Scope, quality and inclusivity of international clinical guidelines on mental health and substance abuse in relation to dual diagnosis, social and community outcomes: a systematic review

Classes of outpatient quality of care among individuals with substance-related disorders, based on a survey and health insurance registry

OBJECTIVES

Improving quality of care for individuals with substance-related disorders (SRD) should be a priority considering SRD are associated with high morbidity. This study aimed to identify classes of individuals with SRD based on their clinical characteristics and the quality of outpatient care they received, and to verify whether better quality of care was associated with other respondent characteristics and more favorable subsequent outcomes.

METHODS

Data came from the 2023-14 and 2015-16 Canadian Community Health Survey (N = 42,099), merged with administrative data from Quebec's health insurance registry. Investigating a cohort of 1473 individuals with SRD, we conducted Latent class analysis based on the respondents' diagnoses and outpatient quality of care indicators such as access, diversity, continuity and regularity of care received in the 12 months preceding interview. Chi-Square, Fisher's exact tests or t-tests, and logistic regression associate classes with sociodemographic and health behavior (e.g., suicidal behaviors) correlates, and outcomes (repeated emergency department use, hospitalization, quality of life) over the three months following interview, respectively.

RESULTS

The study identified four classes: (1) Individuals with polysubstance-related disorders and other health disorders, receiving high diversity and moderate regularity of care (6 % of sample); (2) Individuals with alcohol-related disorders, receiving low quality of care (41 %); (3) Individuals with drug-related disorders, receiving high overall quality of care (9 %); and (4) Individuals with alcohol-related disorders, receiving high continuity of family doctor care (44 %). Classes 2 and 4 showed better social conditions (e.g., higher education), health behaviors, and subsequent outcomes than Classes 1 and 3, despite receiving lower quality of care - especially mental healthcare.

CONCLUSION

Study outcomes related more to health and social conditions than to the quality of outpatient care received, especially as outpatient care alone might not meet needs of Classes 1 and 3 individuals having important health and social issues, unmet care needs and worse outcomes. Results suggest that interventions like assertive community treatment or intensive case management with integrated SRD-mental health disorders treatment could better respond to the needs of Classes 1 and 3. Overall, enhanced care, including peer support, might benefit all individuals with SRD.

Impulsivity and Cognitive Functioning in Inpatients with Concurrent Disorders: A Comparative Study with Healthy Controls and Evaluation of Treatment-Related Changes: Impulsivité et fonctionnement cognitif chez les patients hospitalisés présentant des troubles concomitants : étude comparative avec des témoins sains et évaluation des changements liés au traitement

OBJECTIVE

This study investigated impulsivity and working memory among CD inpatients across treatment and compared to controls.

METHODS

Patients (N = 56, Mage = 38.2, SD = 11.7, 17F) and healthy controls (N = 50, Mage = 31.9, SD = 10.0, 25F) completed a battery of self-report questionnaires and behavioural tasks assessing working memory and impulsivity (response inhibition, delay discounting, reflection, decision-making). Patients were assessed within 2 weeks of admission (baseline) and at 6 months (follow-up). Controls completed a single session at baseline. Patient demographics, diagnostic status, and treatment outcome (discharge with or without medical advice) were retrieved from medical records.

RESULTS

Group differences in demographics were probed for inclusion as covariates. At baseline, patients had greater self-reported impulsivity on the UPPS-P (negative and positive urgency) and BIS (motor and non-planning), and greater delay discounting than controls. Among patients, there was no association between treatment adherence and working memory, self-report, or behavioural impulsivity, and no change in behavioural impulsivity was observed from baseline to follow-up.

CONCLUSIONS

This is the first study to assess impulsivity and working memory in the context of CD treatment. Patients exhibited greater impulsivity on choice-based and various self-report measures. The absence of treatment-related changes in impulsivity and working memory outcomes suggests that conventional treatments may be neglecting to target potentially key areas of functioning. Further research is needed to examine how treatment affects impulsivity and related functions in individuals with CD, and their impact on clinical outcomes.

Tobacco use disorder in patients with other mental disorders: a dual disorder perspective from clinical neuroscience

Tobacco smoking is the leading cause of disability and preventable deaths worldwide, but it should be differentiated from tobacco use disorder, which is, according to the Diagnostic and Statistical Manual of Mental Disorders, a bona fide mental disorder. The rapid delivery of nicotine to the brain activates acetylcholine receptors and stimulates the release of dopamine, both systems implicated in other mental disorders. Rates of tobacco use disorder are much higher among people suffering from other mental disorders and these patients find it more difficult to quit. Dual disorders, from a transdiagnostic perspective, identify patients with substance use disorder, in this case tobacco use disorder, and other mental disorders. A dual disorder is a complex clinical condition that is often underdiagnosed, undertreated, and difficult to manage. Appropriate and integrated tobacco use disorder treatment programs for people also suffering from other mental disorders could improve outcomes. Bio-psycho-social approaches to tobacco use disorder include specific biological treatments (e.g., bupropion, varenicline, cytisine, nicotine replacement therapy or deep trans-magnetic stimulation). However, these treatments don't have the same outcomes in patients with dual disorders. Therefore, as in other dual disorders, harm reduction measures, such as vaping nicotine through electronic cigarettes or tobacco replacement therapies should be considered as alternative tools for dual tobacco use disorder management. These clinical considerations emerge from a narrative literature review and expert consensus and will specifically address considerations for changes in clinical practice to improve the treatment of tobacco use disorder and other mental disorders.

Conceptualization and characterization of "primary" and "secondary" cognitive impairment in schizophrenia

Cognitive impairment represents one of the core features of schizophrenia, involves both neurocognition and social cognition domains, and has a significant negative impact on real-world functioning. The present review provides a framework for the conceptualization and characterization of "primary" and "secondary" cognitive impairment in schizophrenia. In this conceptualization, primary cognitive impairment can be defined as a consequence of the neurobiological alterations that underlie psychopathological manifestations of the disorder, while secondary cognitive impairment can be defined as the results of a source issue that has a negative impact on cognitive performance. Sources of secondary cognitive impairment are frequent in people with schizophrenia and include several different factors, such as positive and negative symptoms, depressive symptoms, autistic symptoms, pharmacotherapy, substance abuse, metabolic syndrome, social deprivation, and sleep disorders. It can be hypothesized that secondary cognitive impairment may be improved by effectively resolving the source issue, while primary cognitive impairment may benefit from dedicated treatment. Further research is required to confirm this hypothesis, to better characterize the distinction between primary and secondary cognitive impairment in a clinical and in a neurobiological perspective, and to evaluate the impact of systematically assessing and treating secondary cognitive impairment.

