Psychiatric co-morbidity and substance use disorders: treatment in parallel systems or in one integrated system?

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Improving assessment and management of suicide risk among people who inject drugs: A mixed methods study conducted at the Medically Supervised Injecting Centre, Sydney

INTRODUCTION

People who inject drugs are 13 times more likely to die by suicide than the general population. Guidelines for responding to risk in this population are limited. Harm reduction services attended by people who inject drugs require targeted strategies to address the complexities of suicide risk among this population.

METHODS

Co-design, engaging health professionals and people with lived experience informed the study. Mixed methods were used to understand the experience of managing suicide risk among clients attending the Medically Supervised Injecting Centre (MSIC) in Sydney. A survey was administered to assess staff confidence in managing risk. Focus groups were conducted with health professionals and MSIC clients to explore experiences of suicide management, response and opportunities for improvement.

RESULTS

Half (N = 17) the MSIC staff surveyed reported over 10 years' experience working with this population. Confidence in managing suicide risk was low. Three key themes emerged from focus groups (N = 17): (i) Autonomy and the need to involve clients in the assessment process; (ii) Trust between clients and health professionals, and transparency in decision-making; and (iii) System barriers, described by health professionals as inadequate referral pathways for clients in distress, and by clients as negative experiences of care, including involuntary admission and not receiving medication (e.g. methadone).

DISCUSSION AND CONCLUSIONS

Revised assessment guidelines and a tailored safety plan were developed. These resources are also suitable for other alcohol and other drug services. The challenge in managing suicide risk in harm reduction services is balancing duty of care with staff-client relationships and client engagement.

The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder

The American Society of Addiction Medicine/American Academy of Addiction Psychiatry (ASAM/AAAP) Clinical Practice Guideline on the Management of Stimulant Use Disorder provides guidance on evidence-based strategies for the treatment of stimulant use disorders (StUDs), stimulant intoxication, and stimulant withdrawal, as well as secondary and tertiary prevention of harms associated with stimulant use. The Clinical Guideline Committee (CGC) comprised experts from ASAM and AAAP representing a range of clinical settings and patient populations. The guideline was developed following modified GRADE methodology. The process included a systematic literature review as well as several targeted supplemental searches. The CGC utilized Evidence to Decision tables to review available evidence and rate the strength of each recommendation. The clinical practice guideline was revised based on external stakeholder review. Key takeaways included: Contingency management represents the current standard of care for treatment of StUDs; Pharmacotherapies may be utilized off-label to treat StUDs; Acute stimulant intoxication can result in life-threatening complications that should be addressed in an appropriate level of care; Secondary and tertiary prevention strategies should be used to reduce harms related to risky stimulant use.

Destination Matters More: Relapse following Hospital-Based Treatment of Substance Use Disorders With and Without Co-Occurring Disorders

OBJECTIVES

Addressing substance use in psychiatric care encounters significant barriers, but the emergence of specialized services offers an opportunity to advance and scale up the integration of addiction services within psychiatric settings. However, research gaps still exist in this field, particularly in understanding the substance relapse rates of people with co-occurring disorders after a psychiatric hospitalization. This study aimed to investigate and compare the relapse rates of patients under inpatient care with exclusively addiction-related issues and those with co-occurring disorders after a hospitalization in a psychiatric ward and gain insights into differences in outcomes for these two patient groups.

METHODS

This retrospective analysis examined electronic medical records of patients admitted to the Acute Psychiatry Ward of the Hospital Clinic of Barcelona with a substance use disorder diagnosis between January 2019 and February 2021. Cox regression was used to identify variables independently associated with the first relapse episode.

RESULTS

From a total of 318 admissions (79.2% with psychiatric comorbidity), 76.1% relapsed during the study follow-up, with a median survival time of 54 days. Younger age, female gender, voluntary admission, and outpatient follow-up were independently associated with relapse. The presence of a co-occurring disorder was not associated with relapse.

CONCLUSION

This study highlights the need for interventions aimed at improving post-discharge abstinence rates for addiction-related hospitalizations. It also challenges the notion that co-occurring disorders automatically imply a worsened prognosis and emphasizes the importance of addressing addiction and psychiatric comorbidity in a comprehensive, integrated, and specialized manner.

Characterizing major depressive disorder and substance use disorder using heatmaps and variable interactions: The utility of operant behavior and brain structure relationships

BACKGROUND

Rates of depression and addiction have risen drastically over the past decade, but the lack of integrative techniques remains a barrier to accurate diagnoses of these mental illnesses. Changes in reward/aversion behavior and corresponding brain structures have been identified in those with major depressive disorder (MDD) and cocaine-dependence polysubstance abuse disorder (CD). Assessment of statistical interactions between computational behavior and brain structure may quantitatively segregate MDD and CD.

METHODS

Here, 111 participants [40 controls (CTRL), 25 MDD, 46 CD] underwent structural brain MRI and completed an operant keypress task to produce computational judgment metrics. Three analyses were performed: (1) linear regression to evaluate groupwise (CTRL v. MDD v. CD) differences in structure-behavior associations, (2) qualitative and quantitative heatmap assessment of structure-behavior association patterns, and (3) the k-nearest neighbor machine learning approach using brain structure and keypress variable inputs to discriminate groups.

RESULTS

This study yielded three primary findings. First, CTRL, MDD, and CD participants had distinct structure-behavior linear relationships, with only 7.8% of associations overlapping between any two groups. Second, the three groups had statistically distinct slopes and qualitatively distinct association patterns. Third, a machine learning approach could discriminate between CTRL and CD, but not MDD participants.

CONCLUSIONS

These findings demonstrate that variable interactions between computational behavior and brain structure, and the patterns of these interactions, segregate MDD and CD. This work raises the hypothesis that analysis of interactions between operant tasks and structural neuroimaging might aide in the objective classification of MDD, CD and other mental health conditions.

A systematic review of evidence on integrated management of psychiatric disorders in youth who use cannabis

Given the risks to mental health associated with cannabis use in youth and the increase in cannabis legalization worldwide and in the U.S., there is a need to understand existing evidence-based approaches to integrated management of psychiatric disorders in youth who use cannabis. This systematic review aimed to appraise the current evidence on integrated treatment for adolescents and young adults with common psychiatric disorders who engage in regular cannabis use. A total of 989 studies were screened for inclusion. Study's titles and abstracts were screened and advanced to full text review for further screening by two independent reviewers. Thirty-five full-text articles were reviewed, with five articles ultimately meeting all criteria for inclusion. Five randomized controlled trials examined the effects of therapeutic interventions in youth with common psychiatric disorders who used cannabis, including two studies on depression, one on bipolar disorder, one on anxiety and one on PTSD were reviewed. No studies were considered high in risk of bias. Overall, there is a paucity of research on the treatment of comorbid adolescent mental health disorders and cannabis use, which limits the ability to draw evidence-based treatment recommendations.

