Treatment of dual diagnosis disorders

Navigating the Complex Intersection of Substance Use and Psychiatric Disorders: A Comprehensive Review

The co-occurrence of substance use disorders (SUDs) and psychiatric conditions, often referred to as comorbidity or concurrent disorders, presents intricate challenges in both diagnosis and treatment. This comprehensive narrative review aims to synthesize and critically evaluate the existing evidence surrounding the management of individuals with comorbid SUDs and psychiatric disorders. Comorbidity in these domains carries profound implications for clinical practice, research, and policymaking, emphasizing the need for a holistic understanding of the intricate dynamics that arise when these conditions coexist. This review explores recent research findings, evidence-based guidelines, and emerging trends within the field, offering valuable insights for clinicians, researchers, and policymakers seeking to navigate the complex terrain of comorbidity in substance use and psychiatric disorders.

Third-Generation Antipsychotics and Lurasidone in the Treatment of Substance-Induced Psychoses: A Narrative Review

This narrative review explores the efficacy and tolerability of third-generation antipsychotics (TGAs)-aripiprazole, cariprazine, brexpiprazole, and lurasidone-for the management of substance-induced psychosis (SIP). SIP is a psychiatric condition triggered by substance misuse or withdrawal, characterized by unique features distinct from those of primary psychotic disorders. These distinctive features include a heightened prevalence of positive symptoms, such as hallucinations and delusions, in addition to a spectrum of mood and cognitive disturbances. This review comprehensively investigates various substances, such as cannabinoids, cocaine, amphetamines, and LSD, which exhibit a greater propensity for inducing psychosis. TGAs exhibit substantial promise in addressing both psychotic symptoms and issues related to substance misuse. This review elucidates the distinctive pharmacological properties of each TGA, their intricate interactions with neurotransmitters, and their potential utility in the treatment of SIP. We advocate for further research to delineate the long-term effects of TGAs in this context and underscore the necessity for adopting an integrated approach that combines pharmacological and psychological interventions. Our findings underscore the intricate and multifaceted nature of treating SIP, highlighting the potential role of TGAs within therapeutic strategies.

Circadian functioning and quality of life in substance use disorder patients with and without comorbid schizophrenia

Sleep disturbances are strongly linked with mental diseases such as substance use disorder (SUD) or schizophrenia (SZ) which can have a detrimental impact on quality of life (QOL), especially when both disorders are comorbid (dual disorder). In absence of studies about both circadian characteristics and QOL in patients with SUD and comorbid SZ (SUD + SZ), we examined a sample of 155 male under treatment, 75 with SUD + SZ and 80 only with SUD. Circadian functioning was evaluated by chronotype, social jet-lag and sleep quality (using the Pittsburgh Sleep Quality Index, PSQI), while the QOL was obtained by the World Health Organization's Quality of Life Questionnaire (WHOQOL)-BREF. SUD + SZ patients were more evening type than SUD, and this chronotype was linked to polydrug use in total sample and SUD + SZ group. We observed that the comorbidity did not lead to worse sleep quality in the SUD and SUD + SZ patients. QOL was poorer in SUD + SZ patients, who showed a negative association of Physical health, Psychological health and Social relationship with suicide attempts and severity of SZ. Lastly, patients with worse QOL also reported poorer sleep quality suggesting that treatment could include circadian adjustments along with a focused approach to lifestyle improvement.

Opening up the black box of recovery processes in persons with complex mental health needs: a qualitative study of place-making dynamics in a low-threshold meeting place

Background

The recovery processes of persons with complex mental health needs take a slow and unpredictable course. Despite the fact that a number of essential building blocks of recovery in this population have been identified (e.g. social relationships, treatment, personal beliefs), the actual process of recovery in persons with complex mental health needs largely remains a black box. The aim of this study was to gain insight into how the recovery processes of persons with complex mental health needs take place, by applying a relational geographical approach and scrutinizing the place-making dynamics of one low-threshold meeting place in Belgium engaging with this group.

Methods

Data collection took place during the height of the COVID-19 pandemic by means of 11 in-depth interviews with different involved actors (service users, staff members, volunteers) and analyzed thematically.

Results

Results showed how the daily practice of the meeting place is continuously reproduced through place-making rituals that create an inclusive space of hospitality, are fueled by creative processes and form an indispensable counterweight for service users’ mental health needs.

Conclusions

To further open up the ‘black box’ of recovery in persons with complex mental health needs, it is vital to focus our analytic gaze onto recovery as a dynamic and relational practice.

Atypical antipsychotic drugs in dual disorders: current evidence and clinical guidelines

BACKGROUND

Concurrent disorder or dual diagnosis refers to a combination of substance use disorders and mental disorders that occur in the same patient simultaneously. These conditions pose significant clinical and healthcare impacts and are often underdiagnosed, undertreated, and complex to manage.

OBJECTIVE

We assessed the quality of current pharmacological recommendations for the management of dual diagnosis, particularly by evaluating the use of second-generation antipsychotics (SGA).

METHOD

A literature search was performed using the PubMed and Scopus databases for publications up to September 21, 2021, without any time restrictions. The following search strings were used: (aripiprazole OR brexpiprazole OR cariprazine OR paliperidone OR risperidone OR quetiapine OR clozapine OR olanzapine) AND (psychosis OR schizophrenia OR schizoaffective) AND ("substance use disorder" OR cocaine OR alcohol OR cannabis OR heroin OR "double diagnosis" OR "dual diagnosis")) NOT (animal OR rat OR mouse) NOT (review or meta-analysis).

RESULTS

The search produced a final set of 41 articles. Most patients were males and were affected by schizophrenia, with cannabis the most abused substance, followed by alcohol. Aripiprazole was the most used drug, either orally or by long-acting formulations, followed by risperidone with oral and long-acting formulations, clozapine, olanzapine, and quetiapine.

CONCLUSION

The findings highlight the use of SGA for the treatment of psychotic symptoms in comorbidity with substance use. Future studies on people with dual diagnosis and focused on long-term evaluations are warranted and need to investigate the efficacy of newly introduced molecules, such as partial D2 agonists and long-acting injectable antipsychotics.

Addressing Dual Disorders in a Medium-Term Admission Unit

Due to the significant functional repercussions suffered by patients with dual disorder, we must evaluate which ones can benefit from intensive rehabilitative therapies in medium-stay psychiatric units. This was a retrospective study of patient medical records which intended to analyze sociodemographic and clinical variables and parameters related to the hospitalization and discharge of patients admitted to the Medium-Stay Unit (MSU) at the Castellón Provincial Hospital Consortium over 2 years (2017 and 2018), according to the presence or absence of dual disorders in these patients. Patients with a dual disorder represented 55.2% of the hospitalized patients. A higher proportion of them were male, were relatively younger, and had an earlier onset of mental illness, fewer associated medical pathologies, and shorter hospital admission times to the Short-Term Hospitalization Unit than those who did not present a dual disorder. A diagnosis on the schizophrenia spectrum with cannabis use or polyconsumption was the most common diagnosis; 98.2% of all the patients responded adequately to admission to the MSU. This work highlighted the need for higher doses of depot paliperidone in patients with dual disorders.

