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

How Does Telehealth Expansion Change Access to Healthcare for Patients With Different Types of Substance Use Disorders?

BACKGROUND

Patients with substance use disorders (SUDs) exhibit low healthcare utilization despite high medical need. Telehealth could boost utilization, but variation in uptake across SUDs is unknown.

METHODS

Using Wisconsin Medicaid enrollment and claims data from December 1, 2018, to December 31, 2020, we conducted a cohort study of telemedicine uptake in the all-ambulatory and the primary care setting during telehealth expansion following the COVID-19 public health emergency (PHE) onset (March 14, 2020). The sample included continuously enrolled (19 months), nonpregnant, nondisabled adults aged 19 to 64 years with opioid (OUD), alcohol (AUD), stimulant (StimUD), or cannabis (CannUD) use disorder or polysubstance use (PSU). Outcomes: total and telehealth visits in the week, and fraction of visits in the week completed by telehealth. Linear and fractional regression estimated changes in in-person and telemedicine utilization. We used regression coefficients to calculate the change in telemedicine utilization, the proportion of in-person decline offset by telemedicine uptake ("offset"), and the share of visits completed by telemedicine ("share").

RESULTS

The cohort (n = 16 756) included individuals with OUD (34.8%), AUD (30.1%), StimUD (9.5%), CannUD (9.5%), and PSU (19.7%). Total and telemedicine utilization varied by group post-PHE. All-ambulatory: total visits dropped for all, then rose above baseline for OUD, PSU, and AUD. Telehealth expansion was associated with visit increases: OUD: 0.489, P < .001; PSU: 0.341, P < .001; StimUD: 0.160, P < .001; AUD: 0.132, P < .001; CannUD: 0.115, P < .001. StimUD exhibited the greatest telemedicine share. Primary care: total visits dropped for all, then recovered for OUD and CannUD. Telemedicine visits rose most for PSU: 0.021, P < .001; OUD: 0.019, P < .001; CannUD: 0.011, P < .001; AUD: 0.010, P < .001; StimUD: 0.009, P < .001. PSU and OUD exhibited the greatest telemedicine share, while StimUD exhibited the lowest. Telemedicine fully offset declines for OUD only.

CONCLUSIONS

Telehealth expansion helped maintain utilization for OUD and PSU; StimUD and CannUD showed less responsiveness. Telehealth expansion could widen gaps in utilization by SUD type.

Exploring dual diagnosis in opioid agonist treatment patients: a registry-linkage study in Czechia and Norway

BACKGROUND

Knowledge of co-occurring mental disorders (termed 'dual diagnosis') among patients receiving opioid agonist treatment (OAT) is scarce. This study aimed (1) to estimate the prevalence and structure of dual diagnoses in two national cohorts of OAT patients and (2) to compare mental disorders between OAT patients and the general populations stratified on sex and standardized by age.

METHODS

A registry-linkage study of OAT patients from Czechia (N = 4,280) and Norway (N = 11,389) during 2010-2019 was conducted. Data on mental disorders (F00-F99; ICD-10) recorded in nationwide health registers were linked to the individuals registered in OAT. Dual diagnoses were defined as any mental disorder excluding substance use disorders (SUDs, F10-F19; ICD-10). Sex-specific age-standardized morbidity ratios (SMR) were calculated for 2019 to compare OAT patients and the general populations.

RESULTS

The prevalence of dual diagnosis was 57.3% for Czechia and 78.3% for Norway. In Czechia, anxiety (31.1%) and personality disorders (25.7%) were the most prevalent, whereas anxiety (33.8%) and depression (20.8%) were the most prevalent in Norway. Large country-specific variations were observed, e.g., in ADHD (0.5% in Czechia, 15.8% in Norway), implying differences in screening and diagnostic practices. The SMR estimates for any mental disorders were 3.1 (females) and 5.1 (males) in Czechia and 5.6 (females) and 8.2 (males) in Norway. OAT females had a significantly higher prevalence of co-occurring mental disorders, whereas SMRs were higher in OAT males. In addition to opioid use disorder (OUD), other substance use disorders (SUDs) were frequently recorded in both countries.

CONCLUSIONS

Results indicate an excess of mental health problems in OAT patients compared to the general population of the same sex and age in both countries, requiring appropriate clinical attention. Country-specific differences may stem from variations in diagnostics and care, reporting to registers, OAT provision, or substance use patterns.

The impact of co-occurring mental health problems on referral to and initiation of treatment among youth under probation supervision: Findings from a cluster randomized trial

INTRODUCTION

Many youth under community supervision have substance use and co-occurring mental health issues. Yet, access to treatment is limited, and many programs cannot address co-occurring disorders. This study examines how co-occurring symptoms among youth on probation affect referral to and initiation of treatment. We hypothesize that both referral and initiation rates will be lower for youth with any co-occurring indicators.

METHODS

This study collected administrative data from 14 sites in three states between March 2014 and November 2017 using JJ-TRIALS, a cluster randomized trial. Among 8552 youth in need of treatment (screened as having a substance use problem, drug possession arrest, positive drug test, etc.), 2069 received a referral to treatment and 1630 initiated treatment among those referred. A co-occurring indicator (n = 2828) was based on symptoms of an internalizing and/or externalizing issue. Descriptive analyses compared referral and initiation by behavioral health status. Two-level mixed effects logistic regression models estimated effects of site-level variables.

RESULTS

Among youth in need with co-occurring internal, external, or both indicators, only 16 %, 18 %, and 20 % were referred to treatment and of those referred, 63 %, 69 %, and 57 % initiated treatment, respectively. Comparatively, 27 % and 83 % of youth with a substance use only indicator were referred and initiated treatment respectively. Multi-level multivariate models found that, contrary to our hypothesis, co-occurring-both (p = 0.00, OR 1.44) and co-occurring-internal indicators (p = 0.06, OR 1.25) predicted higher referral but there were no differences in initiation rates. However, there was substantial site-level variation.

CONCLUSIONS

Youth on probation in need of substance use treatment with co-occurring issues have low referral rates. Behavioral health status may influence youth referral to treatment depending on where a youth is located. Depending on the site, there may be a lack of community programs that can adequately treat youth with co-occurring issues and reduce unmet service needs.

Cognitive impairment as a predictor of long-term psychological distress in patients with polysubstance use disorders: a prospective longitudinal cohort study

BACKGROUND

The association between polysubstance use disorder (pSUD), mental illness, and cognitive impairments is well established and linked to negative outcomes in substance use disorder treatment. However, it remains unclear whether cognitive impairment predicts long-term psychological distress among treatment seeking patients with pSUD. This study aimed to investigate the associations and predictive ability of cognitive impairment on psychological distress one and 5 years after treatment initiation.

METHODS

N = 164 treatment seeking patients with pSUD were sampled at treatment initiation. We examined associations between cognitive impairment according to Montreal Cognitive Assessment® (MoCA®), Wechsler Abbreviated Scale of Intelligence (WASI), and Behaviour Rating Inventory of Executive Function - Adult version (BRIEF-A) administered at treatment initiation and psychological distress defined by the Symptom Check List-90-Revised (SCL-90-R) at treatment initiation, one and five years later. We ran hierarchical logistic regressions to assess the predictive ability of the respective cognitive instruments administered at treatment initiation on psychological distress measured one and five years later including psychological distress at treatment initiation and substance intake at the time-points of the measurements as covariates.

RESULTS

The main results was that MoCA® and BRIEF-A predicted psychological distress at years one and five, but BRIEF-A lost predictive power when accounting for psychological distress at treatment initiation. WASI predicted psychological distress at year one, but not at year five.

CONCLUSIONS

Results from MoCA® and WASI was found to be less sensitive to the effect of psychological distress than BRIEF-A. Cognitive impairment at treatment initiation may hold predictive value on later psychological distress, yet its clinical utility is uncertain.

Abstinence duration and psychopathology among addiction outpatients during 18 months of COVID-19

Background

The COVID-19 pandemic has impacted the mental health of patients with substance use disorder (SUD). However, few longitudinal studies have been done which examine associations between the pandemic, SUD patients' mental health and their drug use.

Objectives

This study aimed to examine duration of abstinence according to psychiatric status among SUD outpatients followed-up for 18 months from the pandemic related lockdown.

Methods

A follow-up study of 316 SUD outpatients was undertaken. Sociodemographic features, and clinical and consumption related variables were recorded. Pre, during and post lockdown information was evaluated. Abstinence/substance use was monitored at the patient's scheduled follow-up appointments, and psychiatric disorders and psychological variables were revaluated at 18 months.

