Concurrent Disorder Management Guidelines. Systematic Review

Concurrent disorder refers to a diverse set of combinations of substance use disorders and mental disorders simultaneously in need of treatment. Concurrent disorders are underdiagnosed, undertreated, and more complex to manage, practicing the best recommendations can support better outcomes. The purpose of this work is to systematically assess the quality of the current concurrent disorders’ clinical recommendation management guidelines. Literature searches were performed by two independent authors in electronic databases, web, and gray literature. The inclusion criteria were English language clinical management guidelines for adult concurrent disorders between 2000 and 2020. The initial search resulted in 8841 hits. A total of 24 guidelines were identified and assessed with the standardized guidelines assessment tool: AGREE II (Appraisal of Guidelines for Research and Evaluation). Most guidelines had acceptable standards, however, only the NICE guidelines had all detailed information on all AGREE II Domains. Guidelines generally supported combinations of treatments for individual disorders with a very small evidence base for concurrent disorders, and they provided little recommendation for further structuring of the field, such as level of complexity or staging, or evaluating different models of treatment integration.

Co-Occurrence of Substance use Disorders with other Psychiatric Disorders: Implications for Treatment Services

Introduction

This paper critically evaluates the literature on the co-occurrence of substance-use disorders (SUDs) with other psychiatric conditions. Our review considers the variety of different associations between the two, and suggests the implications of the literature for the design of treatment services that address both types of disorders. Methods: A narrative review of research and theory was conducted, covering epidemiology of co-occurring psychiatric disorders worldwide, mechanisms underlying co-occurrence, and treatment models. Results: Epidemiological research has documented a high prevalence of co-occurring disorders in both clinical samples and the general population, although the literature is based primarily on studies in high-income countries and some of the overlap might be due to the co-occurrence of milder forms of both types of disorders. Consistent with what has been reported in other reviews, we conclude that clients with co-occurring disorders tend to have a more severe course of illness, more severe health and social consequences, more difficulties in treatment, and worse treatment outcomes than clients with a single disorder; we address the implications of these findings for the design of treatment services. Conclusions: Much of the evidence shows that separately, treatments for both SUD and other psychiatric disorders are effective in reducing substance use and in improving behavioral, familial, and psychosocial outcomes. The evidence further suggests that these outcomes might be improved when treatment modalities are offered in combination within an integrated treatment plan that simultaneously addresses substance abuse and psychiatric problems. It is concluded that there is potentially more to be gained from taking a public health perspective and working on efforts to implement existing evidence-based practices at the systems level, than from the current tendency to look for ever more powerful individual-level interventions at the clinical level.

The Association between Non-Medical Prescription Drug Use and Suicidal Behavior among United States Adolescents

Adolescence represents a vulnerable time for the development of both drug use/abuse and mental illness. Although previous research has substantiated a relationship between drug use and suicidal behavior, little research has examined this relationship with non-medical prescription drug use. Given the growing prevalence of non-medical prescription drug use (NMPDU) among adolescents, this study explored the association between NMPDU and suicidal behavior. Nationally representative data were derived from 16, 410 adolescents who completed the 2009 National Youth Risk Behavior Survey. Approximately 19.8% of participants reported lifetime NMPDU. NMPDU was associated with significantly increased odds of suicidal behavior (P < 0.01), with seriously considering attempting suicide and making a plan about attempting suicide representing the strongest correlates for males and females. Results suggest the importance of 1) continued reinforcement of drug education programs in high school begun at earlier ages and 2) mental health care and screenings among adolescents.

Hope and recovery: a scoping review

Purpose

– Hope is regarded as central to recovery processes. The phenomenon along with its implications for research and practice has, however, gained limited attention within the fields of mental health and substance use. The purpose of this paper is to explore how hope, and what may inspire it, is described within the literature by persons experiencing co-occurring mental health and substance use problems.

Design/methodology/approach

– The method chosen when conducting this literature review was a scoping study. This allows for a broad approach, aiming to examine research activity and identifying potential gaps within existing literature. Searches were conducted in EMBASE Ovid, PsychINFO Ovid, MEDLINE Ovid, CINAHL Ebsco, SveMed+ and Brithish Nursing Index.