Navigating the Complex Intersection of Substance Use and Psychiatric Disorders: A Comprehensive Review

The co-occurrence of substance use disorders (SUDs) and psychiatric conditions, often referred to as comorbidity or concurrent disorders, presents intricate challenges in both diagnosis and treatment. This comprehensive narrative review aims to synthesize and critically evaluate the existing evidence surrounding the management of individuals with comorbid SUDs and psychiatric disorders. Comorbidity in these domains carries profound implications for clinical practice, research, and policymaking, emphasizing the need for a holistic understanding of the intricate dynamics that arise when these conditions coexist. This review explores recent research findings, evidence-based guidelines, and emerging trends within the field, offering valuable insights for clinicians, researchers, and policymakers seeking to navigate the complex terrain of comorbidity in substance use and psychiatric disorders.

Integration of substance use disorder treatment in traditional mental health facilities: Timeseries and cross-sectional evaluations

BACKGROUND

Despite efforts to increase substance use disorder (SUD) treatment provision in the United States (US), the extent to which traditional mental health (MH) facilities offer SUD treatment remains unclear. In the present study, we analyzed the trend in SUD treatment integration among traditional MH facilities in the US from 2014 to 2020 and identified facility-level factors associated with SUD treatment provision.

METHODS

Data were extracted from the National Mental Health Services Survey (N-MHSS). A timeseries logit trend analysis for the multi-year dataset (2014-2020) was conducted to assess a yearly change in odds of SUD treatment provision. With the 2020 survey data, analyses were conducted to identify the differences between facilities offering SUD treatment and facilities not offering such treatment. Finally, exploratory multivariable logistic regression was conducted to estimate odds of SUD treatment provision by facility variables.

RESULTS

US MH facility SUD treatment provision went from 51.7 % (2014) to 57.9 % (2020). A mean sample of 12,312 US MH facilities over seven years, demonstrated a significant but small yearly increase in SUD treatment provision (OR = 1.04, 95 % CI = 1.03, 1.04). Important facility characteristics related to SUD treatment provision for facilities without a core SUD focus were MH diagnostics offered (OR = 2.03), dual-diagnosis program offered (OR = 3.65), state drug/alcohol license maintained (OR = 6.66), and VA setting (OR = 7.94).

CONCLUSIONS

Despite incremental progress in integrating SUD treatment services into US MH facilities, the SUD treatment gap remains large. Training and service development incentives for identified characteristics could help further reduce the treatment gap.

Treatment Approaches for Problematic Pornography Use: A Systematic Review

Problematic pornography use (PPU) is an emerging condition associated with several negative psychological and sexual outcomes. This study aimed to systematically review treatment approaches for PPU. Potentially eligible studies were searched for in PubMed/MEDLINE, Embase, PsycINFO, and Web of Science up to April 1, 2023. The quality of the evidence was assessed with the use of the Joanna Briggs Institute's checklists, the Cochrane risk-of-bias tools, and the GRADE approach. A total of 8936 references were retrieved, and 28 studies were included in the systematic review (n = 500 participants). Included studies were case reports (k = 16), case series (k = 1), quasi-experimental investigations (k = 7), and randomized clinical trials (k = 4). The majority of included studies presented overall low quality and significant risk of bias, with all interventions receiving a low or very low rating according to the GRADE approach. Most studies investigated psychological interventions, with the predominance of second and third wave cognitive behavioral therapy interventions. Pharmacological treatments included opioid antagonists (naltrexone in most cases) and antidepressants, while one study investigated a protocol that included rTMS. Several investigations described the combination of psychological and pharmacological approaches. Most studies did not report on side effects, with online and self-help interventions presenting significant issues in terms of treatment adherence. Even though there are promising options that may have efficacy for the treatment of patients with PPU, the literature in the topic still presents significant limitations that compromise the reaching of more definitive conclusions.

Predictors of short-term response and the role of heavy alcohol use in treatment of depression

BACKGROUND

Depression and alcohol use disorders frequently co-occur. However, research on psychosocial interventions for treating this dual pathology is limited. The Ostrobothnian Depression Study (ODS) aimed to increase the systematic use of evidence-based methods, particularly among patients with comorbid depression and substance use in a naturalistic setting. This is a secondary analysis of the ODS study. The aim of the present study was to explore the predictors of a response to treatment during the first six months of the ODS intervention with a specific focus on the role of comorbid heavy alcohol use.

METHODS

The study sample (n = 242) comprised psychiatric specialist care patients with depression (Beck Depression Inventory score ≥ 17) at baseline. Patients with a baseline Alcohol Use Disorders Identification Test (AUDIT) score > 10 (n = 99) were assigned to the AUD (Alcohol Use Disorder) group in this study. The ODS intervention comprised behavioral activation (BA) for all and additional motivational interviewing (MI) for those in AUD group. The predictors of response to treatment (minimum of 50% reduction in depressive symptoms) during the first six months were analyzed with logistic regression models.

RESULTS

In the total sample at six months (n = 150), predictors of response to treatment were more severe depression (OR 1.10, CI 1.02-1.18), larger amounts of alcohol consumed (OR = 1.16, CI 1.03-1.31) and antipsychotic medication "not in use" (OR = 0.17, CI 0.07-0.44). In the non-AUD group (n = 100), more severe depression (OR 1.12, CI 1.01-1.25) and antipsychotics "not in use" (OR 0.20, CI 0.06-0.67) also predicted a positive response. Among AUD group patients (n = 50), larger amounts of alcohol consumed (OR 1.54, CI 1.04-2.27) and antipsychotic medication "not in use" (OR 0.12, CI 0.02-0.60) predicted a response to the treatment intervention.

CONCLUSIONS

The severity of symptoms and comorbid disorders were found to predict better treatment response, suggesting that the intervention was more effective in patients with severe symptoms. Patients with depression should be treated effectively regardless of having concomitant AUD. The results of this study suggest that BA combined with MI should be one of the treatment options for this dual pathology.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02520271 (11/08/2015).

Gender and addiction and other mental disorders comorbidity: sociodemographic, clinical, and treatment differences

The co-occurrence of substance use disorders (SUD) and other mental disorders (OMD) is assumed to be high, but the details are uncertain in Spain. The objective of the present study was to know the prevalence of this comorbidity, as well as the pharmacological treatment, both in specific addiction treatment networks and in mental health networks, with a gender perspective. Observational, multicenter study, with a randomized sample, of patients under treatment for SUD or OMD in Spain (N = 1783). A specific questionnaire, collecting sociodemographic and clinical variables, diagnosed SUD and OMD, and prescribed psychotropic drugs, was completed by treating clinicians. Differences between females and males were searched. A high prevalence of OMD was found in those patients treated for their SUD (71%), and also of diagnoses of SUD (59%) in people treated for OMD. Significant relationships between addiction to certain substances and specific mental disorders were found (with no main differences between women and men). The treatments for OMD were very common in the addiction treatment networks, but that of SUDs in those patients treated in the mental health networks was less than expected. A high prescription of benzodiazepines was found. Women were less frequently diagnosed with cannabis, opioid, and especially cocaine use disorders, and they had fewer psychotic disorders and more affective, anxiety, sleep, and eating disorders, with the rest being the same, including personality disorders. Women had fewer treatments with agonists and more with antagonists, and more prescriptions of anxiolytics and antidepressants. This study provides preliminary information on the coexistence in routine clinical practice of addictive disorders and other mental disorders in Spain, and on the treatment provided, and shows differences in prevalence and clinical characteristics, and especially in treatment approaches between women and men. Thus, should be useful to adapt the treatment response with greater precision, and with a gender perspective.