Cariprazine as a maintenance treatment in dual schizophrenia: a 6-month observational study in patients with schizophrenia and cannabis use disorder

Schizophrenia is often associated with substance use disorders, particularly cannabis use disorder (CUD). However, treatments frequently fail to address both conditions simultaneously. This study aimed to evaluate the antipsychotic effectiveness of cariprazine in patients with both schizophrenia and CUD in a real-world setting. A 6-month observational study was conducted on 58 patients diagnosed with schizophrenia and CUD, treated with cariprazine. Antipsychotic effectiveness was measured using the Positive and Negative Syndrome Scale and the Clinical Global Impression-Schizophrenia Scale, along with the Improvement and Severity scales. Cannabis consumption and addiction severity were assessed using the Cannabis Abuse Screening Test and the Severity of Dependence Scale, while functioning was evaluated with the Sheehan Disability Inventory. Cariprazine treatment resulted in significant improvements in schizophrenia symptoms (Positive and Negative Syndrome Scale change: -47.88 points, P < 0.0001; Clinical Global Impression-Schizophrenia Scale change: -8.26 points, P < 0.0001). Cannabis use and dependence also decreased (Cannabis Abuse Screening Test change: -7.0 points, P < 0.0001; Severity of Dependence Scale change: -7.88 points, P < 0.0001), alongside improvements in functioning (Sheehan Disability Inventory change: -9.48 points, P < 0.0001). These results suggest that cariprazine is effective for both schizophrenia and CUD, though further research is needed to confirm these findings.

Definition, assessment and treatment of cognitive impairment associated with schizophrenia: expert opinion and practical recommendations

A considerable proportion of patients with schizophrenia perform below population norms on standardized neuropsychological tests, and the performance of those performing within normal range is lower than predicted based on parental education. Cognitive impairment predates the onset of psychosis, is observed during symptom remission and in non-affected first-degree relatives of patients. At the present time, cognitive deficits are regarded as key features of schizophrenia, important determinants of poor psychosocial outcome and targets for both pharmacological and non-pharmacological treatment strategies. A group of eight key opinion leaders reviewed and discussed latest advances in scientific research and current good clinical practices on assessment, management, and treatment of CIAS. In the present paper they summarize the current evidence, identify main gaps between current knowledge and mental health services clinical practice, and provide practical recommendations to reduce the gap.

Expectations and needs of people with illicit substance use disorders in general practice: a qualitative study in Belgium

BACKGROUND

People who use illicit drugs cumulate medical and psychosocial vulnerabilities, justifying a rounded health approach. Both caregivers and patients can form barriers to accessing care, leading to inadequate care. This study aimed to identify the needs and expectations of such patients in general practice.

METHODS

Qualitative research was conducted using semi-structured interviews with 23 people with illicit substance use disorder in Brussels in 2020. Multicentric recruitment was conducted to obtain a heterogeneous mix of sociodemographic profiles and care trajectories. Thematic analysis was performed using RQDA package software.

RESULTS

Participants highlighted several vulnerabilities. These include the presence of significant self-stigmatization and guilt, sometimes to the extent of self-dehumanization, even after years of care, and overdoses masking suicide attempts and early memory disorders. Multiple substance use, smoking in almost all participants, and misuse of benzodiazepines were also noted. The majority of participants expressed the need for an open-minded, non-stigmatizing and empathic GP with a holistic approach that could guide them throughout their life course. The competencies of the GPs in the field of addiction seemed secondary to the participants. Knowledge and good collaboration with the mental health network were assets.

CONCLUSION

Participants expressed the need for GPs with good interpersonal skills, including a non-stigmatizing attitude. The care coordinator role of the GP was highlighted as a key element, as it was a holistic approach focusing on global health (including the social determinants of health) and not only on substance use disorders.

Interventions targeting patients with co-occuring severe mental illness and substance use (dual diagnosis) in general practice settings - a scoping review of the literature

BACKGROUND

People with dual diagnosis die prematurely compared to the general population, and general practice might serve as a setting in the healthcare system to mend this gap in health inequity. However, little is known about which interventions that have been tested in this setting.

AIM

To scope the literature on interventions targeting patients with dual diagnosis in a general practice setting, the outcomes used, and the findings.

DESIGN AND SETTING

A scoping review of patients with dual diagnosis in general practice.

METHODS

From a predeveloped search string, we used PubMed (Medline), PsychInfo, and Embase to identify scientific articles on interventions. Studies were excluded if they did not evaluate an intervention, if patients were under 18 years of age, and if not published in English. Duplicates were removed and all articles were initially screened by title and abstract and subsequent fulltext were read by two authors. Conflicts were discussed within the author group. A summative synthesis of the findings was performed to present the results.

RESULTS

Seven articles were included in the analysis. Most studies investigated integrated care models between behavioural treatment and primary care, and a single study investigated the delivery of Cognitive Behavioral treatment (CBT). Outcomes were changes in mental illness scores and substance or alcohol use, treatment utilization, and implementation of the intervention in question. No studies revealed significant outcomes for patients with dual diagnosis.

CONCLUSION

Few intervention studies targeting patients with dual diagnosis exist in general practice. This calls for further investigation of the possibilities of implementing interventions targeting this patient group in general practice.

