A Review of Integrated Care for Concurrent Disorders: Cost Effectiveness and Clinical Outcomes

Examining Profiles and Treatment Outcomes in Dual Diagnosis: Comparison of Coordinated Treatment With Mental Health Services Versus Addiction Center Alone. A Real-World Data Analysis

OBJECTIVE

The aim of this work was to examine the profile and treatment outcomes of patients with dual pathology depending on whether the patients were attending addiction centers or are being treated in a coordinated model by mental health services.

METHODS

Data from 7225 dual diagnosis patients were used, of whom 2417 (33.5%) received treatment in the mental health coordinated modality. Clinical information was taken from the patients' electronic health record.

RESULTS

Differences were found in patients' sociodemographic and comorbidity profiles according to treatment modality. In general, coordinated care yielded favorable outcomes (higher attendance and lower dropout rates but no differences in retention). The logistic regression analysis identified predictors of patient profiles in coordinated care, emphasizing having a severe mental health disorder (OR = 3.878, 95% CI [3.443, 4.368]; p = .000), being referred by social/health services, or having retired status. Main differences were observed according to the comorbid diagnosis presented, particularly in cases in which the patient had impulse control, hyperkinetic, or cluster C personality disorder.

CONCLUSIONS

While therapeutic outcomes are influenced by associated comorbidities, the disorders prognosis can be favorable with appropriate treatment. Furthermore, analysis of differences according to treatment modality allows for predicting the type of patient who will receive a particular service, which enables the development of tailored treatments.

Individual Trajectories of Specialist Substance Use Disorder and Mental Health Treatment Utilization Among Young Adults With Substance Use Problems: A Cohort Study

OBJECTIVE

The aim of the study was to identify groups of young adults with distinct longitudinal patterns of use of treatment for substance use disorders and mental health (MH) problems and to investigate potential explanatory factors for different patterns of treatment use over time, including sociodemographic factors.

METHODS

The sample consisted of 447 young adults aged 16-29 years who entered long-term residential substance use disorder treatment facilities in Norway from 2011 to 2016. In this study, we obtained data collected by the Norwegian Patient Registry and Statistics Norway. These data were linked with the electronic health record data of the substance use disorder treatment facilities from which the participants were recruited. Growth mixture modeling was performed. The identified groups were further compared using analysis of variance or χ2 test.

RESULTS

Four groups of participants for total treatment use, substance use disorder treatment use, and MH treatment use were identified. Most participants from the overall sample were classified as members of a group characterized by a low and stable pattern of treatment use over time. A group with a high and stable pattern of treatment use was identified in total and MH treatment use. The proportion of participants with higher levels of substance use disorder treatment use at the end of the study period than at the beginning was larger (35%) than in the case of MH treatment use (14.2%). Younger age was associated with a decreasing pattern of MH treatment use and with an increasing pattern of substance use disorder treatment use over time. There were larger proportions of female participants in groups with a stable high use of MH treatment and in groups with an initially increasing trend of substance use disorder treatment use. Findings revealed that most participants across the identified groups were recipients of welfare benefits, had low educational attainment, and were not working.

CONCLUSIONS

Results demonstrated significant variation in trajectories of treatment use among young adults with substance use disorder. Differences in treatment use could indicate differences in symptom severity and complexity. In this study, treatment use was associated with socioeconomic factors, sex, and age. Integrative approaches, including interagency and interdisciplinary collaboration, will often be necessary to sufficiently address the multidimensionality of substance use disorder.

Profiles of Permanent Supportive Housing Residents Related to Their Housing Conditions, Service Use, and Associated Sociodemographic and Clinical Characteristics

As permanent supportive housing (PSH) is the main strategy promoted to reduce homelessness, understanding how PSH resident profiles may be differentiated is crucial to the optimization of PSH implementation - and a subject that hasn't been studied yet. This study identified PSH resident profiles based on their housing conditions and service use, associated with their sociodemographic and clinical characteristics. In 2020-2021, 308 PSH residents from Quebec (Canada) were interviewed, with K-means cluster analysis produced to identify profiles and subsequent analyses to compare profiles and PSH resident characteristics. Of the three profiles identified, Profiles 1 and 2 (70% of sample) showed moderate or poor housing, neighborhood, and health conditions, and moderate or high unmet care needs and service use. Besides their "moderate" conditions, Profile 1 residents (52%) reported being in PSH for more than two years and being less educated. With the "worst" conditions and high service use, Profile 2 (18%) included younger individuals, while Profile 3 (30%) showed the "best" conditions and integrated individuals with more protective determinants (e.g., few in foster care, homelessness at older age, more self-esteem), with a majority living in single-site PSH and reporting higher satisfaction with support and community-based services. Profiles 1 and 2 may be provided with more psychosocial, crisis, harm reduction, and empowerment interventions, and peer helper support. Profile 2 may benefit from more intensive and integrated care, and better housing conditions. Continuous PSH may be sustained for Profile 3, with regular monitoring of service satisfaction and met needs.

Substance Use Within Trials of Psychological Interventions for Psychosis: Sample Inclusion, Secondary Measures, and Intervention Effectiveness

INTRODUCTION

Current clinical guidelines recommend that patients with co-occurring psychosis and alcohol or substance use disorders (A/SUD) receive evidenced-based treatment for both disorders, including psychological intervention for psychosis. However, the efficacy of such treatments for individuals with co-occurring psychosis and A/SUD is unclear.

STUDY DESIGN

Randomized controlled trials (RCTs) of psychological interventions for psychosis were systematically reviewed, to investigate how alcohol and substance use has been accounted for across sample inclusion and secondary measures. Findings from trials including individuals with co-occurring alcohol or substance use issues were then narratively summarized using the Synthesis Without Meta-Analysis guidelines, to indicate the overall efficacy of psychological interventions for psychosis, for this comorbid population.

STUDY RESULTS

Across the 131 trials identified, 60.3% of trials excluded individuals with alcohol or substance use issues. Additionally, only 6.1% measured alcohol or substance use at baseline, while only 2.3% measured alcohol or substance use as a secondary outcome. Across trials explicitly including individuals with alcohol or substance use issues, insufficient evidence was available to conclude the efficacy of any individual psychological intervention. However, preliminary findings suggest that psychoeducation (PE) and metacognitive therapy (MCT) may be proposed for further investigation.