Receipt, Spending, and Clinical Correlates of the Economic Impact Payment Among Middle- and Low-Income U.S. Adults

OBJECTIVE

This study examined characteristics and planned expenses of U.S. adults who received the economic impact payment (EIP) during the COVID-19 pandemic.

METHODS

Using a nationally representative sample of 6,607 middle- and low-income U.S. adults, the authors examined the proportion and correlates of EIP receipt among eligible adults and the associations among planned EIP-financed expenses, challenges with paying expenses, and clinical characteristics.

RESULTS

Of the sample, 78.8% reported that they received the EIP, and 82.3% of EIP recipients reported that it had a positive impact on their life. Being a veteran (odds ratio [OR]=2.59), being married (OR=1.82), having a history of schizophrenia spectrum disorder (OR=1.74) or posttraumatic stress disorder (OR=1.51), and screening negative for recent suicidal ideation (OR=0.49) were associated with EIP receipt. Planned expenses with the EIP were savings, paying debt, and rent and accounted for 63.4% of the total amount. Screening positive for mental health or drug use problems was positively associated with greater planned expenses for substances and gambling. EIP receipt also was associated with fewer problems paying daily expenses, but participants who screened positive for mental health or alcohol use problems were more likely to report problems paying past-month daily expenses.

CONCLUSIONS

Unconditional cash transfers such as the EIP may be important for sustaining the living situation of middle- and low-income populations. The management of funds is important to consider, especially among adults experiencing mental health and substance abuse problems, and such cash transfers may represent opportunities for financial literacy and money management interventions.

Barriers to retention in substance use treatment: Validation of a new, theory-based scale

PURPOSE

Few studies and no theory-based scales have addressed specific barriers to substance use disorder (SUD) treatment retention. The current study, building on the Theory of Planned Behavior (TPB), sought to (a) identify those barriers that are most strongly associated with treatment retention, and most common, and (b) develop and validate a new scale of retention barriers, focusing on TPB attitude and perceived control components.

METHODS

The study administered surveys to 200 participants initiating SUD treatment at a public, outpatient program in Northern California; the analytic sample (N = 156) included only those not strongly coerced into treatment. Surveys included TPB-based measures of treatment barriers; other motivational readiness measures; treatment coercion and social desirability measures; and clinical severity variables and demographics. Discharge status was collected from program records.

RESULTS

Item and scale analyses identified three dimensions of attitudinal barriers (i.e., Low Perceived Treatment Need/Value, Social Concerns, and Concerns about Missing Substances) and two dimensions of perceived control barriers (i.e., Personal Limitations and Basic Logistic Barriers). Results informed creation of a 19-item Barriers to Retention Scale (BRS) with 5 subscales and very good internal reliability (alpha = 0.88). While all subscale scores were correlated with treatment completion, only Concerns about Missing Substances and total BRS scores predicted treatment completion in multivariate analyses.

CONCLUSIONS

The present study identified core dimensions of treatment retention barriers and developed a new scale predictive of treatment completion and potentially useful as a screener and in future research. Results suggest that interventions to improve retention should focus strongly on concerns about the negative impacts of abstaining from alcohol and drugs on craving and quality of life.

Long-acting second-generation and oral antipsychotics for substance use disorders and psychotic symptoms: Prescribing attitudes among Italian psychiatrists

PURPOSE

To explore Italian psychiatrists' attitudes toward the off-label use of second generation antipsychotics (SGAs) in patients with substance use disorder and psychotic symptoms.

DESIGN AND METHODS

A sample of 300 Italian psychiatrists associated with the Italian Society of Neuropsychopharmacology was randomly selected to complete a survey about the off-label prescription of SGAs.

FINDINGS

Oral aripiprazole (32.7%), olanzapine (30.2%), and quetiapine (25.2%) were considered "appropriate." Long-acting antipsychoticss were generally considered "inappropriate."

PRACTICE IMPLICATIONS

Our findings reflect a substantial level of uncertainty and a lack of coherent clinical guidance within the realm of dual diagnosis treatment. Therefore, they emphasize the need to develop specific guidelines to improve the management of pharmacotherapy among this population.

Integrated treatment of dual disorders in The Netherlands: a qualitative study of client experiences

Purpose

Many clients who suffer from severe mental health problems also struggle with alcohol and drug use. And although there seems to be a consensus in most European countries that integrated treatment models (especially the integrated treatment of dual disorder clients model) are best fitted to help these clients, none of these have strong evidence, mostly owing to methodological limitations in the studies. This study aims to contribute to the knowledge of why integrated treatment is helpful by conducting in-depth interviews with dual disorder clients who are currently receiving integrated treatment.

Design/methodology/approach

This study is a qualitative thematic analysis using a timeline tool to elicit participants’ responses. In the interviews, dual diagnosis clients with severe problems reflected on their situation at admission, the care they received in integrated treatment and their opinions on positive and negative elements. The interviews were coded and analysed with MAXQDA.

Findings

In the analyses of the interviews, this study found three clusters of elements that clients indicated were the most helpful during their treatment and recovery process: trusting and meaningful relationship with the team, components of integrated treatment and organisation of care.

Originality/value

The findings emphasized the importance of working relationship in the treatment of complex and long-term problems. This has implications for the evaluation of these integrated treatment models which so far mainly focuses on specific interventions.

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.

Viral Suppression Is Associated with HIV Treatment Self-Efficacy in a Cohort of Women in Washington, DC

The goal of HIV treatment is viral suppression as it is linked with improved health outcomes and decreased risk of viral transmission. We assessed the sociodemographic, behavioral, and patient-provider interaction associations with viral suppression with an administered survey to HIV-seropositive women in the metropolitan Washington, DC, site of the Women's Interagency HIV Study (WIHS) between 2017 and 2018. Logistic and mixed models were used to explore related factors between HIV viral suppression groups and HIV treatment self-efficacy, respectively. Higher HIV treatment self-efficacy and disclosure concerns were positively associated with viral suppression, while illicit drug use had a negative association. In mixed models, more health care provider trust was associated with higher HIV treatment self-efficacy, while depressive symptoms were associated with lower HIV treatment self-efficacy. Depression, illicit substance use, and HIV treatment self-efficacy are potentially modifiable factors that can influence viral suppression. Implementation studies are needed to determine whether interventions to manage depression or self-efficacy and improve trust in health care providers will influence treatment outcomes.

Suicidal ideation in schizophrenia: A cross-sectional study in a tertiary mental hospital in North-East India

INTRODUCTION

Suicide is a leading cause of mortality in schizophrenia. The study attempts to find an association of suicidal ideation, a less studied entity than suicide attempt, with various sociodemographic and clinical profiles in patients with schizophrenia.