Predictors of psychosocial functioning in people diagnosed with schizophrenia spectrum disorders that committed violent offences and in those that did not: Results of the Recoviwel study

Psychosocial functioning represents a core treatment target of Schizophrenia Spectrum Disorders (SSD), and several clinical and cognitive factors contribute to its impairment. However, determinants of psychosocial functioning in people living with SSD that committed violent offences remain to be more thoroughly explored. This study aims to separately assess and compare predictors of psychosocial functioning in people with SSD that did and that did not commit violent offences considering several clinical, cognitive and violence-related parameters. Fifty inmates convicted for violent crimes in a forensic psychiatry setting diagnosed with SSD (OP group) and fifty participants matched for age, gender, education, and diagnosis (Non-OP group) were included in the study. A higher risk of violent relapse as measured by HCR-20 clinical subscale scores (p < 0.002) and greater global clinical severity as measured by CGI-S scores (p = 0.023) emerged as individual predictors of worse psychosocial functioning, as measured by PSP scores, in the OP group. Greater global clinical severity (p < 0.001), worse performance in the processing speed domain as measured by the BACS Symbol Coding (p = 0.002) and TMT-A tests (p = 0.016) and higher levels of non-planning impulsivity as measured by BIS-11 scores (p < 0.001) emerged as individual predictors of worse psychosocial functioning in the Non-OP group. These results confirm that clinical severity impacts psychosocial functioning in all individuals diagnosed with SSD and suggest that while cognitive impairment clearly represents a determinant of worse functional outcomes in most patients, the risk of violent relapse is a specific predictor of worse psychosocial functioning in people with SSD that committed criminal offences.

Dual diagnosis and their care pathways for help-seeking: A multicenter study from India

Background

Understanding pathways to dual diagnosis (DD) care will help organize DD services and facilitate training and referral across healthcare sectors.

Aim

The aim of our study was to characterize the stepwise healthcare and other contacts among patients with DD, compare the characteristics of the first contact persons with common mental disorder (CMD) versus severe mental illness (SMI), and estimate the likelihood of receiving appropriate DD treatment across levels of contacts.

Methods

This cross-sectional, descriptive study in eight Indian centers included newly enrolled patients with DD between April 2022 and February 2023. The research spans varied geographic regions, tapping into regional variations in disease burden, health practices, and demographics. The study categorized healthcare contacts by using the WHO Pathways Encounter Form.

Results

The sample (n = 589) had a median age of 32 years, mostly males (96%). Alcohol was the most common substance; SMI (50.8%) and CMD were equally represented. Traditional healers were a common first contact choice (18.5%); however, integrated DD care dominated subsequent contacts. Assistance likelihood increased from the first to the second contact (23.1% to 62.1%) but declined in subsequent contacts, except for a significant rise in the fifth contact (97.4%). In the initial contact, patients with CMD sought help from public-general hospitals and private practitioners for SUD symptoms; individuals with SMI leaned on relatives and sought out traditional healers for psychiatric symptoms.

Conclusion

Recognizing the cultural nuances, advocating for integrated care, and addressing systemic challenges pave the way to bridge the gap in DD treatment.

Which Factors Are Associated With Comorbid Psychiatric Conditions in Patients Affected by Substance Use Disorders? The Impact of COVID-19 Pandemic on Dual-Diagnosis Subjects

OBJECTIVE

To investigate demographic/cinical variables associated to dual diagnosis and the psychological reaction of dual-diagnosis patients to COVID-19 pandemic.

METHODS

Information was collected at the Addiction Service of Monza, Italy. The Impact of Event Scale-Revised (IES-R), a self-report questionnaire measuring the subjective response to a traumatic event, was administered. Univariate analyses and binary logistic regression were performed. IES-R scores were compared between groups defined by qualitative variables through one-way analyses of variance (ANOVA).

RESULTS

118 outpatients were included, 48.3% with dual diagnosis. Alcohol use disorder and being female were associated to dual diagnosis. IES-R scores were significantly higher in the dual-diagnosis group, especially for personality disorders (PDs). IES-R scores were higher in patients taking treatment for substance use disorder (SUD).

CONCLUSIONS

Females and alcohol abusers were at-risk subjects for dual diagnosis. Patients with SUD and PDs may benefit from additional support, especially when traumatic life events occur.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04694482.

Substance use and its association with mental health among Swiss medical students: A cross-sectional study

BACKGROUND

Studies on mental health and substance use among medical students indicated worrying prevalence but have been mainly descriptive.

AIM

To evaluate the prevalence of substance use in a sample of medical students and investigate whether mental health variables have an influence on substance use.

METHODS

The data were collected as part of the first wave of the ETMED-L, an ongoing longitudinal open cohort study surveying medical students at the University of Lausanne (Switzerland). N = 886 students were included and completed an online survey including measures of mental health (depression, suicidal ideation, anxiety, stress, and burnout) and use of and risk related with several substances (tobacco, alcohol, cannabis, cocaine, stimulants, sedatives, hallucinogens, opioids, nonmedical prescription drugs, and neuroenhancement drugs). We evaluated the prevalence of use of each substance and then tested the association between mental health and substance use in an Exploratory Structural Equation Modeling framework.

RESULTS

Statistical indices indicated a four-factor solution for mental health and a three-factor solution for substance use. A factor comprising risk level for alcohol, tobacco, and cannabis use - which were the most prevalent substances - was significantly associated with a burnout factor and a factor related to financial situation and side job stress. There was a significant association between a factor comprising depression, anxiety, and suicidal ideation and a factor related to the use of sedatives, nonmedical prescription drugs and neuroenhancement drugs. Although their use was less prevalent, a factor comprising the risk level of stimulants and cocaine use was significantly but more mildly related to the burnout factor. A factor comprising stress related to studies and work/life balance as well as emotional exhaustion was not related to substance use factors.

CONCLUSION

In this sample of medical students, the prevalence of substance use was substantial and poorer mental health status was related with higher substance use risk levels.

Comorbid substance use disorder, major depression, and associated disability in a nationally representative sample

BACKGROUND

Major depressive disorders (MDD) and substance use disorders (SUDs) are commonly linked to disability, but there is a lack of research on the risk of disability among individuals who have both SUDs and MD in the general population. This study aimed to investigate the associated risk of disability in people with comorbid SUDs- specifically cannabis use disorder, alcohol use disorder, other drug (except cannabis) use disorder, and a major depressive episode using a nationally representative sample.

METHODS

The 2012 Canadian Community Health Survey- Mental Health (CCHS-MH) data were analyzed using multilevel logistic regression models. The survey included a nationally representative sample of Canadians aged 15 years and older (n = 25,113) residing in the ten Canadian provinces from January to December 2012. The diagnoses of major depressive episodes (MDE) and the SUDs were derived from the DSM-IV diagnostic criteria using a modified WHO-CIDI instrument, while disability was assessed using the World Health Organization Disability Assessment Score (WHODAS) 2.0.

