Clinical presentations and diagnostic issues in dual diagnosis disorders

TAPS-tool reveals severe under detection of substance use problems in patients with severe mental illness

INTRODUCTION

Substance use disorders (SUD) and associated problems are highly prevalent but often undetected in patients with Severe Mental Illness (SMI). This study investigates the prevalence, under-detection, and variables associated with a high risk of SUD in a Dutch sample of adult outpatient SMI patients (N = 83).

METHODS

Substance use (The Tobacco, Alcohol, Prescription medication, and other Substance use -TAPS-tool), quality of life (Manchester Short Assessment of Quality of Life-MANSA), general functioning (Health of the Nation Outcome Scale-HoNOS), DSM-5 classifications and patient characteristics (age, education, marital status) were assessed. Detection of SUD was determined by calculating % agreement of DSM-5 classification to TAPS outcome. A logistic regression analysis was performed to determine the association of patient characteristics, quality of life and general functioning to an increased risk of SUD as determined by the TAPS.

RESULTS

Concerning prevalence, 89% of the patients used tobacco, above guideline-recommended daily limits of alcohol, illicit drugs or prescription medications for nonmedical purposes. Almost all smokers, half of the alcohol users and three-quarter of the patients that use marihuana or stimulant drugs had a high risk of SUD. All patients with high risk of SUD associated with alcohol, drugs or medications also had SUD associated with tobacco use. Concerning under detection less than half of the patients with a high risk of SUD according the TAPS had a SUD in their DSM-5 classification. Gender, partner, age and satisfaction about the relationship with family had a significant association with a high risk of SUD.

CONCLUSIONS

Screening for addiction in an SMI sample with the TAPS-tool revealed a high prevalence of substance use and a high risk of SUD. TAPS outcomes compared to the clinically obtained DSM-5 classification revealed a high degree of under-detection of substance use problems. Smoking seems to pose a specific additional risk of addiction and deserves more attention in treatment to achieve greater health care benefits.

Telemedicine for unhealthy alcohol use in adults living with HIV in Alabama using common elements treatment approach: A hybrid clinical efficacy-implementation trial protocol

Background

Unhealthy alcohol use is an unaddressed barrier to achieving and maintaining control of the human immunodeficiency virus (HIV) epidemic. Integrated screening, treatment of common behavioral and mental health comorbidities, and telemedicine can improve alcohol treatment and HIV clinical and quality of life outcomes for rural and underserved populations.

Objective

In a randomized controlled clinical trial, we will evaluate the effectiveness and implementation of telephone-delivered Common Elements Treatment Approach (T-CETA), a transdiagnostic cognitive behavioral therapy protocol, on unhealthy alcohol use, HIV, other substance use and mental health outcomes among predominantly rural adults with HIV receiving care at community clinics in Alabama.

Methods

Adults with HIV receiving care at four selected community clinics in Alabama will receive a telephone-delivered alcohol brief intervention (BI), and then be assigned at random (stratified by clinic and sex) to no further intervention or T-CETA. Participants will be recruited after screening positively for unhealthy alcohol use or when referred by a provider. The target sample size is 308. The primary outcome will be change in the Alcohol Use Disorder Identification Test (AUDIT) at six- and 12-months post-enrollment. Additional outcomes include HIV (retention in care and viral suppression), patient-reported mental health (anxiety, depression, posttraumatic stress), and quality of life. A range of implementation measures be evaluated including T-CETA provider and client acceptability, feasibility, cost and cost-effectiveness.

Conclusions

This trial will inform alcohol treatment within HIV care programs, including the need to consider comorbidities, and the potential impact of alcohol interventions on HIV and quality of life outcomes.

Co-occurring opioid use disorder and serious mental illness: A selective literature review

OBJECTIVE

The overarching goal of this review is to provide a clinical overview of epidemiology, diagnosis, and treatment, and to discuss the public health impact, social determinants including access to care, and implications for health care delivery and research. It is estimated that approximately 1 in 4 individuals suffering from a serious mental illness (SMI) may have a co-occurring opioid use disorder (OUD). In these individuals, the overall disease burden is higher and clinical outcomes are worse compared to those without a co-occurring illness, making an integrated approach to diagnosis and treatment an urgent priority.

METHODS

We conducted a selective review of the literature to investigate prevalence, etiology for co-occurring OUD and SMI, and diagnostic and clinical guidelines in the United States, and consideration special populations.

FINDINGS

Our findings suggest that, despite the high prevalence of co-occurring OUD and SMI, contemporary diagnostics and treatment approaches are underutilized in this patient population. The literature also suggests that both pharmacological and psychosocial treatment approaches need to be tailored to optimize clinical management, and that integrated treatment is pivotal for improving overall outcomes, yet comprehensive clinical guidelines for co-occurring OUD and SMI are lacking at this time.

Integrated vs non-integrated treatment outcomes in dual diagnosis disorders: A systematic review

Background

The incidence of dual diagnosis (DD) (i.e. substance use disorders [SUD] and co-occurring mental disorders) is widespread; however, they vary widely in permutation and combination. As a result, establishing effective and empirically supported interventions for this clinical population remains challenging.

