Treatment for Substance Use Disorder With Co-Occurring Mental Illness

Long-acting injectable buprenorphine in the real world: case report on dual disorders

OBJECTIVES

Long-acting injectable buprenorphine (LAIB) has demonstrated a good profile for opioid use disorder (OUD) management. However, there is scarce information on LAIB in OUD patients with comorbid mental disorders (dual disorder patients).

METHODS

We present a case report on OUD patients with a comorbid mental disorder who have received LAIB for at least 3 months.

RESULTS

Two women and one man with OUD and another comorbid mental disorder were prescribed with LAIB ranging from three to twelve months. Good adherence and opioid abstinence were observed during the follow-up. Psychopathological issues related to comorbid mental disorders were stabilized. A deep discussion on LAIB in this profile of patients is conducted.

CONCLUSIONS

LAIB in OUD patients with comorbid mental disorders may be a safe and well tolerated option, similar to OUD patients without comorbid mental disorders. LAIB's impact on psychopathological issues requires further high-quality research to understand the real impact of LAIB on OUD and comorbid mental disorders.

Psychotherapies in opioid use disorder: toward a step-care model

Opioid use disorder (OUD) is characterized by a lack of control in opioid use, resulting in psychological distress and deficits in interpersonal and social functioning. OUD is often associated with psychiatric comorbidities that increase the severity of the disorder. The consequences of OUD are dramatic in terms of increased morbi-mortality. Specific medications and psychotherapies are essential tools not only in the treatment of OUD but also in the prevention of suicide and overdoses. In our review, we assess the different types of psychotherapies (counseling, motivational interviewing, contingency management, cognitive-behavioral therapy, and dialectical-behavior therapy) that are delivered to opioid users, either associated or un-associated with OUD medications and/or medications for psychiatric disabilities. We describe the application of these therapies first to adult opioid users and then to adolescents. This work led us to propose a stepped-care model of psychotherapies for OUD which provided information to assist clinicians in decision-making regarding the selection of psychotherapeutic strategies according to patients' OUD severity.

A formative assessment of client characteristics associated with missed appointments in integrated primary care services in rural Arizona

INTRODUCTION

Integrating primary care services in mental healthcare facilities is an uncommon model of care in the United States that could bring several benefits (e.g., improved access to physical healthcare) for vulnerable populations experiencing mental health conditions, especially those living in underserved regions like rural Arizona.

AIM

This formative assessment aimed to understand the sociodemographic and clinical characteristics of clients accessing integrated primary care (IPC) services implemented in 2021 at a community mental healthcare facility in rural Arizona and to explore the proportion of missed appointments. Additionally, we analysed the association between client characteristics and IPC missed appointments.

METHODS

The authors collaborated with a community mental health facility in rural Arizona, which provided deidentified data from 280 clients who accessed IPC services from June 2021 to February 2022.

RESULTS

Most clients were White and of vulnerable socioeconomic status, with a substantial proportion of Native Americans (23.58%). The majority of clients (55.75%) had a mental health disorder (MHD), 23.74% had a substance use disorder (SUD), and 15.10% had comorbid MHD and SUD. Linear regression revealed that experiencing comorbid MHD and SUD was significantly associated with missed appointments. Compared with White clients, Native Americans missed fewer appointments.

CONCLUSION

Future studies conducted from a culturally-centred perspective are crucial to guide strategies to reduce missed appointments in rural IPC services.

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.

Development of the Enthusiastic Substance Use Attitudes Scale: Preliminary Evidence of a Novel Maintenance Factor