CONCLUSION

Overall, co-occurring alcohol and substance use issues have been largely neglected across the recent RCTs of psychological interventions for psychosis; highlighting the challenges of making treatment decisions for these individuals using the current evidence base.

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.

Adult self-reported childhood maltreatment types are associated with treatment satisfaction and alcohol relapse in patients with comorbid substance use and mental health disorders

BACKGROUND AND OBJECTIVES

Individuals with comorbid substance use and mental health disorders (concurrent disorders; CD) report poor treatment outcomes, high prevalence of childhood maltreatment, and mostly negative experiences with treatment. No studies to date have examined childhood maltreatment and treatment outcomes in CD. This study investigated self-reported childhood maltreatment as it relates to treatment satisfaction and substance use relapse among CD patients.

METHODS

The 258 CD inpatients completed a self-report questionnaire package, comprising the Childhood Trauma Questionnaire and the Inpatient Consumer Survey (ICS). Childhood maltreatment was assessed according to five subtypes and self-perceived treatment satisfaction was rated across six ICS domains. Psychiatric diagnoses, substance use status and relapse data were retrieved via patient medical charts.

RESULTS

Emotional neglect was associated with lower ratings across all ICS domains and physical neglect was associated with a lower rating for 'outcome of care'. Childhood sexual abuse was associated with a greater likelihood of alcohol relapse. No other relationships were statistically significant.

DISCUSSION AND CONCLUSIONS

The presence of childhood neglect (but not abuse) was more associated with overall treatment dissatisfaction, and sexual abuse alone increased the likelihood of alcohol relapse. These findings suggest some early adverse experiences in CD patients may increase negative experiences in treatment while others contribute to the risk of substance use. Broader longitudinal research is needed to examine the trajectory leading to negative outcomes.

SCIENTIFIC SIGNIFICANCE

This is the first study to report differential patterns of association by type of childhood maltreatment on negative outcomes in treatment among CD patients.

Identifying patterns of substance use and mental health concerns among adolescents in an outpatient mental health program using latent profile analysis

Though mental health and substance use concerns often co-occur, few studies have characterized patterns of co-occurrence among adolescents in clinical settings. The current investigation identifies and characterizes these patterns among adolescents presenting to an outpatient mental health service in Ontario, Canada. Data come from cross-sectional standardized patient intake assessments from 916 adolescents attending an outpatient mental health program (January 2019-March 2021). Latent profile analysis identified patterns of substance use (alcohol, cannabis, (e-) cigarettes) and emotional and behavioral disorder symptoms. Sociodemographic and clinical correlates of these patterns were examined using multinomial regression. Three profiles were identified including: 1) low substance use and lower frequency and/or severity (relative to other patients in the sample) emotional and behavioral disorder symptoms (26.2%), 2) low substance use with higher emotional and behavioral disorder symptoms (48.2%), and 3) high in both (25.6%). Profiles differed in sociodemographic and clinical indicators related to age, gender, trauma, harm to self, harm to others, and service use. Experiences of trauma, suicide attempts, and thoughts of hurting others increased the odds of adolescents being in the profile high in both substance use and symptoms compared to other profiles. These findings further document the high rates of substance use in adolescents in mental health treatment and the profiles generally map onto three out of four quadrants in the adapted four-quadrant model of concurrent disorders, indicating the importance of assessing and addressing substance use in these settings.

The experience of drug-related client loss for healthcare professionals who support people in addiction

INTRODUCTION

Addiction support and recovery is a multi-faceted support context in which practitioners work with clients who present with increased mortality risks. Drug-related deaths are understood to be a risk factor for complicated grief-reactions but, to date, research has neglected to explore the intricacies of drug-related client loss for practitioners who work with clients experiencing addiction. Due to wider expectations of professional endurance and the demanding nature of health care, grief-related reactions associated with the loss of a client may go unprocessed and, therefore, result in long-term health implications.

METHOD

Fifteen health care professionals took part in individual semi-structured interviews, which were analyzed using reflexive thematic analysis. Participants represented various disciplines in addiction support and recovery, including homelessness, inclusion health, addiction, and emergency medicine.

RESULTS

Three core themes emerged encapsulating the experience of drug-related bereavement for HCPs who support people experiencing addiction, as follows: (i) Grief Beneath the Surface, (ii) The Cost of Caring, and (iii) Finding Closure. The findings identified acute grief-related reactions in HCPs such as self-blame and shame, alongside fears of litigation and questions of clinical competency. Participants' accounts of drug-related client loss emphasized a deep professional connection with those that they work with, with grief-responses akin to the loss of peers, family members, and other close connections. The bereavement experience was complicated by unique compounding variables associated with drug-related deaths, but also by incongruity between their emotional responses to death and their professional responsibilities.

CONCLUSIONS

This article highlights the complex nature of drug-related client loss, and despite their social positioning as experts in their field, HCPs' reactions to client deaths were predominantly human responses to loss. The article identified a need for targeted postvention protocols that address complicated grief while also allowing staff to resume occupational functioning in a measured manner.

A 5-year longitudinal examination of the co-occurring patterns of gambling and other addictive behaviors

OBJECTIVE

We examined the co-occurring patterns of problem gambling and substance/behavioral addiction severity over a five-year period and the predictors of the different co-occurring patterns of problem gambling and addiction severity.

METHODS

We conducted a secondary analysis of the Quinte Longitudinal Study (QLS) data. The QLS is a 5-year prospective longitudinal study of gambling and problem gambling in the Quinte Region in Southern Ontario. The QLS consists of a total of 4,121 participants, including a sample of participants at risk of developing problem gambling. Severity of problem gambling, substance use, and behavioral addictions were used to examine their co-occurring patterns over time. Predictors of the co-occurring patterns included the presence of mental health disorders, personality, stress, happiness, lifesatisfaction, social support, family history, and demographics.

RESULTS

Six co-occurring patterns of problem gambling and addiction severity were identified. The largest co-occurring pattern was characterized by concurrent decrease in gambling and other addictive behaviors. Several co-occurring patterns were characterized by moderate-to-severe problem gambling and other addiction severity that remained stable over time. No co-occurring pattern represented a decrease in gambling followed by increase in other addictive behaviors (e.g., addiction substitution). The presence of mental health disorders, stress, and lifesatisfaction significantly predicted the different co-occurring patterns.