Aim

This study aimed to examine current literature on the treatment outcomes for patients with DD.

Method

A systematic review of randomised controlled trials (RCTs) published between 2009 and 2018 was conducted for two broad intervention categories identified by the literature: non-integrated and integrated treatment. Multiple electronic databases were searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA).

Results

The search generated a total of 743 studies, of which 11 satisfied the inclusion criteria. These studies were thematically synthesised into two main analytical themes: 'treatment outcomes' and 'reported strengths and limitations of DD treatment'. Specifically, integrated treatment held an advantage over non-integrated treatment in significantly improving psychiatric symptomatology. However, no significant benefits were found between integrated and non-integrated treatment regarding substance misuse and treatment retention.

Conclusion

Overall, the results provided insufficient evidence to support the enhanced efficacy of integrated or non-integrated treatment over the other in treating patients with DD.

Contribution

The study's findings were used to provide recommendations to inform the clinical psychological service delivery of dual diagnosis treatment in South Africa and also to identify gaps in the literature and highlight areas for future research.

Implementing clinical guidelines for co-occurring substance use and major mental disorders in Swedish forensic psychiatry: An exploratory, qualitative interview study with mental health care staff

INTRODUCTION

Patients with substance use disorders (SUD) and co-occurring mental disorders (COD) within forensic psychiatric care often suffer poor treatment outcomes and high rates of criminal recidivism, substance use, and psychiatric problems. This study aimed to describe the conditions for, and mental health care staff's experiences with, implementing integrated SUD-focused clinical guidelines, including assessment and treatment for patients with COD at a high-security forensic mental health services (FMHS) facility in Sweden.

METHODS

Study staff conducted nineteen semi-structured interviews with health care staff experienced in administering the new SUD assessment and treatment. The study conducted a thematic analysis to describe the health care staff's experiences with these guidelines and suggestions for improvement.

RESULTS

Most participants reported appreciation for the implementation of clinical guidelines with an SUD focus, an area they considered to have previously been neglected, but also noted the need for more practical guidance in the administration of the assessments. Participants reported the dual roles of caregiver and warden as difficult to reconcile and a similar, hindering division was also present in the health care staff's attitudes toward SUD. Participants' reports also described an imbalance prior to the implementation, whereby SUD was rarely assessed but treatment was still initiated. One year after the implementation, an imbalance still existed, but in reverse: SUD was more frequently assessed, but treatment was difficult to initiate.

CONCLUSIONS

Despite indications of some ambivalence among staff regarding the necessity of the assessment and treatment guidelines, many participants considered it helpful to have a structured way to assess and treat SUD in this patient group. The imbalance between frequent assessment and infrequent treatment may have been due to difficulties transitioning patients across the "gap" between assessment and treatment. To bridge this gap, mental health services should make efforts to increase patients' insight concerning their SUD, flexibility in the administration of treatment, and the motivational skills of the health care staff working with this patient group. Participants considered important for enhancing treatment quality a shared knowledge base regarding SUD, and increased collaboration between different professions and between in- and outpatient services.

Maternal immune activation and adolescent alcohol exposure increase alcohol drinking and disrupt cortical-striatal-hippocampal oscillations in adult offspring

Maternal immune activation (MIA) is strongly associated with an increased risk of developing mental illness in adulthood, which often co-occurs with alcohol misuse. The current study aimed to begin to determine whether MIA, combined with adolescent alcohol exposure (AE), could be used as a model with which we could study the neurobiological mechanisms behind such co-occurring disorders. Pregnant Sprague-Dawley rats were treated with polyI:C or saline on gestational day 15. Half of the offspring were given continuous access to alcohol during adolescence, leading to four experimental groups: controls, MIA, AE, and Dual (MIA + AE). We then evaluated whether MIA and/or AE alter: (1) alcohol consumption; (2) locomotor behavior; and (3) cortical-striatal-hippocampal local field potentials (LFPs) in adult offspring. Dual rats, particularly females, drank significantly more alcohol in adulthood compared to all other groups. MIA led to reduced locomotor behavior in males only. Using machine learning to build predictive models from LFPs, we were able to differentiate Dual rats from control rats and AE rats in both sexes, and Dual rats from MIA rats in females. These data suggest that Dual "hits" (MIA + AE) increases substance use behavior and disrupts activity in reward-related circuits, and that this may be a valuable heuristic model we can use to study the neurobiological underpinnings of co-occurring disorders. Our future work aims to extend these findings to other addictive substances to enhance the translational relevance of this model, as well as determine whether amelioration of these circuit disruptions can reduce substance use behavior.