RESULTS

The strongest predictor of disability was found to be comorbidity. Individuals diagnosed with both a SUD and MDE were 4 to 9 times more likely to experience disability, depending on the substance used, compared to those without either diagnosis.

LIMITATIONS

The study's cross-sectional design limits causal inferences.

CONCLUSIONS

Our research discovered that individuals who have both SUD and MDE are at a significantly higher risk of experiencing disability. This highlights the importance of integrating mental health and addiction services to mitigate the risk of disability and improve overall treatment outcomes.

Stroke and suicide among people with severe mental illnesses

The associations between people with severe mental illnesses (SMI) and the risks of stroke, suicide, and death remain unclear. We examined healthcare service usage among adults with and without SMI and explored the risk of stroke, suicide, and death. We divided 18-80-year-old adults with SMI into catastrophic and non-catastrophic illness groups. These groups were subjected to a 1:5:5 propensity score matching with people without SMI. Data on demographic characteristics, economic factors, environmental factors, comorbid conditions, self-injury behavior, the number of outpatients and ED visits, and hospitalization were collected. The primary outcomes were risks of stroke, suicide, and death. We included 19,570 people with catastrophic SMI, 97,850 with non-catastrophic SMI, and 97,850 controls. Patients with SMI, especially those with catastrophic illnesses, had higher stroke risk, suicide, and death than those without SMI. People with SMI used health services more frequently than those without SMI. Patients with a history of hospitalization or ED access had a higher risk of stroke, suicide, and death. Our data indicate that special attention should be given to patients with SMI, particularly those with a history of healthcare service utilization, such as through more extended hospital stays with high-intensity interventions.

Community-based rehabilitation intervention for people with schizophrenia in Ethiopia (RISE) cluster-randomised controlled trial: An exploratory analysis of impact on food insecurity, underweight, alcohol use disorder and depressive symptoms

We evaluated the effectiveness of community-based rehabilitation (CBR) in reducing depressive symptoms, alcohol use disorder, food insecurity and underweight in people with schizophrenia. This cluster-randomised controlled trial was conducted in a rural district of Ethiopia. Fifty-four sub-districts were allocated in a 1:1 ratio to the facility-based care [FBC] plus CBR arm and the FBC alone arm. Lay workers delivered CBR over 12 months. We assessed food insecurity (self-reported hunger), underweight (BMI< 18.5 kg/m2), depressive symptoms (PHQ-9) and alcohol use disorder (AUDIT ≥ 8) at 6 and 12 months. Seventy-nine participants with schizophrenia in 24 sub-districts were assigned to CBR plus FBC and 87 participants in 24 sub-districts were assigned to FBC only. There was no evidence of an intervention effect on food insecurity (aOR 0.52, 95% CI 0.16-1.67; p = 0.27), underweight (aOR 0.44, 95% CI 0.17-1.12; p = 0.08), alcohol use disorder (aOR 0.82, 95% CI 0.24-2.74; p = 0.74) or depressive symptoms (adjusted mean difference - 0.06, 95% CI -1.35, 1.22; p = 0.92). Psychosocial interventions in low-resource settings should support access to treatment amongst people with schizophrenia, and further research should explore how impacts on economic, physical and mental health outcomes can be achieved.

The Impact of the COVID-19 Pandemic on the Severity of Alcohol Use Disorder: Significance of Dual Disorders

The coronavirus disease 2019 (COVID-19) pandemic has been assumed to impact patients diagnosed with alcohol use disorder (AUD). The severity of the influence that the COVID-19 pandemic had on the symptoms of AUD has not yet been revealed in detail. The aim of this study was to examine the impact of the COVID-19 pandemic on patients diagnosed with AUD. This retrospective study was conducted between 11 March 2017 and 31 May 2022 in Hungary. Medical charts (N = 1082) of inpatients with the diagnosis of AUD were reviewed. Based on the dates of admissions, two groups were created: the 'before COVID-19' group (11 March 2017-10 March 2020) and the 'during COVID-19' group (11 March 2020-31 May 2022). Chi-square tests, independent-sample t-tests, and multinomial logistic regressions were performed. The occurrence of delirium tremens (DT) and psychiatric co-morbidities was significantly higher during the pandemic. Our results showed that the occurrence of DT and psychiatric co-morbidities significantly increased during the pandemic. Our results revealed that the pandemic enhanced the severe consequences of AUD, and the development of AUD might have increased in frequency among individuals previously diagnosed with mental illness during the pandemic. These findings indicate the significance of dual disorders in the post-pandemic period.

Provision of drug and alcohol services amidst COVID-19 pandemic: a qualitative evaluation on the experiences of service providers

BACKGROUND

The impact of COVID-19 pandemic on the provision of drug and alcohol (D&A) services and associated outcomes have been under-researched.

AIM

This study aimed to understand the experiences of service providers in relation to how drug and alcohol (D&A) services were affected during COVID-19 pandemic, including the adaptations made and lessons learnt for the future.

METHOD

Focus groups and semi-structured interviews were conducted with participants from various D&A service organisations across the UK. Data were audio recorded, followed by transcription and thematic analysis.

RESULTS

A total of 46 participants representing various service providers were recruited between October and January 2022. The thematic analysis identified ten themes. COVID-19 required significant changes to how the treatment was provided and prioritised. Expansion of telehealth and digital services were described, which reduced service wait times and increased opportunities for peer network. However, they described missed opportunities for disease screening, and some users risked facing digital exclusion. Participants who provided opiate substitution therapy service spoke of improving service provider/user trust following the shift from daily supervised treatment consumption to weekly dispensing. At the same time, they feared fatal overdoses and non-adherence to treatment.

CONCLUSION

This study demonstrates the multifaceted impact of the COVID-19 pandemic on UK-based D&A service provisions. The long-term impact of reduced supervision on Substance Use Disorder treatment and outcomes and any effect of virtual communications on service efficiency, patient-provider relationships and treatment retention and successes are unknown, suggesting the need for further study to assess their utility.

Key causes and long-term trends related to emergency department and inpatient hospital admissions of homeless persons in England

BACKGROUND

It is estimated that approximately 300,000 people are experiencing homelessness in England. The aim of this study was to evaluate key causes and long-term trends of emergency departments (EDs) and in hospital inpatient admissions of persons experiencing homelessness in England.

