as well as emotional exhaustion was not related to substance use factors.

CONCLUSION

In this sample of medical students, the prevalence of substance use was substantial and poorer mental health status was related with higher substance use risk levels.

Exploring dual diagnosis in opioid agonist treatment patients: a registry-linkage study in Czechia and Norway

BACKGROUND

Knowledge of co-occurring mental disorders (termed 'dual diagnosis') among patients receiving opioid agonist treatment (OAT) is scarce. This study aimed (1) to estimate the prevalence and structure of dual diagnoses in two national cohorts of OAT patients and (2) to compare mental disorders between OAT patients and the general populations stratified on sex and standardized by age.

METHODS

A registry-linkage study of OAT patients from Czechia (N = 4,280) and Norway (N = 11,389) during 2010-2019 was conducted. Data on mental disorders (F00-F99; ICD-10) recorded in nationwide health registers were linked to the individuals registered in OAT. Dual diagnoses were defined as any mental disorder excluding substance use disorders (SUDs, F10-F19; ICD-10). Sex-specific age-standardized morbidity ratios (SMR) were calculated for 2019 to compare OAT patients and the general populations.

RESULTS

The prevalence of dual diagnosis was 57.3% for Czechia and 78.3% for Norway. In Czechia, anxiety (31.1%) and personality disorders (25.7%) were the most prevalent, whereas anxiety (33.8%) and depression (20.8%) were the most prevalent in Norway. Large country-specific variations were observed, e.g., in ADHD (0.5% in Czechia, 15.8% in Norway), implying differences in screening and diagnostic practices. The SMR estimates for any mental disorders were 3.1 (females) and 5.1 (males) in Czechia and 5.6 (females) and 8.2 (males) in Norway. OAT females had a significantly higher prevalence of co-occurring mental disorders, whereas SMRs were higher in OAT males. In addition to opioid use disorder (OUD), other substance use disorders (SUDs) were frequently recorded in both countries.

CONCLUSIONS

Results indicate an excess of mental health problems in OAT patients compared to the general population of the same sex and age in both countries, requiring appropriate clinical attention. Country-specific differences may stem from variations in diagnostics and care, reporting to registers, OAT provision, or substance use patterns.

Is There a Dose-Response Relationship Between Cannabis Use and Violence? A Longitudinal Study in Individuals with Severe Mental Disorders

Introduction: Recent longitudinal studies point toward the existence of a positive relationship between cannabis use and violence in people with severe mental disorders (SMD). However, the existence of a dose-response relationship between the frequency/severity of cannabis use and violence has seldom been investigated. Therefore, this study aims to determine if such a relationship exists in a psychiatric population. Methods: To do so, a total of 98 outpatients (81 males and 17 females, all over 18 years of age) with SMD were recruited at the Institut universitaire de santé mentale de Montréal (Montréal, Canada) and included in the analyses. Clinical evaluations were conducted every 3 months for a year. Substance use, violent behaviors, and potential covariables were assessed through self-reported assessments, urinary testing, as well as clinical, criminal, and police records. Using generalized estimating equations, the association between cannabis use frequency (nonusers, occasional, regular, and frequent users) and violence was investigated, as well as the association between the severity of cannabis use and violent behaviors. Results: It was found that cannabis use frequency and severity were significant predictors of violent behaviors. After adjustment for time, age, sex, ethnicity, diagnoses, impulsivity, and use of alcohol and stimulants, odds ratios were of 1.91 (p<0.001) between each frequency profile and 1.040 (p<0.001) for each increase of one point of the severity of cannabis use score (ranging from 0 to 79). Conclusions: Despite the high attrition rate, these findings may have important implications for clinicians as cannabis use may have serious consequences in psychiatric populations. Nevertheless, the mechanisms underlying this association remain unclear.

Changes in substance use and engagement in gaming/gambling in persons with severe mental illness during the COVID-19 pandemic and earthquakes: a community study in two points

Introduction

External stressors, such as COVID-19 pandemic and earthquake, can cause an increase in substance use and addictive behavior in persons with severe mental illnesses (SMI). We analyzed the changes and predictors of substance use and addictive behavior in SMI during these double disasters in Croatia.

