Identifying co-occurring substance use disorders in community mental health centres. Tailored approaches are needed

Cannabis use, self-perceived risk, perceived peer approval and parental attitudes among youth at clinical high-risk for psychosis

AIM

Cannabis use is associated with greater likelihood of psychosis. The relationship between attitudes about cannabis and use has not been examined in youth at clinical high-risk (CHR) for psychosis. Additionally, the shifting legal landscape can provide a valuable context for evaluating use and related attitudes.

METHODS

This study included 174 participants (44 CHR, 43 healthy control [HC] youth-parent dyads). Youth completed measures of self-reported cannabis use confirmed with a urinalysis, self-perceived risk and perceived peer attitudes. Parents reported attitudes about youth use. Legalization occurred halfway during a 5-year study in Colorado, providing an opportunity to cross-sectionally examine its role in use and attitudes.

RESULTS

Frequency of youth reporting cannabis use was significantly higher in CHR (69%) than control group (30%). Use in CHR group was associated with higher perceived peer approval (r = .57), increased parental permissiveness (r = .28) and lower self-perceived risk (r = -.26). Comparing samples participating pre and post-legalization, use remained stable within each group. Group differences in parental permissiveness shifted; trend toward decrease in permissiveness in CHR group (η²_partial  = .07) and a significant increase in HCs (η²_partial  = .16) were observed. Post-legalization, use in CHR group correlated with higher perceived peer approval (r = .64), lower self-perceived risk (r = -.51) and higher parental permissiveness (r = .35, trend).

CONCLUSIONS

Taken together, results indicate a relationship between self and peer/parental attitudes about cannabis and use in youth at CHR for psychosis. These factors are important to consider within the legalization context given the changes in parental attitudes and a stronger association between use and attitudes in this group post-legalization.

Substance use among patients in specialized mental health services in Norway: prevalence and patient characteristics based on a national census

PURPOSE

The aim of this study was to investigate the clinical and demographic variation in the prevalence of substance use among the general psychiatric population in Norway.

METHODS

A national census in psychiatric institutions and outpatient clinics was conducted. Data were returned for 2358 inpatients (response rate, 65%) and 23,167 outpatients (response rate, 60%). Substance use was measured based on substance use disorder diagnosis or reported substance use in the last 4 weeks (alcohol 2-4 days a week or more frequently/illicit drug use). Regression analyses controlling for demographic and sociodemographic characteristics were carried out.

RESULTS

Substance use was identified in 32.4% of inpatients and 13.9% of outpatients. The most frequently reported substances used were alcohol, sedatives and cannabis. Among inpatients, the prevalence of substance use was highest in patients with schizophrenia, personality disorders and anxiety disorders. Among outpatients, the prevalence was highest in patients with schizophrenia and other psychoses. Inpatients with anxiety disorders and outpatients with schizophrenia and other psychoses had a significantly higher risk of substance use than other patients. In both samples, the prevalence of substance use was higher among males, 24 to 29-year-olds and the most socially deprived.

CONCLUSIONS

This study provides further knowledge about patients at risk for co-morbid substance abuse and poor treatment outcomes. Clinicians may consider targeting patients with schizophrenia and other psychoses, young males and those who are socially deprived in efforts to prevent emerging substance abuse and improve outcomes.

The relationship between cannabis use and cortisol levels in youth at ultra high-risk for psychosis

Recent studies have posited a relationship between cannabis use and the biological stress system, but this critical relationship has not been evaluated during the ultra high-risk (UHR) period immediately preceding the onset of psychotic disorders. Salivary cortisol samples were collected on 46 UHR and 29 control adolescents; these individuals were assessed for current cannabis use with a urine panel and self-report. UHR participants where separated into two groups: Current Cannabis Use (UHR-CU) and No Current Cannabis Use (UHR-NC). Healthy Control participants (HC) were free of cannabis use. Consistent with the literature, results indicate UHR individuals showed elevated cortisol levels when compared to HC participants. Further, we also observed that UHR-CU participants exhibited elevated levels when compared to both the non-using UHR and HC groups. Findings suggest that cannabis use may interact with underlying biological vulnerability associated with the hypothalamic-pituitary-adrenal (HPA) axis system.