CONCLUSIONS

Taken together, the results suggest that in a non-clinical sample, gambling and other co-occurring addictive behaviors are likely to simultaneously decrease over time. Comorbidity of mental health disorders significantly influences co-occurring patterns of gambling and other addictive behaviors.

Policy Complexities in Financing First Episode Psychosis Services: Implementation Realities from a Home Rule State

Over the past decade, significant investments have been made in coordinated specialty care (CSC) models for first episode psychosis (FEP), with the goal of promoting recovery and preventing disability. CSC programs have proliferated as a result, but financing challenges imperil their growth and sustainability. In this commentary, the authors discuss (1) entrenched and emergent challenges in behavioral health policy of consequence for CSC financing; (2) implementation realities in the home rule context of Ohio, where significant variability exists across counties; and (3) recommendations to improve both care quality and access for individuals with FEP. The authors aim to provoke careful thought about policy interventions to bridge science-to-service gaps, and in this way, advance behavioral health equity.

The role of co-occurring disorders in criminal recidivism and psychiatric recovery among adults with opioid use disorder and criminal-legal involvement: A statewide retrospective cohort study

INTRODUCTION

Individuals with opioid use disorder (OUD) in the criminal-legal system commonly present co-occurring mental health disorders. However, evidence-based treatment for high-risk populations such as those with co-occurring disorders is often unavailable within jails and prisons. Coordination of timely and affordable access to behavioral health treatment following incarceration is critical to address the multidimensional needs of people with co-occurring needs. However, the role of co-occurring disorders among adults with OUD and criminal-legal involvement who are accessing community-based treatment is understudied.

METHODS

This retrospective cohort study investigated community and recovery outcomes among 2039 adults with OUD and criminal-legal involvement enrolled in a statewide forensic treatment initiative between October 2015 to March 2018. Using court records and clinical data, we assessed the impact of co-occurring OUD and mental health disorders on criminal recidivism and psychiatric recovery and the moderating role of co-occurring disorders on the relationship between community-based treatment and these outcomes.

RESULTS

We found that 47 % of those with OUD also had an underlying mental health disorder. Co-occurring OUD and mental health disorders predicted higher rates of recidivism during the early stages of treatment. Furthermore, group and individual therapy services were associated with lower odds of recidivism. A co-occurring disorder was an important predictor of more severe behavioral health needs when exiting community-based services and did moderate the relationship between service utilization-specifically group therapy and substance use outpatient services-and psychiatric recovery (i.e., behavioral health needs at exit).

CONCLUSIONS

Co-occurring mental health disorders are highly prevalent among adults with OUD who have criminal-legal involvement, but it appears that they can benefit from social support services in the community. Given the multidimensional needs of this high-risk population, criminal-legal stakeholders and community-based clinicians must work in tandem to develop tailored treatment plans that give individuals with co-occurring OUD and mental health disorders the best chance for success post-incarceration rather than a siloed approach to overlapping disorders.

Congruence couple therapy for alcohol use and gambling disorders with comorbidities (part I): Outcomes from a randomized controlled trial

A nonblinded randomized trial was conducted at two Canadian provincial outpatient addiction clinics that tested the effectiveness of a systemic congruence couple therapy (CCT) versus individual-based treatment-as-usual (TAU) on nine clinical outcomes: (1) primary outcomes-alcohol use and gambling, psychiatric symptoms, and couple adjustment; (2) secondary outcomes-emotion regulation, substance use, depression, post-traumatic stress symptoms, and life stress. Data of primary clients and partners (N = 46) were analyzed longitudinally across baseline, posttreatment (5 months), and follow-up (8 months). Alcohol use disorder (95%) and gambling disorder (5%) were in the severe range at baseline, and co-addiction was 27%. Psychiatric comorbidity was 100%, and 18% of couples were jointly addicted. Between-group comparison favored CCT in primary outcomes with medium-to-large effect sizes (Cohen's h = 0.74-1.44). Secondary outcomes were also significantly stronger for CCT (Cohen's h = 0.27-1.53). Within-group, for all primary outcomes, a significant proportion of symptomatic CCT clients and partners improved, converging with ANOVA results of large effect sizes (0.14-0.29). All secondary outcomes improved significantly in CCT with large effect sizes (0.14-0.50). TAU showed significant within-group improvement in alcohol use, other substance use, and life stress with large effect sizes (0.16-0.40). Primary clients and partners made largely equivalent improvement within CCT and within TAU. Results were triangulated with clients' satisfaction ratings and counselors' reports. Overall, significant within-group effects were detected for CCT both clinically and statistically and between-group difference favored CCT. Future trials are required to validate these promising findings.

Integrated care – panacea or white elephant? A review of integrated care approaches in Australia over the past two decades

Purpose

Integrated care is widely supported as a means of improving treatment outcomes for people with co-occurring mental health and substance use disorders. Over the past two decades, Australian state and federal governments have identified integrated care as a policy priority and invested in a number of research and capacity building initiatives. This study aims to examine Australian research evaluating the effectiveness of integrated treatment approaches to provide insight into implications for future research and practice in integrated treatment.

Design/methodology/approach

This narrative review examines Australian research evaluating empirical evidence of the effectiveness of integrated treatment approaches within specific populations and evidence from initiatives aimed at integrating care at the service or system level.

Findings

Research conducted within the Australian context provides considerable evidence to support the effectiveness of integrated approaches to treatment, particularly for people with high prevalence co-occurring disorders or symptoms of these (i.e. anxiety and depression). These have been delivered through various modalities (including online and telephone-based services) to improve health outcomes in a range of populations. However, there is less evidence regarding the effectiveness of specific models or systems of integrated care, including for more severe mental disorders. Despite ongoing efforts on behalf of the Australian government, attempts to sustain system-level initiatives have remained hampered by structural barriers.

Originality/value

Effective integrated interventions can be delivered by trained clinicians without requiring integration at an organisational or structural level. While there is still considerable work to be done in terms of building sustainable models at a system level, this evidence provides a potential foundation for the development of integrated care models that can be delivered as part of routine practice.