Results

Survival analyses were used to compare the duration of abstinence (in months) from the beginning of the lockdown. It was observed that 70% of patients consumed the main substance for which they were being treated at some point during the follow-up. Men, younger patients, those with more symptoms of anxiety and personality disorders, and patients who experienced increased craving during follow-up, showed shorter duration of abstinence. While patients who had previously maintained at least one year of abstinence, achieved better results.

Conclusions

During the first year and a half of the pandemic, SUD outpatients presented alterations in mental health, such us anxiety, depression and maladaptive personality traits and a high rate of relapse. For this reason, despite the health and social crisis and their restrictive measures, a comprehensive treatment should be ensured.

Attitudes of Gay, Bisexual, and Other Men Who Have Sex with Men (GBM) toward Their Use of Amphetamine-Type Stimulants and Relation to Reducing Use in Three Canadian Cities

BACKGROUND

We explored attitudes of gay, bisexual, and other men who have sex with men (GBM) toward their amphetamine-use and associations with reduced use over time.

METHODS

We recruited sexually-active GBM aged 16+ years in Montreal, Toronto, and Vancouver, Canada, from 02-2017 to 08-2019, with follow-up visits every 6-12 months until November 2020. Among participants who reported past-six-month (P6M) amphetamine-use at enrollment, we used logistic regression to identify demographic, psychological, social, mental health, other substance-use, and behavioral factors associated with reporting needing help reducing their substance-use. We used mixed-effects logistic regression to model reduced P6M amphetamine-use with perceived problematic-use as our primary explanatory variable.

RESULTS

We enrolled 2,449 GBM across sites. 15.5-24.7% reported P6M amphetamine-use at enrollment and 82.6 - 85.7% reported needing no help or only a little help in reducing their substance use. Reporting needing a lot/of help or completely needing help in reducing substance-use was associated with group sex participation (AOR = 2.35, 95%CI:1.25-4.44), greater anxiety symptomatology (AOR = 2.11, 95%CI:1.16-3.83), greater financial strain (AOR = 1.35, 95%CI:1.21-1.50), and greater Escape Motive scores (AOR = 1.07, 95%CI:1.03-1.10). Reductions in P6M amphetamine-use were less likely among GBM who perceived their amphetamine-use as problematic (AOR = 0.17 95% CI 0.10 - 0.29).

CONCLUSIONS

Most amphetamine-using GBM did not feel they needed help reducing their substance use, and many reported reduced amphetamine-use at subsequent visits. Those who perceived their use as problematic were less likely to reduce their use. Further interventions to assist GBM in reducing their use are needed to assist those who perceive their use as problematic.

Substance Use Patterns and Their Association with Depression and Social Factors During COVID-19 Among Harlem Residents in New York City

This study aimed to identify the prevalence of substance use before and during COVID-19; and examined its association with depression and social factors among 437 residents from the neighborhood of Harlem in Northern Manhattan, New York City. Over a third of respondents reported using any substance before COVID-19, and initiating/increasing substance use during COVID-19. The most common substances used before COVID-19 and initiated/increased during COVID-19 were smoking (20.8% vs. 18.3%), marijuana (18.8% vs. 15.3%), and vaping (14.2% and 11.4%). The percentages of any hard drug use were 7.3% and 3.4%, respectively. After adjustment, residents with mild (Prevalence Ratio [PR] = 2.86, 95% CI 1.65, 4.92) and moderate (PR = 3.21, 95% CI 1.86, 5.56) symptoms of depression, and housing insecurity (PR = 1.47, 95% CI 1.12, 1.91) had at least a 47% greater probability of initiating and/or increasing substance use. Conversely, respondents with employment insecurity (PR = 0.71, 95% CI 0.57, 0.88) were 29% less likely to report such patterns. No association was found between substance use initiation and/or increase and food insecurity. High prevalence of substance use during COVID-19 may lead residents to turn to substance use as a coping mechanism for psychosocial stressors. Thus, it is essential to provide accessible and culturally sensitive mental health and substance use services.

Problematic substance use among patients in a Swedish outpatient psychiatry setting: staff and manager perceptions of digital options for increased intervention access

BACKGROUND

Approximately 50% of the patients who globally seek help in psychiatry have been assessed with problematic substance use or been diagnosed with substance use disorder (SUD). Given the high treatment gap for mental health care, in particular SUD, these individuals risk poorer treatment outcomes in psychiatry. Integrated treatment for psychiatric and SUD disorders has been proposed to reduce the treatment gap for SUD, but access to integrated treatment is low. Digital interventions addressing SUD in psychiatry could potentially make treatment available to patients who otherwise would not have access. In this study "digital interventions" comprise an umbrella term covering all kinds of interventions from minimal motivational app-based interventions to internet-based interventions with and without human guidance, up to remote sessions in telepsychiatry. This study aims to explore healthcare staff perceptions of referring patients to digital interventions for reducing problematic substance use, whether or not diagnosed as SUD, in the psychiatric outpatient setting.

METHOD

The study was exploratory with a qualitative design. Data were collected in the Swedish outpatient psychiatry setting, via individual semi-structured interviews with managers, and focus groups with healthcare staff. An adapted form of phenomenological hermeneutical analysis was used to analyze the data.

RESULTS

Three themes emerged from the analysis. The first theme was Encountering obstacles on the path to future implementation of digital interventions, with sub-themes: Lacking resources and Feeling concerned about technical solutions. The second theme was Searching for ways forward to achieve increased access to care, with sub-themes: Blended care could facilitate integrated care and Addressing variations in patients' technical skills. The third theme was Taking steps towards the future, with sub-themes: Wanting to know more about digital interventions and Formulating a vision for the future.

CONCLUSIONS

The study reveals a concern that implementing digital interventions in psychiatry will create additional work or be technically challenging. The staff see significant advantages from the patient perspective, but they feel that they themselves need training in implementing digital interventions. In order to establish constructive implementation of digital interventions for SUD in psychiatry, staff attitudes and concerns need to be considered and addressed. This study was conducted within the Swedish healthcare system and the findings may not generalize to other countries with differing healthcare systems.

Performance measures for alcohol and other drugs services: a commentary

Alcohol and other drugs treatment includes a wide range of service and personal characteristics, along with expected and unexpected barriers to treatment. To capture the benefits and the gaps of a designed treatment, one needs to consider process-of-care and outcome measurements. Process-of-care measures are mainly developments of the rationale proposed by The Washington Circle and capture all variants in the process-of-care as proportions. Outcome measures are strongly related to different concepts of recovery and described as simple yes/no answers type to wide levels of response, such as in Likert-type scales. According to the studies collected here, more realistic periods of data-collection for process-of-care measures and a more reliable format to capture outcome particularities should be designed.

The Prevalence of Comorbidities and Substance Use Disorder

Substance use disorders (SUDs) are complex illnesses and may occur in individuals with other physical and mental illnesses. Common comorbidities for SUDs include mental health illness and/or chronic pain. Nurses face additional risk factors for the development of SUD and comorbid illnesses. The relationships among these comorbidities and SUD are multifaceted, requiring understanding of the individual disease processes and how they may impact the manifestations of one another, as well as response to treatment considerations. Understanding the prevalence of these comorbidities and potential relationships is crucial to prevention, management, and treatment outcomes.

The prevalence of substance use disorders and associated patterns among patients admitted to a psychiatric hospital in Botswana

OBJECTIVE

Substance use disorders (SUDs) have risen substantially, especially in developing nations, and has become one of the world's most significant public health and socioeconomic challenge. This study aimed to determine the prevalence and patterns of substance use disorders among patients admitted at the main psychiatric hospital, Sbrana Psychiatric Hospital in Botswana.

METHOD

The study design was descriptive cross-sectional, involving patients admitted to a psychiatric hospital. SUDs were assessed using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) v13.0. Bivariate analysis was conducted to determine the association between socio-demographic characteristics and SUDs. Multivariate logistic regression was performed to rule out the effect of confounders.

RESULTS

The final analysis involved one hundred and one (101) participants. Participants ages ranged from 18-60 years with over half (59.4%) being male. Majority of participants (85.1%) had ever used studied substances; with 63.4% found to have substance use disorders. The most frequently used substances were tobacco, cannabis, alcohol and cocaine at 58.4%, 42.6%, 34.7% and 12.8% respectively. SUDs were more common among participants who were male, younger age of 18-35 years, single, tertiary education and unemployed.