METHODS

ED and hospital inpatient admissions data were obtained from Hospital Episode Statistics (HES) covering all National Health Service (NHS) England hospitals. Anyone identified or declared to be experiencing homelessness during the service usage are recorded in HES datasets. Data were extracted for the 10-year study period and compared to the general population, which includes all patients attending the ED or admitted to inpatient care in England.

RESULTS

Drug- and alcohol-related causes contribute to the most frequent reasons for attendance and admissions of persons experiencing homelessness in the ED and inpatient respectively. A total of 30,406 ED attendances were recorded for persons experiencing homelessness in the year 2018/2019 (+ 44.9% rise vs 2009/10) of which injuries and poisoning respectively represented 21.8% and 17.9% of all persons experiencing homelessness presentations to the ED. Poisoning (including drug overdose) represented only 1.9% of all attendances by the general population during the same study year (rate ratio vs general populations 9.2 95% CI 9.0-9.4). High mortality rates were observed in relation to presentations attributed to drug- and alcohol-related causes. A total of 14,858 persons experiencing homelessness inpatient admissions were recorded in 2018/2019 (+ 68.6% vs 2009/2010). Psychoactive substance use constituted 12.7% of all admissions in 2018/2019 compared to 0.4% of in the general populations (rate ratio: 33.3, 95% CI: 31.9-34.7). There was a 44.3% rise in the number of admissions related to poisoning in the study period amongst persons experiencing homelessness in England (vs 14.2% in general population).

CONCLUSION

Marked disparities around primary causes of ED and inpatient admissions were identified between persons experiencing homelessness and the general population. There is a continued need for prevention measures to reduce the prevalence of drug and alcohol, injury and poisoning-related admissions to the ED, enhanced service provision at the community level, and multisector collaborations. These initiatives should maximise opportunities for early interventions and improve outcomes for persons experiencing homelessness, including increased accessibility of healthcare and mental health services, particularly in areas that demonstrate increasing ED and inpatient attendance rates over time.

A scoping review of trauma informed approaches in acute, crisis, emergency, and residential mental health care

Experiences of trauma in childhood and adulthood are highly prevalent among service users accessing acute, crisis, emergency, and residential mental health services. These settings, and restraint and seclusion practices used, can be extremely traumatic, leading to a growing awareness for the need for trauma informed care (TIC). The aim of TIC is to acknowledge the prevalence and impact of trauma and create a safe environment to prevent re-traumatisation. This scoping review maps the TIC approaches delivered in these settings and reports related service user and staff experiences and attitudes, staff wellbeing, and service use outcomes.We searched seven databases (EMBASE; PsycINFO; MEDLINE; Web of Science; Social Policy and Practice; Maternity and Infant Care Database; Cochrane Library Trials Register) between 24/02/2022-10/03/2022, used backwards and forwards citation tracking, and consulted academic and lived experience experts, identifying 4244 potentially relevant studies. Thirty-one studies were included.Most studies (n = 23) were conducted in the USA and were based in acute mental health services (n = 16). We identified few trials, limiting inferences that can be drawn from the findings. The Six Core Strategies (n = 7) and the Sanctuary Model (n = 6) were the most commonly reported approaches. Rates of restraint and seclusion reportedly decreased. Some service users reported feeling trusted and cared for, while staff reported feeling empathy for service users and having a greater understanding of trauma. Staff reported needing training to deliver TIC effectively.TIC principles should be at the core of all mental health service delivery. Implementing TIC approaches may integrate best practice into mental health care, although significant time and financial resources are required to implement organisational change at scale. Most evidence is preliminary in nature, and confined to acute and residential services, with little evidence on community crisis or emergency services. Clinical and research developments should prioritise lived experience expertise in addressing these gaps.

Prepulse inhibition deficit as a transdiagnostic process in neuropsychiatric disorders: a systematic review

BACKGROUND

Psychopathological research is moving from a specific approach towards transdiagnosis through the analysis of processes that appear transversally to multiple pathologies. A phenomenon disrupted in several disorders is prepulse inhibition (PPI) of the startle response, in which startle to an intense sensory stimulus, or pulse, is reduced if a weak stimulus, or prepulse, is previously presented.

OBJECTIVE AND METHODS

The present systematic review analyzed the role of PPI deficit as a possible transdiagnostic process for four main groups of neuropsychiatric disorders: (1) trauma-, stress-, and anxiety-related disorders (2) mood-related disorders, (3) neurocognitive disorders, and (4) other disorders such as obsessive-compulsive, tic-related, and substance use disorders. We used Web of Science, PubMed and PsycInfo databases to search for experimental case-control articles that were analyzed both qualitatively and based on their potential risk of bias. A total of 64 studies were included in this systematic review. Protocol was submitted prospectively to PROSPERO 04/30/2022 (CRD42022322031).

RESULTS AND CONCLUSION

The results showed a general PPI deficit in the diagnostic groups mentioned, with associated deficits in the dopaminergic neurotransmission system, several areas implied such as the medial prefrontal cortex or the amygdala, and related variables such as cognitive deficits and anxiety symptoms. It can be concluded that the PPI deficit appears across most of the neuropsychiatric disorders examined, and it could be considered as a relevant measure in translational research for the early detection of such disorders.

Benzodiazepine use, quality of life and psychiatric symptom burden in oral and injectable opioid agonist treatment: a cross-sectional study

BACKGROUND

Use of benzodiazepines (BZD) in patients receiving opioid agonist treatment (OAT) is common and associated with a variety of negative health and social outcomes. This cross-sectional study investigates the impact of BZD use in OAT patients on their quality of life (QoL).

METHODS

A convenience sample of patients receiving oral OAT or heroin-assisted treatment in two outpatient centres in Basel, Switzerland was investigated. Participants (n = 141) completed self-report questionnaires on psychiatric symptoms and psychological distress (The Symptom Checklist 27, SCL-27), depressive state (German version of the Center for Epidemiological Studies Depression Scale), quality of life (Lancashire Quality of Life Profile, LQOLP) and use of BZD and other drugs (self-report questionnaire). Substance use was assessed by urine toxicology testing.