Barriers to Assessing and Treating Trauma in Primary Care and Opportunities for Improvement: Perspectives from Prescribers of Medications for Opioid Use Disorder

Background: Medication for Opioid Use Disorder (MOUD) is a best practice for treating individuals with opioid use disorder (OUD), and primary care-based MOUD management can reduce treatment barriers among OUD patients. Individuals with OUD experience disproportionately high rates of trauma and violence, highlighting the importance of addressing trauma, mental health, and substance use concurrently. However, clear guidelines for trauma-informed treatment in a primary care setting remain poorly established. Methods: A qualitative approach was engaged to explore primary care providers' perceptions of barriers and facilitators to assessing and treating trauma among MOUD patients. Twenty in-depth interviews were conducted in 2021 with Baltimore-based MOUD prescribers, including primary care physicians and nurse practitioners. Interview questions assessed experiences with identifying and treating trauma among MOUD patients, including challenges and opportunities. Results: Providers reported extensive histories of trauma experienced by MOUD patients. Barriers to addressing trauma include a lack of standardized protocols/procedures for identifying trauma, insufficient training/time to assess and treat trauma, and the limited availability of external mental health providers and specialty services. Opportunities included building strong, mutually respectful patient-provider relationships, providing individualized, person-centered care, and establishing connections to coordinated multidisciplinary treatment networks. Conclusions: MOUD treatment within primary care is an important way to increase OUD treatment access, but clearer standards are needed for the treatment of trauma within this patient population. These findings demonstrate opportunities to improve standards and systems such that primary care providers are better equipped to assess and treat the complex histories of trauma experienced by individuals with OUD.

Correlates and consequences of anxiety and depressive symptom trajectories during early treatment for alcohol use

We investigated whether latent trajectories of anxiety and depressive symptoms were associated with clinically relevant variables including treatment attrition among individuals seeking treatment for alcohol use. Participants were drawn from 78 addiction treatment centers and included individuals in treatment for alcohol use, had in-treatment data, and screened positive for anxiety (n = 6147) or depressive symptoms (n = 6197) at intake. Anxiety and depressive symptoms were measured weekly during the first month of treatment. Three trajectories of anxiety symptoms (i.e., Persistent Moderate Anxiety Symptoms, Remitting Moderate Anxiety Symptoms, and Remitting Mild Anxiety Symptoms) and depressive symptoms (i.e., Increasing Moderate Depressive Symptoms, Persistent Moderate Depressive Symptoms, and Remitting Mild Depressive Symptoms) were identified. Women, younger individuals, and individuals who endorsed greater past month benzodiazepine use and depressive symptoms at intake were more likely to be in the Persistent Moderate Anxiety Symptoms trajectory relative to the Remitting Mild Anxiety Symptoms subgroup. Women, individuals who screened positive for anxiety at intake, and individuals reporting past month heroin use were more likely to be in the Increasing Moderate Depressive Symptoms trajectory relative to the Remitting Mild Depressive Symptom trajectory. Trajectories characterized by persistent moderate anxiety and depressive symptoms during the first month of treatment were more likely to drop out of treatment compared to individuals who reported low symptom levels. Findings indicate heterogeneity in the clinical course of anxiety and depressive symptoms among individuals in treatment for alcohol use and highlight that persistently high anxiety and depressive symptoms may pose an impediment to successful treatment completion. Results also demonstrate the importance of considering demographic and clinical characteristics at treatment intake as they may have significant implications for the unfolding of anxiety and depressive symptoms during treatment and subsequent outcomes.

Differences in Substance Use Disorders and Other Mental Disorders in Mental Health and Addiction Settings: Sociodemographic, Clinical, Drug Treatment, and Gender Differences

Different care networks in Spain evaluate the co-occurrence of substance use disorders (SUD) and other mental disorders (OMDs). This study aimed to explore the differences in prevalence, sociodemographic and clinical profile, pharmacological treatment, and gender perspective of the co-occurrence of SUD and OMD between specific addiction treatment networks and mental health networks. This is an observational, cross-multicenter study with a randomized sample of patients under treatment for SUD or OMDs in different autonomous communities of Spain (N = 1783). Sixty-seven health professionals completed an ad hoc online questionnaire, collecting sociodemographic variables with patients diagnosed with SUD and OMDs, and their pharmacological treatments. The findings revealed a high prevalence of OMD in patients treated for SUD (71%) and those for OMD diagnosed with SUD (59%). Specific relationships between the SUDs and OMDs were identified. In networks treating SUDs, the increase in treatment for OMDs was widespread. However, the addition of SUD treatments in mental health networks was less frequent than expected. In addition, an elevated benzodiazepine prescription was detected in both settings. Some possible gender biases in treatments were found. This study provides preliminary information on the coexistence in routine clinical practice of addictive disorders and other mental disorders in Spain. The results revealed that the treatments provided are inefficient for SUDs in patients treated in mental health settings. Furthermore, a high prescription of anxiolytics and differences by sex are shown. These findings may contribute to adapting the treatment response with greater precision and effectiveness.

Comorbid trichotillomania and attention-deficit hyperactivity disorder in adults

BACKGROUND

Individuals with trichotillomania (TTM), a disorder characterized by repetitive pulling out of one's own hair, often have co-occurring ADHD, but little is known about this comorbidity. Additionally, there have been intimations in the literature that treatment of ADHD with stimulants may worsen TTM symptoms. This study aims to examine clinical aspects of individuals with TTM and co-occurring ADHD.

METHODS

308 adults with a current diagnosis of TTM were assessed for ADHD using the Mini International Neuropsychiatric Interview 7.0.2 and Adult ADHD Self Report Scale. Participants also completed clinical measures related to TTM severity, impulsivity, quality of life, and psychosocial dysfunction. A series of analyses of variance were used to calculate differences in scale scores among subjects with and without co-occurring ADHD.

RESULTS

Of the 308 participants, 47 (15.3%) met the clinical threshold for ADHD. Participants with ADHD reported significantly higher scores in all first and second factor traits of impulsivity, including attentional impulsiveness (p < .0001), motor impulsiveness (p < .0001), and non-planning impulsiveness (p < .0001). Interestingly, participants with ADHD did not report significant differences in TTM severity, perceived quality of life, or functional impairment, regardless of medication status.

