Physical and Mental Comorbidity of Substance Use Disorders in Psychiatric Consultations

Preadult polytoxicomania-strong environmental underpinnings and first genetic hints

Considering the immense societal and personal costs and suffering associated with multiple drug use or "polytoxicomania", better understanding of environmental and genetic causes is crucial. While previous studies focused on single risk factors and selected drugs, effects of early-accumulated environmental risks on polytoxicomania were never addressed. Similarly, evidence of genetic susceptibility to particular drugs is abundant, while genetic predisposition to polytoxicomania is unexplored. We exploited the GRAS data collection, comprising information on N~2000 deep-phenotyped schizophrenia patients, to investigate effects of early-life environmental risk accumulation on polytoxicomania and additionally provide first genetic insight. Preadult accumulation of environmental risks (physical or sexual abuse, urbanicity, migration, cannabis, alcohol) was strongly associated with lifetime polytoxicomania (p  = 1.5 × 10^-45; OR = 31.4), preadult polytoxicomania with OR = 226.6 (p = 1.0 × 10^-33) and adult polytoxicomania with OR = 17.5 (p = 3.4 × 10^-24). Parallel accessibility of genetic data from GRAS patients and N~2100 controls for genome-wide association (GWAS) and phenotype-based genetic association studies (PGAS) permitted the creation of a novel multiple GWAS-PGAS approach. This approach yielded 41 intuitively interesting SNPs, potentially conferring liability to preadult polytoxicomania, which await replication upon availability of suitable deep-phenotyped cohorts anywhere world-wide. Concisely, juvenile environmental risk accumulation, including cannabis and alcohol as starter/gateway drugs, strongly predicts polytoxicomania during adolescence and adulthood. This pivotal message should launch more effective sociopolitical measures to prevent this deleterious psychiatric condition.

Let's get physical: improving the medical care of people with severe mental illness

There is clear evidence of increased medical comorbidity and related mortality in people with severe mental illness, despite numerous guidelines for managing medical conditions in this population. This article assesses inequalities in medical treatment and preventive healthcare received by psychiatric patients compared with the general population. It considers whether the medical care provided is adequate and whether published guidelines improve it. Mental health specialists, general practitioners and hospital specialists appear to deliver poorer than average medical care for this vulnerable population. Implementation of physical healthcare guidelines is incomplete and the guidelines must be matched with resources to address this deficit.

Prevalence, correlates and treatment status of alcohol use disorders in psychiatric patients in China

OBJECTIVE

To determine the prevalence, associated factors and treatment status of alcohol use disorders (AUDs) in psychiatric patients in China.

METHODS

We asked 24,379 consecutive patients aged ≥18years who presented at the psychiatric departments in eight hospitals in 2013 whether they had consumed alcoholic beverages in the previous month. Of the 2964 (12.2%) patients who answered yes and were then screened with the Alcohol Use Disorders Identification Test (AUDIT), 1304 (5.3%) screened positive (AUDIT≥7) and, based on DSM-IV criteria, were diagnosed with AUDs by psychiatrists. The treatments prescribed for them were also recorded. Logistic regression was used to identify AUDs associated factors.

RESULTS

The prevalence of AUDs was 2.4% (95% CI: 2.2-2.6%). None of the patients diagnosed with AUDs had got medical treatment for preventing relapse. The risk factors for AUDs were middle-aged or elderly (OR=1.86, 95% CI: 1.23-2.80), and consuming beverages with high degree of alcohol content (OR=2.92, 95% CI: 2.11-4.06).

CONCLUSIONS

The prevalence of AUDs in psychiatric patients in China was not high, but the rate of treatment was dramatically low, indicating the serious neglect of AUDs. Our study suggests an urgent need to improve the situation of unmet need for treatment of psychiatric patients with AUDs.

The epidemiology and progression time from transient to permanent psychiatric disorders of substance-induced psychosis in Taiwan

INTRODUCTION

Substance-induced psychosis (SIP), including alcohol-induced psychotic disorder (AIPD) and substance-induced psychotic disorder (SIPD), is gradually increasing in importance in clinical practice. However, few studies have investigated the epidemiology and progression time from transient to permanent psychiatric disorders for AIPD and SIPD patients.