MATERIALS AND METHODS

It is a cross-sectional study involving 140 patients diagnosed as schizophrenia. Sociodemographic and clinical profiles were collected using a semi-structured proforma. Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, InterSePT Scale for Suicidal Thinking, and Drug Attitude Inventory-10 were applied to assess psychopathology, depressive symptoms, suicidal ideas, and attitude toward psychotropics, respectively. The analysis was done using appropriate statistics.

RESULTS

Majority of the study sample were Hindus, male, unmarried, literate, unemployed, and belonging from lower socioeconomic class. About 25.7% attempted suicide earlier and 29.3% currently have suicidal ideation. A previous suicide attempt, family history of psychiatric illness and that of suicide and comorbid substance use, significantly predicted (p < 0.05) a current suicidal ideation. Ideation has also been found to be significantly correlated to comorbid depression and the positive, negative, emotional, and excitement domains of schizophrenic psychopathology.

CONCLUSION

The current study shows suicidal ideations in schizophrenia patients to be significantly related to schizophrenic psychopathology and comorbid depression, thus calling for a holistic management in preventing a fatal outcome.

Analgesic opioid use disorders in patients with chronic non-cancer pain: A holistic approach for tailored management

Chronic pain is a major public health issue that frequently leads to analgesic opioid prescriptions. These prescriptions could cause addiction issues in high-risk patients with associated comorbidities, especially those of a psychiatric, addictive, and social nature. Pain management in dependent patients is complex and is yet to be established. By combining the views of professionals from various specialties, we conducted an integrative review on this scope. This methodology synthesizes knowledge and results of significant practical studies to provide a narrative overview of the literature. The main results consisted in first proposing definitions that could allow shared vocabulary among health professionals regardless of their specialties. Next, a discussion was conducted around the main strategies for managing prescription opioid dependence, as well as pain in the context of opioid dependence and associated comorbidities. As a conclusion, we proposed to define the contours of holistic management by outlining the main guidelines for creating a multidisciplinary care framework for multi-comorbid patients with chronic pathologies.

Contribution of Behavioral Health Factors to Non-AIDS-Related Comorbidities: an Updated Review

PURPOSE OF REVIEW

We summarize recent literature on the contribution of substance use and depression to non-AIDS-related comorbidities. Discussion of recent randomized clinical trials and implementation research to curtail risk attributed to each behavioral health issue is provided.

RECENT FINDINGS

Smoking, unhealthy alcohol use, opioid use, and depression are common among PWH and individually contribute to increased risk for non-AIDS-related comorbidities. The concurrence of these conditions is notable, yet understudied, and provides opportunity for linked-screening and potential treatment of more than one behavioral health factor. Current results from randomized clinical trials are inconsistent. Investigating interventions to reduce the impact of these behavioral health conditions with a focus on implementation into clinical care is important. Non-AIDS-defining cancers, cardiovascular disease, liver disease, and diabetes are leading causes of morbidity in people with HIV. Behavioral health factors including substance use and mental health issues, often co-occurring, likely contribute to the excess risk of non-AIDS-related comorbidities.

Substance use disorders and risk for treatment resistant depression: a population-based, nested case-control study

BACKGROUND AND AIMS

Treatment-resistant depression (TRD), defined as inadequate treatment response after at least two adequate treatment trials, is common among patients initiating antidepressant treatment. Current or previous substance use disorders (SUD) are common among patients with depression and often lead to worse treatment outcomes. However, in clinical studies, SUD have not been found to increase the risk for TRD. The aim of this study was to investigate the association between SUD and TRD.

DESIGN

Nested case-control study.

SETTING

Nation-wide governmental health-care registers in Sweden.

CASES AND CONTROLS

Data on prescribed drugs and diagnoses from specialized health care were used to establish a prospectively followed cohort of antidepressant initiators with depression (n = 121 669) from 2006 to 2014. Of these, 15 631 patients (13%) were defined as TRD cases, with at least three treatment trials within a single depressive episode. Each case with TRD was matched on socio-demographic data with five controls with depression.

MEASUREMENTS

Crude and adjusted odds ratios (aOR) with 95% confidence intervals (CI) estimated the association between TRD and SUD diagnosis and/or treatment in five different time intervals until the time for fulfillment of TRD definition for the case. The analysis was adjusted for clinical and socio-demographic covariates.

FINDINGS

Having any SUD during, or ≤ 180 days before start of, antidepressant treatment was associated with almost double the risk for TRD [≤ 180 days before: adjusted OR (aOR) = 1.86, CI = 1.70-2.05]. Increased risks for TRD were found ≤ 180 days before treatment start for the subcategories of sedative use (aOR = 2.37; 1.88-2.99), opioids (aOR = 2.02; 1.48-2.75), alcohol (aOR = 1.77; CI = 1.59-1.98) and combined substance use (aOR = 2.31; 1.87-2.99).

CONCLUSIONS

Recent or current substance use disorders is positively associated with treatment resistance among patients initiating treatment for depression.

Psychosocial interventions for people with both severe mental illness and substance misuse

BACKGROUND

Even low levels of substance misuse by people with a severe mental illness can have detrimental effects.

OBJECTIVES

To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care.

SEARCH METHODS

The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison.

MAIN RESULTS

Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence).

AUTHORS' CONCLUSIONS

We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.

The appropriateness of psychotropic medicines: an interview study of service users attending a substance misuse service in England

Background Mental health problems are common in people with substance misuse problems. However, there is a paucity of evidence regarding prescribing of psychotropic medications for people with comorbid mental health and substance misuse problems. Objective To explore the views of service users attending an addiction service on the appropriateness of psychotropic medications prescribed for their co-existing mental health problems. Setting A specialist addiction service in the North of England. Method A phenomenological approach was adopted. Semi-structured interviews were conducted with twelve service users. Data were analysed using thematic framework analysis. Main outcome measure Service users’ views concerning the appropriateness of their prescribed psychotropic medications. Results The following themes captured service users’ views on the appropriateness of their medications: benefits from medicines, entitlement to medicines, and assessment and review. Service users mostly described benefits from their medications (including those prescribed outside guideline recommendations) and there was also an awareness of the adverse effects they experienced from them. It appears that people with substance misuse problems have a particularly strong sense of their own needs and seek to influence prescribing decisions. Service users further described varied practices regarding assessment and review of their medications with evidence of regular reviews while others identified suboptimal or inadequate practices. Conclusion Most service users described improved functioning as a result of their prescribed psychotropic medications. Prescriptions that are inappropriate in terms of their usual indications may well be justified if they assist in stabilising service users and moving them on to recovery.