Challenges to Systems of Long-Term Care: Mapping of the Central Concepts from an Umbrella Review

The ageing of the population poses urgent challenges to the health and social protection sectors, including the need for greater adequacy and integration of health care services provided to older people. It is considered necessary and urgent to understand the state-of-the-art of community-based models of care for older people in institutional care and at home. This study aims to map the concepts that politicians and providers need to address through an umbrella review as a review method. Articles describing the structuring aspects of care models appropriate to the needs in long-term care and systematic reviews or meta-analyses targeting people aged 65 years or more were considered. A total of 350 studies met the inclusion criteria and were included in the review. The results identified the need to contribute to effective and more efficient integration and articulation of all the stakeholders, based essentially on professional care at the patient's homes, focused on their needs using the available technologies, empowering patients and families. Eight categories emerged that addressed factors and variables involved in care models for the long-term care needs of institutionalised and home-based older people as a guarantee of accessibility to healthcare and to enhance the well-being and quality of life of patients and family caregivers.

Cognitive Processing Therapy or Relapse Prevention for comorbid Posttraumatic Stress Disorder and Alcohol Use Disorder: A randomized clinical trial

OBJECTIVE

To compare a Posttraumatic Stress Disorder (PTSD) treatment (Cognitive Processing Therapy; CPT), an Alcohol Use Disorder (AUD) treatment (Relapse Prevention; RP), and assessment-only (AO) for those meeting diagnostic criteria for both PTSD and AUD.

METHOD

Participants with current PTSD/AUD (N = 101; mean age = 42.10; 56% female) were initially randomized to CPT, RP, or AO and assessed post-treatment or 6-weeks post-randomization (AO). AO participants were then re-randomized to CPT or RP. Follow-ups were at immediate post-treatment, 3-, and 12-months. Mixed effects intent-to-treat models compared conditions on changes in PTSD symptom severity, drinking days, and heavy drinking days.

RESULTS

At post-treatment, participants assigned to CPT showed significantly greater improvement than those in AO on PTSD symptom severity (b = -9.72, 95% CI [-16.20, -3.23], d = 1.22); the RP and AO groups did not differ significantly on PTSD. Both active treatment conditions significantly decreased heavy drinking days relative to AO (CPT vs. AO: Count Ratio [CR] = 0.51, 95% CI [0.30, 0.88]; RP vs. AO: CR = 0.34, 95% CI [0.19, 0.59]). After re-randomization both treatment conditions showed substantial improvements in PTSD symptoms and drinking between pre-treatment and post-treatment over the 12-month follow-up period, with RP showing an advantage on heavy drinking days.

CONCLUSION

Treatments targeting one or the other aspects of the PTSD/AUD comorbidity may have salutary effects on both PTSD and drinking outcomes. These preliminary results suggest that people with this comorbidity may have viable treatment options whether they present for mental health or addiction care.

TRIAL REGISTRATION

The trial is registered at clinicaltrials.gov (NCT01663337).

Clinical care of patients with dual disorders in India: diverse models of care delivery

Purpose

This study aims to offer an overview of the models of clinical care of the patients with dual disorders in India.

Design/methodology/approach

All the members of the Dual Diagnosis India Network (DDIN) who shared the clinical care delivery at their center were invited to share the details of their model. In addition, an invite was also sent to those members who could not attend the online session but were interested in contributing the required information about their model. The information shared by the respondents was collated. The different models were then categorized based on their features.

Findings

Following the categorization of the clinical care services organization across different settings, five different models emerged. These were specialized dual diagnosis clinic; services for dual disorders offered as substance use disorder (SUD) treatment services within general psychiatry care; services for dual disorders in general psychiatry care; services for dual disorders offered as SUD treatment services separated from general psychiatry care; and services for dual disorders offered in general psychiatry services combined with exclusive SUD treatment services.

Originality/value

Currently, there is limited literature on models of dual disorders from the low- and middle-income countries. The authors believe that the documentation of these models from India shall be of help while setting up services for dual disorders in other health-care settings. This study can be a valuable resource for making informed choices while setting up new services.

Co-Occurring Obsessive-Compulsive Disorder and Compulsive Sexual Behavior: Clinical Features and Psychiatric Comorbidities

Obsessive-compulsive disorder (OCD) commonly co-occurs with other psychiatric conditions. Though research is limited, there is preliminary evidence that OCD also co-occurs with compulsive sexual behavior (CSB). Yet, few studies have investigated the demographic, clinical, and psychiatric comorbidities associated with co-occurring OCD and CSB. To address this gap, the current study aimed to evaluate rates of co-occurring OCD and CSB, identify demographic and clinical factors associated with comorbid OCD and CSB, and assess associated psychiatric comorbidity. Participants (N = 950) were patients of a large multisite treatment for OCD. Standardized self-report measures were used to assess demographic and clinical characteristics such as anxiety, depression, and severity and dimensions of OCD. Semi-structured interviews including the SCID were used to assess psychiatric comorbidities. A total of 36 (3.8%) of participants met the criteria for CSB. Binary logistic regression analysis revealed that males were significantly more likely to present with CSB than females and CSB was associated with greater psychiatric comorbidity, particularly impulse control disorders. These findings suggest that individuals with co-occurring OCD and CSB may have more complex treatment needs, and more tailored interventions may be necessary.

Gender differences in psychiatric comorbidity and personality characteristics among adults seeking treatment for problematic internet use

In the present study, we investigated gender differences in personality and psychiatric correlates among adults (N = 115) seeking treatment for problematic internet use (PIU) at a specialized clinic in São Paulo, Brazil. All participants were assessed at the beginning of their treatment for co-occurring psychiatric conditions, other addictive behaviors, and personality characteristics. Women (n = 20) were more likely to present with greater rates of psychiatric comorbidity compared to men (n = 95), including mood disorders, anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder, and bulimia nervosa. Women also had a greater severity of certain behavioral addictions, such as compulsive buying and disordered eating. Gender differences were also found across personality characteristics, with women scoring higher on impulsivity, novelty seeking, and self-transcendence compared to men. To our knowledge, the present study is the first to investigate gender differences for PIU in a clinical sample. The results suggest that there are notable gender differences in individuals seeking treatment for PIU which underscores the importance of assessing for co-occurring conditions, especially in women. Understanding the characteristics associated with PIU can help serve to inform the most appropriate interventions to bolster treatment outcomes.

