The Addiction Psychiatrist as Dual Diagnosis Physician: A Profession in Great Need and Greatly Needed

Growing the Psychiatry Workforce Through Expansion or Creation of Residencies and Fellowships: the Results of a Survey by the AADPRT Workforce Task Force

OBJECTIVE

The USA needs to produce more psychiatrists to meet projected workforce deficits. The American Association of Directors of Psychiatric Residency Training Directors (AADPRT) sought to examine opportunities for and obstacles to expanding or creating residencies and fellowships.

METHODS

In November 2019, the authors conducted a survey of residency and fellowship directors. The survey gathered information about new positions, new programs, participation in interprofessional education, and loss of residency or fellowship positions.

RESULTS

The survey was distributed to psychiatry residency (N=231) and fellowship (N=194) directors, with a response rate of 33.4%. One quarter of responding residencies and fellowships reported creating new programs; 24.7% of residency and 17.5% of fellowships reported expansion. The most common reason to develop or expand programs was the shortage of psychiatrists, with the local institution as the most common funding source. Fifty-seven percent reported that they had wanted to expand, but faced barriers, primarily lack of funding. Recruitment and retention of faculty are major challenges. Psychiatry departments frequently (87.5%) participate in interprofessional education, generally perceived as positive. Unfortunately, 15.7% of respondents reported loss of positions or closure of programs.

CONCLUSIONS

Creating and expanding residencies and fellowships are common strategies for addressing the shortage of psychiatrists. Barriers include lack of funding and challenges recruiting/retaining faculty. The loss of residency/fellowship positions or closure of programs is a worrisome trend.

The Penrose Effect and its acceleration by the war on drugs: a crisis of untranslated neuroscience and untreated addiction and mental illness

In 1939, British psychiatrist Lionel Penrose described an inverse relationship between mental health treatment infrastructure and criminal incarcerations. This relationship, later termed the 'Penrose Effect', has proven remarkably predictive of modern trends which have manifested as reciprocal components, referred to as 'deinstitutionalization' and 'mass incarceration'. In this review, we consider how a third dynamic-the criminalization of addiction via the 'War on Drugs', although unanticipated by Penrose, has likely amplified the Penrose Effect over the last 30 years, with devastating social, economic, and healthcare consequences. We discuss how synergy been the Penrose Effect and the War on Drugs has been mediated by, and reflects, a fundamental neurobiological connection between the brain diseases of mental illness and addiction. This neuroscience of dual diagnosis, also not anticipated by Penrose, is still not being adequately translated into improving clinical training, practice, or research, to treat patients across the mental illness-addictions comorbidity spectrum. This failure in translation, and the ongoing fragmentation and collapse of behavioral healthcare, has worsened the epidemic of untreated mental illness and addictions, while driving unsustainable government investment into mass incarceration and high-cost medical care that profits too exclusively on injuries and multi-organ diseases resulting from untreated addictions. Reversing the fragmentation and decline of behavioral healthcare with decisive action to co-integrate mental health and addiction training, care, and research-may be key to ending criminalization of mental illness and addiction, and refocusing the healthcare system on keeping the population healthy at the lowest possible cost.

The Clinical Concept of Opioid Addiction Since 1877: Still Wanting After All These Years

In 1877, the psychiatrist Edward Levinstein authored the first monograph on opioid addiction. The prevalence of opioid addiction prior to his publication had risen in several countries including England, France and Germany. He was the first to call it an illness, but doubted that it was a mental illness because the impairment of volition appeared to be restricted to opioid use: it was not pervasive, since it did not extend to other aspects of the individuals' life. While there has been huge progress in understanding the underlying neurobiological mechanisms, there has been little progress in the clinical psychopathology of addiction and in understanding how it relates to these neurobiological mechanisms. A focus on cravings has limited the exploration of other important aspects such as anosognosia and addiction-related behaviors like smuggling opioids into treatment and supporting the continued provision of co-patients. These behaviors are usually considered secondary reactions, but in clinical practice they appear to be central to addiction, indicating that an improved understanding of the complexity of the disorder is needed. We propose to consider an approach that takes into account the embodied, situated, dynamic, and phenomenological aspects of mental processes. Addiction in this context can be conceptualized as a habit, understood as a distributed network of mental, behavioral, and social processes, which not only shapes the addict's perceptions and actions, but also has a tendency to self-maintain. Such an approach may help to develop and integrate psychopathological and neurobiological research and practice of addictions.

Case Report: Internet Gaming Disorder Associated With Pornography Use

Internet gaming disorder (IGD) is not currently a recognized diagnosis in the Diagnostic and Statistical Manual for Mental Disorders-5 (DSM-5). However, IGD has been noted to warrant further research for possible future inclusion in the DSM. In many ways, IGD strongly resembles substance and gambling addictions. Such characteristics include tolerance, withdrawal, and social and occupational neglect resulting from increased time invested in video game use and acquisition. The use of similar or closely related media is also seen, which mirrors the natural course of substance and gambling addictions. We present a case of a 22-year-old man who exhibited IGD and problems associated with pornography use. This case report exemplifies the sequelae of IGD. Our paper also reviews the possible mechanisms of behavioral addiction, as well as the status of IGD as a potential subcategory of behavioral addiction. Additional research is needed to determine if IGD co-occurs with problematic use of pornography.

Prescription drug monitoring program inquiry in psychiatric assessment: detection of high rates of opioid prescribing to a dual diagnosis population

OBJECTIVE

An epidemic of prescription drug abuse is disproportionately impacting the mentally ill. We examined the utility of a state prescription drug monitoring database for assessing recent controlled substance prescribing to patients presenting for dual diagnosis treatment.

METHOD

In a community mental health center that provides integrated dual diagnosis care, we queried the Indiana Scheduled Prescription Electronic Collection and Tracking (INSPECT) system for all cases that were open as of August 2, 2011, and had been practitioner-diagnosed (per DSM-IV criteria) by January 2, 2012. INSPECT provided a record of controlled substance dispensations to each patient; diagnostic evaluation was conducted blind from prescription data compilation covering the prior 12 months. Demographic data, insurance status, and DSM-IV diagnoses were compiled from the clinic's electronic medical record.

RESULTS

The sample (N = 201) was 51% female, 56% white, and two-thirds uninsured. Over 80% were dually diagnosed with substance use disorders and psychotic, mood, or anxiety disorders. Nicotine and alcohol disorders were identified in most, with about a third diagnosed with cannabis, cocaine, or opioid disorders. A majority of patients (n = 115) had been prescribed opioids in the prior year, with nearly 1 in 5 prescribed an opioid and benzodiazepine simultaneously. Patients were dispensed a mean of 4 opioid prescriptions and 213 opioid pills. More opioid prescriptions correlated with opioid dependence (OR = 1.08; 95% CI, 1.016-1.145), and more prescribers correlated with personality disorder diagnoses (OR = 1.112; 95% CI, 1.001-1.235). Higher rates and riskier patterns of controlled substance prescribing were identified in patients with Medicaid/Medicare insurance compared to uninsured patients.

CONCLUSIONS

Prescription drug monitoring is a powerful tool for assessing addictions and high frequencies of patient exposures to prescribed opioids in a dual diagnosis clinic. Improved prevention and treatment strategies for addictions as facilitated by more research and clinical use of prescription drug monitoring in psychiatric care are warranted.