A retrospective analysis focusing on a group of patients with dual diagnosis treated by both mental health and substance use services

Characteristics and outcomes of patient presentations to the emergency department via police: A scoping review

BACKGROUND

As emergency department (ED) presentations continue to rise, understanding the complexities of vulnerable populations such as people brought in by police (BIBP) is crucial. This review aimed to map and describe the research about people BIBP to the ED.

DESIGN AND METHOD

A scoping review, guided by the Joanna Briggs Institute process, was undertaken. The databases CINAHL, Embase and PubMed were searched between November 2017 and July 2022. The Patterns, Advances, Gaps, Evidence for practice, Research recommendations (PAGER) framework was used to guide the analysis.

RESULTS

A total of 21 studies were included in the review, originating mainly from westernised countries. Examination of patterns across studies revealed four themes: routinely collected data is used to describe people BIBP to the ED; a focus on mental health care; the relationship between care delivery and outcomes; and the role of police in providing emergency care.

CONCLUSION

There is some understanding of the demographic characteristics, clinical characteristics, and outcomes of people BIBP to the ED. Knowledge gaps surrounding sociodemographic factors, prehospital and ED care delivery for people BIBP require further investigation to optimise outcomes for this vulnerable cohort of presenters.

Circadian Characteristics in Patients under Treatment for Substance Use Disorders and Severe Mental Illness (Schizophrenia, Major Depression and Bipolar Disorder)

Dual disorders (substance use and mental illness comorbidity) are a condition that has been strongly associated with severe symptomatology and clinical complications. The study of circadian characteristics in patients with Severe Mental Illness or Substance Use Disorder (SUD) has shown that such variables are related with mood symptoms and worse recovery. In absence of studies about circadian characteristics in patients with dual disorders we examined a sample of 114 male participants with SUD and comorbid Schizophrenia (SZ+; n = 38), Bipolar Disorder (BD+; n = 36) and Major Depressive Disorder (MDD+; n = 40). The possible differences in the sample of patients according to their psychiatric diagnosis, circadian functioning with recordings of distal skin temperature during 48 h (Thermochron iButton^®), circadian typology and sleep-wake schedules were explored. MDD+ patients were more morning-type, while SZ+ and BD+ had an intermediate-type; the morning-type was more frequent among participants under inpatient SUD treatment. SZ+ patients had the highest amount of sleeping hours, lowest arousal and highest drowsiness followed by BD+ and MDD+, respectively. These observed differences suggest that treatment for patients with dual disorders could include chronobiological strategies to help them synchronize patterns with the day-light cycle, since morning-type is associated with better outcomes and recovery.

When policy fails try something different integrated practice improve outcomes for dual diagnosis co-occurring service users accessing mental health services

Purpose

This paper aims to discuss an initiative developed between, Leicestershire Partnership National Health Service Trust and Turning Point, which is the locally commissioned drug and alcohol service in Leicester, Leicestershire and Rutland. The aim was to improve outcomes for clients with dual diagnosis (co-occurring mental health and substance misuse) issues. The purpose of the change in working practice was to engage with local substance misuse agencies more effectively to improve clinical outcomes within this service user group. This was achieved through four interrelated approaches. This comprising providing an integrated service. It included building relationships with substance misuse services, providing specialist dual diagnosis clinics and the introduction of substance misuse workers onto mental health wards and group work specific to substance misuse. The outcomes included easier access to services for service users and greater uptake of service users who were moving onto substance misuse services. This led to a reduction in risk related to prescribing and fewer incidents related to prescribing changes and greater engagement in services. When service users were moving between services better communication led to prescriptions being transferred with no delay and to reduced dropout rates in service. There was improved access to substance misuse services, more referrals and take up of service taking place. There was a greater understanding by staff of co-occurring substance misuse and how to work with this client group. Closer working relationship with substance misuse services and shared skills led to greater confidence in managing this service user group. This demonstrates a cost effective service that can be replicated within similar settings.

Design/methodology/approach

In clinical practice, shared treatment has proved challenging in light of different service models (Laker, 2006). Substance misuse works on the premise of change comes from the individual, where recovery models in mental health offer a formalised approach. One of the challenges faced by services has been the inability for mental health services to recruit and services become overstretched (Rimmer, 2018); this gave an opportunity for a new method of working to be considered. This led to the development of a new service model.

These changes were:

• Improving the interface with substance misuse services to improve access to community substance misuse services for mental health clients.

• To provide specialist staff within the dual diagnosis field to provide a clinic jointly with local drug and alcohol services.