Network Analysis of DSM Symptoms of Substance Use Disorders and Frequently Co-Occurring Mental Disorders in Patients with Substance Use Disorder Who Seek Treatment

Background: Substance use disorders (SUD) often co-occur with other psychiatric conditions. Research on SUD and comorbid disorders generally flows from a categorical diagnostic or dimensional latent variable perspective, where symptoms are viewed as independent indicators of an underlying disorder. In contrast, the current study took a network analysis perspective to examine the relationships between DSM symptoms of SUD, ADHD, conduct disorder (CD), depression (MDD), and borderline personality disorder (BPD). In addition, we explored possible gender differences in the network structures of these symptoms. Method: In a sample of 722 adult treatment-seeking patients with SUD from the International ADHD in Substance Use Disorders Prevalence Study (IASP) we estimated the network structure for 41 symptoms of SUD, ADHD, CD, MDD, and BPD. We described the structure of symptom networks and their characteristics for the total sample, and we compared the symptom networks for males and females. Results: Network analyses identified seven clusters of symptoms, largely corresponding with the DSM diagnostic categories. There were some connections between clusters, mainly between some hyperactivity symptoms and CD and depressive symptoms. ADHD hyperactivity was most central in the symptom network. Invariance tests revealed no significant gender differences in the structure of symptom networks. Conclusions: The current findings support the categorical DSM classification of mental disorders in treatment-seeking patients with SUD. Future network analyses should include a broader range of symptoms and prospectively explore changes in the symptoms network of patients during treatment.

Predictors of Five-Year Readmission to an Inpatient Service among Patients with Alcohol Use Disorders: Report from a Low-Middle Income Country

BACKGROUND

Alcohol use disorder (AUD) is a relapsing-remitting disease that accounted for a sizable proportion of all-cause adult inpatient stays.

OBJECTIVES

To determine the predictors of any and multiple readmissions to inpatient care for AUD within 5 years of the index admission.

METHODS

This retrospective, register-based cohort study assessed consecutive patients with AUD admitted to a publicly-funded inpatient service between January 2007 and December 2014. Binary logistic regression was used to determine independent predictors for readmissions based on relevant demographic, clinical, and treatment variables that showed significant differences (p < 0.05) on univariate analysis.

RESULTS

Among 938 patients (age 35.9 ± 10.3 years; duration of alcohol use 159.6 ± 104.5 months; dual diagnosis 19%; comorbidity of substance use disorder 49.3%; medical disorder 34.8%, 299 (31.9%) and 115 (12.3%) had any and multiple readmissions, respectively. Comorbid "severe mental illness" (Odds ratio [OR] 1.99, 95% confidence interval [CI] 1.11-3.57) and urban residence (OR 1.58, 95% CI 1.13-2.18) increased the odds of any readmission; "Improved" status at discharge (OR 0.51, 95% CI 0.35-0.72) during index hospitalization reduced odds of readmission. Additionally, any medical or psychiatric comorbidities increased (OR 2.23, 95% CI 1.26-3.97), and comorbid substance use disorder decreased (OR 0.41, 95% CI 0.19-0.89) risk of multiple readmissions.

CONCLUSIONS

Clinicians could identify patients at-risk for any and multiple readmissions during the index hospitalization. A policy aimed at reducing the risk of rehospitalization, healthcare cost, and stigma should pay attention to the predictors of readmission. Such policy should further benefit resource-limited settings.

Morbidity and mortality in schizophrenia with comorbid substance use disorders

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Naturalistic exploratory study of the associations of substance use on ADHD outcomes and function

BACKGROUND

Although Attention Deficit Hyperactivity Disorder (ADHD) is associated with an increased risk of substance use disorder (SUD), existing literature on how SUD interacts with ADHD outcomes is limited. This study investigates whether SUD among individuals with ADHD is associated with worse ADHD outcomes and prognosis, and the association between overall functioning and SUD. In addition, we seek to understand whether heavy cannabis use is a better predictor of poorer outcomes compared to SUD status alone.

METHOD

We conducted a retrospective analysis on 50 ADHD patient charts, which were allocated based on SUD status. Subgroup analysis was performed on the total sample population, with allocation based on heavy cannabis use. Mann-Whitney and Chi-Square tests were used for both the primary and subgroup analyses.

RESULTS

SUD status highly correlated with more ADHD-related cognitive impairments and poorer functional outcomes at the time of diagnosis. ADHD patients with comorbid ADHD-SUD scored significantly lower (p = < 0.0001) on objective cognitive testing (Integrated Auditory and Visual Continuous Performance Test (IVA/CPT)) than ADHD patients without SUD. The correlation with poorer ADHD outcomes was more pronounced when groups were allocated based on heavy cannabis use status; in addition to significantly lower IVA/CPT scores (p = 0.0011), heavy cannabis use was associated with more severe fine motor hyperactivity and self-reported hyperactivity/impulsivity scores (p = 0.0088 and 0.0172, respectively).

CONCLUSION

Future research is needed to determine how substance abuse can be a barrier to improved ADHD outcomes, and the effect cannabis and other substances have on cognitive function and pharmacotherapy of ADHD.