METHODS

We utilized the National Health Insurance Research Database (NHIRD) to investigate the incidence and prevalence of AIPD and SIPD in Taiwan and determined the timing of AIPD or SIPD followed by the development of persistent psychotic conditions.

RESULTS

The average incidence and prevalence were 1.97 and 2.94 per 100,000 person-years for AIPD, 3.09 and 5.67 per 100,000 person-years for SIPD in Taiwan. Moreover, 10.9% to 24.3% of subjects with either AIPD or SIPD had a change in diagnosis to either schizophrenia or affective disorder, and ~50% of patients had a psychotic or affective transformation in their first year after AIPD and SIPD diagnoses. The mean progression time of psychotic or affective transformation was 1.9 to 2.7 years.

CONCLUSIONS

SIP is a predictive factor for persistent psychotic and affective transformation, and a three-year follow-up may be an optimal clinical practice to prevent psychotic or affective transformation in 60% of patients.

Does on-site urine toxicology screening have an added diagnostic value in psychiatric referrals in an emergency setting?

OBJECTIVE

The objective was to examine the added diagnostic value of on-site urine toxicology screening (UTS) in the routine assessment of psychiatric patients in an urban emergency setting.

METHOD

A naturalistic two-step prospective cohort study design was used enrolling all emergency room (ER) patients referred for psychiatric consultation. In two consecutive cohorts, diagnosis of drug use was assessed based on routine psychiatric interview without (n=64) and with on-site UTS (ACON) (n=56). In both cohorts, drug use was also assessed by post hoc laboratory-based urine immunoassay (Triage) as the gold standard.

RESULTS

Sensitivity and specificity of diagnosis of drug use based on psychiatric interview only varied (0.75 and 1 in the interview-based cohort; 0.5 and 0.75 in the interview+on-site UTS cohort). The sensitivity and specificity of on-site UTS were 0.93 and 0.97.

CONCLUSIONS

In an ER setting, the validity of the diagnosis of drug abuse exclusively based on psychiatric interview is low. The use of on-site UTS provides accurate data on drug use and is more practical as compared to post hoc laboratory assessment. On-site UTS has an added diagnostic value of drug use with high sensitivity and specificity.

Quality of medical care for people with and without comorbid mental illness and substance misuse: systematic review of comparative studies

BACKGROUND

There has been long-standing concern about the quality of medical care offered to people with mental illness.

AIMS

To investigate whether the quality of medical care received by people with mental health conditions, including substance misuse, differs from the care received by people who have no comparable mental disorder.

METHOD

A systematic review of studies that examined the quality of medical care in those with and without mental illness was conducted using robust critical appraisal techniques.

RESULTS

Of 31 valid studies, 27 examined receipt of medical care in those with and without mental illness and 10 examined medical care in those with and without substance use disorder (or dual diagnosis). Nineteen of 27 and 10 of 10, respectively, suggested inferior quality of care in at least one domain. Twelve studies found no appreciable differences in care or failed to detect a difference in at least one key area. Several studies showed an increase in healthcare utilisation but without any increase in quality. Three studies found superior care for individuals with mental illness in specific subdomains. There was inadequate information concerning patient satisfaction and structural differences in healthcare delivery. There was also inadequate separation of delivery of care from uptake in care on which to base causal explanations.

CONCLUSIONS

Despite similar or more frequent medical contacts, there are often disparities in the physical healthcare delivered to those with psychiatric illness although the magnitude of this effect varies considerably.

Psychiatric consultation and substance use disorders

Background

A substantial number of patients in general hospitals will evince substance abuse problems but a majority is unlikely to be adequately identified in the referral-consultation process. This failure may preclude patients from receiving effective interventions for substance use disorders.

Objectives

1. To evaluate all referred patients for possible substance use disorders. 2. To ascertain the degree of convergence between patients referred for chemical problems and the corresponding DSM diagnosis. 3. To compare demographic data for substance abusing patients and referrals not so classified. 4. To evaluate conditions concomitant with substance use disorders.