Background: Expectancies, motives, and attitudes toward substances are cognitive factors that partially account for substance use; however, existing measures tend to have monotonous phrasing, diverging from the enthusiastic attitude toward the perceived benefits of substance use exhibited by those who use substances regularly in informal settings. Objective: I aimed to characterize a new cognitive maintenance factor that precedes substance use by creating a brief, multidimensional measure to capture this tone nuance, which I called the Enthusiastic Substance Use Attitudes Scale (ESUAS). Method: Undergraduate students (n = 198) between ages 18 and 62 (M = 19.15, SD = 3.65; 66.2% women; 71.71% White) completed the study for course credit. Results: I used exploratory and confirmatory factor analyses to reduce a 90-item item pool based on a comprehensive qualitative thematic analysis of social media, traditional media, and the scientific literature to an 18-item hierarchical bifactor model. This model contained nine specific factors, which are (1) sociability, (2) enjoyment, (3) physical health, (4) mental health, (5) relaxation, (6) personal growth, (7) performance enhancement, (8) boredom, and (9) life processing; two general factors, which are (1) substance-induced emotion regulation and (2) substance-based assistance; and a higher-order single factor above the nine specific factors - resulting in twelve highly internally consistent, empirically supported scales. Further, the ESUAS demonstrated excellent structural, convergent, divergent, incremental, and diagnostic validity. The degree of enthusiasm towards substance use positively related to substance use disorder symptomology, polysubstance use, neuroticism, and difficulty with regulating emotions while negatively relating to one's psychological quality of life and agreeableness. Conclusion: The ESUAS may be an effective tool for professionals to characterize these enthusiastic attitudes further and measure a more ecologically valid view of the perceived benefits of substance use among those who use substances, thereby developing a more compassionate, non-stigmatizing understanding within the general public, advancing medicinal uses of illicit substances, and improving conceptualizations and treatments.

Polypharmacy in antipsychotic pharmacological treatment among patients with dual diagnosis in Denmark

INTRODUCTION

Antipsychotic polypharmacy is prevalent, however literature on antipsychotic polypharmacy during treatment among patients with dual diagnosis is largely non-existent. This study aims to investigating the extent of antipsychotic polypharmacy dual diagnosis patients during hospitalisations.

METHODS

Utilizing cohort data from an integrated dual diagnosis in-patient facility from patients hospitalized between 1 March 2012, to 31 December 2016, we compared the mean antipsychotic medication administered at admission and discharge and examined covariate associations with logistic regressions.

RESULTS

The study identified 907 hospital admissions, of which 641 were the first for each patient during the period. At admission, 74.1% received antipsychotics; polypharmacy spanned psychiatric disorders. categories. Patients with affective or personality spectrum disorders were less likely to have antipsychotic polypharmacy upon admission compared to those with psychosis spectrum disorders. 2013-2016 admissions presented less polypharmacy than 2012. Mean antipsychotic numbers remained unchanged for >30-day hospitalizations. Patients admitted without antipsychotic polypharmacy with an affective spectrum disorder or aged 41-50 or over 51 years old were less likely to be discharged with antipsychotic polypharmacy when compared to patients with psychosis spectrum disorder or aged 18-30 years old.

CONCLUSION

Approximately three-quarters of admitted patients were treated with antipsychotic medication. Antipsychotic polypharmacy was observed across all psychiatric disorder categories, indicating potential off-label use. Addressing antipsychotic polypharmacy during treatment is challenging, even for specialised facilities. Rational antipsychotic prescribing, deprescribing protocols, and further prescription pattern research are needed.

Gender and addiction and other mental disorders comorbidity: sociodemographic, clinical, and treatment differences

The co-occurrence of substance use disorders (SUD) and other mental disorders (OMD) is assumed to be high, but the details are uncertain in Spain. The objective of the present study was to know the prevalence of this comorbidity, as well as the pharmacological treatment, both in specific addiction treatment networks and in mental health networks, with a gender perspective. Observational, multicenter study, with a randomized sample, of patients under treatment for SUD or OMD in Spain (N = 1783). A specific questionnaire, collecting sociodemographic and clinical variables, diagnosed SUD and OMD, and prescribed psychotropic drugs, was completed by treating clinicians. Differences between females and males were searched. A high prevalence of OMD was found in those patients treated for their SUD (71%), and also of diagnoses of SUD (59%) in people treated for OMD. Significant relationships between addiction to certain substances and specific mental disorders were found (with no main differences between women and men). The treatments for OMD were very common in the addiction treatment networks, but that of SUDs in those patients treated in the mental health networks was less than expected. A high prescription of benzodiazepines was found. Women were less frequently diagnosed with cannabis, opioid, and especially cocaine use disorders, and they had fewer psychotic disorders and more affective, anxiety, sleep, and eating disorders, with the rest being the same, including personality disorders. Women had fewer treatments with agonists and more with antagonists, and more prescriptions of anxiolytics and antidepressants. This study provides preliminary information on the coexistence in routine clinical practice of addictive disorders and other mental disorders in Spain, and on the treatment provided, and shows differences in prevalence and clinical characteristics, and especially in treatment approaches between women and men. Thus, should be useful to adapt the treatment response with greater precision, and with a gender perspective.