Temporal associations between medication adherence for patients with schizophrenia and opioid dependence: A 17-year Canadian Cohort Study

The current study investigated whether a previously reported beneficial effect of methadone maintenance therapy (MMT) on antiretroviral adherence is also present in relation to antipsychotic treatment for schizophrenia. Administrative data were linked over a 17-year period for 1996 people who were dually diagnosed with schizophrenia and opioid dependence and, as an indicator of further marginalization, experienced at least one episode of correctional supervision in British Columbia. Adherence was estimated using the medication possession ratio (MPR ≥ 0.80), calculated in each 120-day period beginning with the first date of concurrent use of MMT and antipsychotic medication. Generalized Estimating Equations were used to estimate the association between independent and dependent variables. The probability of antipsychotic adherence doubled in periods that were preceded by a period of MMT adherence (AOR: P: 2.07; 95% CI: 1.90-2.26). Subgroup and sensitivity analyses yielded results similar to those derived through the primary analysis, examining: conviction history; length of follow-up; initiation of MMT prior to antipsychotic induction; excluding participants who died during the study period; and restricted to participants who received methadone exclusively as part of a MMT program. Despite a strong temporal association between MMT and antipsychotic adherence, overall MPRs for both prescriptions remained <0.50 throughout the study period. Antipsychotic adherence was more than twice as likely following periods of adherence to MMT among dually-diagnosed patients. Research is needed to identify the conditions responsible for MMT adherence, and to further clarify the relationship between opioid agonist treatment and antipsychotic pharmacotherapy in this vulnerable and under-studied population.

Treatment of substance use disorders with co-occurring severe mental health disorders

PURPOSE OF REVIEW

To provide an update of treatment for substance use in patients with co-occurring substance use disorders (SUD) and mental health disorders (dual diagnosis) with a focus on both pharmacological and psychosocial interventions.

RECENT FINDINGS

A total of 1435 abstracts were identified, of which we selectively reviewed 43 for this narrative review. There is emerging evidence, both clinical and neurobiological, that clozapine is a more efficacious antipsychotic in treatment of individuals with schizophrenia and SUD. The use of depot atypical antipsychotic paliperidone palmitate in this population is also promising. Although valproate remains the treatment of choice in individuals with bipolar disorder and SUD, present evidence suggests that lithium and quetiapine may not be effective in this population. Naltrexone is the most effective anticraving agent in individuals with severe mental illness (SMI) and comorbid alcohol use disorders. The use of opioid substitution therapy in individuals with SMI and comorbid opioid use disorders is also associated with favorable outcomes. Varenicline shows promise in patients with SMI who smoke tobacco. Psychosocial interventions should be instituted early in the course of treatment. They should ideally be high intensity and based on established therapies used for SUD.

SUMMARY

The paucity of systematic studies in individuals with co-occurring mental health disorders and SUD remains a concern, given the enormous burden that they pose. However, there are a number of studies which have evaluated interventions, both psychosocial and pharmacological, which show promise and can guide clinical practice. VIDEO ABSTRACT: http://links.lww.com/YCO/A49.

Randomized controlled trial of telephone monitoring with psychiatry inpatients with co-occurring substance use and mental health disorders

Background Psychiatry inpatients frequently have co-occurring substance use and mental health disorders, which are related to poor post-discharge outcomes. Telephone monitoring is effective in specialty substance use disorder treatment settings in increasing continuing care and 12-step program utilization and improving substance use outcomes. This study examined the effectiveness of telephone monitoring among psychiatry inpatients with co-occurring substance use and mental health disorders. Methods This randomized controlled trial (n = 406) compared usual care to usual care plus telephone monitoring (one in-person session during the inpatient stay, followed by weekly telephone contact for three months post-discharge). Follow-ups were conducted at end-of-intervention (three months post-baseline) and nine and 15 months post-baseline (73% followed). Primary outcomes were number of days out of the past 30 of drinking alcohol, using drugs, and experiencing psychological problems. Secondary outcomes were outpatient substance use treatment, and 12-step group, utilization. Results Longitudinal modeling found that patients in both conditions improved over time on each primary outcome. Improvement was comparable between conditions on alcohol and drug use and psychological problems. Receipt of outpatient treatment decreased over the follow-up period and was not related to condition. Likelihood of attending 12-step group meetings did not change over follow-ups, and was not related to condition. Conclusions Improvement over time was evident regardless of condition assignment. Patients maintained attendance at 12-step groups from pre- to post-discharge. Short-term telephone monitoring in addition to usual care for patients with co-occurring substance use and mental health disorders may not be sufficiently intensive to achieve additional improvements on outcomes.

Total and cause-specific standardized mortality ratios in patients with schizophrenia and/or substance use disorder

Individuals with schizophrenia or substance use disorder have a substantially increased mortality compared to the general population. Despite a high and probably increasing prevalence of comorbid substance use disorder in people with schizophrenia, the mortality in the comorbid group has been less studied and with contrasting results. We performed a nationwide open cohort study from 2009 to 2015, including all Norwegians aged 20-79 with schizophrenia and/or substance use disorder registered in any specialized health care setting in Norway, a total of 125,744 individuals. There were 12,318 deaths in the cohort, and total, sex-, age- and cause-specific standardized mortality ratios (SMRs) were calculated, comparing the number of deaths in patients with schizophrenia, schizophrenia only, substance use disorder only or a co-occurring diagnosis of schizophrenia and substance use disorder to the number expected if the patients had the age-, sex- and calendar-year specific death rates of the general population. The SMRs were 4.9 (95% CI 4.7-5.1) for all schizophrenia patients, 4.4 (95% CI 4.2-4.6) in patients with schizophrenia without substance use disorder, 6.6 (95% CI 6.5-6.8) in patients with substance use disorder only, and 7.4 (95% CI 7.0-8.2) in patients with both schizophrenia and substance use disorder. The SMRs were elevated in both genders, in all age groups and for all considered causes of death, and most so in the youngest. Approximately 27% of the excess mortality in all patients with schizophrenia was due to the raised mortality in the subgroup with comorbid SUD. The increased mortality in patients with schizophrenia and/or substance use disorder corresponded to more than 10,000 premature deaths, which constituted 84% of all deaths in the cohort. The persistent mortality gap highlights the importance of securing systematic screening and proper access to somatic health care, and a more effective prevention of premature death from external causes in this group.

A review of Indian research on co-occurring cannabis use disorders& psychiatric disorders

BACKGROUND & OBJECTIVES

Cannabis is a widely used illicit drug and its use is often associated with co-occurring psychiatric disorders. This systematic review was aimed to provide information on the published Indian studies on co-occurring cannabis use disorders and psychiatric disorders.

METHODS

An electronic search of available Indian literature using relevant search terms was carried out in May 2015 and 52 articles in English language published from India were included in the current review.