• Introduction of substance misuse workers as team members on acute mental health and rehab wards.

• Group Substance Misuse programmes.

Findings

Working within an integrated model, yet maintaining separate organisations, by offering joint training and clinics has led to a greater understanding of each organisation’s work and increased engagement within the service user group.The introduction of substance misuse workers to acute and rehab mental health inpatient services encouraged service users to engage at the point of admission and to be referred into locally commissioned substance misuse services prior to the point of discharge. Engagement with staff has demonstrated better engagement with substance service by service users following discharge.For clients able to take leave assessment could take place prior to discharge. This led to an increased uptake in services. Due to no opiate substitution given on discharge decreased risk of prescribed medication overdose at point of discharge and led to increase in returning straight to substance misuse services. This meant that service users received medication quicker and the right dose and on discharge ensured reduced risk. The prescribing of Naloxone at discharge is yet to be assessed, but the risk of an overdose within seven days is well-documented and Naloxone is key in reversing this trend. This change in practice can be replicated in any mental health setting and has increased access to services for those using substances.

Originality/value

Is original no other services have substance workers or joint clinics across the UK. First inpatient unit to welcome patients back post-discharge to attend groups.

Determinants of Revolving Door in an Acute Psychiatric Ward for Prison Inmates

Among the different types of heavy use of mental health services, frequent inpatient admission in acute care units of individuals unable to return to their usual environment refers to as revolving-door (RD). RD in prisoners is related to increased violence (acted and supported) and suicidal recidivism. We explored the determinants of RD in 200 inmates from the Swiss-French speaking areas who were admitted to the sole acute psychiatric care unit for all of the Swiss-French counties, located in Geneva. The Cuzick's test for trend across ordered groups, Kruskal-Wallis test and oneway ANOVA were used to compare demographic and clinical variables between single (one admission, N = 100), frequent (3-7, N = 69) and RD (more than 8, N = 31) during a 12 months period. In addition, univariate and multivariable ordered logistic regression modes were built to examine the determinants of RD. The sample included 27 women (mean age: 31.2 years) and 173 men (34.5 years) who were admitted during the period 2014-2019. The vast majority were single (65%) with low level of education (<6 years, 78%). Suicidal behavior was the more frequent reason for admission (57%). Psychiatric history was positive in 77.5% of cases and in 54.5% of cases there was at least one episode of inpatient psychiatric care. The more frequent ICD-10 psychiatric diagnosis in the last admission were psychotic disorder (38%), personality disorder (29.5%) and adjustment disorder (19.5%). In contrast, depressive episodes (7%) and bipolar disorder (4.5%) were rare. Group comparison showed that the presence of court-ordered treatments, suicidal behavior, personality and psychotic disorders was associated with significantly increased frequency of RD use. In univariate models, the same factors were positively associated with RD, the highest odds ratio being found for court-ordered treatments (5.77) and personality disorders (2.14). In contrast, the diagnosis of adjustment disorders was related to decreased RD use (OR 0.25). Court-ordered treatments and personality disorders were the only factors to predict RD in multivariable regression models. These findings suggest that acute psychiatric care in these patients did not depend of environmental stressors but rather represents the expression of a long-lasting vulnerability related to their psychological profile and criminal status.

Coping Strategies in Male Patients under Treatment for Substance Use Disorders and/or Severe Mental Illness: Influence in Clinical Course at One-Year Follow-Up

Coping strategies have an impact on substance use disorders (SUD), relapses, and clinical variables, but knowledge on this area is scarce. We explored the coping strategies used during treatment in patients with dual diagnosis (DD), SUD, and severe mental illness (SMI), and the relation with clinical course and relapses at one-year follow-up. A sample of 223 patients was divided into three groups depending on diagnosis: DD (N = 80; SUD with comorbid schizophrenia or major depressive disorder), SUD only (N = 80), and SMI only (N = 63; schizophrenia or major depressive disorder). MANCOVA analyses reflected differences in self-criticism and problem avoidance, with a higher use of these in the DD and SUD groups. The coping strategies used differed depending on the presence/absence of a SUD, but not depending on psychiatric diagnosis. At one-year follow-up, social support was the only strategy that predicted the presence of relapses in DD patients with schizophrenia (positively), and in SMI patients with major depressive disorder (negatively). Thus, social support was associated with relapses, but the relationship was different depending on psychiatric diagnosis. Further studies should analyze the implications of social support as a coping strategy in different mental disorders, as well as its usefulness in individualized interventions.