Methods

Questionnaires exploring the presence of substance or behavior addiction disorder, mental ill health [Depression Anxiety Stress Scales-21 (DASS-21), Insomnia Severity Index (ISI), Perceived Stress Scale (PSS), Obsessive-Compulsive Inventory-Revised], coping mechanisms, and perceived social support [Multidimensional Scale of Perceived Social Support (MSPSS)] were administered among 90 participants with SMI included in the RECOVER-E study in May/June 2020 (first COVID-19 wave, Zagreb earthquake) and in December 2020/January 2021 (second COVID-19 wave, Petrinja earthquake).

Results

In both time points, a major increase was observed in tobacco smoking (25.0%; 28.6%, respectively) predicted by discontinuation of antidepressants and higher DASS-21 score. Increased sedative use was observed (24.4%; 23.8%, respectively) predicted by higher PSS and ISI scores, lower MSPSS scores, antipsychotic discontinuation and not receiving community mental health team (CMHT) service.

Discussion

In persons with SMI during a double disaster special attention needs to be given to reducing mental-ill health and stress, providing social support and continuity of psychiatric care, through medications and CMHTs.

Psychotic-Like Experiences and Concurrent Substance Use Among People Who Use New Psychoactive Substances

New psychoactive substances (NPS) are a group of substances that mimic established drugs, e.g., cannabinoids, stimulants, and opioids. NPS use has been associated with psychotic-like experiences, but current research is limited. This study focused on NPS use and psychotic-like experiences in persons attending substance use services in South-West Finland. The primary aim was to evaluate if NPS use associates with psychotic-like experiences, and if the association is independent of comorbid psychotic illness. As a secondary aim, this study evaluated concurrent substance use among people who use NPS.

The study was based on a voluntary and anonymous survey administered on-site for people attending substance use services. The survey was conducted in 17 substance use service centers in South-West Finland in 2019, totaling 219 respondents. Information on substance use, service use due to psychotic episodes, and comorbid psychotic illness was collected. A validated PROD questionnaire was used for information on psychotic-like experiences.

In all, 17% of 219 participants (n = 38) reported NPS use. After adjustments with comorbid psychotic illness, age, and gender, NPS use associated with PROD-screen positivity, i.e., reporting at least three psychotic-like symptoms. NPS use also associated with service use due to substance-induced psychotic episodes, and extensive use of several substances.

In this study, NPS use associated with psychotic-like experiences independently of comorbid psychotic illness. However, as NPS use is also associated with heavy use of several substances, this study implicates concurrent substance use as a confounding factor when studying NPS use, which should be considered in future research.

Coping and Co-Occurrence of Gaming Disorder and Substance Use in Recovering Substance Users

BACKGROUND

There are a wide range of negative effects associated with both substance use disorders and behavioural disorders and their co-occurrence. Understanding the way in which at-risk populations (e.g., substance-abstinent users) interact with potentially addictive behaviours (e.g., gaming) and substance use-while navigating life stressors through differing coping styles-can inform preventative strategies.

METHODS

Therefore, the present study investigated 64 clinical participants and 138 general population participants. Each cohort was required to complete a battery of psychometric scales exploring problematic behaviours, problematic substance use, co-occurrence, and coping styles. Additional exploratory direct comparisons of gamers in the clinical cohort and gamers in the general cohort were carried out.

RESULTS

The study's findings suggest that gamers from different populations (i.e., general and clinical) share similar at-risk behaviours. These problematic behaviours were more pronounced among abstinent substance use gamers, and more specifically among poly-substance use gamers.

CONCLUSIONS

The findings of the present study add to the literature and suggest that dysfunctional coping style and the co-occurrence of problematic behaviours may have an impact on the assessment and potential treatment of substance abstinent gamers. The findings offer support for an integrated treatment approach, wherein both substance use and the other problematic behaviours (e.g., gaming) are considered in tandem.

Effect of long-acting injectable antipsychotics on emergency department visits and hospital admissions in people with bipolar disorder: A retrospective mirror-image analysis from the Northern Milan Area Cohort (NOMIAC) study

BACKGROUND

Mood recurrences in bipolar disorder (BD) are often associated with poor treatment adherence. Despite long-acting injectable antipsychotics (LAIs) may favor treatment compliance, their use in BD is still poorly explored.

METHODS

This mirror-image study investigated the effect of LAIs initiation on the number of emergency department (ED) visits and days of hospitalization, among individuals with BD from the mental health services of a large area of the Metropolitan City of Milan. The mirror periods were 365 days either side of the LAI initiation. Individual medical records were retrospectively reviewed.