RESULTS

Studies on cannabis and associated psychotic disorders (n=16) chiefly described acute episodes with predominant positive symptoms, following cannabis use. Some studies (n=6) observed an overall increased prevalence of all psychiatric disorders and symptoms owing to cannabis use, while others (n=14) elaborated on high rates of substance use in those with psychiatric disorders. The effect of cannabis use on cognitive function was the focus of some of the Indian studies (n=7). All these studies barring one had all male subjects, and a single study described the service delivery model for those with dual diagnosis disorders in India. Most of the research used cross-sectional observational design and focussed on treatment-seeking population.

INTERPRETATION & CONCLUSIONS

A review of Indian literature on cannabis use and its association with psychiatric disorders indicates a high co-prevalence of psychotic disorders, especially in vulnerable individuals as well as high rates of co-occurrence of other psychiatric comorbidities. However, there is limited focus on exploring the aetiological association between cannabis use and psychiatric disorders; understanding the neurobiology of this association and management-related issues.

Dual Diagnosis and Total Hip Arthroplasty

The co-occurrence of a mental illness and a substance abuse disorder (SUD) is common and has been referred to as a "dual diagnosis" (DD). Although studies have independently investigated mental illness alone and SUD alone, few have examined the effects of these entities combined on complications. A search of the Medicare database from 2005 to 2012 identified 2000 DD patients who underwent total hip arthroplasty (THA). They were compared with 86,976 patients with mental illness only and 590,689 controls (no mental illness or SUD). Medical comorbidities and postoperative complications at 30-day, 90-day, and minimum 2-year time points were analyzed. There was a significant increase (P<.001) in 7 (53.8%) of 13 recorded postoperative medical complications, including acute renal failure (odds ratio [OR], 1.78), postoperative anemia (OR, 1.31), and blood transfusion (OR, 1.24), at the 90-day time point. In addition, there was a statistically significant increase overall in periprosthetic infection (periprosthetic joint infection OR, 4.30; P<.001), periprosthetic fracture (OR, 2.80; P<.001), dislocation (OR, 6.38; P<.001), and the need for THA revision (OR, 3.58; P<.001). When compared with patients with mental illness only, DD patients remained at significantly (P<.001) increased risk for 90-day and overall postoperative surgical complications, including dislocation, periprosthetic joint infection, and THA revision. Patients with a DD were at significant risk for perioperative complications compared with both control patients and patients with mental illness only. Studies investigating only psychiatric disease or only SUD may miss a vulnerable cohort. Further investigation is needed to exactly define to what extent DD amplifies complication rates. [Orthopedics. 2018; 41(3):e321-e327.].

The Concept of Recovery as Experienced by Persons with Dual Diagnosis: A Systematic Review of Qualitative Research From a First-Person Perspective

OBJECTIVES

In recent years, the concept of recovery has gained ground in the treatment of persons with dual diagnosis. Recovery refers to living a meaningful life despite limitations caused by mental illness and substance use disorders. It also implies that support for persons with dual diagnosis should be organized according to the personal needs and wishes of its users. Therefore, it is important to gain insight into the aspects that persons with dual diagnosis deem important for their recovery process. This systematic review aims to summarize existing qualitative research on the meaning of recovery from the perspective of persons with dual diagnosis.

METHODS

A literature search was conducted following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for systematic reviews in the following databases: Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Medline, Embase, and Web of Science.

RESULTS

Sixteen studies using a qualitative research design were retained in which four overarching themes could be identified. The first theme focused on feeling supported by family and peers and being able to participate in the community. The second theme focuses on the need for a holistic and individualized treatment approach, seeing the persons "behind the symptoms." The third theme that emerged was having personal beliefs, such as fostering feelings of hope, building a new sense of identity, gaining ownership over one's life, and finding support in spirituality. The last theme identified was the importance of meaningful activities that structure one's life and give one motivation to carry on.

CONCLUSIONS

In this review, the participants pleaded for "flexibility" in mental health care, i.e., an approach that allows for both successes and failures. However, in order to come to a more comprehensive theoretical model of recovery in persons with dual diagnosis, future research is necessary to gain insight into the underlying mechanisms of recovery processes.

Canadian Schizophrenia Guidelines: Schizophrenia and Other Psychotic Disorders with Coexisting Substance Use Disorders

OBJECTIVE

Persons with schizophrenia and other psychotic disorders frequently have coexisting substance use disorders that require modifications to treatment approaches for best outcomes. The objectives of this review were to identify evidence-based practices best practices that improve outcomes for individuals with schizophrenia and substance used disorders.

METHOD

We reviewed guidelines that were published in the last 5 years and that included systematic reviews or meta-analyses. Most of our recommendations came from 2 publications from the National Institute for Health and Care Excellence (NICE): the 2011 guidance titled Coexisting Severe Mental Illness (Psychosis) and Substance Misuse: Assessment and Management in Healthcare Settings and the 2014 guidance titled Psychosis and Schizophrenia in Adults: Prevention and Management. We placed these recommendations into the Canadian context to create this guideline.

RESULTS

Evidence supports the inclusion of individuals with coexisting substance use disorders in first-episode psychosis programs. The programs should integrate psychosis and substance use treatments, emphasizing ongoing monitoring of both substance use and patterns and symptoms. The best outcomes are achieved with combined use of antipsychotic medications and addiction-based psychosocial interventions. However, limited evidence is available to recommend using one antipsychotic medication over another or one psychosocial intervention over another for persons with schizophrenia and other psychotic disorders with coexisting substance use disorders.

CONCLUSIONS

Treating persons who have schizophrenia and other psychotic disorders with coexisting substance use disorders can present clinical challenges, but modifications in practice can help engage and retain people in treatment, where significant improvements over time can be expected.

Dual Diagnosis: Coexisting Substance Use Disorders and Psychiatric Disorders

Dual diagnosis is a prevalent and serious health problem. These disorders challenge psychiatric mental health and addiction nurses to treat 2 distinct disorders. Despite advances in the treatment of these disorders, there remains a void in the ideal approach. This article offers psychiatric nurses opportunities to improve their expertise in the identification of vulnerable or high-risk populations by using integrated screening and brief interventions to discern treatment options. Patients who require comprehensive treatment to stabilize 1 or both disorders further challenge nurses to have a basic understanding of the powerful effects of substance use on psychiatric conditions and vice versa.

Co-Occurrence of Substance use Disorders with other Psychiatric Disorders: Implications for Treatment Services

Introduction

This paper critically evaluates the literature on the co-occurrence of substance-use disorders (SUDs) with other psychiatric conditions. Our review considers the variety of different associations between the two, and suggests the implications of the literature for the design of treatment services that address both types of disorders. Methods: A narrative review of research and theory was conducted, covering epidemiology of co-occurring psychiatric disorders worldwide, mechanisms underlying co-occurrence, and treatment models. Results: Epidemiological research has documented a high prevalence of co-occurring disorders in both clinical samples and the general population, although the literature is based primarily on studies in high-income countries and some of the overlap might be due to the co-occurrence of milder forms of both types of disorders. Consistent with what has been reported in other reviews, we conclude that clients with co-occurring disorders tend to have a more severe course of illness, more severe health and social consequences, more difficulties in treatment, and worse treatment outcomes than clients with a single disorder; we address the implications of these findings for the design of treatment services. Conclusions: Much of the evidence shows that separately, treatments for both SUD and other psychiatric disorders are effective in reducing substance use and in improving behavioral, familial, and psychosocial outcomes. The evidence further suggests that these outcomes might be improved when treatment modalities are offered in combination within an integrated treatment plan that simultaneously addresses substance abuse and psychiatric problems. It is concluded that there is potentially more to be gained from taking a public health perspective and working on efforts to implement existing evidence-based practices at the systems level, than from the current tendency to look for ever more powerful individual-level interventions at the clinical level.