CONCLUSIONS

There is a high prevalence of substance use and SUDs among psychiatric patients in Botswana. Structured screening and interventions to manage substance use disorders should be part of routine care at the psychiatric health care facilities in Botswana. Consideration should be given to screening all patients admitted to psychiatric hospitals in Botswana for SUDs using the ASSIST.

The Role of Lifestyle on Adherence to Treatment in a Sample of Patients with Unipolar and Bipolar Depression

Introduction: Poor adherence to treatment is currently stated to be one of the causes of depression relapse and recurrence. The aim of the present study is to assess potential differences in terms of clinical and lifestyle features related to adherence to treatment in a sample of patients with unipolar and bipolar depression. Methods: One hundred and eight patients with a diagnosis of unipolar or bipolar depressive episode were recruited from January 2021 to October 2022. Adherence to psychopharmacological treatment was assessed using the clinician rating scale. Descriptive and association analyses were performed to compare subgroups based on adherence to treatment. Results: Lower levels of adherence to treatment were associated with fewer years of education, work impairment, manic prevalent polarity lifetime, and greater comorbidity with alcohol and drug abuse. The majority of patients with positive adherence did not report any hospitalization and involuntary commitment lifetime. Conclusions: Patients with a positive treatment adherence showed significant differences in terms of lifestyle and clinical features compared to non-adherent patients. Our results may help to identify patients more likely to have poor medication adherence, which seem to lead to a worse disease course and quality of life.

Integrated vs non-integrated treatment outcomes in dual diagnosis disorders: A systematic review

Background

The incidence of dual diagnosis (DD) (i.e. substance use disorders [SUD] and co-occurring mental disorders) is widespread; however, they vary widely in permutation and combination. As a result, establishing effective and empirically supported interventions for this clinical population remains challenging.

Aim

This study aimed to examine current literature on the treatment outcomes for patients with DD.

Method

A systematic review of randomised controlled trials (RCTs) published between 2009 and 2018 was conducted for two broad intervention categories identified by the literature: non-integrated and integrated treatment. Multiple electronic databases were searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA).

Results

The search generated a total of 743 studies, of which 11 satisfied the inclusion criteria. These studies were thematically synthesised into two main analytical themes: 'treatment outcomes' and 'reported strengths and limitations of DD treatment'. Specifically, integrated treatment held an advantage over non-integrated treatment in significantly improving psychiatric symptomatology. However, no significant benefits were found between integrated and non-integrated treatment regarding substance misuse and treatment retention.

Conclusion

Overall, the results provided insufficient evidence to support the enhanced efficacy of integrated or non-integrated treatment over the other in treating patients with DD.

Contribution

The study's findings were used to provide recommendations to inform the clinical psychological service delivery of dual diagnosis treatment in South Africa and also to identify gaps in the literature and highlight areas for future research.

Coproduction in evaluating a dual diagnosis tool with youth in a residential mental health service

Purpose

The purpose of this study was to utilise a lived experience (LE) informed/co-designed approach to explore the service-user experience of using the reasons for use package (RFUP) within a youth residential rehabilitation mental health setting.

Design/methodology/approach

LE researchers (those who have lived through mental illness or distress), Master of social work students, a community of mental health service manager, community of mental health researchers, dual diagnosis service researchers and university-based researchers collaborated on the project. The study used an exploratory, qualitative approach of semi-structured interviews to invite young people's experiences of the resource. The research team conducted a collaborative thematic analysis drawing on the range of perspectives.

Findings

Through five interviews with young people, key themes identified included: client factors and extra-therapeutic events, relationship factors, technique/model factors/delivery and outcomes/things noticed.

Practical implications

The RFUP was a useful clinical tool with the young people in this pilot as it improved awareness of reasons for drug use and impact on mental health, service user to staff relationship, quality of the resource, mode of delivery and participant self-knowledge.

Originality/value

Young people valued the supportive role that the RFUP played in facilitating positive relationships with their workers.

Adolescents with substance use problems in outpatient treatment: a one-year prospective follow-up study focusing on mental health and gender differences

Background

Although several studies have found a high incidence of coexisting mental health problems among adolescents with substance use problems, follow-up studies addressing how these conditions change over time are rare. The study will describe and analyze indications of mental health problems and how various risk factors predict outcomes 1 year after initial treatment contact. In addition, gender-specific risk factors are explored.

Methods

A clinical sample of 455 adolescents (29% girls, median age 17 years) answered a structural interview at baseline and were followed up using official records 1 year after initiated treatment. Bivariate associations and logistic regressions were conducted to analyse the links between risk factors at the individual, social, and structural levels as well as links between various mental illness symptoms at treatment start and indications of mental health problems 1 year later were analysed.

Results

The results show that mental health problems among adolescents largely persisted 1 year after start of outpatient care for substance use problems. Forty-two per cent of the sample displayed indications of mental health problems at follow-up, and registrations for both outpatient treatment and psychiatric medication were more common among the girls. Girls also reported more mental illness symptoms at treatment start than boys did, especially anxiety. Depression and suicidal thoughts had predictive values regarding indications of mental health problems and small cumulative effects were found for 6–10 co-occurring risk factors.

Conclusions

Adolescents with depression and suicidal thoughts at treatment start should yield attention among clinicians as these general risk factors could predict indication of mental health problems at 1 year follow-up effectively. Also, patients with more than six co-occurring risk factors seem more vulnerable for continued mental health problems. Generally, girls displayed a greater mental health and psychosocial burden at treatment initiation and were more likely to show indication of mental health problems at follow-up. These results suggests that girls are more likely to get psychiatric out-treatment parallel to, or after, substance abuse treatment. We recommend further investigation of gender differences and gender-specific needs in substance use treatment.

Prevalence of mental disorders among people with opioid use disorder: A systematic review and meta-analysis

BACKGROUND

Opioid use disorder (OUD) and mental disorders are major public health issues and comorbidity is common. Among people with OUD, comorbid mental disorders are associated with poorer health outcomes. To our knowledge, this is the first systematic review and meta-analysis to estimate prevalence of specific mental disorders among people with OUD.

METHODS

We searched Embase, MEDLINE, and PsycInfo from 1990 to 2021 for observational studies of depression, anxiety, post-traumatic stress disorder (PTSD), bipolar, personality, and other pre-specified mental disorders among people with OUD. We pooled current and lifetime estimates of each disorder using random-effects meta-analyses with 95% Confidence Intervals (CIs). Meta-regressions and stratified analyses were used to assess heterogeneity of prevalence estimates by methodological factors and sample characteristics.

FINDINGS

Of the 36,971 publications identified, we included data from 345 studies and 104,135 people with OUD in at least one pooled estimate. Among people with OUD, the prevalence of current depression was 36.1% (95%CI 32.4-39.7%), anxiety was 29.1% (95%CI 24.0-33.3%), attention-deficit/hyperactivity disorder was 20.9% (95%CI 15.7-26.2%), PTSD was 18.1% (95%CI 15.4-20.9%), and bipolar disorder was 8.7% (95%CI 6.7-10.7%). Lifetime prevalence of anti-social personality disorder was 33.6% (95%CI 29.1-38.0%) and borderline personality disorder was 18.2% (95% CI 13.4-23.1%). Sample characteristics and methodological factors, including sex, were associated with variance of multiple prevalence estimates.

INTERPRETATION

Our findings emphasise the need for access to mental disorder treatment among people with OUD. Specific mental disorder estimates may inform clinical guidelines, treatment services, and future research for people with OUD, including subpopulations with distinct treatment needs.

A Multicenter Study on the Impact of Gender, Age, and Dual Diagnosis on Substance Consumption and Mental Health Status in Outpatients Treated for Substance Use Disorders During COVID-19 Lockdown

Objective COVID-19 and lockdown measures impacted mental health globally and had a particular impact on patients with substance use disorders (SUD). However, the impact of gender, age, and dual diagnosis on consumption patterns and mental health during COVID-19 lockdown among patients with SUD has not been analyzed in depth. Therefore, this study aimed to examine substance use and mental health status during COVID-19 lockdown considering gender, age, and previous dual diagnosis in patients with SUD treated in different outpatient addiction clinics in Catalonia. Methods: Thirteen clinics participated and 588 patients were enrolled in the study, of whom 70.7% were men and 29.3% were women. The mean age was 48 ± 11.3 years, and 63.2% had dual diagnoses. Results: Men reported significantly more frequent alcohol and cocaine consumption during lockdown, while women experienced more anxiety and depressive symptoms. Younger patients more frequently reported consuming cocaine and cannabis, breaking the lockdown rule, worsened family relationships, and reduced incomes. Older patients more frequently reported maintaining abstinence. Previous dual diagnosis was more often associated with benzodiazepine use disorder, less active working during lockdown, and more anxiety and depressive symptoms than not having previous dual diagnosis. Conclusions: Both new psychiatric symptoms and general worsening of existing symptoms were frequent during the lockdown. Differences based on the gender, age, and dual diagnosis of outpatients treated for substance use disorders should be considered in the planning of protection measures such as home confinement.