DISCUSSION

The data suggest that ADHD is common in adults with TTM, and the comorbidity is associated with heightened impulsivity. The co-occurrence of ADHD does not affect individuals' quality of life, symptom severity, or functionality. Taking stimulant medications for ADHD also did not appear to affect TTM severity, despite past case reports suggesting these medications may lead to onset or worsening of TTM.

Factors associated with 60-day adherence to "safer supply" opioids prescribed under British Columbia's interim clinical guidance for health care providers to support people who use drugs during COVID-19 and the ongoing overdose emergency

AIMS

In March 2020, British Columbia issued Risk Mitigation Guidance (RMG) to support prescribing of pharmaceutical alternatives to illicit drugs, in order to reduce risk for COVID-19, overdose, and withdrawal among people who use drugs. This study evaluated factors associated with 60-day adherence to novel opioid alternatives prescribed at an inner-city health centre in Victoria, Canada.

METHODS

A chart review was conducted to collect data on sociodemographic information, medical histories, and follow-up services among all clients prescribed novel opioid alternatives from March 2020-August 2020 (n = 286). Bivariable and multivariable regression were used to identify independent and adjusted factors associated with 60-day adherence.

RESULTS

Overall, 77% of 286 clients were still receiving opioids after 60 days of follow-up. Medications included hydromorphone (n = 274), sustained-release oral morphine (n = 2), and oxycodone (n = 9). The adjusted odds of 60-day adherence to novel opioid alternatives were significantly higher for those receiving a mental health medication (aOR = 3.49, 95%CI = 1.26, 11.00), a higher maximum daily dosage of RMG prescriptions (aOR = 1.03 per mg increase, 95%CI = 1.01, 1.04), and those with continuous receipt of OAT (aOR = 6.25, 95%CI = 2.67, 15.90).

CONCLUSIONS

Higher dosages and co-prescription of mental health medications and OAT may help support better adherence to this form of prescriber-based "safer supply". Further work is needed to identify optimal prescribing practices and the longer term impacts of differing implementation scenarios.

Network Analysis of DSM Symptoms of Substance Use Disorders and Frequently Co-Occurring Mental Disorders in Patients with Substance Use Disorder Who Seek Treatment

Background: Substance use disorders (SUD) often co-occur with other psychiatric conditions. Research on SUD and comorbid disorders generally flows from a categorical diagnostic or dimensional latent variable perspective, where symptoms are viewed as independent indicators of an underlying disorder. In contrast, the current study took a network analysis perspective to examine the relationships between DSM symptoms of SUD, ADHD, conduct disorder (CD), depression (MDD), and borderline personality disorder (BPD). In addition, we explored possible gender differences in the network structures of these symptoms. Method: In a sample of 722 adult treatment-seeking patients with SUD from the International ADHD in Substance Use Disorders Prevalence Study (IASP) we estimated the network structure for 41 symptoms of SUD, ADHD, CD, MDD, and BPD. We described the structure of symptom networks and their characteristics for the total sample, and we compared the symptom networks for males and females. Results: Network analyses identified seven clusters of symptoms, largely corresponding with the DSM diagnostic categories. There were some connections between clusters, mainly between some hyperactivity symptoms and CD and depressive symptoms. ADHD hyperactivity was most central in the symptom network. Invariance tests revealed no significant gender differences in the structure of symptom networks. Conclusions: The current findings support the categorical DSM classification of mental disorders in treatment-seeking patients with SUD. Future network analyses should include a broader range of symptoms and prospectively explore changes in the symptoms network of patients during treatment.

The relationship between outpatient service use and emergency department visits among people treated for mental and substance use disorders: analysis of population-based administrative data in British Columbia, Canada

Background

Research findings on the association between outpatient service use and emergency department (ED) visits for mental and substance use disorders (MSUDs) are mixed and may differ by disorder type.

Methods

We used population-based linked administrative data in British Columbia, Canada to examine associations between outpatient primary care and psychiatry service use and ED visits among people ages 15 and older, comparing across people treated for three disorder categories: common mental disorders (MDs) (depressive, anxiety, and/or post-traumatic stress disorders), serious MDs (schizophrenia spectrum and/or bipolar disorders), and substance use disorders (SUDs) in 2016/7. We used hurdle models to examine the association between outpatient service use and odds of any ED visit for MSUDs as well count of ED visits for MSUDs, stratified by cohort in 2017/8.

Results

Having had one or more MSUD-related primary care visit was associated with lower odds of any ED visit among people treated for common MDs and SUDs but not people treated for serious MDs. Continuity of primary care was associated with slightly lower ED use in all cohorts. One or more outpatient psychiatrist visits was associated with lower odds of ED visits among people treated for serious MDs and SUDs, but not among people with common MDs.

Conclusion

Findings highlight the importance of expanded access to outpatient specialist mental health services, particularly for people with serious MDs and SUDs, and collaborative models that can support primary care providers treating people with MSUDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07759-z.

Treatment Needs and Service Delivery for Patients with Dual Disorders During the COVID-19 Pandemic: Findings From the WADD Survey

The COVID-19 pandemic has posed a great challenge for the existing health systems. The restrictions imposed across countries on the movement of people and the realignment of health care services in response to the pandemic are likely to negatively affect the health status and delivery of mental health services to persons with dual disorders (PWDD). Methods: An online survey was conducted among mental health professionals involved in providing care to PWDD to better understand the problems encountered and identify potential solutions in providing continued treatment for PWDD during the COVID-19 pandemic. Results: The findings confirmed significant disruption in the delivery of treatment services for PWDD during the COVID-19 pandemic. Dissatisfaction with personal protective equipment, inadequate COVID-19 testing services at treatment facility, and lack of guidelines on providing continued treatment services to PWDD by national authorities or professional bodies were identified as the likely reasons for this disruption. Conclusions: These concerns in turn need to be addressed by the policy-makers, hospital management staff, and other stakeholders. Specifically, there should be a focus on developing and disseminating guidelines to assist mental health professionals in setting-up and providing continued treatment services to PWDD via tele-psychiatry and other novel digital strategies.

Examination of referral source and retention among women in residential substance use disorder treatment: a prospective follow-up study

Background

Court-mandated substance use disorder (SUD) treatment, as compared to nonmandated treatment, has been associated with increased retention and completion. However, whether child protective services (CPS)-mandated women’s residential SUD treatment leads to improved treatment retention in comparison to criminal justice (CJ)-mandated and nonmandated treatment remains unclear.

Purpose

This study compared the number of days retained in residential SUD treatment among three referral sources (CPS, CJ, and nonmandated), while also examining whether having a co-occurring mental health disorder or increased stress, depression, anxiety, and PTSD symptomology contributed to decreased retention. This study tested the hypothesis that women mandated by the CPS and CJ systems would have improved residential SUD treatment retention compared with nonmandated women.