Dual Diagnosis in Adolescents with Problematic Use of Video Games: Beyond Substances

The technological revolution has led to the birth of new diagnoses, such as gaming disorder. When any addiction, including this one, is associated with other mental disorders, it is considered a dual diagnosis. The objectives of this current work were to estimate the prevalence of dual diagnoses in the adolescent general population while also considering the problematic use of video games and substance addiction and assessing its psychosocial risk factors. Thus, we carried out a cross-sectional study with a sample of 397 adolescents; 16.4% presented problematic videogame use and 3% presented a dual diagnosis. Male gender increased the probability of both a dual diagnosis (OR [95% CI] = 7.119 [1.132, 44.785]; p = 0.036) and problematic video game use (OR [95% CI] = 9.85 [4.08, 23.77]; p < 0.001). Regarding personality, low conscientiousness, openness, and agreeableness scores were predictors of a dual diagnosis and problematic videogame use, while emotional stability predicted a dual diagnosis (OR [95% CI] = 1.116 [1.030, 1.209]; p = 0.008). Regarding family dynamics, low affection and communication increased both the probability of a dual diagnosis (OR [95% CI] = 0.927 [0.891, 0.965]; p < 0.001) and problematic video game use (OR [95% CI] = 0.968 [0.945, 0.992]; p = 0.009). Regarding academic performance, bad school grades increased the probability of a dual diagnosis. In summary, male gender, certain personality traits, poor communication, and poor affective family dynamics should be interpreted as red flags that indicate an increased risk of a dual diagnosis in adolescents, which could require early intervention through specific detection programs.

Integration of Care in Complex and Fragmented Service Systems: Experiences of Staff in Flexible Assertive Community Treatment Teams

Introduction:

To provide more integrated care, several countries have implemented the Flexible Assertive Community Treatment (FACT) model. However, this model does not guarantee full integration, especially in complex and fragmented service systems like in Norway. Hence, we investigated which barriers that might reduce the potential for integrated care in the Norwegian system, as described by staff in FACT teams, and how they adjust their way of working to increase the opportunities for integration.

Methods:

Online focus group interviews involving 35 staff members of five Norwegian FACT teams were conducted using a semi-structured interview guide. The material was analysed using thematic text analysis.

Results:

Six themes described the barriers to integrated care in the service system: fragmentation, different legislation and digital systems, challenges in collaboration, bureaucracy and limited opening hours. Three themes described adjustments in the teams’ way of working to enhance integration: working as the responsible co-ordinator, being a collaborator, and the only entry channel into the service system.

Conclusion:

The FACT team staff described several barriers to integration within the system. However, they made some adjustments in their way of working that might provide opportunities for integrated care within complex and fragmented service systems.

The relationship between outpatient service use and emergency department visits among people treated for mental and substance use disorders: analysis of population-based administrative data in British Columbia, Canada

Background

Research findings on the association between outpatient service use and emergency department (ED) visits for mental and substance use disorders (MSUDs) are mixed and may differ by disorder type.

Methods

We used population-based linked administrative data in British Columbia, Canada to examine associations between outpatient primary care and psychiatry service use and ED visits among people ages 15 and older, comparing across people treated for three disorder categories: common mental disorders (MDs) (depressive, anxiety, and/or post-traumatic stress disorders), serious MDs (schizophrenia spectrum and/or bipolar disorders), and substance use disorders (SUDs) in 2016/7. We used hurdle models to examine the association between outpatient service use and odds of any ED visit for MSUDs as well count of ED visits for MSUDs, stratified by cohort in 2017/8.

Results

Having had one or more MSUD-related primary care visit was associated with lower odds of any ED visit among people treated for common MDs and SUDs but not people treated for serious MDs. Continuity of primary care was associated with slightly lower ED use in all cohorts. One or more outpatient psychiatrist visits was associated with lower odds of ED visits among people treated for serious MDs and SUDs, but not among people with common MDs.

Conclusion

Findings highlight the importance of expanded access to outpatient specialist mental health services, particularly for people with serious MDs and SUDs, and collaborative models that can support primary care providers treating people with MSUDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07759-z.

Wait No Longer: Reducing Medication Wait-Times for Individuals with Co-Occurring Disorders

Objective: Community addiction treatment agencies have utilized Network for the Improvement of Addiction Treatment (NIATx), a proven implementation strategy, to reduce appointment wait-times. However, its effectiveness at reducing medication access wait-times has not been explored. Thus, we conducted an exploratory analysis to evaluate the impact of the NIATx implementation strategies on reduced wait-times to addiction, psychotropic or both medications for individuals with co-occurring disorders (COD). Methods: In a cluster-randomized waitlist control group design, community addiction treatment agencies (n = 49) were randomized to receive the NIATx strategy (Cohort 1, n = 25) or to a Waitlist control (Cohort 2, n = 24). All agencies had a 12-month active intervention period. The primary outcome was the medication encounter wait-time. A univariate general linear model analysis utilizing a logarithmic (log10) transformation examined medication wait-times improvements. Results: The intent-to-treat analysis for psychotropic medications and both medications (reflecting integrated treatment) showed significant main effects for intervention and time, especially comparing Baseline and Year 1 to Year 2. Conversely, only the main effect for time was significant for addiction medications. Wait-time reductions in Cohort 1 agencies was delayed and occurred in the sustainment phase. Wait-times to a psychotropic, addiction, or both medications encounter declined by 3 days, 4.9 days, and 6.8 days, respectively. For Cohort 2 agencies, reduced wait-times were seen for psychotropic (3.4 days), addiction (6 days), and both medications (4.9 days) during their active implementation period. Same- or next-day medication access also improved. Conclusions: NIATx implementation strategies reduced medication encounter wait-times but timing of agency improvements varied. Despite a significant improvement, a three-week wait-time to receive integrated pharmacological interventions is clinically suboptimal for individuals with a COD in need of immediate intervention. Community addiction treatment agencies should identify barriers and implement changes to improve medication access so that their patients "wait no longer" to receive integrated treatment and medications for their COD.