RESULTS

In bivariate analysis, total QoL scores were significantly lower for lifetime, current, and prolonged BZD users compared to participants without the respective use patterns. There was no significant relationship between BZD dose and QoL. In multivariable linear regression models controlling for psychiatric symptom load and depressive state, only lifetime use predicted lower QoL, whereas other BZD use patterns were not significantly associated.

CONCLUSIONS

The association of lower QoL and BZD use in OAT patients is strongly confounded by co-occurring depressive state and psychiatric symptoms. Careful diagnosis and treatment of co-occurring mental disorders in OAT is paramount to improve QoL in this patient population and may also help reduce BZD use.

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.

The Inflammatory Signals Associated with Psychosis: Impact of Comorbid Drug Abuse

Psychosis and substance use disorders are two diagnostic categories whose association has been studied for decades. In addition, both psychosis spectrum disorders and drug abuse have recently been linked to multiple pro-inflammatory changes in the central nervous system. We have carried out a narrative review of the literature through a holistic approach. We used PubMed as our search engine. We included in the review all relevant studies looking at pro-inflammatory changes in psychotic disorders and substance use disorders. We found that there are multiple studies that relate various pro-inflammatory lipids and proteins with psychosis and substance use disorders, with an overlap between the two. The main findings involve inflammatory mediators such as cytokines, chemokines, endocannabinoids, eicosanoids, lysophospholipds and/or bacterial products. Many of these findings are present in different phases of psychosis and in substance use disorders such as cannabis, cocaine, methamphetamines, alcohol and nicotine. Psychosis and substance use disorders may have a common origin in an abnormal neurodevelopment caused, among other factors, by a neuroinflammatory process. A possible convergent pathway is that which interrelates the transcriptional factors NFκB and PPARγ. This may have future clinical implications.

Clinical pharmacists in primary care general practices: evaluation of current workforce and their distribution

BACKGROUND

General practices in primary care across England are increasingly employing clinical pharmacists to help tackle the workforce crisis and alleviate pressure. Clinical pharmacists can provide administrative and clinical duties, including non-medical prescribing, advice on polypharmacy and medicines optimisation. The aim of this study was to investigate the distribution of clinical pharmacists in general practice across England, and explore the relationship between the distribution and regional demography.

METHODS

This study used publicly available government database from various sources pertaining to primary care general practice workforce and population demographics of England. The number and distribution of pharmacists working within general practices in England were analysed and compared across practices considering general practitioner (GP), nurse and patient population in the practices, patients age ≥ 65 years and over and the Index of Multiple Deprivation (IMD) scores.

RESULTS

Twenty two percentage (1469 of 6674) of practices in England were found to have access to a clinical pharmacist, equating to 1358 full-time equivalent (FTE) pharmacists and a mean pharmacist FTE of 10.07 (95% CI 8.40, 11.75, SD = 9.84) per Clinical Commissioning Group (CCG). A significant relationship between pharmacist FTE and the number of patients 65 years and older [r (132) = 0.75, P < 0.001)] was observed; however, the distribution was not related to population deprivation scores.

CONCLUSIONS

Approximately one in five general practices in England have access to a clinical pharmacist. Further research is needed to ensure wider and equitable distribution based on workforce needs and practice population demography.

Addictive and other mental disorders: a call for a standardized definition of dual disorders

The persistent difficulty in conceptualizing the relationship between addictive and other mental disorders stands out among the many challenges faced by the field of Psychiatry. The different philosophies and schools of thought about, and the sheer complexity of these highly prevalent clinical conditions make progress inherently difficult, not to mention the profusion of competing and sometimes contradictory terms that unnecessarily exacerbate the challenge. The lack of a standardized term adds confusion, fuels stigma, and contributes to a "wrong door syndrome" that captures the difficulty of not only diagnosing but also treating addictive and other mental disorders in an integrated manner. The World Association on Dual Disorders (WADD) proposes the adoption of the term "Dual Disorder" which, while still arbitrary, would help harmonize various clinical and research efforts by rallying around a single, more accurate, and less stigmatizing designation.

Homelessness and the use of Emergency Department as a source of healthcare: a systematic review

BACKGROUND

Persons experiencing homelessness (PEH) often use hospital Emergency Department (ED) as the only source of healthcare. The aim of this study was to undertake a systematic review to identify the prevalence, clinical reasons and outcomes in relation to ED visits by PEH.

METHODS

A protocol-led (CRD42020189263) systematic review was conducted using search of MEDLINE, EMBASE, CINAHL and Google Scholar databases. Studies that reported either the prevalence of homelessness in the ED or clinical reasons for presentation to ED by PEH and published in English language were included. Definitions of homelessness used by study authors were accepted.

RESULTS

From the screening of 1349 unique titles, a total of 36 studies were included. Wide variations in the prevalence and key cause of presentations were identified across the studies often linked to differences in country, study setting, disease classification and data collection methods. The proportion of ED visits contributed by PEH ranged from 0.41 to 19.6%. PEH made an average of 0.72 visits to 5.8 visits per person per year in the ED [rate ratio compared to non-homeless 1.63 to 18.75]. Up to a third and quarter of the visits were contributed by alcohol-related diagnoses and substance poisoning respectively. The percentage of PEH who died in the ED ranged from 0.1 to 0.5%.

CONCLUSIONS

Drug-, alcohol- and injury-related presentations dominate the ED visits by PEH. Wide variations in the data were observed in regard to attendance and treatment outcomes. There is a need for prevention actions in the community, integrated discharge and referral pathways between health, housing and social care to minimise frequent usage and improve attendance outcomes.

Ambient ozone exposure and hospitalization for substance abuse: A time-stratified case-crossover study in Taipei

A number of studies investigating the possibility that air pollutant exposures increases the risk of adverse effects on mental health including frequency of suicide and depression, is a major growing public health concern. Human data demonstrated that exposure to various ambient air contaminants including ozone (O₃) adversely affected nervous system functions. It is also well-established that substance abuse produces central nervous system dysfunctions with resultant increase in suicide rates. However, the role of substance abuse in combination with O₃ exposure on mental health remained to be determined. The aim of this investigation was to conduct a time-stratified case-crossover study to examine the possible correlation between short-term ambient O₃ exposure and daily hospital admissions for substance abuse, including alcohol dependence syndrome and non-dependent abuse of drugs, in Taipei from 2009 to 2013. In our single pollutant model, a 35% rise in interquartile (IQR) O₃ levels on cool days and a 12% elevation on warm days was associated with increase in mental health hospitalizations. In our two-pollutant models, O₃ remained significantly associated with elevated number of hospitalizations after adding any one of possible air pollutants, PM₁₀, PM_2.5, SO₂, NO₂, and CO, to our model on cool and warm days. Data suggested that temperature may affect the association between outdoor ambient air O₃ exposure and enhanced risk of hospitalization for substance abuse. Further study is needed to better understand these findings.