Latent class profile of psychiatric symptoms and treatment utilization in a sample of patients with co-occurring disorders

Objective:

To identify symptom-based subgroups within a sample of patients with co-occurring disorders (CODs) and to analyze intersubgroup differences in mental health services utilization.

Methods:

Two hundred and fifteen patients with COD from an addiction clinic completed the Symptom Checklist 90-Revised. Subgroups were determined using latent class profile analysis. Services utilization data were collected from electronic records during a 3-year span.

Results:

The five-class model obtained the best fit (Bayesian information criteria [BIC] = 3,546.95; adjusted BIC = 3,363.14; bootstrapped likelihood ratio test p < 0.0001). Differences between classes were quantitative, and groups were labeled according to severity: mild (26%), mild-moderate (28.8%), moderate (18.6%), moderate-severe (17.2%), and severe (9.3%). A significant time by class interaction was obtained (chi-square [χ²_[15]] = 30.05, p = 0.012); mild (χ²_[1] = 243.90, p < 0.05), mild-moderate (χ²_[1] = 198.03, p < 0.05), and moderate (χ²_[1] = 526.77, p < 0.05) classes displayed significantly higher treatment utilization.

Conclusion:

The classes with more symptom severity (moderate-severe and severe) displayed lower utilization of services across time when compared to participants belonging to less severe groups. However, as pairwise differences in treatment utilization between classes were not significant between every subgroup, future studies should determine whether subgroup membership predicts other treatment outcomes.

Outcome of patients with dual diagnosis in secondary psychiatric care

BACKGROUND

Dual diagnosis (DD) is a common co-morbidity of mental illness and substance use disorder (SUD) and patients with DD are prone to complications. Better knowledge on the outcome, mortality and management of patients with DD in usual secondary psychiatric care would help to inform improved treatment strategies in the future.

AIMS

To explore the functional outcome and mortality of patients with DD receiving psychiatric treatment. To assess the recognition of substance use disorders (SUDs) in terms of diagnosis, and the associations of clinically diagnosed SUDs with treatment-related variables.

METHODS

The sample of 330 patients was collected by screening all currently treated patients with the Alcohol Use Disorders Identification Test (AUDIT) and a question about other substances used. The inclusion criteria were AUDIT >7 and/or reported use of other substances during the preceding 12 months. The Global Assessment of Functioning scale was used to assess functional outcomes during a 2-year follow-up. Information concerning treatment and patient characteristics was collected retrospectively.

RESULTS

Level of functioning remained stable among all study patients during follow-up. The mortality rate was not increased. Effective medication use was associated with improved functional outcomes. SUDs were underdiagnosed. A clinically diagnosed SUD seemed to have an impact on the regularity of appointments and the doses of prescribed medications.

CONCLUSIONS

Given our results suggesting a stable level of functioning, patients with DD appear to be well managed within secondary psychiatric care. Attention should be paid to more precise diagnostics of SUDs and to effective use of medication.

Alcohol use disorders

Alcohol use disorders are common in developed countries, where alcohol is cheap, readily available, and heavily promoted. Common, mild disorders often remit in young adulthood, but more severe disorders can become chronic and need long-term medical and psychological management. Doctors are uniquely placed to opportunistically assess and manage alcohol use disorders, but in practice diagnosis and treatment are often delayed. Brief behavioural intervention is effective in primary care for hazardous drinkers and individuals with mild disorders. Brief interventions could also encourage early entry to treatment for people with more-severe illness who are underdiagnosed and undertreated. Sustained abstinence is the optimum outcome for severe disorder. The stigma that discourages treatment seeking needs to be reduced, and pragmatic approaches adopted for patients who initially reject abstinence as a goal. To engage people in one or more psychological and pharmacological treatments of equivalent effectiveness is more important than to advocate a specific treatment. A key research priority is to improve the diagnosis and treatment of most affected people who have comorbid mental and other drug use disorders.

Medications between psychiatric and addictive disorders

INTRODUCTION

Many epidemiological studies have revealed a frequent co-occurrence of psychiatric and substance use disorders. The term used in the literature to refer to this co-occurrence is dual diagnosis. The high prevalence of dual diagnosis has led physicians to observe the effects of medication prescribed to treat psychiatric disorders on the co-occurring substance use disorder and vice versa. The concept of medications between psychiatric and addictive disorders stems from these clinical observations, alongside which, however, it has developed from the observation that both psychiatric and substance use disorders share common neurobiological pathways and trigger common cognitive disorders. This has led researchers to develop medications on the basis of neurobiological and cognitive rationales.

MATERIAL AND METHOD

In our article, we review peculiar medications based on neurobiological and cognitive rationales and that have an impact in both psychiatric and addictive disorders.

RESULTS

We highlight how interesting these new prescriptions are for clinical observation and for the treatment of patients suffering from dual diagnosis.

CONCLUSION

We then go on to discuss the interest in them from the perspective of clinical practice and clinical research, in that the development of medications to treat dual diagnosis helps to further our knowledge of both psychiatric and substance use disorders.

Professionals' perception on the management of patients with dual disorders

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Review of Indian Research on Co-occurring Psychiatric Disorders and Alcohol use Disorders

Excessive use of alcohol has been identified as a major contributor to the global burden of disease. Excessive use of alcohol is a component cause of more than 200 disease and injury conditions. Alcohol use has been associated with increased morbidity and mortality across all regions of the world including South-East Asia. Epidemiological as well as clinic-based studies from Western countries have reported a high prevalence of co-occurrence of alcohol use disorder and psychiatric disorders. The research has established the clinical relevance of this comorbidity as it is often associated with poor treatment outcome, severe illness course, and high service utilization. Understandably, dual disorders in from of alcohol use disorders and psychiatric disorders present diagnostic and management challenge. The current article is aimed to review systematically the published Indian literature on comorbid alcohol use disorders and psychiatric disorders.