Adolescents with substance abuse problems in outpatient treatment: A one-year prospective follow-up study

Aim:

There is a lack of knowledge about how adolescents with substance abuse problems manage after taking part in treatment. It is also difficult to perform traditional follow-up studies with this group. This article presents the outcome of a prospective study of 455 adolescents who underwent outpatient treatment, based on data taken from official registers. It aims to describe and analyse indications of continued use of substance (CUS) and how various risk and protective factors predict outcomes after initiated treatment at a Maria clinic in Sweden.

Design:

The study is based on structured interviews at intake, and the data that indicated CUS were taken from several different national registers. The analyses included descriptive data and bivariate associations, logistic regressions and a CHAID analysis.

Results:

Almost two thirds of the adolescents have no indication of CUS at one-year follow-up. The ten studied risk factors independently were weak predictors of CUS and it was instead the accumulation of risk factors that were linked to a negative outcome.

Conclusion:

The majority of adolescents who start outpatient treatment for substance abuse problems return to a lesser extent in registers that may indicate a continued problem with alcohol and drugs one year later. A concentration of more than five risk factors appears to be associated with a registration. The study also provides an example of an alternative method for following up adolescents with alcohol and drug abuse problems.

An Examination of Psychiatric Severity and Social Cohesion Outcomes within Oxford Houses

It is estimated that nearly 20 million adults in the United States have a substance use disorder (SUD), and 8.4 million of those adults have a comorbid mental disorder. Roughly half of those adults with a SUD and a psychiatric comorbidity fail to receive adequate treatment for either the SUD or the mental disorder (combined or separately). However, this sub-population has shown positive treatment outcomes (e.g., improved quality of life and increased length of stay in a recovery home) when allotted the proper resources to treat the overlapping symptomologies associated with their multiple diagnoses. Many individuals with SUD and psychiatric comorbidity receive community-based support from recovery residences, a ubiquitous form of aftercare treatment in the United States. The aim of the present study was to investigate the relationship between psychiatric severity index scores (a proxy for psychiatric comorbidity that measures social functioning, impairment, symptoms, and behavior), length of stay in Oxford Houses (OHs), and quality of life. The present study found a significant negative relationship between length of stay and psychiatric severity scores, and between psychiatric severity scores and quality of life scores. Psychiatric severity was observed to predict decreased quality of life, while length of stay predicted decreased psychiatric severity. Psychiatric severity mediated the relationship between length of stay and quality of life based on house composition.

COVID-19 Lockdown and Consumption Patterns among Substance Use Disorder Outpatients: A Multicentre Study

INTRODUCTION

COVID-19 has had a great impact on mental health in the general population. However, few studies have focused on patients with substance use disorders (SUDs). This research aimed to compare the clinical status and substance use patterns of SUD outpatients, before and during confinement due to the COVID-19 pandemic.

METHODS

This multicentre study recruited 588 patients (29.2% women; M age = 47.4 ± 11.7 years) in thirteen centres for addiction treatment in Catalonia, Spain. All subjects were evaluated with validated instruments and ad hoc questionnaires. The sample was divided into 3 groups according to how the substance consumption pattern changed during lockdown (maintained pattern, worsened pattern, and improved pattern).

RESULTS

More than 62% of the patients maintained or worsened their consumption pattern during confinement, and about 38% improved throughout this time. Diverse factors were associated with the changes in pattern like age, addiction severity, psychological distress during lockdown, social and familial issues, and therapeutic variables.

CONCLUSION

The home lockdown during the COVID-19 pandemic was associated with major implications for substance consumption and psychiatric distress among SUD outpatients. Considering this, the need to plan appropriate interventions in cases of similar health crises is highlighted.

Is There an Association Between Salivary Cortisol and Dropping Out of Inpatient Substance Addiction Treatments? A Prospective Repeated Measures Study

Several studies have found an association between salivary cortisol levels and dropping out of inpatient substance addiction treatment programs. The results are mixed due to variations in the study design and the lack of standardized routines for cortisol assessment. The aim of this study was to investigate whether there was (1) an association between salivary cortisol levels and dropping out from inpatient substance addiction treatments; (2) higher predictive validity for dropout in one of the cortisol indexes: Area Under the Curve with respect to ground (AUC_G) or Daily Cortisol Slope (DCS); (3) an interaction effect with time for each cortisol index; and (4) different dropout rates for sex and patients in short-term versus long-term treatment programs. This was a prospective, repeated-measures observational study. Patients (n = 173) were recruited from 2 inpatient facilities in the central region of Norway between 2018 and 2021. Salivary cortisol was measured 4 times during the treatment period, with 8 samples collected over 2 consecutive days at each time point. Cortisol levels were calculated using the cortisol indices AUC_G and DCS. Dropout was used as the outcome measure at each time point. Associations were calculated using a logistic linear regression. The results suggest a main effect of AUC_G, whereby higher levels reduce dropout risk (OR = 0.92, P = .047). An interaction with time in treatment also revealed a higher dropout risk (OR = 1.09, P = .044) during week 4 of the treatment, depending on the AUC_G. These results support using AUC_G as the recommended index when assessing cortisol, and that the relationship between cortisol levels and length of treatment should be further investigated.

Perceived care coordination among permanent supportive housing participants: Evidence from a managed care plan in the United States

Homelessness is a pervasive public health problem in the United States (U.S.). Under the U.S. Affordable Care Act, the nation's public health insurance program (Medicaid) was expanded to serve more individuals, including those experiencing homelessness. Coupled with changes in financial incentives designed to reduce healthcare costs, health plans, hospitals and large health systems have started to operate permanent supportive housing (PSH) programmes as a healthcare benefit. To better understand patient perceptions of care coordination in a PSH programme operated by a large health plan in Southern California, we conducted 22 semi-structured in-depth patient interviews between October and November 2019. Two coders analysed these data inductively and deductively, using pre-identified domains and open coding. Coding reliability and thematic saturation were also assessed. Findings indicated positive experiences with care coordination for physical health and social supports, such as food distribution and transportation. Identified service gaps included mental health support and help securing public assistance (e.g., cash benefits). Opportunities to enhance PSH care coordination were also identified, such as the need for a simplified approach. Hospitals, health plans and systems considering PSH programmes may look to these results for implementation guidance.

The Impact of Depressive Symptoms on Response to Integrated Cognitive Behavioral Therapy for Substance Use Disorders and Intimate Partner Violence

Purpose

Past studies demonstrated the efficacy of integrated cognitive-behavioral therapy (CBT) for substance use disorder (SUD) and intimate partner violence (IPV) as well as high rates of depressive symptoms in this population. However, little is known about how depressive symptoms impact treatment outcomes. We hypothesized that integrated CBT, but not standard drug counseling (DC), would buffer the negative effects of depressive symptoms on treatment response.

Design/methodology/approach

A secondary analysis of a randomized trial compared men assigned to 12 weeks of integrated CBT for SUD and IPV (n=29) to those in DC (n=34).

Findings

Most (60%) of the sample reported any depressive symptoms. Controlling for baseline IPV, reporting any depressive symptoms was associated with more positive cocaine screens during treatment. Among men with depressive symptoms, integrated CBT but not DC was associated with fewer positive cocaine screens. Controlling for baseline alcohol variables, integrated CBT and depressive symptoms were each associated with less aggression outside of intimate relationships (e.g., family, strangers) during treatment. For men without depressive symptoms, integrated CBT was associated with less non-IPV aggression compared to DC. Effects were not significant for other substances, IPV, or at follow-up.

Originality

Although integrated CBT's efficacy for improving SUD and IPV has been established, moderators of treatment response have not been investigated.

Practical Implications

Integrated CBT buffered depressive symptoms' impact on cocaine use, yet only improved non-IPV aggression in men without depressive symptoms.