Findings

– The authors included five articles and one book. None of these presented first-hand experiences of hope and there appears to be a gap in the literature. All included material underlined the importance of the phenomenon to those experiencing co-occurring mental health and substance use problems.

Originality/value

– Hope seems as important to people experiencing co-occurring problems as to anyone else. There appears to be a need for further research on how persons experiencing co-occurring problems perceive hope and what may inspire it. Hope and what people hope for take many forms and can arise unexpectedly. Practitioners need to take in account the diversity of the phenomenon and find ways of inspiring hope in collaboration with those in need of support.

Consumer and practitioner perceptions of the harm reduction approach in a community mental health setting

Harm reduction in community mental health settings can be effective in engaging persons with co-occurring disorders in services. In this qualitative study, personal interviews and grounded theory methods were used to explore the experiences of 21 mental health practitioners and 15 consumers with co-occurring disorders at a community mental health housing program that uses harm reduction. Results indicate that while harm reduction enhanced therapeutic alliances, ethical and emotional tensions between practitioners and consumers regarding their views on self-determination and tolerance of drug-related behaviors were also evident. These tensions are explored and implications for practice and education are provided.

Classification of co-occurring depression and substance abuse symptoms predicts suicide attempts in adolescents

Although both depression and substance use have been found to contribute to suicide attempts, the synergistic impact of these disorders has not been fully explored. Additionally, the impact of subthreshold presentations of these disorders has not been researched. We utilized the Quadrant Model of Classification (a matrix of severity of two disorders) to assess for suicide attempt risk among adolescents. Logistic regression was used to examine the impact of co-occurring disorder classification on suicide risk attempts. Results indicate that quadrant classification had a dramatic impact on suicide attempt risk, with individuals with high severity co-occurring disorders at greatest risk.

Indian research on comorbidities

The objective of this paper is to provide a review on the psychiatric comorbidity research in India based on the data published in the last six decades. The comorbidity data world over reflects that it is a much more common phenomenon than observed in routine clinical practice. In India, research into this domain of psychiatry has been limited, with comorbidity reported to be as high as 60%. In the few publications in this area, most of the authors have looked into substance related comorbidity. Small numbers of studies have looked into comorbid conditions in child psychiatry, especially mental retardation and very few studies have looked at other comorbidities. The landmarks in the studies in the area of psychiatric comorbidity have been highlighted in this review article.

Substance dependence and remission in schizophrenia: A comparison of schizophrenia and affective disorders

The present study examined psychiatric functioning, substance use and consequences, and motivation to change in people with schizophrenia and affective disorders and current or remitted cocaine dependence. Data were collected as part of a naturalistic, longitudinal study examining substance use, motivation to change, and the process of change in people with schizophrenia and affective disorders who were currently dependent or in remission from cocaine dependence. We examined the following questions: (1) Do those in remission show better psychiatric functioning than those who are currently dependent? (2) How do people with schizophrenia and current cocaine dependence differ in terms of substance use and consequences from people with schizophrenia in remission and people with affective disorders and current drug dependence? (3) What internal factors and external factors are associated with changes in substance use in schizophrenia and how do these compare to those in nonpsychotic affective disorders? Results indicated that people with schizophrenia and current dependence reported higher levels of positive and negative symptoms than those in remission. Remission status was related to less use of other drugs, fewer days of drug problems, less distress from drug problems, and more lifetime drug-related consequences. Those with current dependence reported more days of drinking and drinking to intoxication, as well as higher rates of current alcohol use disorders than the remitted group. When compared to those with affective disorders and cocaine dependence, those with schizophrenia and current dependence reported fewer days of problems associated with their drug use, less distress from drug problems, and fewer recent and lifetime consequences associated with their drug use. The schizophrenia dependent group generally showed the lowest readiness to change, fewest efforts being made to change, and lowest confidence in the ability to change. Implications of these findings are discussed.