Method

Consecutive one-year referrals (524) to consultation-liaison psychiatric services were scrutinized for chemically-related problems by psychiatric consultants.

Results

Of the referrals, 176 met criteria for substance use disorders (SUD) (57% alcohol; 25% other drugs; 18% both alcohol and other drugs). Persons diagnosed with SUD tended to be younger, male, non-Caucasian, unmarried, and unemployed. They were more likely to be depressed, have liver and other gastrointestinal problems, and to have experienced traumatic events; they also tended to have current financial difficulties. Most were referred for SUD evaluation by personnel in general medicine and family practice. Following psychiatric consultation, SUD designated patients were referred mainly to substance abuse treatment programs. The only variable related to recommended inpatient versus outpatient services for individuals with SUD was the Global Assessment of Functioning Axis (GAF) with persons having lower estimated functioning more likely to be referred for inpatient interventions.

Conclusions

These data are similar to the results of past studies in this area. Unlike previous investigations in the domain of consultative-liaison psychiatry, financial stressors and specific consultant recommendations were included in data gathering. Although the results are encouraging in that individuals with SUD were identified and potentially sent for appropriate treatment, the likelihood is that many patients with SUD remain unrecognized and do not receive necessary consultative and treatment services.

The role of medical conditions and primary care services in 5-year substance use outcomes among chemical dependency treatment patients

INTRODUCTION

Health problems are prevalent in chemical dependency (CD) treatment populations, and often precede reductions in substance use among untreated populations. Few studies have examined whether medical problems predict better long-term outcomes in treated individuals, or how primary care utilization and CD/primary care service integration affects long-term outcomes among those with health problems.

METHOD

In a sample of 598 CD patients in a private health plan, logistic regression models examined whether substance abuse-related medical conditions (SAMCs), integrated medical and CD care, and on-going primary care predicted remission of CD problems at 5 years.

RESULTS

Those with SAMCs were no more likely than others to be remitted at 5 years except among young adults and those with medical, but not psychiatric SAMCs. Higher levels of medical problem severity at intake and receiving integrated CD and primary care in the index treatment episode predicted remission in the full sample and among those with SAMCs. Among those with SAMCs, individuals with ongoing medical care - 2-10 primary care visits - in the 5 years following intake were more likely to be remitted at 5 years than those with fewer visits.

CONCLUSIONS

This study highlights the potentially important role of medical services in the long-term treatment of CD disorders. CD treatment may benefit from a disease management approach similar to that recommended for other chronic medical problems: specialty care when the condition is severe followed by services in primary care when the condition is stabilized.

Nine-year psychiatric trajectories and substance use outcomes: an application of the group-based modeling approach

This study identifies longitudinal psychiatric trajectories of 934 adult individuals entering chemical dependency treatment in a private, managed care health plan and examines the relationship of these trajectories with substance use (SU) outcomes. The authors apply a group-based modeling approach to identify trajectory groups based on repeated measures of psychiatric severity for 9 years and identify four distinct groups. Results of multivariate logistic generalized estimating equation models find an association between psychiatric trajectories and long-term SU. Older cohorts and life course measures of marital status and employment status as individuals changed over time are related to drug and some alcohol outcomes.

Adolescents with co-occurring substance use and mental conditions in a private managed care health plan: prevalence, patient characteristics, and treatment initiation and engagement

This study examined the prevalence, patient characteristics, and treatment initiation and engagement of adolescents with co-occurring substance use (SU) and serious mental health (MH) diagnoses in a private, managed care health plan. We identified 2,005 adolescents aged 12-17, who received both SU and MH diagnoses within a 1-year window between 1/1/2000 and 12/31/2002; 57% were girls. Gender variations were found in diagnoses received and point of identification. Being dually diagnosed in specialty departments (rather than Primary Care and Emergency) and receiving both diagnoses within a shorter time period were associated with treatment initiation and engagement.