Research Limitations/Implications

This study found some evidence for differential response to CBT by depressive symptoms on cocaine and aggression at end of treatment, which did not persist three months later. Future studies should explore mechanisms of integrated CBT for SUD and IPV, including mood regulation, on depressive symptoms in real-world samples.

The association between internalizing and externalizing severity with current use of cigarettes, e-cigarettes, and alcohol in adults: Wave 1 of the Population Assessment of Tobacco and Health (PATH) study

INTRODUCTION

Concurrent tobacco/alcohol use is common in adults, and associated with the severity of symptoms experienced by those with mental health disorders. However, few studies have explored this relationship across different combinations of tobacco products [i.e., conventional cigarette (CC) and electronic cigarette (EC)] and alcohol.

METHODS

Data from the Wave 1 (2013-2014) Population Assessment of Tobacco and Health study were used. A total of 15,947 adults aged 18 years or older with complete study information were included. Multinomial logistic regression analyses were performed to determine the relationship between lifetime internalizing/externalizing severity and past 30-day use of tobacco and alcohol, adjusting for nicotine dependence (ND), sex, age, race, education, and income.

RESULTS

Internalizing severity was more strongly associated with CC and alcohol use (moderate AOR = 1.47, 95% CI = 1.22-1.77; high AOR = 1.29, 95% CI = 1.03-1.61) as well as alcohol-exclusive use (moderate AOR = 1.58, 95% CI = 1.27-1.96; high AOR = 1.31, 95% CI = 1.05-1.64) while externalizing severity was more strongly associated with EC and alcohol use (high AOR = 2.97, 95% CI = 1.84-4.81, moderate AOR = 2.29, 95% CI = 1.53-3.43) when accounting for ND compared to none. The relationship between externalizing severity with EC use was dependent on alcohol being used with EC.

CONCLUSIONS

The associations between psychopathology (internalizing vs. externalizing severity) varies by different combinations of alcohol, CC, and EC. Further, these relationships may be mediated through ND. Future investigations into the comorbidity between mental disorder symptoms with tobacco and alcohol use should consider use of specific substances as well as their combination.

Impact of Cluster B Personality Disorders in Drugs Therapeutic Community Treatment Outcomes: A Study Based on Real World Data

BACKGROUND

The impact of dual pathology on treatment outcomes is unclear, with the literature reporting both favorable and unfavorable evidence. The main aim of this study was to determine how dual pathology affects treatment outcomes using real world data obtained from inpatients that began treatment in therapeutic communities.

METHOD

The data of 2458 inpatients were used. Clinical information was obtained from electronic medical records. Reliability of diagnosis was checked and revealed a mean kappa value of 0.88.

RESULTS

Of the sample, 41.8% were discharged after achieving the therapeutic objectives. Patients diagnosed with Cluster B personality disorders were found to have a higher risk of dropping out of treatment (HR = 1.320; z = 2.61; p = 0.009).

CONCLUSIONS

Personality traits exhibited by Cluster B patients can interfere with treatment in therapeutic communities. There is a need to develop specific interventions for these inpatient groups, which could be implemented in therapeutic communities.

Sexual orientation and gender identity disparities in co-occurring depressive symptoms and probable substance use disorders in a national cohort of young adults

This study examined sexual orientation and gender identity differences in co-occurring depressive symptoms and substance use disorders (SUDs) among young adults in the Growing Up Today Study national cohort (n = 12,347; ages 20-35; 93% non-Hispanic white). Self-administered questionnaires assessed recent co-occurring depressive symptoms and probable nicotine dependence, alcohol use disorder, and drug use disorder. Multinomial logistic regressions with generalized estimating equations quantified differences in prevalences of depressive symptoms only, SUDs only, and co-occurrence, among sexual minorities (mostly heterosexual; lesbian, gay, and bisexual [LGB]) compared to completely heterosexual participants, and gender minorities compared to cisgender participants. Analyses stratified by sex assigned at birth revealed sexual minorities evidenced greater odds of co-occurrence than their completely heterosexual counterparts (assigned female AORs: 3.11-9.80, ps < 0.0001; assigned male AORs: 2.90-4.87, ps < 0.001). Sexual orientation differences in co-occurrence were pronounced among LGB participants assigned female at birth who evidenced nearly 10 times the odds of co-occurring depressive symptoms with nicotine dependence and drug use disorders than did heterosexual participants assigned female at birth. Relationships between gender identity and co-occurrence were generally weaker, possibly due to low power. Gender minorities assigned male at birth, however, evidenced greater odds of co-occurring depressive symptoms and alcohol use disorders (AOR 2.75, p = 0.013) than their cisgender counterparts. This study adds to the limited research quantifying sexual orientation or gender identity differences in recent co-occurring depressive symptoms and SUDs among young adults and suggests sexual and gender minority young adults should be prioritized in prevention and treatment of co-occurring depression and SUDs.

Prevalence and Demographic Correlates of Substance Use among Adults with Mental Illness in Eastern Cape, South Africa: A Cross-Sectional Study

This study reports on the prevalence and demographic correlates of substance use among individuals with mental illness in the Eastern Cape, South Africa. This cross-sectional study was conducted in the Outpatient Clinic of a large hospital in the Eastern Cape, South Africa. A pre-validated tool on alcohol and psychoactive drug use was administered to 390 individuals with mental illness. Multivariable logistic regression models were fitted to explore the demographic correlates of alcohol and psychoactive drug use. Of the total participants (N = 390), 64.4% and 33.3% reported lifetime (ever used) and past-year use of alcohol, respectively, but the prevalence of risky alcohol use was 18.5%. After adjusting for relevant covariates, only male sex, younger age, and rural residence remained significantly associated with risky alcohol use. The prevalence of ever-use and past-year use of psychoactive substances was 39.7% and 17.4%, respectively. The most common substance ever used was cannabis (37.4%). Male sex, younger age, owning a business, and being unemployed were significantly associated with higher odds of lifetime and past-year use of psychoactive substances. Findings highlight the need for dedicated infrastructure and staff training in the management of these dual diagnoses in the region.

Staff experiences of encountering and treating outpatients with substance use disorder in the psychiatric context: a qualitative study

Background

High comorbidity exists between mental illness and substance use disorders (SUD). Patients in psychiatry living with problematic alcohol or drug consumption can experience a sense of exclusion, where seeking help for SUD can be perceived as stigmatizing. The aim of this study is to illuminate staff experiences of encountering patients with SUD within the psychiatric outpatient context.

Methods

The study was exploratory, with a qualitative design. Interviews with outpatient psychiatry managers and focus groups with clinical staff focused on the experience of encountering patients with SUD. Data were evaluated using content analysis inspired by phenomenological-hermeneutic methodology.

Results

Three themes were identified and each illuminated by two sub-themes. Bridging the organizational gap included sub-themes of having an established collaboration and facing difficulties in the collaboration; Having beliefs about the patient you encounter included sub-themes of working with patients who are exposed to prejudicial thoughts and expressing prejudicial thoughts about the patient. Striving to achieve a therapeutic alliance included sub-themes of having a feeling of developing together and supporting the patient towards recovery.

Conclusion

A life-world perspective, used to interpret results, indicated that caring for patients with SUD in psychiatry was perceived as difficult, where collaboration between psychiatry and addiction care was often experienced as problematic. Based on these findings, we believe that the current gap between the psychiatry and addiction care could be reduced to some extent by offering patients digital treatment for SUD. In this way, patients could remain under the care of their regular psychiatric clinic without having to physically visit SUD services. Thus, a virtual bridge could be established to bring psychiatry and addiction care closer to each other for the patients’ benefit.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-021-00235-9.

Neurocognitive functioning among people accessing an addiction neuropsychology clinic with and without a history of offending behaviour

Effectiveness of interventions for violent behaviour may be undermined by the presence of neurocognitive impairment, which is known to be common among alcohol and other drug (AOD) users and violent offenders. The current study aimed to examine whether the cognitive functioning of individuals with AOD histories presenting to a specialist addiction neuropsychology service differed according to their offending history (i.e. non-offending, non-violent offending and violent offending), using a retrospective case file audit design. Data were extracted from 190 clients. Tests assessed a breadth of cognitive domains. Violent offenders demonstrated the lowest premorbid IQ out of the three groups, and a significantly higher proportion of violent offenders presented with impaired divided attention and impaired cognitive inhibition compared to non-violent offenders. Rates of impairment across groups were well beyond those expected within the general population. Delivery of both AOD and violence interventions should be adapted to accommodate individuals' cognitive difficulties.