RESULTS

Sixty-eight individuals with BD initiating a LAI over the index period were included. We estimated that LAI initiation overall reduced both ED visits (p = 0.002) and days of hospitalization (p < 0.001). This remained true only for those participants who i) continued LAI for the entire 12-month period of observation and ii) were treated with a second-generation antipsychotic LAI. In addition, LAI initiation reduced number of hospitalization days during hypo/manic (p = 0.013), but not depressive (p = 0.641) episodes, as well as compulsory admission days (p = 0.002).

LIMITATIONS

Due to the retrospective design, we could not collect systematic information on symptom severity and reasons of LAI discontinuation. Moreover, the limited sample size did not allow us to estimate effectiveness of single LAI agents.

CONCLUSIONS

Our study provides additional insight on the effectiveness of LAIs in BD, supporting their clinical utility for pragmatic outcomes such as ED visits and hospitalizations. Further longitudinal research is needed to clarify the real-world effectiveness of LAIs for BD clinical management.

Co-Occurrence of Gaming Disorder and Other Potentially Addictive Behaviours between Australia, New Zealand, and the United Kingdom

Background: Evidence suggests that gamers can have varying experiences of disordered gaming behaviours due to coping mechanisms and how they can act as risk or protective factor in the development and/or maintenance of disordered behaviours. A particular area of interest is how this may manifest across different countries. Understanding the interplay of these potential risk and protective factors within different countries will aid identifying and preventing disordered behaviours. Methods: Three cohorts were recruited from Australia, New Zealand, and the United Kingdom. Each cohort was required to complete a battery of psychometric scales exploring problematic behaviours, problematic substance use, co-occurrence, coping styles, and personality. A latent profile analysis was conducted to examine the differences between cohorts and further investigated with additional analyses. Results: The findings suggested that a minority of gamers were affected by gaming disorder, and there appeared an at-risk cohort who utilise gaming as a maladaptive coping strategy. Other accompanying potentially addictive behaviour or substance use may be exacerbated as a result, the manifestation of which can be influenced by cultural elements. Conclusions: When considering gamers from countries which hold similar views, it is important to be cognisant of the variations found in the manifestations of disordered gaming and accompanying potentially addictive behaviours. This will allow for a more precise identification of at-risk behaviours, which will result in more favourable treatment outcomes for those who are considered at-risk or high-risk individuals.

Nurse-led mental and physical healthcare for the homeless community: A qualitative evaluation

Increased morbidity and mortality rates are prominent issues among homeless individuals. To help reduce these health inequalities, dedicated senior mental and physical health nurses have been deployed to work within and alongside local statutory and voluntary organisations. This qualitative evaluation examined the impact of nurse-led homeless healthcare in Warwickshire, United Kingdom. During January and February 2021, online semi-structured interviews were conducted with 17 professionals including the mental and physical homeless health nurses (n = 4), statutory health and local authority professionals (n = 4), and voluntary and community sector professionals (n = 9). Interviews were qualitatively analysed using inductive, reflexive thematic analysis. Data analysis identified three overarching themes related to the meaning, impact and future development of nurse-led homeless healthcare: (1) Nurse-led homeless healthcare and health inequalities, (2) The multi-agency approach of nurse-led homeless healthcare, and (3) Future development of nurse-led homeless healthcare. The findings confirm the benefits of homeless healthcare in reducing health inequalities and promoting a more accessible, flexible and person-centred approach to holistic care. Yet, prevailing organisational and system-level barriers were also identified as currently limiting the capacity, provision and practicalities of delivering nurse-led homeless healthcare. Recommendations were identified with international relevance and included: (i) continued implementation of person-centred healthcare for homeless individuals, (ii) strengthening of organisational collaboration and communication pathways to improve coordinated care, (iii) development of the managerial and structural aspects of provision, (iv) addressing limitations associated with scope and capacity to ensure that delivered healthcare is adequately intensive, (v) increased availability of clinical or therapeutic spaces, and (vi) implementation of long-term plans supported by evaluation and commissioning.

How did the COVID-19 lockdown impact patients with dual diagnoses?

Purpose

Individuals with dual diagnoses might experience significant clinical and social vulnerabilities during the pandemic and lockdown. This study aims to compare medication adherence, substance use, clinical stability and overall functioning before and during lockdown periods.

Design/methodology/approach

This was a cross-sectional survey among patients registered in dual diagnosis clinic of an addiction psychiatry center in Northern India between March 2019 and February 2020. This study approached 250 patients for telephonic interviews. This study assessed adherence to medications with the brief adherence rating scale (BARS). Global functioning was measured by global assessment of functioning. Clinical interviews assessed substance use and the clinical status of psychiatric disorders.