Co-Occurring Psychiatric and Substance Use Disorders: Clinical Survey Among a Rural Cohort of Italian Patients

PURPOSE

Dual diagnosis (DD) is the co-occurrence of both a mental illness and a substance use disorder (SUD). Lots of studies have analysed the integrated clinical approach, which involves both psychiatry and toxicology medical experts. The purpose of this study is to analyse the socio-demographic characteristics and treatment strategies of patients with DD in a rural area of Italy.

PATIENTS AND METHODS

Clinical data of 750 patients were collected in 2016 through the analysis of health plan records.

RESULTS

The rate of co-occurring disorders is highly variable among people with SUD. In the considered area, patients with DD are 24%, of these only 46.1% have been treated with an integrated clinical program. Moreover, this percentage is further reduced (35.8%) if only patients with heroin use disorder are considered.

CONCLUSION

A comprehensive revision of DD treatment is needed, especially for people suffering from heroin use disorder and living in remote areas. Meticulous data analysis from other addiction health services of rural areas could be necessary to identify a science-based clinical intervention.

Factors Associated with Unplanned Early Discharges from a Dual Diagnosis Inpatient Detoxification Unit in Israel

OBJECTIVES

Currently, Israel has a single governmental inpatient dual diagnosis detoxification unit. We provide a cross-section of patient profiles in this study as well as explore possible associations between clinical/demographic factors and the unplanned early discharge of patients from the unit, aiming at improving rehabilitation success rates.

METHODS

In this retrospective study, medical records of all patients admitted to the unit between January 1, 2012, and July 1, 2013, were examined (N = 323). ICD-10 was used for diagnosis. Statistical analysis was carried out using Pearson's chi-squared test and binary logistic regression.

RESULTS

Patients admitted to our unit were affected by schizophrenia (31.8%), personality disorder (25%), and depression (18.3%). Substances in use included alcohol (67.5%), cannabis (8.35%), and benzodiazepines (9%). Almost half of the patients were polysubstance users (48.9%). The unit had high rates of immigrants, mainly ex-USSR- and Ethiopian-born. It had low rates of individuals who had served in the army (52.8%), despite the service being mandatory in Israel. Sixty-eight percent of patients completed the program as planned, and 32% were discharged early: 8.6% discharged due to drug use in detoxification settings, violence, or hospitalization for clinical reasons and 23.2% discharged against medical advice. Immigrants had increased rates of completing the program as scheduled. Of the 46.7% of patients with severe mental illness, 44.3% were discharged early. Higher education and a diagnosis of depression were associated with program completion as planned. Using logistic regression, we found that patients with disability pensions (odds ratio [OR] = 0.36; 95% confidence interval [CI] [0.14-0.91]; p = .03) and polysubstance use (OR = 0.39; 95% [CI] [0.23, 0.66], p < .001) had a higher risk of early discharge. Upon completion of individual programs, 52% were referred to an ambulatory addiction center and 13% to a nationally sponsored dual diagnosis therapeutic community.

CONCLUSIONS

Israel's single official dual diagnosis detox inpatient unit has satisfactory annual program completion rates when compared to similar institutions. A suboptimal treatment regimen may contribute to the early discharge of patients with polysubstance use and diagnosed personality disorders. An association between early discharges and a disability pension warrant further investigation, as there is no apparent connection between the two.

Perspectives of cannabis use in the life experience of men with schizophrenia

Substance use amongst people with schizophrenia is well-established: up to 50% report using illicit substances. The occurrence of both conditions can also induce people to disengage from mental health services. The research question sought to understand, from the perspective of both service users and clinicians, cannabis use within the experience of people with schizophrenia. The transcripts of the seven participants and the two focus groups were analysed using interpretative phenomenological analysis. Service Users and Clinicians were recruited from Assertive outreach community-based teams. seven male service users who described their ethnic identity as 'black', diagnosed with schizophrenia and a history of treatment disengagement and 12 clinicians who worked with this client group. The two component study involved semi-structured interviews with the Service Users and two focus groups with the Clinicians. Service Users perceived cannabis use as a means by which they could 'reestablish their identity' that had been damaged and the social consequences of diagnosis. Clinicians similarly perceived drugs, cannabis in particular, as a significant part of the service users' life. This study provides greater depth to understanding cannabis use within the experience of people with a diagnosis of schizophrenia.