Prevalence and clinical correlates of substance use amongst acute psychiatric inpatients in Gauteng, South Africa

Background

Mental disorders and substance use disorders (SUD) commonly occur together, impacting healthcare outcomes. The diagnosis of substance use is often inadequate when comorbidity is present. It is vital to understand the prevalence of substance use amongst psychiatric patients to inform both clinical practice and service development in South Africa.

Aim

To ascertain the prevalence and clinical correlates of SUD amongst acute psychiatric inpatients.

Setting

The setting for this study was Helen Joseph Hospital acute psychiatric ward.

Methods

A cross-sectional study was conducted whereby consecutively admitted patients were invited to participate in a structured clinical interview utilising the alcohol use disorders identification test (AUDIT) and drug use disorders identification test (DUDIT) questionnaires. Statistical comparisons were made between those with and without SUD.

Results

Of 150 participants, 100 (67%) were identified with a SUD. Those with SUD were younger (p = 0.0010), more often male (p = 0.012), less likely to have a disability grant (p = 0.015) and more likely to be brought to hospital by police, ambulance or self than by a family member (p = 0.025). Almost half of people with bipolar disorder (47.3%) and schizophrenia (41.4%) had comorbid SUD. Twenty-three (15%) participants identified with SUD on questionnaire had been missed clinically. Only two participants were referred for inpatient substance rehabilitation on discharge.

Conclusion

Substance use disorders are highly prevalent amongst psychiatric inpatients. The AUDIT and DUDIT are potentially useful screening tools in routine clinical practice. Greater collaboration between psychiatric and substance rehabilitation services is recommended.

Alcohol Use Disorder Is Differently Associated With Psychotic Symptoms According To Underlying Psychiatric Disorders: A General Population Study

Aims

Psychotic symptoms can occur in the general population, and alcohol use disorder (AUD) is an identified vulnerability factor. However, it remains unclear how AUD is associated with psychotic symptoms, depending on the underlying psychiatric condition.

We aimed to compare the prevalence of psychotic symptoms among subjects with different types of psychiatric disorders, i.e. unipolar or bipolar disorders, anxiety disorders, psychotic disorders or no psychiatric disorder, depending on whether or not there was an underlying AUD.

Methods

In a 38,694-subject general population study, we compared the likelihood of occurrence of seven types of psychotic symptoms, depending on the AUD status and the underlying psychiatric disorders, after adjustment for age, sex, marital status, education and income levels.

Results

In unipolar depression and anxiety disorders, almost all types of psychotic symptoms were found associated with AUD (odds ratios (ORs) between 1.98 and 2.19). In contrast, in bipolar disorder, only auditory hallucinations were associated with AUD (OR = 2.50). In psychotic disorders, only thought broadcasting was more frequent among subjects with AUD (OR = 1.78).

Conclusion

Our findings in depression and anxiety disorders are in line with the ‘dual diagnosis’ concept, which posits that comorbid psychiatric/addictive disorders form distinctive entities that are more frequently associated with non-specific severity factors, here psychotic symptoms. The co-occurrence of AUD in bipolar/psychotic disorders was not associated with a generalized increased occurrence of psychotic symptoms but altered their manifestations with an increased risk of auditory hallucinations for bipolar disorder and thought broadcasting for psychotic disorders.

Comorbidity of Alcohol Use and Other Psychiatric Disorders and Suicide Mortality: Data from the South Korean National Health Insurance Cohort, 2002 to 2013

BACKGROUND

Previous studies have indicated that alcohol use disorder (AUD) and other psychiatric disorders increase the risk of suicide mortality. However, little research has investigated the concomitant effect of comorbid psychiatric disorders on suicide mortality. This study aimed to investigate the effect of comorbid AUD on suicide mortality of individuals with another psychiatric disorder using a national data sample.

METHODS

We used the National Health Insurance Service-National Sample Cohort data from 2002 to 2013. We selected individuals with specific psychiatric disorders based on the International Classification of Diseases, 10th revision (F10-F48). Overall, the study included 741,601 participants. We utilized a prioritization process to identify the primary diagnosis for those with multiple diagnoses. All-cause mortality rates and suicide rates per 100,000 person-year (days) and the standardized mortality ratio (SMR) were calculated. Then, we compared the suicide-specific SMR of 3 different groups: (i) specific psychiatric disorder versus general public; (ii) specific psychiatric disorder comorbid with AUD versus general public; and (iii) specific psychiatric disorder comorbid with AUD versus specific psychiatric disorder without comorbid AUD.

RESULTS

Patients with any specific psychiatric disorder showed higher suicide-specific SMR compared to the general population. Being comorbid with AUD further increased the risk of suicide among psychiatric patients. In particular, patients with bipolar affective disorders, organic mental disorders, or depressive disorders comorbid with AUD had about 2 to 4 times higher suicide-specific SMR compared to those without AUD (bipolar affective disorder: SMR = 3.01, 95% confidence interval (CI) [1.49, 4.54]; organic mental disorder: SMR = 3.43, 95% CI [1.05, 5.81]; depressive disorder: SMR = 2.06, 95% CI [1.52, 2.61]).