Protective Factors Against Psychological Distress Among Inpatients in Substance Use Treatment: A Cross-Sectional Study

Several studies have found co-occurrence between substance abuse and mental health problems, as well as an association between treatment retention and psychological distress. The aim of this study was to investigate the association of possible protective factors with psychological distress. The present study tested physical activity, self-esteem and sense of coherence, and psychological distress level among inpatients in substance use treatment. The study design was cross-sectional and multicenter. Patients (N = 167) were recruited in 2018 from 10 Norwegian inpatient facilities. They self-reported on 3 validated measurement instruments: Rosenberg Self-Esteem Scale, Antonovsky’s Sense of Coherence Scale, and frequency of physical activity. The Hopkins Symptom Checklist-10 was used as an outcome variable of psychological distress. The associations were investigated with multiple linear and logistic regression methods. The results suggested that high self-esteem and sense of coherence were protective factors against high levels of psychological distress: self-esteem (β = −.39, P < .001) and sense of coherence (β = −.352, P < .001). The results offer support for a salutogenic approach in substance use disorder (SUD) treatment by enhancing individuals’ protective factors to reduce psychological distress.

Characterisation of presentations to a community-based specialist addiction neuropsychology service: Cognitive profiles, diagnoses and comorbidities

INTRODUCTION AND AIMS

Cognitive impairment is a common feature of individuals with substance-use disorders. However, research tends to exclude highly complex clinical cases, limiting the generalisability of findings for 'real-world' populations. The objective of this study was to examine the complexities associated with addiction, substance use and cognitive impairment through the characterisation of client presentations to a newly established specialised addiction neuropsychology service.

DESIGN AND METHODS

Retrospective case file audit. Neuropsychological assessment reports for consenting clients over a 4-year period were de-identified and reviewed. Cognitive domains assessed included attention, processing speed, working memory, intellectual functioning, memory and executive functioning.

RESULTS

Of the 200 case files examined, the majority were male clients, with 11 years or lower of education and a history of daily substance use, with 30% continuing to use daily. Seventy-one percent had a formal mental health diagnosis and 41% had reported a history of trauma. The most prevalent cognitive impairments were observed in complex attention (50%) and memory (40%). New diagnoses were conveyed in 25% of cases, comprising acquired brain injury (16%) and neurodevelopmental disabilities (9%).

DISCUSSION AND CONCLUSIONS

It is common for clients with substance use histories referred to an addiction neuropsychology service to present with complex histories including psychosocial difficulties, comorbid mental health and medical issues and cognitive impairment. As such, careful diagnostic formulations are required when multiple factors may contribute to cognitive deficits. This study highlights the importance of a state-wide specialist addiction neuropsychology service in supporting diagnostic clarification and informing relevant treatment approaches.

Levels of mental distress over 18 years after entering treatment for substance use disorders: A longitudinal cohort study

Aims:

The aims were to investigate whether baseline characteristics and problematic substance use were related to change in mental distress over time in patients with substance use disorders during an 18-year period.

Method:

This was a prospective, longitudinal study of patients followed for 18 years after entering specialised treatment for substance use disorders. A sample of 291 patients was recruited in 1997 and 1998. Mental distress was measured using the Hopkins Symptom Checklist 25 at baseline, and at six and 18 years. Lifetime psychiatric disorders and substance use disorders at baseline were measured using the Composite International Diagnostic Interview, while personality disorders were measured using the Millon Clinical Multiaxial Inventory II. At the six- and 18-year follow-ups, substance use was measured using the Alcohol Use Disorders Identification Test and the Drug Use Disorders Identification Test. Linear mixed model was estimated to assess the overall level of mental distress over 18 years for participants with complete data at baseline (n = 232).

Results:

In an adjusted model, problematic substance use assessed simultaneously with mental distress, having lifetime affective, anxiety and personality disorder at baseline were associated with greater levels of mental distress over the 18-year period. The change in mental distress from baseline to the six-year, but not to the 18-year, follow-up was significantly larger among females than among males.

Conclusion:

The results suggests a reciprocal relationship over time between substance use and mental health problems. Also, there seems to be an additive effect between ongoing problematic substance use and lifetime mental disorders on greater levels of mental distress. This addresses the importance of integrated treatment for both substance use disorders and mental disorders to improve the long-term course for patients with these comorbid disorders.

Comparing the Personality Traits of Patients with an Eating Disorder versus a Dual Diagnosis

Objectives: This cross-sectional study explored personality traits of individuals receiving treatment in a private clinic for an eating disorder (ED) compared to those receiving treatment for a dual diagnosis (DD; defined as an addiction to illegal drugs and/or alcohol along with a mental illness, in this case an ED). The aims of this study were to: (a) assess the personality profiles and differentiating traits between the ED and DD groups, (b) analyze differences in personality traits of restrictive ED versus bingeing ED profiles, and lastly (c) compare the individuals Temperament and Character Inventory-Revised (TCI-R) results to their personality clusters as per the Diagnostic and Statistical Manual of Mental Disorders - 5^th edition (DSM-5). Methods: The TCI-R is a self-report questionnaire consisting of seven scales, each with their own subscales, which provide a fuller understanding of each temperament and character trait evaluated. This questionnaire was given to patients (n = 67) receiving treatment at a private institute specialized in eating disorders in Barcelona, Spain and the surrounding areas, along with the State-Trait Anxiety Inventory (STAI), Beck Depression Inventory-II (BDI-II), and the Barratt Impulsiveness Scale-11 (BIS-11). These subsequent questionnaires were given as they are often found to be comorbidities of ED. Results: The ED group (n = 41), regarding the TCI-R scales, showed higher scores in harm avoidance (HA), reward dependence (RD), persistence (P), cooperativeness (C) and self-directedness (SD). Whereas, the DD (n = 26) group, showed higher scores in novelty seeking (NS) and self-transcendence (ST). Also, there was a significant positive correlation between the DD group and the extravagance (NS3) subscale of novelty seeking across models. When comparing the two ED groups, the restrictive profile (RP) to the bingeing profile (BP), there were significant negative correlations in the TCI-R subscales of dependence (RD4) and perfectionism (P4) whereas there were positive correlations in the TCI-R subscale of responsibility (SD1). Conclusions: These results support previous studies and help to appraise differences in personality traits between specific groups in a clinical setting.

Mental health problems among young people in substance abuse treatment in Sweden

BACKGROUND

Young people with substance use problems face a high risk of co-occurring mental health problems, something that may involve a more difficult life situation, social problems as well as worse treatment outcomes. The aim of this study is to analyse self-reported mental health problems among young people receiving outpatient treatment for substance use problems in Sweden. We explore what types of mental health problems are more or less predominant, and whether there are significant differences between boys and girls. In addition, we analyse how various mental health problems covary with indicators of substance abuse severity.

METHODS

The study is based on structured interviews with 1970 young people enrolled at outpatient clinics in 11 Swedish cities. The data was analysed through frequency- and averages-calculations, Chi-square tests and multivariate logistic regression analyses.

RESULTS

Self-reported mental health problems were common among the young people in the study. A relatively large percentage of the total group (34-54%) reported problems such as concentration difficulties, sleeping difficulties, anxiety and depression. At the same time, many of the young people did not report any symptoms and only a small group, about 20%, reported diagnosed mental health disorders. The results show substantial gender differences, with girls reporting significantly higher levels of mental health problems. Multivariate logistic regression analyses demonstrated significant associations between severity of drug use problems and anxiety, concentration difficulties, aggression, hallucinations and mental stress caused by experiences of trauma.

CONCLUSIONS

Treatment needs are diverse within this group of young people who use drugs. Since girls report higher levels of all mental health problems, and a larger burden of psychosocial risk factors than boys, they are likely to require more comprehensive treatment interventions. The link between more severe drug problems and mental health problems points to the importance of exploring this relationship in treatment. A multidisciplinary approach, in which co-occurring problems can be addressed simultaneously, may be the best treatment form for many young people with drug problems.

Latent profiles of family background, personality and mental health factors and their association with behavioural addictions and substance use disorders in young Swiss men

Background:

Recent theories suggest that behavioural addictions and substance use disorders may be the result of the same underlying vulnerability. The present study investigates profiles of family background, personality and mental health factors and their associations with seven behavioural addictions (to the internet, gaming, smartphones, internet sex, gambling, exercise and work) and three substance use disorder scales (for alcohol, cannabis and tobacco).