Telephone monitoring and 15-month outcomes for patients with co-occurring substance use and mental health disorders: Moderating effects of high-risk patient characteristics

INTRODUCTION

Telephone monitoring interventions for substance use disorders are an important component of continuing care to reduce relapse and connect patients to services. However, a knowledge gap still exists as to which patient groups benefit most from them. This secondary analysis of a randomized controlled trial examined moderators of associations between telephone monitoring and 15-month substance use outcomes among patients with co-occurring substance use and mental health disorders. High-risk patient characteristics at baseline were examined as potential moderators of the effectivness of telephone monitoring, including history of incarceration, severity of depression symptoms, and suicide risk.

METHODS

Participants were 406 psychiatry inpatients with documented substance use and mental health disorders who were randomized to treatment as usual (TAU; n = 199) or TAU plus telephone monitoring (TM; n = 207). Outcomes included abstinence self-efficacy (Brief Situational Confidence Questionnaire) and alcohol and drug use severity (Addiction Severity Index composites) at 15-month follow-up. Analyses examined main effects of treatment condition and moderators, and interactions between treatment condition and moderators.

RESULTS

The study found five significant main effects, three of which were qualified by significant interactions. Incarceration history was associated with higher drug use severity; higher suicide risk was associated with higher abstinence self-efficacy. Regarding interaction effects, among participants with an incarceration history, TM compared to TAU was associated with significantly lower alcohol use severity at 15-month follow-up; this finding did not hold for never-incarcerated participants. For participants with less severe depression symptoms, TM compared to TAU was associated with significantly lower alcohol use severity and higher abstinence self-efficacy at follow-up; this did not hold for participants with more severe depression symptoms. Suicide risk was not a significant moderator of any outcome.

CONCLUSIONS

Results indicate that TM is effective in improving alcohol use severity and abstinence self-efficacy for some subgroups of patients, including patients with an incarceration history or less severe depression. Results inform the clinical provision of substance use disorder care by means of telehealth, which increased due to the COVID-19 pandemic.

Utilising the Implementation of Integrated Care to Develop a Pragmatic Framework for the Sustained Uptake of Service Innovations (SUSI)

The provision of integrated care (IC) across alcohol and other drug (AOD) and mental health (MH) services represents the best practice, yet the consistent delivery of IC in routine practice rarely occurs. Our hypothesis is that there is no practical or feasible systems-change approach to guide staff, researchers, or consumers through the complex transition that is required for the sustained uptake of IC across diverse clinical settings. To address this gap, we combined clinical and consumer expertise with the best available research evidence to develop a framework to drive the uptake of IC. The goal was to develop a process that is both standardised by the best available evidence and can be tailored to the specific characteristics of different health services. The result is the framework for Sustained Uptake of Service Innovation (SUSI), which comprises six core components that are applied in a specified sequence and a range of flexible activities that staff can use to deliver the core components according to their circumstances and preferences. The SUSI is evidence-based and practical, and further testing is currently underway to ensure it is feasible to implement in different AOD and MH services.

Sleep Apnea and Substance Use Disorders Associated with Co-Occurrence of Anxiety Disorder and Depression among U.S. Adults: Findings from the NSDUH 2008-2014

Few studies have focused on sleep apnea and substance use disorders with co-occurrence of anxiety disorder and depression. This study included a total of 270,227 adults, 9268 with co-occurrence of anxiety disorder and depression in the past year, from the combined 2008-2014 National Survey on Drug Use and Health (NSDUH) data, which are the latest datasets with measures of anxiety disorder and sleep apnea. Weighted multinomial logistic regression analyses were used to estimate the associations between anxiety disorder and depression and their co-occurrence. Comorbidity was highly prevalent: 40.4% of those with depression also met the criteria for anxiety disorder, whereas 51.8% of those with anxiety disorder also met the criteria for depression. The prevalences of anxiety only and co-occurrence increased from 2008 to 2014. The prevalences of anxiety disorder only, depression only, and co-occurrence of anxiety disorder and depression in individuals with sleep apnea were 4.4%, 12.9%, and 12.2%, respectively, and the prevalences in substance use disorders were 6.4%, 9.4%, and 10.7%, respectively. The results showed that sleep apnea, substance use disorders, and nicotine dependence were significantly associated with increased odds of anxiety disorder, depression, and co-occurrence (all p values < 0.0001). Furthermore, several chronic diseases (asthma, bronchitis, hypertension, and heart disease) were associated with the co-occurrence of anxiety disorder and depression. These findings suggest clinicians and other healthcare providers consider screening for depression and anxiety with sleep apnea and substance use disorders for improved therapeutic outcomes.