Methods

Multiple regression analyses were conducted on data for a diverse sample of 245 women (Hispanic: N = 141, Black: N = 50, White: N = 50) mandated or nonmandated (CJ: N = 114, CPS: N = 82, nonmandated: N = 49) into residential SUD treatment to determine each group’s treatment retention outcomes. Results: Women mandated to SUD residential treatment by the CPS system remained in treatment significantly longer (p = .046), compared to women not mandated, representing a 34.4% increase in retention. Findings further revealed a corresponding 2.3% decrease in retention (p = .048) for each one-unit increase in a patient’s stress score, whereas those with a co-occurring mental health diagnosis had a 43.6% decrease in SUD treatment retention (p < .001).

Conclusions

Policy and clinical considerations include (a) increasing case management support and wraparound services that meet the multiple service needs of women who are nonmandated to residential SUD treatment, and (b) incorporating a more nuanced treatment approach that manages mental health disorders and stress symptomology early in treatment when women are most vulnerable to relapse and treatment dropout.

Trial registration

ClinicalTrials.gov Identifier: NCT02977988 (first posted November 30, 2016; last update posted October 7, 2019); U.S. NIH Grant/Contract: 5R01DA038648.

Viral Suppression Is Associated with HIV Treatment Self-Efficacy in a Cohort of Women in Washington, DC

The goal of HIV treatment is viral suppression as it is linked with improved health outcomes and decreased risk of viral transmission. We assessed the sociodemographic, behavioral, and patient-provider interaction associations with viral suppression with an administered survey to HIV-seropositive women in the metropolitan Washington, DC, site of the Women's Interagency HIV Study (WIHS) between 2017 and 2018. Logistic and mixed models were used to explore related factors between HIV viral suppression groups and HIV treatment self-efficacy, respectively. Higher HIV treatment self-efficacy and disclosure concerns were positively associated with viral suppression, while illicit drug use had a negative association. In mixed models, more health care provider trust was associated with higher HIV treatment self-efficacy, while depressive symptoms were associated with lower HIV treatment self-efficacy. Depression, illicit substance use, and HIV treatment self-efficacy are potentially modifiable factors that can influence viral suppression. Implementation studies are needed to determine whether interventions to manage depression or self-efficacy and improve trust in health care providers will influence treatment outcomes.

Factors Associated with Substance Use Disorder Treatment Completion, Rhode Island, USA, 2018

INTRODUCTION

The successful retention of individuals with substance use disorders in treatment remains a challenge but is an important indicator of positive post-treatment outcomes. The aim of this study is to advance understanding of pre-admission factors associated with substance use treatment completion in Rhode Island.

METHODS

Data for this longitudinal analysis are from the RI Behavioral Health On-Line Database (RI-BHOLD). The primary outcome of interest was substance use treatment completion defined as any planned discharge from treatment, including transfers to other facilities. Associations were assessed using generalized estimating equations (GEE) to account for the potential of repeated measures for the same individuals.

RESULTS

Among the 7,351 clients discharged from a substance use treatment program in RI in 2018, the treatment completion rate was 58.1%. There was a positive relationship between the frequency of attendance of voluntary self-help groups and odds of treatment completion. Treatment completion rates were lower among those who reported use of opioids (AOR: 0.59; 95% CI: 0.52-0.66) and other drugs (AOR: 0.52; 95% CI: 0.44-0.62), compared to alcohol and for those with co-occurring mental health conditions (AOR: 0.85; 95% CI: 0.76-0.94).

CONCLUSIONS

This study highlights the importance of social connectedness in substance use disorder treatment completion. Future research is needed to identify the characteristics of persons who are most likely to benefit from self-help groups and the optimal combination of treatment participation and attendance of self-help groups across a spectrum of disorder severity and community resources.

The impact of psychiatric comorbidity on treatment discontinuation among individuals receiving medications for opioid use disorder

BACKGROUND

Psychiatric illness complicates the clinical course of opioid use disorder (OUD) including treatment using medication for OUD (MOUD). The purpose of this study was to assess the relationship between psychiatric comorbidity and MOUD discontinuation, stratified by whether the client dropped out of treatment or whether MOUD was terminated by the addiction facility.

METHODS

The study population consisted of individuals with OUD receiving MOUD. Data was derived from the 2015-2017 Treatment Episodes Dataset - Discharges (TEDS-D), which includes discharge records from addiction treatment centers across the United States. The association between psychiatric comorbidity and MOUD discontinuation (including client dropout and facility termination) was assessed using multivariable logistic regression models that included clinically relevant covariates (age, sex, race, education, employment status, living arrangement, prior addiction treatment, intravenous opioid use, primary opioid used at admission, polysubstance use, previous arrests, length of stay, and referral source).

RESULTS

Psychiatric comorbidity decreased the odds of client dropout (adjusted odds ratio (aOR): 0.88, 95 % confidence interval (CI): 0.86 - 0.89) but increased the odds of MOUD being terminated by the treatment facility (aOR: 1.59, 95 % CI: 1.56-1.63). The association between psychiatric comorbidity and MOUD discontinuation varied considerably between states.

CONCLUSIONS

Individuals with psychiatric illness are slightly less likely to drop out of MOUD treatment but are more likely to have their treatment prematurely terminated by the treatment facility. This emphasizes the importance of considering psychiatric illness when providing OUD treatment and suggests that measures to improve MOUD retention for individuals with psychiatric illness are required.

Childhood Trauma Predicts Less Remission from PTSD among Patients with Co-Occurring Alcohol Use Disorder and PTSD

Post-traumatic stress disorder (PTSD) is highly prevalent among patients hospitalized for an alcohol use disorder (AUD). Hospitalization can improve PTSD and AUD outcomes in some but not all patients, but we lack data on the baseline predictors of PTSD non-remission. This study aimed to determine the baseline risk factors for non-remitted PTSD in patients hospitalized for an AUD. Of 298 AUD inpatients recruited in a rehabilitation center (Le Courbat, France), we included 91 AUD inpatients with a co-occurring PTSD and a longitudinal assessment at baseline (T1) and before discharge (T2: 8 weeks later). Patients were assessed for PTSD diagnosis/severity (PCL-5=PTSD Checklist for DSM-5), different types of trauma including childhood trauma (LEC-5=Life Events Checklist for DSM-5/CTQ-SF=Childhood Trauma Questionnaire, Short-Form), and AUD diagnosis/severity (clinical interview/AUDIT=Alcohol Use Disorders Identification Test). Rate of PTSD remission between T1 and T2 was 74.1%. Non-remitted PTSD at T2 was associated with a history of childhood trauma (physical, emotional or sexual abuse, physical negligence), but not with other types of trauma experienced, nor baseline PTSD or AUD severity. Among patients hospitalized for an AUD with co-occurring PTSD, PTSD remission was more strongly related to the existence of childhood trauma than to AUD or PTSD severity at admission. These patients should be systematically screened for childhood trauma in order to tailor evidence-based interventions.