CONCLUSIONS

Our data indicate that having a psychiatric disorder increases the risk of committing suicide. More importantly, comorbid AUD further increases this risk of suicidal death for certain psychiatric disorders. This shows the importance of determining whether patients with psychiatric disorders have comorbid AUD to prevent suicide.

Predictors of Alcohol Withdrawal Readmissions

Aims

Hospital readmissions serve as a major benchmark for the quality of care and alcohol withdrawal (AW) may lead to multiple hospitalizations and readmissions. We sought to evaluate readmission rates and predictors of having AW-related readmissions in a nationally representative sample.

Short summary

In a nationally representative sample, AW readmission within 30 days and multiple readmissions during the year were high and were particularly predicted by discharge against medical advice (AMA), comorbid psychosis, comorbid depression, poor socioeconomic status, comorbid drug abuse and alcohol-related medical disease.

Methods

Subjects from the 2013 Nationwide Readmissions Database (NRD) with AW as a primary or secondary diagnosis. Cross-sectional and retrospective analyses were performed using regression methods appropriate for the NRD complex sampling design. The outcome measures were AW-related readmission, 30-day readmission and multiple readmissions.

Results

In 2013, 393,118 discharges involved ICD-9 coding for AW and 41.5% of these included AW as the primary discharge diagnosis. The rate of AW-related readmission in 2013, as estimated from first-quarter index events, was 58.8% (95% confidence interval (CI) 57.5-60.1), with an average of 1.8 readmissions (95% CI 1.7-1.9). The 30-day readmission rate, estimated from January-November index events, was 19.7% (95% CI 19.0-20.4). The strongest independent predictors of yearly, 30-day and multiple readmission were discharged AMA and comorbid psychotic disorder.

Conclusion

AW readmission within 30 days and multiple readmissions during the year were common and were particularly predicted by AMA discharge and comorbid psychotic disorder. While these and other factors can help identify high-risk patients, further study to determine causal mechanisms may aid efforts to improve both the outcomes and costs associated with acute AW treatment.

Influence of comorbid alcohol use disorders on the clinical patterns of major depressive disorder: A general population-based study

BACKGROUND

To compare the symptom patterns of major depressive disorder (MDD) among subjects with MDD and 1) no alcohol use disorder (AUD), 2) alcohol abuse and 3) alcohol dependence, respectively.

METHODS

In a general population survey of 38,694 French individuals, MDD and AUDs were assessed using the Mini International Neuropsychiatric Interview 5.0.0 (MINI). A total of 4339 subjects (11.2%) in the sample met the criteria for MDD. Among them, 413 (9.5%) AUD subjects were identified: 138 (3.2%) for alcohol abuse and 275 (6.3%) for alcohol dependence. The associations of each of the ten MDD criteria of the MINI and psychiatric clinical features were compared among the three groups. The relative profiles of 'MDD + AUD' vs. 'MDD alone' were determined using a multivariable stepwise regression model.

RESULTS

With the noAUD group as the reference, sadness (OR = 0.46; 95%CI, 0.29-0.74) and anhedonia (OR = 1.66; 95%CI, 1.06-2.73) were only associated with alcohol abuse. Sleep disorders (OR = 2.07; 95%CI, 1.51-2.88), feelings of guilt (OR = 1.41; 95%CI, 1.05-1.90), diminished concentration/indecisiveness (OR = 1.52; 95%CI, 1.12-2.07) and thoughts of death (OR = 1.95; 95%CI 1.49-2.55) were only associated with alcohol dependence. Weight or appetite variations were both associated with alcohol abuse (OR = 1.7; 95%CI, 1.15-2.53) and dependence (OR = 1.41; 95%CI, 1.06-1.88). Bipolar disorder and PTSD were only associated with alcohol dependence. Psychotic features, previous suicide attempts, and panic disorder were more frequent in the MDD-AUD group.

CONCLUSION

MDD-AUD subjects displayed a more severe profile with specific symptomatology and comorbidity profiles compared to MDD-only subjects.

Improving the Knowledge, Attitudes, and Practices of Mental Health Professionals Regarding Dual Diagnosis Treatment - a Mixed Methods Study of an Intervention

This study examined an intervention, which aimed at improving the dual diagnosis treatment at eight Danish mental health centres. The intervention included training in dual diagnosis treatment to program champions who were intended to implement at their workplace the knowledge gained from training. The study used mixed methods (questionnaires, interviews, and field observations) to examine whether there was a change in the knowledge, attitudes, and practices of the colleagues of the program champions following the intervention. Results showed that the intervention overall yielded improvement in knowledge and attitudes, while the impact on assessment and treatment practices was limited. Possible factors that might have affected the implementation of the intervention as well as the weaknesses of the intervention and the study are discussed.