Methods:

The sample consisted of 5287 young Swiss men (mean age = 25.42) from the Cohort Study on Substance Use Risk Factors (C-SURF). A latent profile analysis was performed on family background, personality and mental health factors. The derived profiles were compared with regards to means and prevalence rates of the behavioural addiction and substance use disorder scales.

Results:

Seven latent profiles were identified, ranging from profiles with a positive family background, favourable personality patterns and low values on mental health scales to profiles with a negative family background, unfavourable personality pattern and high values on mental health scales. Addiction scale means, corresponding prevalence rates and the number of concurrent addictions were highest in profiles with high values on mental health scales and a personality pattern dominated by neuroticism. Overall, behavioural addictions and substance use disorders showed similar patterns across latent profiles.

Conclusion:

Patterns of family background, personality and mental health factors were associated with different levels of vulnerability to addictions. Behavioural addictions and substance use disorders may thus be the result of the same underlying vulnerabilities.

Unique versus shared associations between self-reported behavioral addictions and substance use disorders and mental health problems: A commonality analysis in a large sample of young Swiss men

BACKGROUND AND AIMS

Behavioral addictions (BAs) and substance use disorders (SUDs) tend to co-occur; both are associated with mental health problems (MHPs). This study aimed to estimate the proportion of variance in the severity of MHPs explained by BAs and SUDs, individually and shared between addictions.

METHODS

A sample of 5,516 young Swiss men (mean = 25.47 years old; SD = 1.26) completed a self-reporting questionnaire assessing alcohol, cannabis, and tobacco use disorders, illicit drug use other than cannabis, six BAs (Internet, gaming, smartphone, Internet sex, gambling, and work) and four MHPs (major depression, attention-deficit hyperactivity disorder, social anxiety disorder, and borderline personality disorder). Commonality analysis was used to decompose the variance in the severity of MHPs explained (R²) by BAs and SUDs into independent commonality coefficients. These were calculated for unique BA and SUD contributions and for all types of shared contributions.

RESULTS

BAs and SUDs explained between a fifth and a quarter of the variance in severity of MHPs, but individual addictions explained only about half of this explained variance uniquely; the other half was shared between addictions. A greater proportion of variance was explained uniquely or shared within BAs compared to SUDs, especially for social anxiety disorder.

CONCLUSIONS

The interactions of a broad range of addictions should be considered when investigating their associations with MHPs. BAs explain a larger part of the variance in MHPs than do SUDs and therefore play an important role in their interaction with MHPs.

Associations between polygenic risk for tobacco and alcohol use and liability to tobacco and alcohol use, and psychiatric disorders in an independent sample of 13,999 Australian adults

BACKGROUND

Substance use, substance use disorders (SUDs), and psychiatric disorders commonly co-occur. Genetic risk common to these complex traits is an important explanation; however, little is known about how polygenic risk for tobacco or alcohol use overlaps the genetic risk for the comorbid SUDs and psychiatric disorders.

METHODS

We constructed polygenic risk scores (PRSs) using GWAS meta-analysis summary statistics from a large discovery sample, GWAS & Sequencing Consortium of Alcohol and Nicotine use (GSCAN), for smoking initiation (SI; N = 631,564), age of initiating regular smoking (AI; N = 258,251), cigarettes per day (CPD; N = 258,999), smoking cessation (SC; N = 312,273), and drinks per week (DPW; N = 527,402). We then estimated the fixed effect of these PRSs on the liability to 15 phenotypes related to tobacco and alcohol use, substance use disorders, and psychiatric disorders in an independent target sample of Australian adults.

RESULTS

After adjusting for multiple testing, 10 of 75 combinations of discovery and target phenotypes remained significant. PRS-SI (R² range: 1.98%-5.09 %) was positively associated with SI, DPW, and with DSM-IV and FTND nicotine dependence, and conduct disorder. PRS-AI (R²: 3.91 %) negatively associated with DPW. PRS-CPD (R²: 1.56 %-1.77 %) positively associated with DSM-IV nicotine dependence and conduct disorder. PRS-DPW (R²: 3.39 %-6.26 %) positively associated with only DPW. The variation of DPW was significantly influenced by sex*PRS-SI, sex*PRS-AI and sex*PRS-DPW. Such interaction effect was not detected in the other 14 phenotypes.

CONCLUSIONS

Polygenic risks associated with tobacco use are also associated with liability to alcohol consumption, nicotine dependence, and conduct disorder.

Are Computer-Based Treatment Programs Effective at Reducing Symptoms of Substance Misuse and Mental Health Difficulties Within Adults? A Systematic Review

Objective: Comorbid substance misuse and mental health difficulties are recognized as a leading contributor to disease burden worldwide. Amid cuts to health care services, computer-based interventions may provide support for patients experiencing these difficulties. The aims of this systematic review were to identify and investigate the efficacy of these computer-based interventions at improving substance misuse and mental health outcomes.Methods: A systematic search was conducted of CINAHL Plus, PsycARTICLES, PsycINFO, Medline, Web of Science, and the Cochrane Library. Gray literature was also searched for relevant papers. Data were extracted from 33 papers, which met eligibility criteria by reporting a computer-based intervention designed to treat substance misuse and mental health in adults. Quality assessments were conducted on these papers.Results: Computer-based interventions generally led to an improvement of substance misuse and mental health outcomes within groups and when compared against waitlist control and psychoeducation. Computer-based interventions were effective at improving dual diagnosis outcomes, and improvements to mental health outcomes specifically were maintained for up to nine months. However, the combined effect of computer-based interventions and therapist support was found to be more effective than the effects of computer-based interventions alone.Conclusions: Many papers were limited by high attrition rates commonly attributed to "digital" interventions. Future research should consider systematically recruiting a range of participants, including those potentially affected by the digital divide, and incorporating methods within research to maintain engagement. This review was also limited by the heterogeneity of the papers reported, many of which differed between targeting dual diagnosis and targeting either substance misuse or mental health respectively, with outcomes investigating other difficulties out of curiosity.

Reconsidering the associations between self-reported alcohol use disorder and mental health problems in the light of co-occurring addictions in young Swiss men

BACKGROUND

Alcohol use disorder (AUD) is known to co-occur with other addictions, as well as with mental health problems. However, the effects of other addictions co-occurring with AUD on mental health problems were rarely studied and not considering them may bias estimates of the association between AUD and mental health problems. This study investigated which role co-occurring addictions play for the cross-sectional associations between self-reported AUD and mental health problems.

METHOD

Participants were 5516 young Swiss men (73.0% of those that gave written informed consent) who completed a self-report questionnaire. Using short screening questionnaires, we assessed three substance use disorders (alcohol, cannabis and tobacco), seven behavioural addictions (internet, gaming, smartphone, internet sex, gambling, work, exercise) and four mental health problems (major depression, bipolar disorder, attention deficit hyperactivity disorder (ADHD) and social anxiety disorder). Differences in the proportions of mental health problems were tested using logistic regressions between (1) participants with no AUD and AUD, (2) participants with no AUD and AUD alone and (3) participants with no AUD and AUD plus at least one co-occurring addiction.

RESULTS

Overall, (1) participants with AUD had higher proportions of major depression (Odds ratio (OR [95% confidence interval]) = 3.51 [2.73, 4.52]; ADHD (OR = 3.12 [2.41, 4.03]); bipolar disorder (OR = 4.94 [3.38, 7.21]) and social anxiety (OR = 2.21 [1.79, 2.73])) compared to participants with no AUD. Considering only participants with AUD alone compared to participants with no AUD (2), differences in proportions were no longer significant for major depression (OR = 0.83 [0.42, 1.64]), bipolar disorder (OR = 1.69 [0.67, 4.22]), social anxiety (OR = 1.15 [0.77, 1.73]) and ADHD (OR = 1.65 [1.00, 2.72]) compared to participants with no AUD. In contrast, (3) proportions of mental health problems were considerably higher for participants with AUD plus at least one other addiction when compared to participants with no AUD, with OR's ranging from 2.90 [2.27, 3.70] for social anxiety, 4.03 [3.02, 5.38] for ADHD, 5.29 [4.02, 6.97] for major depression to 6.64 [4.44, 9.94] for bipolar disorder.