Differences in Substance Use Disorders and Other Mental Disorders in Mental Health and Addiction Settings: Sociodemographic, Clinical, Drug Treatment, and Gender Differences

Different care networks in Spain evaluate the co-occurrence of substance use disorders (SUD) and other mental disorders (OMDs). This study aimed to explore the differences in prevalence, sociodemographic and clinical profile, pharmacological treatment, and gender perspective of the co-occurrence of SUD and OMD between specific addiction treatment networks and mental health networks. This is an observational, cross-multicenter study with a randomized sample of patients under treatment for SUD or OMDs in different autonomous communities of Spain (N = 1783). Sixty-seven health professionals completed an ad hoc online questionnaire, collecting sociodemographic variables with patients diagnosed with SUD and OMDs, and their pharmacological treatments. The findings revealed a high prevalence of OMD in patients treated for SUD (71%) and those for OMD diagnosed with SUD (59%). Specific relationships between the SUDs and OMDs were identified. In networks treating SUDs, the increase in treatment for OMDs was widespread. However, the addition of SUD treatments in mental health networks was less frequent than expected. In addition, an elevated benzodiazepine prescription was detected in both settings. Some possible gender biases in treatments were found. This study provides preliminary information on the coexistence in routine clinical practice of addictive disorders and other mental disorders in Spain. The results revealed that the treatments provided are inefficient for SUDs in patients treated in mental health settings. Furthermore, a high prescription of anxiolytics and differences by sex are shown. These findings may contribute to adapting the treatment response with greater precision and effectiveness.

Psychiatric and substance use disorders in a predominately low-income, black sample in early midlife

Decades of research have documented elevated rates of psychopathology among individuals affected by poverty. However, many studies have relied on predominately White samples, and on brief symptom screening measures which may not fully capture the experiences of individuals of color (who are disproportionately affected by poverty in the United States.) The present study examines prevalence rates of probable major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder, substance use disorder, and alcohol use disorder in a predominately Black sample that grew up in urban poverty, utilizing structured neuropsychiatric interview methods. Data are drawn from a subsample of the Chicago Longitudinal Study (CLS), which has followed a large cohort for over four decades. Outcomes were assessed using the Mini International Neuropsychiatric Interview (M.I.N.I.) 7.0.2. Results indicate high probable rates of all measured outcomes, with notably high rates of substance use and alcohol use disorder compared to rates reported in previous national studies. Differences by sex and childhood neighborhood poverty, as well as significant comorbidity among psychiatric, substance and alcohol use disorders were also detected. Findings underscore an urgent need for community-based, culturally tailored prevention and intervention initiatives to support the mental health of individuals living in poverty. The high prevalence of psychiatric, substance and alcohol use disorders in this study likely reflect systematic inequities faced by low-income people of color in the United States. Future directions for research and practice are discussed.

'The Drugs Did For Me What I Couldn't Do For Myself': A Qualitative Exploration of the Relationship Between Mental Health and Amphetamine-Type Stimulant (ATS) Use

Substance use and mental ill health constitute a major public health burden, and a key global policy priority is to reduce illicit and other harmful substance use. Amphetamine-type stimulants (ATS) are the second most used class of illicit drugs and a range of mental health issues have been documented amongst users. This paper explores the relationship between mental health and ATS use, through a thematic analysis of qualitative interviews with n = 18 current and former ATS users in England. The findings are presented by trajectory point of; (1) Initiation of ATS use; (2) continued and increased ATS use and (3) decreased and remitted ATS use. This work helps to develop understanding around the complex and bi-directional relationship between ATS use and mental health. Many ATS users lead chaotic lives and engage in multiple risk behaviours, however there is a need to better understand and conceptualise the dynamic interaction between different individual, social, environment and cultural factors that determine individuals’ mental health and substance use. There is no ‘one size fits all’ approach to prevention and treatment, and these findings highlight the need for more joined-up, tailored and holistic approaches to intervention development.

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.