Seeking mental health care from private health practitioners among individuals with alcohol dependence/abuse; results from a study in the French general population

INTRODUCTION

Better knowledge of the factors that have an impact on pathways to mental health care may contribute greatly to organizing optimum health-care delivery. However, surveillance systems concerning alcohol problems in the French general population are suboptimal. The objectives of this study were to investigate: 1) the prevalence of mental health-care seeking in individuals with alcohol abuse/dependence in France, 2) which category of medical practitioner was consulted, and 3) psychological and socio-environmental factors associated with mental health-care seeking.

METHODS

A total sample of 22,138 individuals was interviewed in a telephone survey. Individual data on alcohol dependence/abuse and other mental health disorders were collected using the Composite International Diagnosis Interview - short form. Mental health-care seeking was assessed, together with data on living conditions, deprivation, and self-reported drinking problems. Only respondents meeting criteria for alcohol dependence/abuse were included in analyses.

RESULTS

Less than half of the 722 respondents with alcohol abuse/dependence had sought mental health care in the preceding 12 months, of whom 90.5% consulted their general practitioner (GP) (56.1%), or both a general practitioner and a psychiatrist (34.4%). Mental health-care seeking was associated with female sex, previous alcohol discussion with a doctor, and the presence of psychiatric comorbidities arising in the preceding 12 months. Living environment, socio-economic status, or self-reported drinking problems had no influence.

DISCUSSION

A minority of people with alcohol abuse/dependence sought mental health care, mainly in relation to psychiatric comorbidities. In addition, most people consulting a GP were not referred to a psychiatrist. However, social deprivation and living in rural areas did not hinder mental health-care seeking among respondents. Adequate protocols to treat alcohol disorders could be implemented among private health-care providers to improve management of alcohol problems in France.

Comparison of 12-step groups to mutual help alternatives for AUD in a large, national study: Differences in membership characteristics and group participation, cohesion, and satisfaction

BACKGROUND

Many studies suggest that participation in 12-step groups contributes to better recovery outcomes, but people often object to such groups and most do not sustain regular involvement. Yet, research on alternatives to 12-step groups is very sparse. The present study aimed to extend the knowledge base on mutual help group alternatives for those with an alcohol use disorder (AUD), sampling from large, active, abstinence-focused groups including Women for Sobriety (WFS), LifeRing, and SMART Recovery (SMART). This paper presents a cross-sectional analysis of this longitudinal study, using baseline data to describe the profile and participation characteristics of attendees of these groups in comparison to 12-step members.

METHODS

Data from participants 18 and over with a lifetime AUD (N=651) were collected using Web-based surveys. Members of alternative 12-step groups were recruited in collaboration with group directors, who helped publicize the study by emailing meeting conveners and attendees and posting announcements on social media. A comparison group of current (past-30-day) 12-step attendees was recruited from an online meeting hub for recovering persons. Interested parties were directed to a Webpage where they were screened, and eligible participants completed an online survey assessing demographic and clinical variables; in-person and online mutual help involvement; and group satisfaction and cohesion. Analyses involved comparing those identifying WFS, SMART, and LifeRing as their primary group to 12-step members on the above characteristics.

RESULTS

Compared to 12-step members, members of the mutual help alternatives were less religious and generally higher on education and income. WFS and LifeRing members were also older, more likely to be married, and lower on lifetime drug and psychiatric severity; meanwhile, LifeRing and SMART members were less likely to endorse the most stringent abstinence goal. Finally, despite lower levels of in-person meeting attendance, members of all the 12-step alternatives showed equivalent activity involvement and higher levels of satisfaction and cohesion, compared to 12-step members.

CONCLUSIONS

Results suggest differences across 12-step groups and their alternatives that may be relevant when advising clients on a choice of mutual help group. Meanwhile, findings for high levels of participation, satisfaction, and cohesion among members of the mutual help alternatives suggest promise for these groups in addressing addiction problems.

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.

Personality in male patients with substance use disorder and/or severe mental illness

Dual diagnosis (DD) is the coexistence of a substance use disorder (SUD) and severe mental illness (SMI). The aim of this study is to determine for the first time if a specific personality pattern exists for DD patients compared to those who only have SUD or SMI. The sample was composed of 102 male, 34 patients in each group (DD, SUD and SMI). DD and SMI groups included 20 schizophrenic and 14 depressed patients respectively. Cloninger's TCI-R was administered together with a structured interview of sociodemographic and clinical characteristics. All the temperament dimensions and Self-directedness provided differences among groups. The DD and SUD showed significant higher scores in Novelty Seeking regarding SMI, whereas for Harm Avoidance the SUD subjects scored lower with respect to the DD and SMI group. Persistence was significant lower for the DD and SMI groups compared to the SUD patients. The DD obtained low significant scores in Reward Dependence in relation to the SUD and Self-directedness in relation to the SUD and SMI. Our data highlight the presence of a different personality profiles among DD, SUD and SMI disorders. Taking into account the patients' personality can benefit the clinical course and minimize the DD impact.