Sustainment of Integrated Care in Addiction Treatment Settings: Primary Outcomes From a Cluster-Randomized Controlled Trial

OBJECTIVE

Integrated treatment services are the gold standard for addressing co-occurring mental and substance use disorders, yet they are not readily available. The Network for the Improvement of Addiction Treatment (NIATx) was hypothesized to be an effective strategy to implement and sustain integrated mental health and substance use care in addiction treatment programs. This study examined sustainment of integrated services for up to 2 years after the active implementation phase.

METHODS

The effectiveness of NIATx strategies to implement and sustain integrated services was evaluated by using a cluster-randomized, waitlist control group design. Forty-nine addiction treatment organizations were randomly assigned to either NIATx1 (active implementation strategy) or NIATx2 (waitlist control). The Dual Diagnosis Capability in Addiction Treatment Index was used to evaluate organizations' capability to provide integrated care. The NIATx Stages of Implementation Completion scale was used to assess participation in and adherence to the NIATx implementation process. Linear mixed-effects modeling was used to evaluate changes from baseline to end of the sustainment period.

RESULTS

Both cohorts sustained their capability to provide integrated treatment services. Both groups achieved successful implementation and sustained integrated services to a similar degree, regardless of sustainment year. Sustainment did not vary as a function of NIATx adherence.

CONCLUSIONS

The delivery of integrated treatment services was sustained for 2 years after receipt of active implementation support. Future research should consider how contextual factors may predict, mediate, and moderate sustainment outcomes.

Integrating Harm Reduction into Outpatient Opioid Use Disorder Treatment Settings : Harm Reduction in Outpatient Addiction Treatment

Opioid use disorder (OUD) is increasingly recognized as a chronic, relapsing brain disease whose treatment should be integrated into primary care settings alongside other chronic conditions. However, abstinence from all non-prescribed substance use continues to be prioritized as the only desired goal in many outpatient, primary care-based treatment programs. This presents a barrier to engagement for patients who continue to use substances and who may be at high risk for complications of ongoing substance use such as human immunodeficiency virus (HIV), hepatitis C virus (HCV), superficial and deep tissue infections, and overdose. Harm reduction aims to reduce the negative consequences of substance use and offers an alternative to abstinence as a singular goal. Incorporating harm reduction principles into primary care treatment settings can support programs in engaging patients with ongoing substance use and facilitate the delivery of evidence-based screening and prevention services. The objective of this narrative review is to describe strategies for the integration of evidence-based harm reduction principles and interventions into outpatient, primary care-based OUD treatment settings. We will offer specific tools for providers and programs including strategies to support safer injection practices, assess the risks and benefits of continuing medications for opioid use disorder in the setting of ongoing substance use, promote a non-stigmatizing program culture, and address the needs of special populations with ongoing substance use including adolescents, parents, and families.

A systematic review of addiction substitution in recovery: Clinical lore or empirically-based?

This systematic review synthesized the literature examining addiction substitution during recovery from substance use or behavioral addictions. A total of 96 studies were included with sample sizes ranging from 6 to 14,885. The most common recovery addictions were opioids (30.21%), followed by cannabis (20.83%), unspecified use (17.71%), nicotine (12.50%), alcohol (12.50%), cocaine (4.17%), and gambling (2.08%). Statistical results were provided by 70.83% of the studies. Of these, 17.65% found support for addiction substitution, whereas 52.94% found support for concurrent recovery. A total of 19.12% found no statistical changes and 10.29% found both significant increases and decreases. The remaining 29.17% of studies provided descriptive data, without statistical tests. Predictors of addiction substitution were provided by 22.92% of the studies and 11.46% included information on impact of addiction substitution on treatment outcomes. Overall, male gender, younger age, greater substance use severity, and presence of mental health disorders were associated with addiction substitution. Addiction substitution was associated with poorer treatment outcomes. A limitation of the present systematic review is the use of significance counting for the quantitative synthesis. More research examining changes in addiction during recovery would aid in the development of more effective treatments for addictive disorders and prevent addiction substitution.

Posttraumatic Stress Disorder Symptomatology and Substance Use in an Outpatient Concurrent Disorders Sample

OBJECTIVE

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) present a complex and often severe clinical presentation within a concurrent disorders context. The objective of this study was to examine associations between PTSD symptoms and SUD outcomes to better understand the clinical phenomenon of comorbid PTSD and SUD. Multivariate statistical methods were used to test the hypothesis that elevated PTSD symptoms, both at the level of global severity and specific PTSD symptom clusters, are associated with greater substance use and related problems.

METHODS

Data were collected from an intake assessment battery within a specialized concurrent disorders outpatient service in Hamilton, ON. The sample comprised 326 participants (mean age = 37.19, 45.4% female). Structural equation models examined associations between PTSD and alcohol, cannabis, and substance use frequency and problems, controlling for age and sex. Alcohol was ultimately dropped from the model due to non-significant bivariate associations.

RESULTS

Higher global PTSD symptomatology was significantly associated with higher cannabis and other substance use frequency and related problems. Analyses using PTSD cluster scores showed higher scores for alterations in arousal were positively associated with cannabis-related problems, drug-related problems, and cannabis and other substance use frequency. Avoidance was significantly associated with cannabis frequency and cannabis-related problems. In general, effect sizes were small in magnitude, accounting for between 9% and 25% of variance.

CONCLUSION

Significant cluster-level associations indicate the importance of specific PTSD symptoms (hyperarousal, avoidance) in relation to substance use when identifying therapeutic targets among individuals presenting with comorbid PTSD-SUD. This multivariate approach provides a higher resolution and potentially more clinically informative representation of the complex clinical presentation of PTSD and SUD in a concurrent disorder population and could guide the development of more effective treatment paths.

Assessing patient information and decision-support needs in problematic alcohol use and co-occurring depression to inform shared decision-making interventions

The authors assessed the informational and decision-support needs of patients, families, and clinicians when deciding on treatment for problematic alcohol use and depression. Patients (n = 56), family members (n = 16), and clinicians (n = 65) with experience deciding on treatment for problematic alcohol use and depression were eligible. Participants completed an online decisional needs assessment survey. Stakeholder groups identified numerous difficult patient-level treatment decisions and elevated decisional conflict. Participants preferred patient-led or shared treatment decision-making (75%-95.4%). Patients (32.6%) reported not being as involved in treatment decision-making as preferred, a higher proportion than reported by clinicians (16.4%; p = .056). More patients (19.6%) than clinicians (3.6%) reported clinician-led treatment decision-making, with little or no patient involvement (p = .022). Stakeholder preferences for future decision-support resources included online information for use outside consultations.