Personal recovery in individuals diagnosed with substance use disorder (SUD) and co-occurring attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD)

The process of personal recovery in people diagnosed with substance use disorder and comorbid attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD) was mapped. Four general themes representing four consecutive stages in the recovery process were identified in both client groups: (1) crisis and diagnosis; (2) dealing with agitation, symptoms, and burden; (3) reorganization of life; and (4) meaningful life. However, the personal recovery outcomes and the need for support were different for the two clients groups. Based on these findings, mental health nurses can offer recovery supporting care tailored to the challenging needs of these clients. For the SUD+ADHD group, overall, a coaching attitude is preferred. For the SUD+ASD group, overall, instructional, supportive and directive attitude is needed.

Olanzapine as the ideal "trip terminator"? Analysis of online reports relating to antipsychotics' use and misuse following occurrence of novel psychoactive substance-related psychotic symptoms

OBJECTIVE

The pharmacological self-management of novel psychoactive substance (NPS)-induced psychopathological consequences represents a fast growing phenomenon. This is facilitated by the frequent sharing of NPS intake experiences online and by the ease of access to a range of psychotropic medications from both the online and street market. Olanzapine is anecdotally reported by Web users to be the most frequent self-prescribed medication to cope with NPS-induced psychoses. Hence, we aimed here at better assessing olanzapine use/misuse for this purpose.

METHODS

Exploratory qualitative searches of 163 discussion fora/specialized websites have been carried out in four languages (English, German, Spanish, and Italian) in the time frame November 2012-2013.

RESULTS

Most NPS-users allegedly self administer with olanzapine to manage related psychotic crises/"bad trips". This may be typically taken only for a few days, at a dosage range of 5-50 mg/day.

CONCLUSIONS

Only a few research studies have formally assessed the effectiveness of olanzapine and indeed of other second-generation antipsychotics to treat NPS-induced psychosis. Olanzapine was suggested here from a range of pro drug websites as being the "ideal" molecule to terminate "bad trips". Health professionals should be informed about the risks related to olanzapine misuse.

'I'm a sick person, not a bad person': patient experiences of treatments for alcohol use disorders

Background

Emerging research indicates that standard treatments for alcohol use disorders may not fully meet the needs of patients with co‐occurring severe mental health symptoms. Investigating health quality indicators may provide insight into how current treatment might be improved.

Objective

To better understand the experiences of patients receiving treatment for alcohol use disorders and compare the experiences of patients with and without co‐occurring severe mental health symptoms.

Design

Cross‐sectional qualitative research design using semi‐structured interviews methods and framework analysis approach.

Setting

Inpatient hospital, outpatient service, inpatient detoxification clinic and a residential/ therapeutic community.

Participant's

Thirty‐four patients receiving treatment for an alcohol use disorder.

Main variables studied

Themes relating to patients' experiences of continuity of care, treatment need and satisfaction with treatment were studied. The qualitative data were divided into two groups: patients with (n = 15) and without (n = 19) severe mental health symptoms.

Results

Five themes relating to patient satisfaction with treatment were identified, including: perceived effectiveness of treatment, supportive relationships, specialized but holistic care, patient autonomy and continuity of care. A diverse range of patient treatment needs, staff and service continuity and stigma were also identified as major themes. Five basic themes were identified as more critical to the experiences of patients with severe mental health symptoms.

Discussion and conclusions

Findings suggest that patients look for supportive relationships with others, to be involved in treatment decisions, effective specialized and holistic approaches to care and a non‐judgemental treatment environment.

Delivery of a mainstreaming treatment model towards co-existing difficulties: a brief exploration of practitioners’ understanding, views and reported experiences

Purpose

– The purpose of this paper is to describe the delivery of a mainstreaming model within a public sector, mental health (National Health Service (NHS)) organisation. The model promotes the inclusivity of a spectrum of presentations from co-existing moderate anxiety and depression to severe mental disorder (psychosis) and problematic substance and alcohol use.

Design/methodology/approach

– This paper introduces the delivery of three collective approaches, termed the “three essential elements” to support a mainstreaming treatment model, facilitated by a “Dual Diagnosis Lead”. The model encompasses; a “direct access” referral pathway, joint collaboration with practitioners and the delivery of a “Dual Diagnosis” training programme. An independent evaluation was commissioned to explore eight mental health and substance misuse practitioners’ views and experiences in relation to the impact of the mainstreaming model. This paper also considers feedback from 230 course participants attending a one day “Dual Diagnosis” training programme.

Findings

– This paper suggests that practitioners may benefit from the implementation of the mainstreaming approach and the delivery of this approach could be moving “Dual Diagnosis” interventions closer to mainstream practice.

Research limitations/implications

– The limitations of the mainstreaming model are acknowledged in relation to the generalisation of practitioners’ views and reported experiences.

Originality/value

– This paper offers a description of the delivery of a mainstreaming model involving the “three essential elements”. The model provides a useful insight and demonstrates the possibilities which may be achieved when attempting to implement a mainstreaming treatment approach within mainstream mental health and drug and alcohol services.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia. Part 3: Update 2015 Management of special circumstances: Depression, Suicidality, substance use disorders and pregnancy and lactation

These updated guidelines are based on the first edition of the World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia published in the years 2005 and 2006. For this 2015 revision, all available publications pertaining to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations which are clinically and scientifically relevant. They are intended to be used by all physicians diagnosing and treating patients with schizophrenia. Based on the first version of these guidelines a systematic review, as well as a data extraction from national guidelines have been performed for this update. The identified literature was evaluated with respect to the strength of evidence for its efficacy and subsequently categorised into six levels of evidence (A-F) and five levels of recommendation (1-5). This third part of the updated guidelines covers the management of the following specific treatment circumstances: comorbid depression, suicidality, various comorbid substance use disorders (legal and illegal drugs), and pregnancy and lactation. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication and other pharmacological treatment options) of patients with schizophrenia.

Comorbid substance use disorders in schizophrenia: a latent class approach

Schizophrenia is a complex psychiatric disorder with a characteristic disease course and heterogeneous etiology. While substance use disorders and a family history of psychosis have individually been identified as risk factors for schizophrenia, it is less well understood if and how these factors are related. To address this deficiency, we examined the relationship between substance use disorders and family history of psychosis in a sample of 1219 unrelated patients with schizophrenia. The lifetime rate of substance use disorders in this sample was 50%, and 30% had a family history of psychosis. Latent class mixture modeling identified three distinct patient subgroups: (1) individuals with low probability of substance use disorders; (2) patients with drug and alcohol abuse, but no symptoms of dependence; and (3) patients with substance dependence. Substance use was related to being male, to a more severe disease course, and more acute symptoms at assessment, but not to an earlier age of onset of schizophrenia or a specific pattern of positive and negative symptoms. Furthermore, substance use in schizophrenia was not related to a family history of psychosis. The results suggest that substance use in schizophrenia is an independent risk factor for disease severity and onset.

Need for care and life satisfaction in adult substance use disorder patients with and without attention deficit hyperactivity disorder (ADHD) or autism spectrum disorder (ASD)

PURPOSE

To identify care needs of adult substance use disorder (SUD) patients with and without co-occurring attention deficit hyperactivity disorder (ADHD) or autism spectrum disorder (ASD).