Dual diagnosis: A systematic review of the organization of community health services

BACKGROUND

Dual diagnosis (DD), as the co-occurrence of a substance use disorder and a psychiatric disorder, is underestimated, under-diagnosed and often poorly treated throughout the world, although it is highly prevalent in people suffering from a mental disorder.

AIMS AND METHODS

This review analyzed 48 studies from a PubMed and PsycINFO databases search, in order to verify the state of the art regarding the organization of community health services for DD treatment.

RESULTS

Four macro-themes have been identified: service organization, critical issues, assessment tools and evidence-based interventions. An effective service recognizes the complexity of DD, promotes a common staff culture, and tailors the organization to local needs. The main critical issues in its implementation include the lack of specific staff training, the poor management of resources and the need for greater personalization of care plans, with attention to psychosocial interventions. Integrated service assessment tools can be used as a benchmark measure at the program level for implementation planning and at the national level to affect policy change. The integrated treatment model for DD should also aim to improve access to care and offer treatments based on scientific evidence. It is also evident that the integration of services can improve outcomes but it is not a guarantee for it.

CONCLUSION

There is an urgent need to improve networking between mental health and addiction services in order to deal with DD and create new integrated intervention models, paying attention to an approach to the whole person, seen in his/her absolute uniqueness.

Dispensation of attention deficit hyperactivity disorder (ADHD) medications in patients receiving opioid agonist therapy; a national prospective cohort study in Norway from 2015 to 2017

BACKGROUND

It is estimated that up to a third of patients on opioid agonist therapy (OAT) have attention deficit hyperactivity disorder (ADHD). Treatment by ADHD medication, including a centrally acting stimulant (CAS) or atomoxetine is one of the essential approaches. This study evaluates the use of dispensed ADHD medications in the Norwegian OAT population in the period from 2015 to 2017. Types and doses of ADHD medications, co-dispensations of other potentially addictive drugs like benzodiazepines, z-hypnotics, gabapentinoids, and non-OAT opioids, as well as direct-acting antivirals (DAA) against hepatitis C infection, are investigated.

METHODS

Information about all dispensed ADHD medication, OAT opioids, and the defined potentially addictive drugs were recorded from the Norwegian Prescription Database. Dispensation rates, the types, and the doses of dispensed ADHD medications were estimated by summarizing the number of dispensations, and the dispensed doses. Logistic regression analyses were employed to assess the associations between ADHD medication, and OAT opioid use, and dispensations of other potentially addictive drugs and DAAs against hepatitis C infection.

RESULTS

A total of 9235 OAT patients were included. The proportion of patients who were dispensed ADHD medication increased from 3.5 to 4.6% throughout the study period. The three most dispensed CAS were short- and intermediate-acting methylphenidate (55%), lisdexamphetamine (24%), and dexamphetamine (17%) in 2017. Buprenorphine, rather than methadone, as OAT opioid (adjusted odds ratio: 1.6, CI: 1.2-2.1) was associated with being dispensed ADHD medication. Among patients who received CAS and OAT opioids each calendar year, the dispensed doses of methylphenidate increased from 63 mg/day in 2015 to 76 mg/day in 2017 (p = 0.01). Sixty percent of patients receiving ADHD medications were also dispensed other addictive drugs concomitantly in 2017. Similar results were found in 2015 and 2016.

CONCLUSION

Co-prescription of ADHD medications was low among patients on OAT in Norway, considering a high prevalence of ADHD in this patient group. On the other hand, concurrent dispensations of multiple addictive drugs were common in this population. Understanding the underlying reasons for such prescribing is essential, and research on how to optimize ADHD medication of patients with ADHD receiving OAT is needed.

Depression, post-traumatic stress disorder, suicidality and self-harm among people who inject drugs: A systematic review and meta-analysis

BACKGROUND

A range of negative experiences and circumstances that are common among people who inject drugs (PWID) are risk factors for developing mental disorders. Despite this, there has been no systematic review of the prevalence of mental health indicators among PWID. Thus, we aimed to estimate the prevalence of depression, post-traumatic stress disorder (PTSD), suicidality and self-harm among PWID.

METHODS

We searched the peer-reviewed and grey literature for data on depression, PTSD, suicidality and non-suicidal self-harm among PWID from sources published from 2008-2018. We pooled estimates of depression and suicidality using random-effects meta-analysis and provided a narrative summary of estimates of PTSD and self-harm.

FINDINGS

We found 23 studies that reported on these mental health indicators among PWID. The pooled estimate for current severe depressive symptomology was 42.0 % (95 % confidence interval [CI] = 21.3, 62.8 %), and for a depression diagnosis was 28.7 % (95 % CI = 20.8, 36.6 %). With much variation, the pooled lifetime prevalence of a suicide attempt was 22.1 % (95 % CI = 19.3, 24.9 %). There were only two studies each that reported on PTSD and non-suicidal self-harm among PWID.

INTERPRETATION

Recent data investigating these mental health indicators among PWID was limited, particularly from low- and middle-income countries. Even so, estimates were high and call for further research into the epidemiology of such mental health disorders and self-harming behaviours, as well as the promotion of integrated mental health and substance dependence treatment. Finally, incorporating suicide prevention strategies into services accessed by PWID must be considered as a harm reduction priority.

Methylphenidate for Attention-Deficit and Hyperactivity Disorder in Adult Patients With Substance Use Disorders: Good Clinical Practice

Attention-deficit and hyperactivity disorder (ADHD) is a widespread neurodevelopmental disorder in children and adolescents, persisting into adulthood in a majority of them. ADHD and substance use disorders (SUDs) commonly co-occur in the clinical adult population. The higher-than-normal prevalence rates of SUDs in people with ADHD indicate increased risk for developing SUD. This narrative review deals with the question of whether or not adults with both disorders should be treated with methylphenidate (MPH), addressing specific issues surrounding this form of treatment. MPH is considered as first-line pharmacotherapy for ADHD. However, because of its stimulant-like reinforcing properties, MPH has a significant addictive potential to which persons with SUDs are especially susceptible. Appropriate treatment is therefore complex. Because of concerns about misuse and diversion of MPH medication, clinicians may be reluctant to use MPH to manage ADHD symptoms in these patients. However, it is essential to diagnose and treat ADHD adequately as appropriate therapy reduces the impairments, as well as the risk of developing comorbid disorders and poor treatment response. MPH should not be deprived of these patients because of the risk for misuse, especially as several strategies can be applied to minimize this risk. To conclude, carefully applied guideline-based diagnostics to clarify the potential presence of ADHD as well as a responsible prescription practice in a well-defined therapeutic setting with reliable monitoring of medication intake and regular consultations are essential conditions for a safe and proficient MPH treatment of ADHD in patients with SUD.