Diagnosing comorbidity in psychiatric hospital: challenging the validity of administrative registers

BACKGROUND

This study will explore the validity of psychiatric diagnoses in administrative registers with special emphasis on comorbid anxiety and substance use disorders.

METHODS

All new patients admitted to psychiatric hospital in northern Norway during one year were asked to participate. Of 477 patients found eligible, 272 gave their informed consent. 250 patients (52%) with hospital diagnoses comprised the study sample. Expert diagnoses were given on the basis of a structured diagnostic interview (M.I.N.I.PLUS) together with retrospective checking of the records. The hospital diagnoses were blind to the expert. The agreement between the expert's and the clinicians' diagnoses was estimated using Cohen's kappa statistics.

RESULTS

The expert gave a mean of 3.4 diagnoses per patient, the clinicians gave 1.4. The agreement ranged from poor to good (schizophrenia). For anxiety disorders (F40-41) the agreement is poor (kappa = 0.12). While the expert gave an anxiety disorder diagnosis to 122 patients, the clinicians only gave it to 17. The agreement is fair concerning substance use disorders (F10-19) (kappa = 0.27). Only two out of 76 patients with concurrent anxiety and substance use disorders were identified by the clinicians.

CONCLUSIONS

The validity of administrative registers in psychiatry seems dubious for research purposes and even for administrative and clinical purposes. The diagnostic process in the clinic should be more structured and treatment guidelines should include comorbidity.

Clinical presentations and diagnostic issues in dual diagnosis disorders

PURPOSE OF REVIEW

The co-occurrence of mental disorders and substance use disorders (SUDs) is very common, and associated with substantial psychiatric morbidity, functional and quality of life impairments, and societal costs. However, dual disorders are often underdetected, misdiagnosed and inadequately treated in both substance abuse and mental health settings.

RECENT FINDINGS

Individuals with dual or multiple disorders generally have worse clinical features and long-term outcomes than those with single disorders. However, findings can vary depending on factors such as type(s) of psychiatric disorder(s) and substance(s) involved, and whether the mental disorder is primary or secondary, or substance-induced or independent. Underdiagnosis or misdiagnosis of dual disorders may occur due, in part, to the use of measurement instruments and diagnostic approaches that have uncertain clinical utility.

SUMMARY

Routine, thorough, and integrated screening and diagnosis of dual disorders are needed to facilitate implementation of appropriate treatment. Results suggest that forthcoming revisions to the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases should categorize and define mental and SUDs such that clinicians can more readily detect and diagnose all types of substance use and mental health comorbid conditions. Adoption and widespread use of appropriate screening, assessment and diagnostic instruments, and more thorough diagnostic (clinimetric) approaches are recommended.

A cross-sectional study of patients with and without substance use disorders in Community Mental Health Centres

BACKGROUND

Epidemiological studies have consistently established high comorbidity between psychiatric disorders and substance use disorders (SUD). This comorbidity is even more prominent when psychiatric populations are studied. Previous studies have focused on inpatient populations dominated by psychotic disorders, whereas this paper presents findings on patients in Community Mental Health Centres (CMHCs) where affective and anxiety disorders are most prominent. The purpose of this study is to compare patients in CMHCs with and without SUD in regard to differences in socio-demographic characteristics, level of morbidity, prevalence of different diagnostic categories, health services provided and the level of improvement in psychiatric symptoms.

METHODS

As part of the evaluation of the National Plan for Mental Health, all patients seen in eight CMHCs during a 4-week period in 2007 were studied (n = 2154). The CMHCs were located in rural and urban areas of Norway. The patients were diagnosed according to the ICD-10 diagnoses and assessed with the Health of the Nation Outcome Scales, the Alcohol Use Scale and the Drug Use Scale.

RESULTS

Patients with SUD in CMHCs are more frequently male, single and living alone, have more severe morbidity, less anxiety and mood disorders, less outpatient treatment and less improvement in regard to recovery from psychological symptoms compared to patients with no SUD.

CONCLUSION

CMHCs need to implement systematic screening and diagnostic procedures in order to detect the special needs of these patients and improve their treatment.