Neurobiological underpinnings and modulating factors in schizophrenia spectrum disorders with a comorbid substance use disorder: A systematic review

Recently there is a growing interest in the interaction of schizophrenia spectrum disorders (SSD) and substance use disorders (SUD), a condition named dual schizophrenia spectrum disorders (SSD+). While previous research has focused on clinical and cognitive aspects, little is known about the impact of comorbidity in the brain structure and functions. Evidence suggests that dual diagnosis patients, including SSD+, show a better neurocognitive functioning during the first years of illness, followed by a serious long-term decline. The initial search retrieved 94 articles, 12 were excluded for being redundant and 49 for not fulfilling the selection criteria. Thirty-three structural and functional neuroimaging studies that compare SSD and SSD+ patients were included. Both groups exhibited more brain alterations, in comparison to only SUD patients and healthy controls. SSD+ patients are less cognitively and emotionally impaired than non-dual SSD, but worse than healthy controls. The neurobiological alterations are prominent in SSD+ after five years of illness or longer. Moreover, SUD characteristics are important modulating factors, contrary to clinical severity or specific SSD diagnosis.

Factors Influencing the Frequency of Emergency Department Utilization by Individuals with Substance Use Disorders

This study assessed the characteristics of individuals with substance use disorders (ISUDs) according to their frequency of emergency department (ED) utilization, and examined which variables were associated with an increase in ED visits using Andersen's model. Data linkage of administrative databanks from three sources [addiction rehabilitation centre registry, physician billing systems, and hospital discharge databank] for 4526 ISUDs was performed. Predisposing, enabling and need factors associated with number of ED visits were determined using a negative binomial regression model and generalised estimating equations. The rate of ED utilization for this population was 9.6 %. Increased number of ED visits was associated with the following variables: older age, social fragmentation, number of consultations with general practitioners, number of consultations with psychiatrists, number of consultations with other types of physicians, alcohol abuse, drug abuse, schizophrenia, anxiety disorders, personality disorders, co-occurring substance dependence and mental disorders, co-occurring substance dependence and chronic physical disorders, and co-occurring mental health disorders and chronic physical disorders. By contrast, a diagnosis of substance dependence, co-occurring drug and alcohol abuse, and a co-occurring diagnosis of substance dependence with mental health and chronic physical disorders decreased ED visits. Efforts to reduce avoidable use of EDs should focus on chronic-disease management and other related strategies aimed at reinforcing services to ISUDs in the community, especially for ISUDs with a co-occurring diagnosis of either mental health disorders or chronic physical disorders.

Factors associated with high use of general practitioner and psychiatrist services among patients attending an addiction rehabilitation center

BACKGROUND

This study aimed to 1) identify the characteristics of individuals with substance use disorders (SUDs) who make high use of services provided by general practitioners (GP) and psychiatrists while receiving services concurrently from an addiction rehabilitation center (ARC), and 2) to compare high service users to moderate and low service users.

METHODS

Data were compiled for 4,407 individuals with SUDs who were receiving services from an ARC in 2004. The data came from the merging of four databases: the ARC data registry (January 1(st), 2004-December 31, 2004), the Quebec Health Insurance Board database (March 31, 2003-April 1st, 2005), the Quebec provincial database for hospitalizations (March 31, 2003-April 1st, 2005), and the Quebec National Institute of Public Health database (2004). Independent variables were grouped according to the Andersen Behavioral Model of Health Services Use: predisposing, enabling and need factors. Generalized estimating equations analyses were performed to assess the influence of individual and neighborhood-level characteristics on high use of services outside the ARC provided by GPs and psychiatrists. Benjamini-Hochberg's procedure was applied to correct for multiple comparisons.

RESULTS

About 97 % of individuals attending the ARC consulted a GP or a psychiatrist during the two-year study period, for a mean of 1.5 consultations per month. Findings revealed that 5 % of the sample made 26 % of all consultations over the two years, and they were defined as high users. No single predisposing factor was associated with high use. One enabling factor significantly increased the risk of being a high user of services from general practitioners and psychiatrists: receiving services at the ARC for three years prior to 2004. Four needs factors, all related to mental health diagnoses (schizophrenia, mood disorder, anxiety disorder, personality disorder), predicted high use of general practitioner and psychiatrist services.

CONCLUSIONS

This study found that nearly all individuals with SUDs receiving services from an ARC were users of health services from GPs and psychiatrists outside the ARC. High users most probably accessed them in inpatient settings. No previous study has compared high service users with low and moderate users among individuals with SUDs. Considering that ARCs are treating individuals with complex needs, some of whom make high use of medical professionals, both ARCs and their clients could benefit from increased collaboration and integration between the addictions and mental healthcare sectors.