TOBACCO USE DISORDER AND DUAL DISORDERS Joint statement by the Spanish Psychiatry Society and the Spanish Dual Disorders Society

Tobacco Use Disorder (TUD) is a health problem of the first order in the world population, affecting a vulnerable population, such as people with other mental disorders, whose morbidity and mortality are increased as a result.

Associations of common mental disorder with alcohol use in the adult general population: a systematic review and meta-analysis

BACKGROUND AND AIMS

Research has shown that alcohol use and common mental disorders (CMDs) co-occur; however, little is known about how the global prevalence of alcohol use compares across different CMDs. We aimed to (i) report global associations of alcohol use (alcohol use disorder (AUD), binge drinking and consumption) comparing those with and without a CMD, (ii) examine how this differed among those with and without specific types of CMDs and (iii) examine how results may differ by study characteristics.

METHODS

We used a systematic review and meta-analysis. Cross-sectional, cohort, prospective, longitudinal and case-control studies reporting the prevalence of alcohol use among those with and without a CMD in the general population were identified using PsycINFO, MEDLINE, PsyARTICLES, PubMed, Scopus and Web of Science until March 2020. Depression, anxiety and phobia were included as a CMD. Studies were included if they used a standardized measure of alcohol use. A random-effects meta-analysis was conducted to generate pooled prevalence and associations of AUD with CMD with 95% confidence intervals (CI). A narrative review is provided for binge drinking and alcohol consumption RESULTS: A total of 512 full-texts were reviewed, 51 included in our final review and 17 in our meta-analyses (n = 382 201). Individuals with a CMD had a twofold increase in the odds of reporting an AUD [odds ratio (OR) = 2.02, 95% CI = 1.72-2.36]. The odds of having an AUD were similar when stratified by the type of CMD (mood disorder: OR = 2.00, 95% CI = 1.62-2.47; anxiety/phobic disorder: OR = 1.94, 95% CI = 1.35-2.78). An analysis of study characteristics did not reveal any clear explanations for between-study heterogeneity (I²  > 80%). There were no clear patterns for associations between having a CMD and binge drinking or alcohol consumption, respectively.

CONCLUSIONS

People with common mental disorders (depression, anxiety, phobia) are twice as likely to report an alcohol use disorder than people without common mental disorders.

Medicines prescribing for homeless persons: analysis of prescription data from specialist homelessness general practices

Background

Specialist homelessness practices remain the main primary care access point for many persons experiencing homelessness. Prescribing practices are poorly understood in this population.

Objective

This study aims to investigate prescribing of medicines to homeless persons who present to specialist homelessness primary care practices and compares the data with the general population.

Setting

Analyses of publicly available prescribing and demographics data pertaining to primary care in England.

Methods

Prescribing data from 15 specialist homelessness practices in England were extracted for the period 04/2019-03/2020 and compared with data from (a) general populations, (b) the most deprived populations, and (c) the least deprived populations in England.

Main outcome measure

Prescribing rates, measured as the number of items/1000 population in key disease areas.

Results

Data corresponding to 20,572 homeless persons was included. Marked disparity were observed in regards to prescribing rates of drugs for Central Nervous System disorders. For example, prescribing rates were 83-fold (mean (SD) 1296.7(1447.6) vs. 15.7(9.2) p = 0.033) items), and 12-fold (p = 0.018) higher amongst homeless populations for opioid dependence and psychosis disorders respectively compared to the general populations. Differences with populations in the least deprived populations were even higher. Prescribing medicines for other long-term conditions other than mental health and substance misuse was lower in the homeless than in the general population.

Conclusions

Most of the prescribing activities in the homeless population relate to mental health conditions and substance misuse. It is possible that other long-term conditions that overlap with homelessness are under-diagnosed and under-managed. Wide variations in data across practices needs investigation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11096-022-01399-3.

The CAMP study: feasibility and clinical correlates of standardized assessments of substance use in a youth psychiatric inpatient sample

BACKGROUND

To determine: (a) the feasibility and acceptability of administering a standardized electronic assessment of substance use and other mental health concerns to youth admitted to an inpatient psychiatric unit, and (b) the prevalence and clinical correlates of substance use in this sample.

METHODS

The sample included 100 youth between the ages of 13 to 17 years admitted to an inpatient psychiatric unit in Ontario, Canada between September and November 2019 (78% response rate). Youth data were comprised of electronic self-reported assessments (during hospitalization and 6-months following) and chart reviews (99% consented; historical and prospective). Frontline staff completed a self-report survey assessing their perceptions of the need for standardized substance use assessments, training, and interventions on the unit (n = 38 Registered Nurses and Child and Youth Workers; 86% response rate). Analyses included descriptive statistics, correlations, regression, and qualitative content analysis.

RESULTS

Feasibility of standardized youth self-reported mental health and substance use assessments was evident by high response rates, little missing data, and variability in responses. 79% of youth had used at least one substance in their lifetime; 69% reported use in the last 3 months. Substance use was positively correlated with severity of psychiatric symptoms (τb 0.17 to 0.45) and number of psychiatric diagnoses (τb 0.17 to 0.54) at index. Based on prospective and retrospective data, substance use was also positively related to mental health symptom severity at follow-up and repeat mental health related hospital visits. Frontline staff reported a need for standardized assessment, training, and interventions on the unit, indicative of acceptability.

CONCLUSIONS

This study demonstrated the feasibility, acceptability and clinical importance of administering a standardized mental health and substance use assessment among youth experiencing psychiatric hospitalization.