The Impact of the Medicaid Expansion on Telemental Health Utilization in Four Midwestern States

Introduction: Low-income populations experience many barriers to accessing affordable, high-quality mental health services. One promising approach to improving access to care may be utilizing telemedicine in combination with expanding state Medicaid programs to cover low-income childless adults. This combination has the potential to reduce the prevalence of untreated mental illness; improve low-income populations' health and well-being; and save individuals', health care centers', and federal and state governments' money. Materials and Methods: A secondary data analysis on state Medicaid claims data was performed to calculate the percent difference in telemental health claims from 2014 through 2017 between two Medicaid expansion and two nonexpansion states in the Midwest. The percent change in claims during this time period within each of the four states was also calculated. Lastly, the difference between Medicaid telemental health utilization and other types of Medicaid telemedicine utilization was examined. Results: The Medicaid expansion states (Iowa and Minnesota) had 54% more telemental health claims per 10,000 state population than nonexpansion states (Nebraska and Wisconsin) from 2014 through 2017. During this time period, Iowa, Minnesota, and Nebraska experienced 481%, 329%, and 12% increases in Medicaid telemental health claims, respectively, and Wisconsin experienced a 10% decrease. Discussion and Conclusions: Medicaid telemental health utilization has been increasing since 2014 in the two Medicaid expansion states, especially in Iowa, while utilization has remained relatively constant in the two Medicaid nonexpansion states. This has implications for informing Medicaid policies, particularly with regard to Medicaid expansion and telemedicine reimbursement.

Changes in Loss Sensitivity During Treatment in Concurrent Disorders Inpatients: A Computational Model Approach to Assessing Risky Decision-Making

BACKGROUND

Recent studies have employed computational modeling to characterize deficits in aspects of decision-making not otherwise detected using traditional behavioral task outcomes. While prospect utility-based modeling has shown to differentiate decision-making patterns between users of different drugs, its relevance in the context of treatment has yet to be examined. This study investigated model-based decision-making as it relates to treatment outcome in inpatients with co-occurring mental health and substance use disorders.

METHODS

50 patients (Mage = 38.5, SD = 11.4; 16F) completed the Cambridge Gambling Task (CGT) within 2 weeks of admission (baseline) and 6 months into treatment (follow-up), and 50 controls (Mage = 31.9, SD = 10.0; 25F) completed CGT under a single outpatient session. We evaluated 4 traditional CGT outputs and 5 decisional processes derived from the Cumulative Model. Psychiatric diagnoses and discharge data were retrieved from patient health records.

RESULTS

Groups were similar in age, sex, and premorbid IQ. Differences in years of education were included as covariates across all group comparisons. All patients had ≥1 mental health diagnosis, with 80% having >1 substance use disorder. On the CGT, patients showed greater Deliberation Time and Delay Aversion than controls. Estimated model parameters revealed higher Delayed Reward Discounting, and lower Probability Distortion and Loss Sensitivity in patients relative to controls. From baseline to follow-up, patients (n = 24) showed a decrease in model-derived Loss Sensitivity and Color Choice Bias. Lastly, poorer Quality of Decision-Making and Choice Consistency, and greater Color Choice Bias independently predicted higher likelihood of treatment dropout, while none were significant in relation to treatment length of stay.

CONCLUSION

This is the first study to assess a computational model of decision-making in the context of treatment for concurrent disorders. Patients were more impulsive and slower to deliberate choice than controls. While both traditional and computational outcomes predicted treatment adherence in patients, findings suggest computational methods are able to capture treatment-sensitive aspects of decision-making not accessible via traditional methods. Further research is needed to confirm findings as well as investigate the relationship between model-based decision-making and post-treatment outcomes.

Improving Medication Access within Integrated Treatment for Individuals with Co-Occurring Disorders in Substance Use Treatment Agencies

BACKGROUND

The best approach to provide comprehensive care for individuals with co-occurring disorders (CODs) related to substance use and mental health is to address both disorders through an integrated treatment approach. However, only 25% of behavioral health agencies offer integrated care and less than 7% of individuals who need integrated treatment receive it. A project used a cluster-randomized waitlist control group design to evaluate the effectiveness of Network for the Improvement of Addiction Treatment (NIATx) implementation strategies to improve access to addiction and psychotropic medications.

METHODS

This study represents a secondary analysis of data from the NIATx project. Forty-nine agencies were randomized to Cohort1 (active implementation group, receiving the NIATx strategy [n=25]) or Cohort2 (waitlist control group [n=24]). Data were collected at three time points (Baseline, Year1 and Year2). A two-level (patient within agency) multinomial logistic regression model investigated the effects of implementation strategy condition on one of four medication outcomes: both medication types, only psychotropic medication, only addiction medication, or neither medication type. A per-protocol analysis included time, NIATx fidelity, and agency focus as predictors.

RESULTS

The intent-to-treat analysis found a statistically significant change in access to addiction versus neither medication, but Cohort1 compared to Cohort2 at Year1 showed no differences. Changes were associated with the experimental intervention and occurred in the transition from Year 1 to Year 2, where greater increases were seen for agencies in Cohort2 versus Cohort1. The per-protocol analysis showed increased access to both medications and addiction medications from pre- to post-intervention for agencies in both cohorts; however, differences in change between high- and low-implementation agencies were not significant.

CONCLUSIONS

Access to integrated services for people with CODs is a long-standing problem. NIATx implementation strategies had limited effectiveness in improving medication access for individuals with CODs. Implementation strategy adherence is associated with increased medication access.