Traumatic stress and the mediating role of alcohol use on HIV-related sexual risk behavior: results from a longitudinal cohort of South African women who attend alcohol-serving venues

BACKGROUND

In South Africa, alcohol contributes to the HIV epidemic, in part, by influencing sexual behaviors. For some, high levels of alcohol consumption may be driven by previous traumatic experiences that result in traumatic stress. The purpose of this study was to quantify the longitudinal association between traumatic stress and unprotected sex among women who attend drinking venues and to assess whether this association was explained by mediation through alcohol use.

METHODS

Data were collected in 4 waves over a year from a prospective cohort of 560 women who regularly attended alcohol-serving venues in a Cape Town township. Longitudinal mixed models examined (1) the relationship between traumatic stress and counts of unprotected sex and (2) whether alcohol use mediated the association between traumatic stress and unprotected sex.

RESULTS

Most women reported elevated traumatic stress (80%) and hazardous alcohol use (88%) at least once during the study period. In models adjusted for covariates, traumatic stress was associated with unprotected sex (b = 0.28, SE = 0.06, t = 4.82, P < 0.001). In addition, traumatic stress was associated with alcohol use (b = 0.27, SE = 0.02, t = 14.25, P < 0.001) and was also associated with unprotected sex (b = 0.20, SE = 0.06, t = 3.27, P < 0.01) while controlling for alcohol use (b = 0.28, SE = 0.07, t = 4.25, P < 0.001). The test for the mediated effect established that alcohol use was a significant mediator, accounting for 27% of the total effect of traumatic stress on unprotected sex.

CONCLUSIONS

These results highlight the need to address traumatic stress among female venue patrons as an important precursor of HIV risk due to alcohol use.

Longitudinal cohort study of depression, post-traumatic stress, and alcohol use in South African women who attend alcohol serving venues

BACKGROUND

In South Africa, alcohol use poses a public health burden. Hazardous alcohol use often co-occurs with psychological distress (e.g., depression and post-traumatic stress). However, the majority of the research establishing the relationship between alcohol use and psychological distress has been cross-sectional, so the nature of co-occurring changes in psychological distress and alcohol use over time is not well characterized. The objective of this study is to examine the longitudinal relationship between psychological distress and alcohol use among South African women who attend alcohol serving venues.

METHODS

Four waves of data were collected over the course of a year from 560 women in a Cape Town township who attended drinking venues. At each assessment wave, participants reported depressive symptoms, post-traumatic stress symptoms, and alcohol use. Multilevel growth models were used to: 1) assess the patterns of alcohol use; 2) examine how depressive symptoms uniquely, post-traumatic stress symptoms uniquely, and depressive and post-traumatic stress symptoms together were associated with alcohol use; and 3) characterize the within person and between person associations of depressive symptoms and post-traumatic stress symptoms with alcohol use.

RESULTS

Women reported high levels of alcohol use throughout the study period, which declined slightly over time. Post-traumatic stress symptoms were highly correlated with depressive symptoms. Modeled separately, both within person and between person depressive and post-traumatic stress symptoms were uniquely associated with alcohol use. When modeled together, significant between person effects indicated that women who typically have more post-traumatic stress symptoms, when controlling for depressive symptoms, are at risk for increased alcohol use; however, women with more depressive symptoms, controlling for post-traumatic stress symptoms, do not have differential risk for alcohol use. Significant within person effects indicated an interaction between depressive and post-traumatic stress symptoms; women reported more alcohol use than usual at times when they had higher post-traumatic stress symptoms, and this increase in alcohol use was further exacerbated for women who also had higher depressive symptoms than usual.

CONCLUSIONS

These findings suggest that interventions targeting post-traumatic stress, especially when post-traumatic stress is comorbid with depression, may reduce alcohol use among South African women who drink.

Problem solving styles among people who use alcohol and other drugs in South Africa

The present study examines the relationship between problem-solving styles, socio-demographic variables and risk of alcohol and other drug (AOD)-related problems among a South African population. The Social Problem-Solving Inventory-Revised, Center for Epidemiologic Studies Depression Scale (CES-D) and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) were administered to a convenience sample of 1000 respondents. According to the ASSIST, 32% and 49% of respondents met criteria for moderate to high risk of alcohol use and illicit drug use respectively. After adjusting for the effects of other variables in the model, respondents who were of "Coloured" ancestry (PR=1.20, 95% CI 1.0-1.4), male (PR=1.19, 95% CI 1.04-1.37), older (PR=1.01, 95% CI 1.00-1.02), who adopted an avoidance style of coping with problems (PR=1.03, 95% CI 1.01-1.05) and who met criteria for depression (PR=1.42, 95% CI 1.12-1.79) were more likely to be classified as having risky AOD use. This suggests that interventions to improve problem solving and provide people with cognitive strategies to cope better with their problems may hold promise for reducing risky AOD use.

Predictors and moderators of aftercare appointment-keeping following brief motivational interviewing among patients with psychiatric disorders or dual diagnosis

OBJECTIVE

Non-adherence to psychiatric and substance abuse treatment recommendations, especially with regard to aftercare outpatient appointment-keeping following hospitalizations, exacts a high cost on mental health spending and prevents patients from receiving therapeutic doses of treatment. Our primary objective was to evaluate the relationship between potential predictors and moderators of aftercare appointment-keeping among a group of adult patients immediately following hospitalization for severe psychiatric disorders or dual diagnosis.