Causes, Nature and Toxicology of Fentanyl-Analogues Associated Fatalities: A Systematic Review of Case Reports and Case Series

Objective

Mortalities due to fentanyl derivatives are on the rise with novel fentanyl analogues and still emerging on the global illicit drug market. They are highly potent and very fatal in low doses, yet there has been a lack of systematic research surrounding this subject. This review aims to assess the causes, nature, and toxicology of fatalities associated with fentanyl analogues.

Methods

Five databases: Scopus, Embase, Medline, PubMed and Google Scholar were searched from inception to October 2020 to identify case studies and case series reporting fentanyl analogue-related fatalities. Two independent reviewers screened and selected the articles followed by the data extraction from each article, which included demography, route of administration, causes and nature of death, and the fentanyl analogue implicated. All articles were then subject to quality assessment tools developed by the Joanna Briggs Institute (JBI). A narrative synthesis was undertaken.

Results

The initial data search yielded 834 articles, only 14 of which met the inclusion criteria - this included nine case reports and five case series. Of the 1079 fentanyl-analogue related deaths reported, the majority of them occurred in the US (n=1044, 96.8%). The majority of fatalities were male (n=766, 71%), white (n=884, 87%) and in the age ranges 25-34 and 35-44 years (30.5% and 29.6%, respectively). The most common route of administration was intravenous (n=319, 66%) and the manner of death was almost exclusively accidental (99.7%). The predominant cause of death was fentanyl-analogue toxicity (n=292, 85.4%) and involved mixed drug toxicity (n=47, 13.7%). The mean post-mortem fentanyl analogue concentration was 31.6 ng/mL.

Conclusion

Most fatalities were reported in the US involving young white males. Overdose through intravenous administration and by mixed drug toxicities with other opioids were the major causes of death. Deaths reported in peer-reviewed literature were relatively less than those reported by real-world data.

Representation of persons experiencing homelessness and coding of homelessness in general practices: descriptive evaluation using healthcare utilisation data

Background

Epidemiological studies focused on primary healthcare needs of persons experiencing homelessness (PEH) are often based on data from specialist homeless healthcare services.

Aim

To explore the presentation of PEH, coding of homelessness, and associated health conditions in mainstream primary care general practices in England.

Design & setting

EMIS electronic database search of medical records was conducted across 48 general practices in a clinical commissioning group (CCG), representing one of the most socioeconomically deprived regions in England, which also lacks a specialist primary healthcare service for PEH.

Method

Key terms and codes were used to identify PEH, their respective diagnoses across 22 health conditions, and prescribed medications over the past 4 years.

Results

From a population of approximately 321 000, 43 (0.013%) people were coded as PEH, compared with a homelessness prevalence of 0.5% in the English general population. Mental health conditions were the most prevalent diagnoses among the PEH registrants (56.6%); the recorded prevalence of other common long-term conditions in PEH was lower than the levels observed in PEH registered with specialist homelessness health services.

Conclusion

In a population with approximately four times higher rate of statutory homelessness, PEH representation in mainstream general practices was under-represented by several folds. As homelessness overlaps with mental health, substance misuse, and long-term health conditions, consistent coding of homelessness in medical records is imperative in order to offer tailored support and prevention actions when patients present for services.

Clinical characteristics, attendance outcomes and deaths of homeless persons in the emergency department: implications for primary health care and community prevention programmes

OBJECTIVES

Persons experiencing homelessness (PEH) are known to be often excluded from primary health care and community prevention programmes leading to high use of hospital emergency departments (EDs). This study aimed to identify demographic features, clinical characteristics and attendance outcomes of PEH presenting to ED.

STUDY DESIGN

Analysis of routinely collected data set.

METHODS

Clinical presentations and drug prescription data of PEH who presented a major ED in the West Midlands region of England from 2014 to 2019 were extracted and analysed using descriptive and inferential statistics.

RESULTS

During the study period, 3271 of 596,198 presentations were made by PEH; 74% PEH attendees were male. Drug- and alcohol-related conditions, as well as pain and injury constituted the most frequent reasons for presentation, contributing to over half of all presentations. A significantly higher proportion of males (n = 481, 20.3%) presented with drug and alcohol problems than females (n = 93, 11.2%) (P ≤ 0.001). However, pain was the primary reason for presentation for twice as many female patients (n = 189, 22.8%) compared with males (n = 305, 12.9%) (P < 0.001). Nearly one in five left the ED before being assessed and a total of 39 patients (1.2%) died in the ED and 785 (24.0%) required in-patient admissions to the same hospital.

CONCLUSIONS

Drug, alcohol and pain including the need of opioid analgesics constituted the majority of presentations made by PEH in ED. The observed rate of death of PEH in ED is 12 times higher than the general population. A very high proportion of PEH also leave the ED before being treated. Future research should focus on strengthening community interventions, particularly to improve access to those at risk of dual diagnoses of substance misuse and mental health problems. Interventions involving multisector collaborations are needed to improve seamless discharge from ED and minimise repeat attendance. Gender differences in the nature of presentations and ED outcomes needs to be investigated further.

Partial Agonists and Dual Disorders: Focus on Dual Schizophrenia

Dual disorder is a term applied to patients with an addictive disorder and other mental disorder. Epidemiological studies have established that dual disorders are an expectation rather than an exception. They are difficult to diagnose and treat and constitute a huge burden for both patients and their relatives and society. Current treatments are a combination of those needed to treat the addictive disorder with those focused on the co-occurring psychiatric disorder. Focusing specifically on schizophrenia, growing scientific evidence supports the existence of a shared vulnerability for substance use in these patients and those at risk. Various antipsychotics have been found to be useful in the treatment of psychotic symptoms and disorders; however, few effective treatments have been identified until now for substance use disorders in patients with dual schizophrenia. Partial agonism stands as a new pharmacological option available in recent years. Molecules with this kind of action may act as functional agonists or as antagonists, depending on the surrounding levels of the neurotransmitter. Studies have found their efficacy in schizophrenia, addiction, anxiety and depression. Certain partial agonist antipsychotics seem to have a role in the treatment of dual schizophrenia. That could be the case with cariprazine. Because of its higher affinity for dopaminergic D3 receptors compared to D2, a potential to prevent relapse to addiction, added to its antipsychotic efficacy, has been suggested. Here we briefly review current advances and future directions and introduce some personal insights into the role of partial agonists in co-occurring schizophrenia and substance use.