Treatment approaches for dual diagnosis clients in England

INTRODUCTION

Dual diagnosis (DD, co-occurrence of substance use and mental health problems) prevalence data in England are limited to specific regions and reported rates vary widely. Reliable information on actual service provision for dual diagnosis clients has not been collated. Thus a national survey was carried out to estimate dual diagnosis prevalence in treatment populations and describe the service provision available for this client population in drug/alcohol (DAS) and mental health services (MHS).

DESIGN

A questionnaire was sent to managers of 706 DAS and 2374 MHS. Overall, 249 (39%) DAS and 493 (23%) MHS participated in the survey.

RESULTS

In both DAS and MHS, around 32% of clients were estimated to have dual diagnosis problems. However, fewer than 50% of services reported assessing clients for both problem areas. Regarding specific treatment approaches, most services (DAS: 88%, MHS: 87%) indicated working jointly with other agencies. Significantly fewer services used joint protocols (DAS: 55%, MHS: 48%) or shared care arrangements, including access to external drug/alcohol or mental health teams (DAS: 47%, MHS: 54%). Only 25% of DAS and 17% of MHS employed dual diagnosis specialists.

CONCLUSIONS

Dual diagnosis clients constitute a substantial proportion of clients in both DAS and MHS in England. Despite recent policy initiatives, joint working approaches tend to remain unstructured.

Evolving U.S. service model for patients with severe mental illness and co-occurring substance use disorder

Co-occurring severe mental illness and substance use disorder has been recognized as a common problem in the U.S. since the early 1980s (1-3). For these individuals with co-occurring disorders, research demonstrates the effectiveness of various forms of combining, blending, or integrating mental health and substance abuse treatments (4). The evolving U.S. service model for integrated dual disorders treatment emphasizes several key elements: implementation, leadership, training, engagement, assessment, counseling for all patients, ancillary treatments for those with multiple needs, secondary treatments for patients who are nonresponders, and quality assurance regarding process and outcomes.

Development of Service Intensity Criteria and Program Categories for Individuals with Co-Occurring Disorders

Many patients present a clinical situation in which psychiatric symptomatology and substance related symptomatology are inextricably intertwined. A paradox exists for these patients, in that both the addictions and mental health systems of care, and the level of care assessment methodologies associated with each system, are designed for one type of disorder only, or only one disorder at a time. As a result, these individuals are perceived as "system misfits." Our inability to assess these patients accurately and place them appropriately contributes to poor outcomes and high costs. These costs consist of expensive utilization of scarce system resources. There is a growing need for a more integrated methodology for level of care assessment, in which both psychiatric and substance symptomatology can be assessed simultaneously to generate a wider array of programmatic interventions for individuals with co-occurring disorders. This article describes efforts to build upon the Patient Placement Criteria published by the American Society of Addiction Medicine, Second Edition (ASAM PPC-2) to develop a revised instrument that is much more capable of evaluating the placement needs of individuals who present with combinations of psychiatric and substance symptomatology.

Clinical aspects of substance abuse in persons with schizophrenia

OBJECTIVE

To review the current knowledge on the problem of psychoactive substance abuse by persons with schizophrenia, with particular attention to issues of direct relevance to clinical practice.

METHOD

The author examined the literature from the last 2 decades and data from studies in which he was involved.

RESULTS

Schizophrenia sufferers show an elevated liability for substance abuse. Such comorbidity may derive from self-medication attempts, a common neuropathology for addiction and schizophrenia, the psychotogenic properties of certain drugs, or the influence of environmental factors. Among schizophrenia patients receiving treatment, substance misuse is associated with more severe symptoms and poorer therapeutic response. The presence of a chronic psychosis impedes treatment of the substance problem in traditional, nonpsychiatric addiction programs. Better outcomes are observed in integrated therapy services, where patients receive appropriate care for both conditions.

CONCLUSION

Dual-pathology patients need comprehensive care with appropriate pharmacotherapy and psychosocial interventions. This treatment can be best provided within the context of a continuing care psychiatric service.