Assessing factors associated with discharge from opioid agonist therapy due to incarceration in the United States

The following study investigates factors associated with discharge from OAT due to incarceration in a sample of 64,331 discharges in the United States. Multinomial regression investigated the association between demographic factors, prior arrest, referral source (i.e criminal justice agency) intravenous drug use, types of drug used, length of prior treatment and discharge due to incarceration compared to completing treatment or discharge due to other reasons. African Americans, Latinx, and Native Americans were at greater risk of discharge due to incarceration compared to whites. Referral to OAT from criminal justice agencies and self-referral was associated with increased risk of discharge from OAT due to incarceration compared to referral from a health care provider. Substance use of heroin, benzodiazepines, synthetic opioids, cocaine and non-prescription use of methadone were associated with discharge due to incarceration. Risk of discharge due to incarceration was higher for patients who reported intravenous drug use and who reported a co-morbid psychiatric problem. These findings enrich a nascent body of literature on mechanisms associated with attrition from OAT due to incarceration and emphasize the need for programs to divert people with OUD from incarceration to increase engagement and retention in OAT.

Impact of Substance Use and Mental Health Comorbidity on Health Care Access in Canada

Objective: Psychological disorders and substance use comorbidity is associated with greater symptomatology and a worse prognosis. Previous research has highlighted discrepancies in the level of use of health care services in individuals experiencing comorbidity compared to those with mental disorders or substance use disorders alone. The purpose of the current study was to compare mental health service use (i.e., access, number of professionals accessed, helpfulness of services received, and number of hours of services received) among individuals with mental disorders, substance use disorders, and comorbid disorders. Methods: Participants consisted of respondents to the 2012 Canadian Community Health Survey-Mental Health (N = 25,133). The researchers used a mixture of binary logistic regressions, Poisson regressions, linear regressions, and ordinal logistic regression to explore the impact of demographic variables, psychological distress, and clinical categories on health care access. Results: The mental disorders group, OR = 0.52, p = .008, 95% CI [0.32, 0.85], d = 0.36, and the substance use disorders group, OR = 0.31, p = .001, 95% CI [0.16, 0.60], d = 0.65, were significantly less likely than the comorbid group to report having accessed a professional in the past year. There were no significant differences in the perceived level of helpfulness for interventions received or in the time spent in professional consultation when comparing the substance use disorders and mental disorders groups to the comorbid group. Conclusions: Although the level of access to health care was low overall, those with concurrent disorders were more likely to access mental health services than those with substance use disorders or mental disorders only. The findings of this study reveal various treatment gaps, especially in those experiencing substance use disorders, and reaffirm the importance of improving treatment accessibility for these individuals.

A systematic review of comprehensive interventions for substance abuse: Focus on victimization

Violence victimization is common among men and women who use substances and is associated with co-occurring health issues such as PTSD, depression and HIV. Substance use interventions, therefore, should include integrated components that are designed to address co-occurring health issues among victimized substance-using individuals. This systematic review synthesized the evidence on efficacy of comprehensive, integrated, multicomponent interventions for victimized substance-using individuals. The efficacy of integrated multicomponent intervention strategies was assessed for the following syndemic conditions: mental health, substance misuse, violence, and HIV risk. Seventeen studies were identified. Examples of effective components were empowerment strategies for violence, mindfulness-based stress reduction for mental health, social cognitive skill building for addressing HIV risk and psychoeducation for substance misuse. Although in this review, some components were found to be effective, we identified methodological limitations of included studies which calls for more rigorous research in this area. Further, there is lack of evidence base for multicomponent interventions for victimized substance-using individuals in developing countries. Additional studies are needed to establish rigorous evidence base for multicomponent interventions for victimized substance using individuals that help them cope effectively with their trauma of violence and address their needs.

Behavioral health treatment utilization among individuals with co-occurring opioid use disorder and mental illness: Evidence from a national survey

BACKGROUND

Past research shows that among individuals with substance use disorders, the presence of a co-occurring mental illness can influence the initiation, course, and success of behavioral health treatment, but little research has examined people with opioid use disorder (OUD) specifically.

METHODS

Using the 2008-2014 National Survey on Drug Use and Health, this study examines the utilization of substance use disorder and mental health treatment among individuals with OUD and different degrees of mental illness severity. The study also examined types of treatment, perceived unmet need for treatment, and barriers to care.

RESULTS

47% of individuals with OUD and co-occurring mild/moderate mental illness did not receive any behavioral health treatment, and 21% of those with co-occurring serious mental illnesses did not receive any behavioral health treatment. Among those with OUD and co-occurring mild/moderate mental illness, 16% reported receiving both substance use disorder and mental health treatment; among those with co-occurring serious mental illness the rate was 32%. The most common form of treatment was prescription medication for mental health, and this was true regardless of whether or not the individual had any mental illness. More than 50% of the study population reported financial difficulties as a barrier to treatment.

CONCLUSION

A high proportion of individuals with OUD and co-occurring mental illness are not receiving needed care. However, nearly one in five of those with OUD but no diagnosed mental illness is receiving prescription medication for mental illness. These findings suggest that there is a need to better facilitate access to and coordinate behavioral health care across settings for individuals with OUD.

Models of Concurrent Disorder Service: Policy, Coordination, and Access to Care

Background: Societal capacity to address the service needs of persons with concurrent mental health and substance-use disorders has historically been challenging given a traditionally siloed approach to mental health and substance-use care. As different approaches to care for persons with concurrent disorders emerge, a limited understanding of current models prevails. The goal of this paper is to explore these challenges along with promising models of coordinated care across Canadian provinces. Materials and methods: A scoping review of policies, service coordination and access issues was undertaken involving a review of the formal and gray literature from 2000 to 2018. The scoping review was triangulated by an analysis of provincial auditor general reports. Results: Models of concurrent disorders service were found to have evolved unevenly. Challenges related to the implementation of models of collaborative care and local networks that foster service coordination and policy accountability were found to inhibit integrated care. Conclusion: Emergent models of coordinated care were found to include collaborative care, regional networks with centralized access to care, clinical information-sharing, cross-training, improved scope of care to include psychologists and alignment of physician incentives with patient needs to better support patient care.