DESIGN AND METHODS

An exploratory study using the European Addiction Severity Index, the Camberwell Assessment of Needs, and the Manchester Short Assessment of Quality of Life to assess and compare care needs and perceived quality of life.

FINDINGS

All patients are dissatisfied with parts of their existence. SUD patients have fewer care needs than SUD patients with co-occurring ADHD or ASD. The SUD and SUD + ADHD groups report needs in similar domains. The SUD + ASD group shows a greater number of and more extensive care needs.

PRACTICE IMPLICATIONS

Differences in the care needs of adult SUD patients with and without ADHD or ASD should be taken into account when developing evidence-based nursing care interventions.

Continuity of Care in Dual Diagnosis Treatment: Definitions, Applications, and Implications

OBJECTIVE

The goal of this work is to review the current literature on continuity of care in the treatment of people with dual diagnosis. In particular, this review set out to clarify how continuity of care has been defined, applied, and assessed in treatment and to enhance its application in both research and clinical practice.

METHODS

To identify articles for review, the term "continuity" and combinations of "substance" and "treatment" were searched in electronic databases. The search was restricted to quantitative articles published in English after 1980. Papers were required to discuss "continuity" in treatment samples that included a proportion of patients with a dual diagnosis.

RESULTS

A total of 18 non-randomized studies met the inclusion criteria. Analysis revealed six core types of continuity in this treatment context: continuity of relationship with provider(s), continuity across services, continuity through transfer, continuity as regularity and intensity of care, continuity as responsive to changing patient need, and successful linkage of the patient. Patient age, ethnicity, medical status, living status, and the type of mental health and/or substance use disorder influenced the continuity of care experienced in treatment. Some evidence suggested that achieving continuity of care was associated with positive patient and treatment-related outcomes.

CONCLUSIONS

This review summarizes how continuity of care has been understood, applied, and assessed in the literature to date. Findings provide a platform for future researchers and service providers to implement and evaluate continuity of care in a consistent manner and to determine its significance in the treatment of people with a dual diagnosis.

Everyday life consequences of substance use in adult patients with a substance use disorder (SUD) and co-occurring attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD): a patient's perspective

BACKGROUND

Although the prevalence of substance use disorder (SUD) with co-occurring attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD) is relatively high in adult patients, there is hardly any knowledge about these dual diagnoses. A recent study reported met- and unmet needs for several life domains regarding these patient groups. To improve treatment, it is necessary to identify the everyday life consequences of SUD and co-occurring ADHD or ASD in adult patients.

METHODS

Qualitative study using in-depth interviews. 11 SUD + ADHD and 12 SUD + ASD patients participated in the study. The interview transcripts were coded and analysed according to the seven steps for descriptive phenomenology by Colaizzi.

RESULTS

Both patients with ADHD and patients with ASD can get caught in a jumble of thoughts and emotions which can often lead to agitation and impulsivity in the case of ADHD or passivity and melancholia in the case of ASD with co-occurring SUD in both cases. Initially substance use ameliorates the symptoms and related problems, but both patient groups can later experience even greater problems: difficulties with the structuring of daily life due to a lack of planning (SUD + ADHD) or due to a lack of initiative (SUD + ASD). Both groups indicate that structure helps them function better. They also recognize that substance use disorganizes their lives and that an absence of structure contributes to substance use in what becomes a vicious circle which needs to be broken for effective treatment and care.

CONCLUSIONS

This study provides insight into the daily life consequences of SUD with a co-occurring ADHD or ASD. Substance use is reported to solve some ADHD- or ASD-related problems in the short run but have negative consequences in the long run (i.e., contribute to already impaired cognitive functioning). Insight is provided into what clinicians can do to break this vicious circle and thus help ADHD patients to refrain from action and ASD patients to take action.

Genetic and environmental influences on the relationship between adult ADHD symptoms and self-reported problem drinking in 6024 Dutch twins

BACKGROUND

Cross-sectional and longitudinal studies have shown a positive association between attention deficit hyperactivity disorder (ADHD) and problematic alcohol use in adults. To what extent this association is explained by genetic and environmental factors is largely unknown.

METHOD

Data on ADHD and alcohol consumption were collected by self-report in 6024 adult Dutch twins. ADHD symptoms were assessed by three subscales of the Conners' Adult ADHD Rating Scales - Self-Report: Screening Version (CAARS-S:SV): inattentiveness, hyperactivity and the ADHD index (ADHD-I). Problem drinking was defined as at least two self-reported alcohol-related problems on the CAGE questionnaire. Structural equation modelling was applied to the bivariate twin data to estimate genetic and environmental influences.

RESULTS

Heritability of ADHD symptoms ranged between 32% and 40% and heritability of problem drinking was 50%. The positive correlation between ADHD symptoms and problem drinking was confirmed in this general population sample, with phenotypic correlations between 0.20 and 0.28 and genetic correlations between 0.39 and 0.50. Phenotypic correlations are primarily (61-100%) explained by genetic influences with non-shared environmental influences explaining the remaining covariance. No significant quantitative or qualitative gender differences in covariance structure were found.

CONCLUSIONS

This study convincingly shows that ADHD symptoms and problem drinking are moderately but significantly correlated in adults and that genetic correlations are primarily underlying this association. This suggests that early interventions are required to prevent adolescents with ADHD from developing problematic levels of alcohol use. Furthermore, clinicians who treat alcohol-dependent patients should be aware that the patient may have a co-morbid condition of ADHD; integrated interventions are required.

Treatment seeking and barriers to treatment for alcohol use in persons with alcohol use disorders and comorbid mood or anxiety disorders

PURPOSE

This study compared the prevalence and patterns of treatment seeking and barriers to alcohol treatment among individuals with alcohol use disorders (AUD) with and without comorbid mood or anxiety disorders.

METHODS

We used data from the national epidemiologic survey on alcohol and related conditions to examine alcohol treatment seeking, treatment settings and providers, perceived unmet need for treatment and barriers to such treatment. Our sample consisted of 5,003 individuals with AUD with a comorbid mood or anxiety disorder and 6,734 individuals with AUD but without mood or anxiety disorder comorbidity.

RESULTS

The group with mood or anxiety disorder comorbidity was more likely to seek alcohol treatment than the group without such comorbidity (18 vs. 12 %, p < 0.001). The comorbid group was also more likely to perceive an unmet need for such treatment (8 vs. 3 %, p < 0.001) and to report a larger number of barriers (2.81 vs. 2.20, p = 0.031). Individuals with AUD with comorbid mood or anxiety disorders were more likely than those without to report financial barriers to alcohol treatment (19 vs. 10 %, p = 0.032).

CONCLUSIONS

Individuals with AUD and comorbid mood or anxiety disorders would likely benefit from the expansion of financial access to alcohol treatments and integration of services envisioned under the Affordable Care Act.