Findings

One hundred fifty patients were recruited. The mean age of the sample was 35.8 years. The sample had a slight preponderance of alcohol dependence. Depressive disorder was the largest category of psychiatric diagnosis. Compared to prelockdown period, during the lockdown, there were an increased number of days of nonadherence (X2 17.61, p <  0.05), proportion of patients underdosing (X2 8.96, p = 0.003) and lower BARS scores (t = 10.52, df = 144, p < 0.0001). More patients were abstinent from substances during the lockdown (X2 49.02, p < 0.0001). Clinical stability of psychiatric disorders did not differ during the two-time points, but overall functioning decreased during the lockdown (t = 2.118, p = 0.036). This study observed a small positive correlation (r = 0.2, p = 0.02) between functioning and adherence levels.

Originality/value

Lockdown was associated with poor medication adherence, change in substance use patterns and functional impairment. In the future, treatment programs and policies must take preemptive steps to minimize the effects of restrictions.

Mapping Problematic Drinking Trends over Time in Urban, Semi-Urban, and Rural Populations

Current alcohol public health policy in Australia is not uniform but is generally focused on restricting access and early prevention of problematic alcohol use. Semi-urban and rural populations are at greater risk of disease and other poor health outcomes due to a variety of factors. Little is known about problematic drinking patterns over time in semi-urban and rural populations. This study aims to assess patterns of problematic drinking defined as both long-term risky and heavy episodic drinking over time by age, sex, and mental health status among urban, semi-urban and rural populations). Four waves (2004 to 2016) of the Australian NDSHS (National Drug Strategy Household Survey) were analyzed to assess problematic drinking of participants over 18 years of age. We used regression models and predictive margins to identify trends in problematic drinking over time based on age, sex, and mental health status. Our results show young adults across all regions, males, and mentally well individuals in urban areas have reductions in the risk of problematic drinking over time. Middle-aged adults across all regions, females, and those with varying mental health presentations in rural areas have some increases in risk of problematic drinking over time. The general conclusion is that targeted alcohol-related public health policy may need to change and focus on females, middle-aged individuals, and those living in rural areas. Programs to support problematic drinking in people with mental health disorders may also need to be a priority.

Disentangling the Association between ADHD and Alcohol Use Disorder in Individuals Suffering from Bipolar Disorder: A Systematic Review and Meta-Analysis

Attention Deficit-Hyperactivity disorder (ADHD) may influence rates of Alcohol Use Disorder (AUD) among individuals suffering from Bipolar Disorder (BD). The aim of this systematic review and meta-analysis was to estimate the strength and consistency of the potential association between ADHD and AUD in BD. We searched main electronic databases for studies indexed up to November 2020. We included observational studies investigating the association between ADHD and AUD among individuals with BD. The association between ADHD and AUD was estimated using odds ratios (ORs) with 95% Confidence Intervals (CIs). Eleven studies, involving 2734 individuals with BD (516 with ADHD), were included in the meta-analysis. Individuals with both BD and ADHD had higher rates of AUD as compared with subjects with BD only (34.0% vs. 18.3%). The estimated OR of AUD for ADHD was 2.50 (95% CI: 1.91 to 3.27; I2 = 13.0%). Study-level characteristics did not influence the effect size. No risk of publication bias was estimated. Despite some limitations, this meta-analysis estimated an association between ADHD and AUD among individuals suffering from BD. At least a portion of the high rates of AUD in BD may, thereby, be related to comorbid ADHD. Longitudinal studies are needed to clarify the nature of this relationship.

Psychological and Demographic Determinants of Substance Use and Mental Health During the COVID-19 Pandemic