The Clinical Utility of Food Addiction: Characteristics and Psychosocial Impairments in a Treatment-Seeking Sample

Little is known about the characteristics of individuals seeking treatment for food addiction (FA), and the clinical utility of FA has yet to be established. To address these gaps, we examined (i) the demographic, eating pathology, and psychiatric conditions associated with FA and (ii) whether FA is associated with psychosocial impairments when accounting for eating-related and other psychopathology. Forty-six patients seeking treatment for FA completed self-report questionnaires and semi-structured clinical interviews. The majority of the sample were women and self-identified as White, with a mean age of 43 years. Most participants (83.3%) presented with a comorbid psychiatric condition, most commonly anxiety and mood disorders, with a mean of 2.31 comorbid conditions. FA was associated with binge eating severity and anxiety symptoms, as well as psychological, physical, and social impairment. In regression analyses controlling for binge eating severity, food cravings, depression, and anxiety, FA remained a significant predictor only of social impairment. Taken together, the results suggest that individuals seeking treatment for FA are likely to present with significant comorbid conditions, in particular anxiety disorders. The results of the present research provide evidence for the clinical utility of FA, particularly in explaining social impairment.

Vital Signs: Characteristics of Drug Overdose Deaths Involving Opioids and Stimulants - 24 States and the District of Columbia, January-June 2019

Introduction

Provisional estimates indicate that drug overdose deaths increased in 2019 after a slight decrease in 2018. In 2018, overdose deaths primarily involved opioids, with continued increases in deaths involving illicitly manufactured fentanyls (IMFs). Deaths involving stimulants such as cocaine and methamphetamine are also increasing, mainly in combination with opioids.

Methods

CDC analyzed data on drug overdose deaths during January–June 2019 from 24 states and the District of Columbia (DC) in the State Unintentional Drug Overdose Reporting System to describe characteristics and circumstances of opioid- and stimulant-involved overdose deaths.

Results

Among 16,236 drug overdose deaths in 24 states and DC, 7,936 (48.9%) involved opioids without stimulants, 5,301 (32.6%) involved opioids and stimulants, 2,056 (12.7%) involved stimulants without opioids, and 943 (5.8%) involved neither opioids nor stimulants. Approximately 80% of overdose deaths involved one or more opioid, and IMFs were involved in three of four opioid-involved overdose deaths. IMFs, heroin, cocaine, or methamphetamine (alone or in combination) were involved in 83.8% of overdose deaths. More than three in five (62.7%) overdose deaths had documentation of at least one potential opportunity for overdose prevention intervention.

Conclusions and implications for public health practice

Identifying opportunities to intervene before an overdose death and implementing evidence-based prevention policies, programs, and practices could save lives. Strategies should address characteristics of overdoses involving IMFs, such as rapid overdose progression, as well as opioid and stimulant co-involvement. These efforts should be complemented by efforts to prevent initiation of prescription opioid and stimulant misuse and illicit drug use.

Concurrent Disorder Management Guidelines. Systematic Review

Concurrent disorder refers to a diverse set of combinations of substance use disorders and mental disorders simultaneously in need of treatment. Concurrent disorders are underdiagnosed, undertreated, and more complex to manage, practicing the best recommendations can support better outcomes. The purpose of this work is to systematically assess the quality of the current concurrent disorders’ clinical recommendation management guidelines. Literature searches were performed by two independent authors in electronic databases, web, and gray literature. The inclusion criteria were English language clinical management guidelines for adult concurrent disorders between 2000 and 2020. The initial search resulted in 8841 hits. A total of 24 guidelines were identified and assessed with the standardized guidelines assessment tool: AGREE II (Appraisal of Guidelines for Research and Evaluation). Most guidelines had acceptable standards, however, only the NICE guidelines had all detailed information on all AGREE II Domains. Guidelines generally supported combinations of treatments for individual disorders with a very small evidence base for concurrent disorders, and they provided little recommendation for further structuring of the field, such as level of complexity or staging, or evaluating different models of treatment integration.

EPA guidance on the quality of mental health services: A systematic meta-review and update of recommendations focusing on care coordination

BACKGROUND

The quality of mental health services is crucial for the effectiveness and efficiency of mental healthcare systems, symptom reduction, and quality of life improvements in persons with mental illness. In recent years, particularly care coordination (i.e., the integration of care across different providers and treatment settings) has received increased attention and has been put into practice. Thus, we focused on care coordination in this update of a previous European Psychiatric Association (EPA) guidance on the quality of mental health services.

METHODS

We conducted a systematic meta-review of systematic reviews, meta-analyses, and evidence-based clinical guidelines focusing on care coordination for persons with mental illness in three literature databases.

RESULTS

We identified 23 relevant documents covering the following topics: case management, integrated care, home treatment, crisis intervention services, transition from inpatient to outpatient care and vice versa, integrating general and mental healthcare, technology in care coordination and self-management, quality indicators, and economic evaluation. Based on the available evidence, we developed 15 recommendations for care coordination in European mental healthcare.

CONCLUSIONS

Although evidence is limited, some concepts of care coordination seem to improve the effectiveness and efficiency of mental health services and outcomes on patient level. Further evidence is needed to better understand the advantages and disadvantages of different care coordination models.

The Conceptual Framework of Dual Disorders and Its Flaws

When psychiatric illness and substance use disorder coexist, the clinical approach to the patient is, unsurprisingly, awkward. This fact is due to a cultural context and, more directly, to the patient's psychiatric condition and addiction behaviors-a situation that does not favor a scientific approach. In dual disorder facilities, several types of professionals work together: counselors, social workers, psychologists, and psychiatrists. Treatment approaches vary from one service to another and even within the same service. It is crucial to provide dual disorder patients with multiple treatments, comprising hospitalization, rehabilitative and residential programs, case management, and counselling. Still, when treating dual disorder (DD) heroin use disorder (HUD) patients, it is advisable to follow a hierarchical algorithm. First, we must deal with addiction: by detoxification, whenever possible. This means starting most patients on anti-craving pharmacological maintenance, though aversion therapy may be appropriate for a few of them. Opiate antagonists may be used with heroin-addicted patients as long as those patients are only mildly ill. In contrast, agonist opioid medications, i.e., buprenorphine and methadone suit moderately and severely ill patients, respectively. Achieving control of mood instability or psychotic episodes is the next step, to be followed by a prevention strategy to counteract residual cravings and dominate mood disorders or psychotic episodes through long-term pharmacological maintenance that is focused on a double target.