Gender Differences in Depression and Quality of Life in Current and Abstinent Ketamine Users

Ketamine use has become of increasing concern because it has spread in many parts of the world during the past few years. Substance users usually have depression and a lower quality of life (QoL). The aim of this study was to explore depression and QoL in ketamine users, and to further examine the role of gender in relation to differences in depression and QoL in ketamine users. This study recruited 204 current ketamine users, 102 abstinent ketamine users and 102 healthy controls. The demographic data, severity of depression and QoL were recorded. Analysis of Variance (ANOVA) was employed to compare the associations of ketamine use status with depression and QoL. Gender differences were examined by moderator analysis. The current ketamine users with and without ketamine use disorder, in addition to the abstinent ketamine users with ketamine use disorder, have more severe depression and a lower QoL than healthy controls. There were significant gender differences in depression and QoL in abstinent ketamine users with ketamine use disorder. Ketamine users have more severe depression and a lower QoL. In particular, depression and a lower QoL are still prominent in abstinent ketamine users. The gender differences in depression and QoL are significant in abstinent ketamine users.

Recent/Childhood Adversities and Mental Disorders Among US Immigrants

Past research documents the heterogeneity in US immigrants, particularly in terms of racial and ethnic categories and specific ethnic subgroups. The present study builds on this research foundation by investigating heterogeneity in immigrants' experiences of adversity, both recent and during childhood, and associations with mental disorders. Data are drawn from 6,131 adult immigrants in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III. Prevalence estimates for mental disorders and adversities were calculated overall and by gender. Latent class analysis was utilized to characterize patterns of self-reported experiences of childhood and recent adversities, and multinomial logistic regression established the statistical association between latent class membership and past-year mental disorder outcomes (substance use disorder only, mood/anxiety/trauma disorder only, co-occurring disorder, or no mental disorder). Neglect was the most commonly-reported childhood adversity among immigrant men and women. Prevalence of meeting criteria for a substance use disorder only, or a mood/anxiety/trauma disorder only, varied between men and women, yet no gender differences were observed in prevalence of co-occurring disorders. For latent class analyses, a five-class solution was selected based on fit indices and parsimony. Approximately 10.0% of the sample was categorized in the latent class characterized by severe childhood adversities, while 57.5% was classified in the latent class with low probabilities of reported adversities. The relative risk of meeting criteria for a past-year substance use disorder only (compared to no substance use or mood/anxiety/trauma disorder) was more than three times as high for members of the class with severe childhood adversities (RRR, 3.26; 95% CI, 2.08-5.10), as well as the class with recent employment/financial adversities (RRR, 3.82; 95% CI, 2.36-6.19), compared to the class with low adversities. The relative risk of past-year co-occurring disorders (compared to no disorder) was more than 12 times as high for those in the severe childhood adversities class (RRR, 12.21; 95% CI, 7.06-21.10), compared to the class with low adversities. Findings underscore the importance of considering both recent and childhood adversities when assessing and providing services for US immigrant groups.

Attention Deficit/Hyperactivity Disorder and Global Severity Profiles in Treatment-Seeking Patients with Substance Use Disorders

INTRODUCTION

Comorbid attention deficit/hyperactivity disorder (ADHD) is present in 15-25% of all patients seeking treatment for substance use disorders (SUDs). Some studies suggest that comorbid ADHD increases clinical severity related to SUDs, other psychiatric comorbidities, and social impairment, but could not disentangle their respective influences.

OBJECTIVES

To investigate whether comorbid adult ADHD in treatment-seeking SUD patients is associated with more severe clinical profiles in these domains assessed altogether.

METHODS

Treatment-seeking SUD patients from 8 countries (N = 1,294: 26% females, mean age 40 years [SD = 11 years]) were assessed for their history of DSM-IV ADHD, SUDs, and other psychiatric conditions and sociodemographic data. SUD patients with and without comorbid ADHD were compared on indicators of severity across 3 domains: addiction (number of SUD criteria and diagnoses), psychopathological complexity (mood disorders, borderline personality disorder, lifetime suicidal thoughts, or behavior), and social status (education level, occupational and marital status, and living arrangements). Regression models were built to account for confounders for each severity indicator.

RESULTS

Adult ADHD was present in 19% of the SUD patients. It was significantly associated with higher SUD severity, more frequent comorbid mood or borderline personality disorder, and less frequent "married" or "divorced" status, as compared with the absence of comorbid ADHD. ADHD comorbidity was independently associated with a higher number of dependence diagnoses (OR = 1.97) and more psychopathology (OR = 1.5), but not marital status.

CONCLUSIONS

In treatment-seeking SUD patients, comorbid ADHD is associated with polysubstance dependence, psychopathological complexity, and social risks, which substantiates the clinical relevance of screening, diagnosing, and treating ADHD in patients with SUDs.