Background: Alcohol consumption and distress have increased among Canadians since the start of the COVID-19 pandemic. Methods: We examined whether sociodemographic and COVID-19-related worries are associated with various combinations of alcohol consumption and comorbid psychological distress variables among a Canadian sample of adults. Data were derived from a sample of Canadian adults (N = 1,005, 49.6% female) who participated in an online survey in May 2020. Four multivariate ordinal logistic regression models were used to estimate the odds of binge drinking, increased alcohol consumption during the pandemic, and psychological distress. Predictor variables used in the analyses included self-reported sociodemographic characteristics, financial worries, COVID-19 impact on work, and worrying about getting ill. Results: Women were found to have higher odds of increased drinking and anxiety. Also being divorced, separated, or widowed was associated with higher odds of binge drinking and anxiety, and binge drinking and depression. Furthermore, being 60 or older was associated with lower odds of binge drinking and depression and increased drinking and depression, as well as lower odds of increased drinking and depression and increased drinking and anxiety. High income groups were associated with higher odds of binge drinking, increased drinking, and mental distress. Compared to those less worried, being very worried about finances were associated with higher odds of binge drinking and anxiety, increased drinking and anxiety, and increased drinking and depression. Also, being very worried about getting ill with COVID was associated with higher odds of binge drinking and anxiety and increased drinking and anxiety. Conclusion: Our findings identify several demographic and COVID-related worries for increased odds of alcohol intake and co-morbid psychological distress during the COVID-19 pandemic, including identifying as a woman, high income groups, being divorced, separated or widowed, and experiencing financial worries and COVID illness worries. These characteristics should be considered when developing prevention and treatment programs for adults with problematic alcohol use and comorbid anxiety and depression.

Scope, quality and inclusivity of international clinical guidelines on mental health and substance abuse in relation to dual diagnosis, social and community outcomes: a systematic review

OBJECTIVE

It is estimated that up to 75% of patients with severe mental illness (SMI) also have substance use disorder (SUD). The aim of this systematic review was to explore the scope, quality and inclusivity of international clinical guidelines on mental health and/or substance abuse in relation to diagnosis and treatment of co-existing disorders and considerations for wider social and contextual factors in treatment recommendations.

METHOD

A protocol (PROSPERO CRD42020187094) driven systematic review was conducted. A systematic search was undertaken using six databases including MEDLINE, Cochrane Library, EMBASE, PsychInfo from 2010 till June 2020; and webpages of guideline bodies and professional societies. Guideline quality was assessed based on 'Appraisal of Guidelines for Research & Evaluation II' (AGREE II) tool. Data was extracted using a pre-piloted structured data extraction form and synthesized narratively. Reporting was based on PRISMA guideline.

RESULT

A total of 12,644 records were identified. Of these, 21 guidelines were included in this review. Three of the included guidelines were related to coexisting disorders, 11 related to SMI, and 7 guidelines were related to SUD. Seven (out of 18) single disorder guidelines did not adequately recommend the importance of diagnosis or treatment of concurrent disorders despite their high co-prevalence. The majority of the guidelines (n = 15) lacked recommendations for medicines optimisation in accordance with concurrent disorders (SMI or SUD) such as in the context of drug interactions. Social cause and consequence of dual diagnosis such as homelessness and safeguarding and associated referral pathways were sparsely mentioned.

CONCLUSION

Despite very high co-prevalence, clinical guidelines for SUD or SMI tend to have limited considerations for coexisting disorders in diagnosis, treatment and management. There is a need to improve the scope, quality and inclusivity of guidelines to offer person-centred and integrated care.

Improving the treatment of patients with dual diagnosis in emergency departments

Dual diagnosis involves the co-occurrence of severe mental illness and substance misuse. Recent guidance has sought to improve the initial identification of dual diagnosis and the ongoing management of patients with confirmed dual diagnoses. However, service provision between mental health teams and emergency departments (EDs) can be disjointed, resulting in suboptimal care. This article explores the care of patients who present at EDs with symptoms arising from a combination of severe mental illness and substance misuse. The author aims to alter the approach of multidisciplinary teams by applying change management theory, resulting in patients being treated by multiple healthcare disciplines in a more coordinated way. This will be demonstrated through a case study that follows a patient with dual diagnosis on the journey through an emergency department. Guidelines identifying best practice will be referred to and care failings in the patient's journey will be analysed. The author also provides an overview of how change management theory can be used to implement a new protocol for managing the treatment of patients with a dual diagnosis.