CONCLUSIONS

AUD was associated with all four measured mental health problems. However, these associations were mainly due to the high proportions of these mental health problems in participants with AUD plus at least one co-occurring addiction and only to a lesser degree due to participants with AUD alone (i.e. without any other co-occurring addictions). Hence, estimates of the association between AUD and mental health problems that do not consider other addictions may be biased (i.e. overestimated). These findings imply that considering addictions co-occurring with AUD, including behavioural addictions, is important when investigating associations between AUD and mental health problems, and for the treatment of AUD and co-morbid disorders.

Cross-national patterns of substance use disorder treatment and associations with mental disorder comorbidity in the WHO World Mental Health Surveys

AIMS

To examine cross-national patterns of 12-month substance use disorder (SUD) treatment and minimally adequate treatment (MAT), and associations with mental disorder comorbidity.

DESIGN

Cross-sectional, representative household surveys.

SETTING

Twenty-seven surveys from 25 countries of the WHO World Mental Health Survey Initiative.

PARTICIPANTS

A total of 2446 people with past-year DSM-IV SUD diagnoses (alcohol or illicit drug abuse and dependence).

MEASUREMENTS

Outcomes were SUD treatment, defined as having either received professional treatment or attended a self-help group for substance-related problems in the past 12 months, and MAT, defined as having either four or more SUD treatment visits to a health-care professional, six or more visits to a non-health-care professional or being in ongoing treatment at the time of interview. Covariates were mental disorder comorbidity and several socio-economic characteristics. Pooled estimates reflect country sample sizes rather than population sizes.

FINDINGS

Of respondents with past-year SUD, 11.0% [standard error (SE) = 0.8] received past 12-month SUD treatment. SUD treatment was more common among people with comorbid mental disorders than with pure SUDs (18.1%, SE = 1.6 versus 6.8%, SE = 0.7), as was MAT (84.0%, SE = 2.5 versus 68.3%, SE = 3.8) and treatment by health-care professionals (88.9%, SE = 1.9 versus 78.8%, SE = 3.0) among treated SUD cases. Adjusting for socio-economic characteristics, mental disorder comorbidity doubled the odds of SUD treatment [odds ratio (OR) = 2.34; 95% confidence interval (CI) = 1.71-3.20], MAT among SUD cases (OR = 2.75; 95% CI = 1.90-3.97) and MAT among treated cases (OR = 2.48; 95% CI = 1.23-5.02). Patterns were similar within country income groups, although the proportions receiving SUD treatment and MAT were higher in high- than low-/middle-income countries.

CONCLUSIONS

Few people with past-year substance use disorders receive adequate 12-month substance use disorder treatment, even when comorbid with a mental disorder. This is largely due to the low proportion of people receiving any substance use disorder treatment, as the proportion of patients whose treatment is at least minimally adequate is high.

Treatment-resistant depression as risk factor for substance use disorders-a nation-wide register-based cohort study

BACKGROUND AND AIMS

Treatment-resistant depression (TRD) is common among patients with major depressive disorder (MDD). MDD may increase the risk for developing substance use disorders (SUD). The aim of this study was to investigate the risk for developing SUD among patients with TRD compared with other depressed patients.

DESIGN

Observational cohort study.

SETTING

Nation-wide governmental health registers in Sweden.

PARTICIPANTS

All patients aged 18-69 years with an MDD diagnosis in specialized health care who had received at least one antidepressant prescription during 2006-14 were identified. Patients with at least three treatment trials within a single depressive episode were classified with TRD.

MEASUREMENTS

Patients with TRD were compared with the whole MDD cohort regarding risk for obtaining a SUD diagnosis or medication using survival analyses adjusted for socio-demographics and comorbidities.

FINDINGS

Of 121 669 MDD patients, 13% were classified with TRD. Among the patients without any history of SUD, patients with TRD had a risk increase for any SUD both ≤ 1 and > 1 year after antidepressant initiation [> 1 year hazard ratio (HR) = 1.4; 95% confidence interval (CI) = 1.3-1.5]. Risks were elevated for the subcategories of opioid (HR = 1.9, 95% CI = 1.4-2.5) and sedative SUD (HR = 2.7, 95% CI = 2.2-3.2). Patients with a history of SUD had a risk increase for any SUD ≤ 1 year after start of treatment (HR = 1.2, 95% CI = 1.1-1.4), and both ≤ 1 year and > 1 year for sedative (> 1 year HR = 2.0, 95% CI = 1.3-3.0) and multiple substance SUD (HR = 1.9, 95% CI = 1.4-2.5).

CONCLUSIONS

Patients with treatment-resistant depression may be at greater risk for substance use disorders compared with other patients with major depressive disorder. Patterns may differ for patients with and without a history of substance use disorders, and for different categories of substance use disorder.

Mortality, cause of death and risk factors in patients with alcohol use disorder alone or poly-substance use disorders: a 19-year prospective cohort study

BACKGROUND

This study investigated cause of death, mortality rates and explored if baseline characteristics were associated with risk of death in patients with alcohol use disorder alone or poly-substance use disorders.

METHODS

This was a prospective, longitudinal study of patients followed for 19 years after entering specialized treatment for substance use disorders. At baseline 291 patients (mean age 38.3 years, standard deviation 11.4 years, 72% male) with high psychiatric co-morbidity were recruited; 130 (45%) had lifetime alcohol use disorder alone, while 161 (55%) had poly-substance use disorders. Time and causes of death were gathered from the Norwegian Cause of Death Registry. Lifetime psychiatric symptom disorders and substance use disorders at baseline were measured with The Composite International Diagnostic Interview and personality disorders at baseline were measured with The Millon Clinical Multiaxial Inventory II.

RESULTS

Patients with alcohol use disorder alone more often died from somatic diseases (58% versus 28%, p = 0.004) and more seldom from overdoses (9% versus 33%, p = 0.002) compared with patients with poly-substance use disorders. The crude mortality rate per 100 person year was 2.2 (95% confidence interval: 1.8-2.7), and the standardized mortality rate was 3.8 (95% confidence interval: 3.2-4.6) in the entire cohort during 19 years after entering treatment. Having lifetime affective disorder at baseline was associated with lower risk of death (Hazard Ratio 0.58, 95% confidence interval: 0.37-0.91). Older age was associated to increased risk of death among men (p < 0.001) and non-significantly among patients with poly-substance use (p = 0.057). The difference in association between age and risk of death was significantly different between men and women (p = 0.011) and patients with alcohol use disorder alone and poly-substance use disorders (p = 0.041).

CONCLUSIONS

Patients with alcohol use disorder alone died more often from somatic disease than patients with poly-substance use disorders, and all subgroups of patients had an increased risk of death compared with the general population. Men with long-lasting substance use disorders are a priority group to approach with directed preventive measures for somatic health before they reach 50 years of age.

A longitudinal analysis of cannabis use and mental health symptoms among gay, bisexual, and other men who have sex with men in Vancouver, Canada

BACKGROUND

Cannabis use, anxiety, and depression are common among gay, bisexual, and other men who have sex with men (gbMSM) and some report using cannabis to manage mental health symptoms.

METHODS

Sexually-active gbMSM aged ≥16 years were recruited into a longitudinal cohort through respondent-driven sampling and completed study visits every six months. Data on demographics, drug use, and anxiety and depression symptoms were collected via a self-administered computer-based survey. A study nurse determined previous mental health diagnoses and treatment. Using multivariable generalized linear mixed models, we examined factors associated with regular cannabis use (≥weekly in the previous 3 months) and, among individuals who reported anxiety or depression/bipolar diagnoses, factors associated with moderate/severe anxiety or depression symptoms.

RESULTS

Of 774 participants (551 HIV-negative, 223 HIV-seropositive), 250 (32.3%) reported regular cannabis use, 200 (26.4%) reported ever being diagnosed with anxiety, and 299 (39.3%) reported ever being diagnosed with depression or bipolar disorder at baseline. Regular cannabis use was positively associated with HIV-seropositivity (aOR = 2.23, 95%CI:1.40-3.54) and previous mental health diagnosis (aOR = 1.52, 95%CI: 1.00-2.31, p = 0.05). Among those previously diagnosed with anxiety or depression/bipolar disorder, regular cannabis use was not associated with moderate/severe anxiety (aOR = 1.16, 95%CI:0.69-1.94) or depression symptoms (aOR = 0.96, 95%CI:0.59-1.58), respectively.

LIMITATIONS

Because of observational study design, we are unable to determine absolute effect.

CONCLUSIONS

Regular cannabis use was more likely among HIV-positive gbMSM and those previously diagnosed with a mental health disorder. No association was found between regular cannabis use and severity of anxious or depressive symptoms among those diagnosed with these conditions.