METHODS

Candidate predictors and moderator variables included demographics, psychiatric status, psychiatric symptom severity, and inpatient group adherence, while aftercare appointment-keeping was defined as attendance at the first aftercare appointment. Participants were 121 adult inpatients with a psychiatric disorder or dual diagnosis originally enrolled in an earlier randomized controlled trial comparing standard treatment with standard treatment plus brief motivational interviewing for increasing adherence.

RESULTS

RESULTS indicated that, across treatment conditions, those who were female, did not have dual diagnosis, were older (older than 33 years), and were less educated (<high school) attended their first aftercare appointment at significantly higher rates than their counterparts. A treatment-by-gender interaction was noted, where only men were significantly more likely to keep their first aftercare appointment if they received standard treatment plus brief motivational interviewing, compared to standard treatment alone (OR = 9.58, p < .001).

CONCLUSIONS

Findings suggest that gender, dual diagnosis status, age and education may be an important predictors of aftercare treatment adherence and that gender may be a moderator of motivational interviewing among individuals with psychiatric disorders or dual diagnosis.

Healthcare utilization in medical intensive care unit survivors with alcohol withdrawal

BACKGROUND

Rehospitalization is an important and costly outcome that occurs commonly in several diseases encountered in the medical intensive care unit (ICU). Although alcohol use disorders are present in 40% of ICU survivors and alcohol withdrawal is the most common alcohol-related reason for admission to an ICU, rates and predictors of rehospitalization have not been previously reported in this population.

METHODS

We conducted a retrospective cohort study of medical ICU survivors with a primary or secondary discharge diagnosis of alcohol withdrawal using 2 administrative databases. The primary outcome was time to rehospitalization or death. Secondary outcomes included time to first emergency department or urgent care clinic visit in the subset of ICU survivors who were not rehospitalized. Cox proportional hazard models were adjusted for age, gender, race, homelessness, smoking, and payer source.

RESULTS

Of 1,178 patients discharged from the medical ICU over the study period, 468 (40%) were readmitted to the hospital and 54 (4%) died within 1 year. Schizophrenia (hazard ratio 2.23, 95% CI 1.57, 3.34, p < 0.001), anxiety disorder (hazard ratio 2.04, 95% CI 1.30, 3.32, p < 0.01), depression (hazard ratio 1.62, 95% CI 1.05, 2.40, p = 0.03), and Deyo comorbidity score ≥3 (hazard ratio 1.43, 95% CI 1.09, 1.89, p = 0.01) were significant predictors of time to death or first rehospitalization. Bipolar disorder was associated with time to first emergency department or urgent care clinic visit (hazard ratio 2.03, 95% CI 1.24, 3.62, p < 0.01) in the 656 patients who were alive and not rehospitalized within 1 year.

CONCLUSIONS

The presence of a psychiatric comorbidity is a significant predictor of multiple measures of unplanned healthcare utilization in medical ICU survivors with a primary or secondary discharge diagnosis of alcohol withdrawal. This finding highlights the potential importance of targeting longitudinal multidisciplinary care to patients with a dual diagnosis.

Polysubstance use in cannabis users referred for treatment: drug use profiles, psychiatric comorbidity and cannabis-related beliefs

BACKGROUND

Population-based surveys demonstrate cannabis users are more likely to use both illicit and licit substances, compared with non-cannabis users. Few studies have examined the substance use profiles of cannabis users referred for treatment. Co-existing mental health symptoms and underlying cannabis-related beliefs associated with these profiles remains unexplored.

METHODS

Comprehensive drug use and dependence severity (Severity of Dependence Scale-Cannabis) data were collected on a sample of 826 cannabis users referred for treatment. Patients completed the General Health Questionnaire, Cannabis Expectancy Questionnaire, Cannabis Refusal Self-Efficacy Questionnaire, and Positive Symptoms and Manic-Excitement subscales of the Brief Psychiatric Rating Scale. Latent class analysis was performed on last month use of drugs to identify patterns of multiple drug use. Mental health comorbidity and cannabis beliefs were examined by identified drug use pattern.

RESULTS

A three-class solution provided the best fit to the data: (1) cannabis and tobacco users (n = 176), (2) cannabis, tobacco, and alcohol users (n = 498), and (3) wide-ranging substance users (n = 132). Wide-ranging substance users (3) reported higher levels of cannabis dependence severity, negative cannabis expectancies, lower opportunistic, and emotional relief self-efficacy, higher levels of depression and anxiety and higher manic-excitement and positive psychotic symptoms.

CONCLUSION

In a sample of cannabis users referred for treatment, wide-ranging substance use was associated with elevated risk on measures of cannabis dependence, co-morbid psychopathology, and dysfunctional cannabis cognitions. These findings have implications for cognitive-behavioral assessment and treatment.