Pre-Discharge Predictors of 1-Year Rehospitalization in Adolescents and Young Adults with Severe Mental Disorders: A Retrospective Cohort Study

Background and objectives: Readmissions of youths hospitalized for a severe mental disorder are common events and bear a remarkable human, social, and economic burden. The current study aimed at evaluating predictors of 1-year rehospitalization in a sample of adolescents and young adults with severe mental disorders. Materials and Methods: Data for ≤25-year-old inpatients with a severe mental disorder and consecutively admitted between 1 January 2016 and 30 June 2019 were collected. Subjects were retrospectively assessed over a follow-up period of one year after the index discharge to track readmissions—i.e., the primary outcome variable. Standard descriptive statistics were used. The association between variables and 1-year rehospitalization was estimated using the univariate Cox proportional hazards regression model. We then carried out a multivariable Cox regression model, also estimating the covariate-adjusted survivor function. Hazard ratios (HRs) with related 95% confidence intervals (95% CIs) were provided. Results: The final sample included 125 individuals. The multivariable Cox regression model estimated that co-occurring substance use disorders (HR = 2.14; 95% CI: 1.08 to 4.26; p = 0.029) and being admitted for a suicide attempt (HR = 2.49; 95% CI: 1.13 to 5.49; p = 0.024) were both significant predictors of 1-year rehospitalization. Conclusions: Our study showed that comorbid substance use disorders and being admitted for a suicide attempt were predictors of early readmission in youths with severe mental disorders. Although their generalizability is limited, our findings could contribute to improve the quality of young patients’ mental health care by identifying vulnerable subjects who may benefit from tailored interventions to prevent rehospitalizations.

Substance use disorders among youth with chronic physical illness

This study estimated prevalence of substance use disorder in youth with chronic physical illness; quantified magnitudes of association between different chronic physical illnesses with substance use disorder; and, tested whether mental disorder moderates these associations. Data come from 6,377 individuals aged 15-30 years in the Canadian Community Health Survey-Mental Health. Alcohol, cannabis, or other drug use disorder measured using the WHO Composite International Diagnostic Interview 3.0. Individuals with chronic physical illness were more likely to have other drug use disorder compared to healthy controls (2.4% vs. 1.3%; p < .001), but not more likely to have alcohol (7.8% vs. 6.8%) or cannabis use disorder (5.0% vs. 3.6%). Odds of alcohol use disorder were higher among individuals with musculoskeletal conditions, OR = 1.41 (1.03-1.93), but lower among individuals with neurological conditions, OR = 0.49 (0.33-0.72), compared to healthy controls. No associations were found for cannabis use disorder. Odds of other drug use disorder were higher among individuals with endocrine conditions, OR = 2.88 (1.37-6.06). In the presence vs. absence of major depressive disorder, odds for substance use disorder were higher among individuals with respiratory or endocrine conditions. However, odds were lower among individuals with comorbid neurological and major depressive disorders or comorbid respiratory and generalized anxiety disorders. The complexity of the association between chronic physical illness and substance use disorder is compounded when accounting for the moderating effect of mental disorder, which in some contexts, results in a reduced likelihood of substance use disorder in youth with chronic physical illness.

The economic impact of violence perpetration in severe mental illness: a retrospective, prevalence-based analysis in England and Wales

Background

Calls for increased funding for mental health services require many lines of evidence in support, including estimates of economic impact. One understudied source of cost is violence perpetrated by individuals with severe mental illness. Estimating this economic impact can inform budget planning across several government sectors and emphasise the importance of violence prevention. Therefore, we aimed to provide a comprehensive estimate of the economic costs of violence perpetrated by people with severe mental illness.

Methods

For this retrospective analysis, we used a prevalence-based modelling approach to estimate the annual economic cost of violent incidents committed by people with severe mental illness in England and Wales during 2015–16. The model was based on secondary data, including the association between violence and severe mental illness, illness prevalence, recidivism, absolute numbers of violent incidents in 2015–16, and costs to society per violent crime, by area of spending. Uncertainty was addressed with probabilistic and deterministic sensitivity analyses that tested the effect of underreporting of domestic violence and distributions of crime types in individuals with severe mental illness.

Outcomes

The estimated annual economic impact of violence perpetrated by people with severe mental illness was £2·5 (95% CI 1·4–4·5) billion in England and Wales in 2015–16, or 5·3% of the total estimated societal cost of violence. The largest contributors to the cost of violent crime perpetrated by individuals with severe mental illness were the cost of physical and emotional harm to victims (£1·4 [95% CI 0·8–2·5] billion), followed by lost productivity of victims (£348.0 [190·0–628·8] million), while the combined cost to the police and criminal justice system was £561·3 (305·9–1009·2) million and the cost to health services was £136·7 [74·3–246·3] million. The additional cost to secure forensic care was estimated to be £487·7 (302·0–709·1) million.

Interpretation

The economic impact of violence perpetrated by individuals with severe mental illness is potentially important. Preventing violence, especially through services for individuals with comorbid substance misuse, and reducing recidivism might lead to cost savings at a governmental and individual level, in addition to the clinical and societal benefits.