Measuring levels of comorbidity in drug user* emergency patients treated in Ontario hospitals

We examined the nature and extent of health problems in drug user patients initially treated in emergency departments and who were subsequently admitted to all hospitals in Ontario, using data from the Hospital Medical Records Institute (HMRI). The modified standardized morbidity ratio (modified SMR) is introduced to improve the measurement and visual display of reduced morbidity as well as excess morbidity. During 1985-86, about 75% of drug user patients entered hospital through the emergency department. There were 5077 emergency patients with primary drug use-related diagnoses and 9827 with secondary drug use-related diagnoses. Cases with poisoning diagnosis made up over 80% of all drug use cases treated in emergency departments. Cases with non-dependent abuse of drugs accounted for 8-12% of emergency drug user patients, whereas those with drug dependence accounted for about 3% of emergency drug user patients. These patients had more than three times the comorbidity experience of all hospital patients. They had excess comorbidity due to mental disorders, infectious and parasitic disorders, and injury and poisoning diagnoses. However, they had reduced comorbidity due to complications of pregnancy, childbirth, and the puerperium and from congenital anomalies and conditions originating in the perinatal period. Cocaine patients were more likely to have infectious parasitic diseases and diseases of the skin and subcutaneous tissue, while amphetamine patients were more likely to have diseases of the digestive system and of the musculo-skeletal system and connective tissue.

Utilization and cost impact of integrating substance abuse treatment and primary care

OBJECTIVE

To examine the impact of integrating medical and substance abuse treatment on health care utilization and cost.

RESEARCH DESIGN

Randomized clinical trial assigning patients to one of two treatment modalities: an Integrated Care model where primary health care is provided along with substance abuse treatment within the unit and an Independent Care model where medical care is provided in the HMO's primary care clinics independently from substance abuse treatment.

SUBJECTS

Adult patients entering treatment at the outpatient Chemical Dependency Recovery Program in Kaiser Sacramento.

MEASURES

Medical utilization and cost for 12 months pretreatment and 12 months after treatment entry.

RESULTS

For the full, randomized cohort, there were no statistically significant differences between the two treatment groups over time. However, among the subset of patients with substance abuse related medical conditions (SAMC), Integrated Care patients had significant decreases in hospitalization rates (P = 0.04), inpatient days (P = 0.05) and ER use (P = 0.02). Total medical costs per member-month declined from 431.12 US dollars to 200.03 US dollars (P = 0.02). Among SAMC Independent Care patients, there was a downward trend in inpatient days (P = 0.08) and ER costs (P = 0.05) but no statistically significant decrease in total medical cost.

CONCLUSIONS

(Non)findings for the full sample suggest that integrating substance abuse treatment with primary care, may not be necessary or appropriate for all patients. However, it may be beneficial to refer patients with substance abuse related medical conditions to a provider also trained in addiction medicine. There appear to be large cost impacts of providing integrated care for such patients.

Six-month outcomes of hospital-based psychiatric substance use consultations

Substance use disorders and their health complications are prevalent in general hospitals. Among intervention measures, specialized substance use consultations by a general hospital psychiatric consultation team have been described. Because outcome data are scanty, effectiveness of specialist consultations is not known. To analyze effectiveness of focused, semistructured consultations by clinically competent consultants, we conducted a prospective 6-month follow-up in a hospital-based psychiatric substance use consultation service. We aimed to measure severity of dependence and changes in substance use and to find out which variables at the consultation anticipated abstinence or reduction in substance use. Among general hospital patients referred for substance use consultation, 30% (46/155) of the male patients and 56% (35/63) of the female patients reported either abstinence or reduction in substance use at the 6-month follow-up. Changes in weekly alcohol consumption and SADD (Short Alcohol Dependence Data) scores were statistically significant (P<0.001) and clinically highly meaningful. Absence of earlier psychiatric or substance use treatment and fewer adverse substance use consequences predicted reduction in substance use. Compliance and outcomes were remarkable among female patients, and improvement was promoted by unbroken family relations. In all, hospital-based psychiatric substance use consultations seemed to be effective as the only treatment among socially adjusted substance use patients, whereas patients with psychiatric comorbidity and/or chronic substance use problems needed more vigorous help.