Funding

Wellcome Trust, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, and NIHR Applied Research Collaboration Oxford and Thames Valley.

Dual diagnosis: A systematic review of the organization of community health services

BACKGROUND

Dual diagnosis (DD), as the co-occurrence of a substance use disorder and a psychiatric disorder, is underestimated, under-diagnosed and often poorly treated throughout the world, although it is highly prevalent in people suffering from a mental disorder.

AIMS AND METHODS

This review analyzed 48 studies from a PubMed and PsycINFO databases search, in order to verify the state of the art regarding the organization of community health services for DD treatment.

RESULTS

Four macro-themes have been identified: service organization, critical issues, assessment tools and evidence-based interventions. An effective service recognizes the complexity of DD, promotes a common staff culture, and tailors the organization to local needs. The main critical issues in its implementation include the lack of specific staff training, the poor management of resources and the need for greater personalization of care plans, with attention to psychosocial interventions. Integrated service assessment tools can be used as a benchmark measure at the program level for implementation planning and at the national level to affect policy change. The integrated treatment model for DD should also aim to improve access to care and offer treatments based on scientific evidence. It is also evident that the integration of services can improve outcomes but it is not a guarantee for it.

CONCLUSION

There is an urgent need to improve networking between mental health and addiction services in order to deal with DD and create new integrated intervention models, paying attention to an approach to the whole person, seen in his/her absolute uniqueness.

Predictors of Suicidal Behaviors during Hospitalization among Adolescents Admitted Due to Suicidal Behaviors: A 10-Year Retrospective Naturalistic Study

Objectives: Suicidality during hospitalization is a common phenomenon with potential devastating consequences. We attempted to identify risk factors for in-hospital suicidality in a high risk group of adolescent inpatients hospitalized for suicidal behaviors (SB). Methods: The database of a tertiary adolescent psychiatric ward was screened for patients hospitalized consecutively for SB during 2001-2010. Data on documented demographic, clinical, and behavioral risk factors were collected. Suicidal events during hospitalization were classified according to the Columbia Classification Algorithm of Suicide Assessment. Results: The sample included 122 inpatients (53% female) aged 10-19 (Mean=15.77, Standard Deviation=2.89) years admitted for SB. Thirty-seven youth (30%) exhibited SB during the hospitalization period (the "suicidal group"), ten of which attempted suicide while hospitalized. There were no significant differences in demographic and clinical parameters between the suicidal and the non-suicidal groups. Younger age, history of drug use and a history of non-suicidal self-injury (NSSI) were independent predictors of a SA during hospitalization. A previous SA added significant risk to SA during hospitalization only in the group that had a history of NSSI. Conclusions: A high risk of SB exists among adolescents hospitalized for suicidality. The risk assessment for SA during hospitalization should include age, history of drug use and previous SA combined with a history of NSSI. Future studies should expand the efforts to identify potential risk factors of SB during hospitalization in this unique high-risk group.

Challenges in working with patients with dual diagnosis

Purpose

Studies have shown that mental health professionals find working with patients with dual diagnosis challenging, and the purpose of this paper is to examine some of these challenges.

Design/methodology/approach

In total, 85 mental health professionals from 8 different mental health centres in Denmark were interviewed. The data analysis was inspired by a grounded theory approach.

Findings

Different challenges in the dual diagnosis treatment were identified and they suggested that the focus of treatment was mainly on the mental illness rather than the substance use disorder. The single focus of the treatment made it challenging to treat patients with dual diagnosis sufficiently. While several studies explain the single focus by inadequate competencies among professionals, the present study suggests that the single focus is also explained by the way that the treatment is organised. For instance, standardized treatment packages and insufficient guidelines on substance abuse treatment make it challenging to treat patients with dual diagnosis.

Originality/value

This paper suggests that a more flexible, and a longer period of, treatment, together with more sufficient guidelines on dual diagnosis treatment and a more formalized collaboration with the substance abuse treatment centres, will make it a less challenging issue to treat patients with dual diagnosis.

Narratives of recovery in people with coexisting mental health and alcohol misuse difficulties

Purpose

Existing literature has examined what recovery means to people with co-occurring difficulties, but does little to examine experiences of recovery as a process. The purpose of this paper is to use a narrative approach to explore the process of recovery as an individual journey in a social context. It focuses on people who use alcohol in order to explore the impact of alcohol’s specific cultural meanings on the recovery journey.

Design/methodology/approach

Ten interviews with people with coexisting mental health and alcohol misuse difficulties were conducted, audio-recorded, and transcribed. The transcriptions were analysed using narrative analysis.

Findings

Most participants’ narratives shared a three-part structure, from a traumatic past, through an episode of change, to an ongoing recovery phase. Change and recovery were attributed to several factors including flexible and practical support from services, therapeutic relationships with key professionals, and peer support. Some participants redefined themselves and their alcohol use in relation to ideas of what it is to be “normal”.

Research limitations/implications

The research excluded people who recover outside of services, replicating a shortcoming of much research in this area.

Practical implications

The value placed on professionals having specialised therapeutic skills in working with trauma highlights the need for training in this area. The role for practical and material support underlines the importance of multi-agency working.

Originality/value

The narrative methodology enables the study to draw links between personal stories of recovery and wider social influences, allowing comment on the implications for services. Further, the experiences of people with coexisting mental health and alcohol misuse difficulties have rarely been studied apart from the dual diagnosis population in general, so this paper is able to investigate the specific challenges for this population.

Patterns of Management of Patients With Dual Disorder (Psychosis) in Italy: A Survey of Psychiatrists and Other Physicians Focusing on Clinical Practice

Patients with severe psychotic disorders such as schizophrenia, schizoaffective, and bipolar disorders frequently suffer from concomitant substance use disorders (SUDs)-Dual Disorder (DD) patients. In order to better understand current practices for management of patients with psychotic episodes and concomitant SUD in Italy, we carried out a survey of psychiatrists on current routine practice among prescribers. These aspects can help to identify at-risk patients, improve current prescribing practices, and favor early intervention. An ad hoc survey of 17 questions was administered to psychiatrists via electronic polling and on-line distribution; 448 completed questionnaires were collected. Comorbid substance abuse was most frequently diagnosed within the context of anxiety disorder (46%), followed by bipolar disorder (25%), and schizophrenia/schizoaffective disorder (12%). The vast majority of respondents felt that patient management was becoming more complex due to substance abuse. The areas reported to be most affected in patients with SUD were functioning, interpersonal relations, and impulsivity, while sensory perception disorders, ideation, agitation, and impulsivity were the most frequently reported symptoms. In the acute setting, haloperidol was used as the first-line agent of choice followed by aripiprazole and olanzapine. In the maintenance phase, aripiprazole was the dominantly used first-line agent, followed by olanzapine. Almost half of respondents used long-acting agents, while about one-third did not. Among those prescribing long-acting agents, efficacy, control of impulsivity, and control of specific symptoms were cited as motivators, while in the maintenance phase, better adherence, and tolerability were mainly cited. From the responses to the present survey, it is clear that the respondents are aware of the problem of SUD in psychotic patients. While treatment be optimized in terms of the choice and formulation of antipsychotics, greater emphasis should be placed on efficacy, tolerability, and the negative metabolic consequences of some antipsychotics. When considering the ideal antipsychotic, long-acting agents were considered to be superior in reducing relapse, even if current treatment guidelines often give preference to oral formulations.

First-generation antipsychotics and QTc: any role for mediating variables?

OBJECTIVE

Corrected QT (QTc) interval prolongation is often associated with use of first-generation antipsychotics (FGAs). However, other factors require appropriate consideration, including age and gender, the role of other known medications associated with QTc prolongation, and severe comorbid conditions, such as co-occurring alcohol abuse/dependence. We aimed to study potential mediating roles of different, related, candidate variables on QTc.

METHODS

We capitalized on data from a large (N = 2366), cross-sectional, national survey, the STAR Network QTc study, using a representative sample of people taking FGAs, and recruited from mental health services across Italy.

RESULTS

About one-third of the sample was treated with FGAs, and almost one-tenth of the subjects took a different, additional, drug known to cause QTc prolongation. Our findings confirmed that there is an impact from FGAs, age, gender, alcohol misuse, and concurrent risky drugs on QTc. However, comorbid alcohol abuse/dependence and concurrent risky drugs did not mediate the effect of FGAs on QTc.

CONCLUSIONS

Our findings showed that FGAs, concurrent risky drugs, and alcohol use disorders prolonged QTc. FGAs had a direct effect on QTc, confirming the need for clinicians to monitor a risk that could lead to sudden unexplained death. Copyright © 2016 John Wiley & Sons, Ltd.