Substance use consequences, mental health problems, and readiness to change among Veterans seeking substance use treatment

Individuals seeking substance use treatment who have one or more co-occurring mental health problems tend to have lower treatment engagement, higher rates of attrition, and poorer treatment outcomes. Readiness to change (RTC) is an integral construct in the recovery process, with higher RTC associated with improved treatment outcomes. However, the impact of psychiatric symptoms on RTC is not fully understood, especially among specialty subpopulations, such as military Veterans. Therefore, the aim of the present study was to examine the associations of mental health problems with RTC in a sample of Veterans initiating outpatient substance use treatment. The present sample was comprised of 278 Veterans (12% women, M_age = 48.22, SD = 14.06) who completed self-report intake measures assessing past month substance use frequency, substance-related consequences, symptoms of insomnia, depression, and anxiety, and importance and confidence to change one's substance use. Four separate canonical correlation analyses focusing on RTC alcohol, opioid, cannabis, and nicotine use were conducted. Veterans' inclusion in each analysis was not mutually exclusive. Results indicated that greater depression, anxiety, consequences, and frequency of alcohol use corresponded with greater importance to change alcohol use. Likewise, greater depression, anxiety, and insomnia symptoms along with frequency of use and consequences related to greater importance and confidence to change one's opioid use. In contrast, greater anxiety, depression, insomnia, and frequency of use were associated with less confidence in one's ability to change cannabis use. None of these variables were related to one's RTC nicotine use. Findings highlight the importance of assessing mental health problems at outset of substance use treatment, as they may be an indication of RTC and could be used as a catalyst to advance Veterans forward in the process of behavior change.

Behavioral activation and behavioral inhibition sensitivities in patients with substance use disorders: A study from India

INTRODUCTION

Addictive disorders are an epiphenomenon of underlying vulnerabilities. Research over the past decades into these vulnerabilities has distinguished internalizing and externalizing spectra as two distinct personality factors underlying substance use disorders (SUDs). In this study, we explore the behavioral activation and inhibition factors in patients with SUD.

MATERIALS AND METHODS

A total of 240 patients with SUD were recruited for the study. Behavioral inhibition system-behavioral activation/approach system (BIS-BAS) scale was used to assess the three domains of the behavioral activation, namely drive, fun seeking and reward responsiveness, and the behavioral inhibition as a single domain. BIS and BAS subscale total scores, inter-domain correlation, factor structure, and difference in the early-onset and late-onset SUD subgroup scores were calculated.

RESULTS

The drive, fun seeking, and reward responsiveness showed a moderate degree of correlation among each other ranging from 0.30 to 0.36. The behavioral inhibition subscale had a modest correlation r = 0.26 with the reward responsiveness subdomain of behavioral activation. The factor structure remained valid at two- and four-factor solutions apart from few items with inconsistent loading. The early-onset n = 209 (87.1%) and late-onset n = 31 (12.9%) SUD subgroup analysis showed a statistically significant difference in the mean scores of drive and fun-seeking subscales with P < 0.05.

DISCUSSION AND CONCLUSIONS

Behavioral activation and inhibition remain two valid personality factors in patients with SUDs. Patients with early onset of SUD have a significantly higher behavioral activation scores in the drive, and fun-seeking subfactors suggesting a higher externalizing tendency.

Psychiatric comorbidity and intimate partner violence among women who inject drugs in Europe: a cross-sectional study

Women who inject drugs (WWID) are an especially vulnerable group of drug users. This study determined the prevalence of psychiatric comorbidity and intimate partrner violence (IPV), and factors associated with psychiatric comorbidity among WWID recruited from drug treatment services (67%) and harm reduction services in five European regions in Austria, Catalonia, Italy, Poland, and Scotland. Psychiatric comorbidity was assessed among 226 WWID using the Dual Diagnosis Screening Instrument. IPV was assessed using the Composite Abuse Scale and injecting and sexual risk behaviors were assessed using a battery of questionnaires adapted and developed for the study. Eighty-seven percent met criteria for at least one lifetime psychiatric disorder. The most common disorders were depression (76%), panic (54%), and post-traumatic stress (52%). WWID recruited in drug treatment services were almost three times as likely (OR 2.90 95% CI 1.30-6.43; p = 0.007) to meet criteria for a lifetime psychiatric disorder than those recruited from harm reduction services, specifically dysthymia (OR 5.32 95% CI 2.27-12.48; p = 0.000) and post-traumatic stress disorder (OR 1.83 95% CI 1.02-3.27; p = 0.040). WWID who reported sharing needles and syringes were almost three times as likely to meet criteria for lifetime psychiatric comorbidity than those who did not (OR 2.65 95% CI 1.07-6.56). Compared to WWID who had not experienced IPV, victims (70%) were almost two times more likely to meet criteria for post-traumatic stress disorder (OR 1.95 95% CI 1.10-3.48). Psychiatric comorbidity and IPV among WWID are common. Drug treatment and harm reduction services should address psychiatric comorbidity and IPV to improve treatment outcomes.

Prevalence and correlates of substance use among psychiatric inpatients

PURPOSE

This study aimed at examining correlates of substance use among patients diagnosed with psychiatric disorders in Jordan.

METHODS

This study used a nonexperimental descriptive survey design. Data were collected through using DUSI-R scale obtained through a self-designed questionnaire. A total of (203) subjects satisfied the inclusion criteria.

RESULTS

Most used substances prior to admission were caffeine (78.2%), cigarette (60.9%), and alcohol (22.2%), while the least were heroin (1.2%) and inhalants (0.08%). Patients diagnosed with schizophrenia had higher percentages among all other disorders (n = 16, 21.9%), although there was no statistical difference among patients related to their psychiatric disorders.

CONCLUSION

We recommend that mental health professionals be equipped with necessary skills to manage substance use among patients with psychiatric disorders.

International Consensus Statement on Screening, Diagnosis and Treatment of Substance Use Disorder Patients with Comorbid Attention Deficit/Hyperactivity Disorder

Adult attention deficit/hyperactivity disorder (ADHD) often co-occurs with substance use disorders (SUD) and is associated with early onset and more severe development of SUD and with reduced treatment effectiveness. Screening tools allow for a good recognition of possible ADHD in adults with SUD and should be used routinely, followed by an ADHD diagnostic process initiated as soon as possible. Simultaneous and integrated treatment of ADHD and SUD, using a combination of pharmaco- and psychotherapy, is recommended. Long-acting methylphenidate, extended-release amphetamines, and atomoxetine with up-titration to higher dosages may be considered in patients unresponsive to standard doses. This paper includes evidence- and consensus-based recommendations developed to provide guidance in the screening, diagnosis and treatment of patients with ADHD-SUD comorbidity.

The association between depression, anxiety and substance use among Canadian post-secondary students

PURPOSE

This study aims to examine the association between depression, anxiety and substance use among Canadian post-secondary students.

METHODS

This study used data from the spring 2016, American College Health Association - National College Health Assessment II (ACHA-NCHA II) survey. It includes 43,780 college students from 41 Canadian post-secondary institutions. The exposure variables of interest were alcohol, cannabis and tobacco use, and the outcome variables of interest were diagnosis or treatment for depression and/or anxiety. Descriptive statistics, univariate and multivariate logistic regression models were used to analyze our data.

RESULTS

Our study found that 14.7% of post-secondary students were diagnosed or treated for depression and 18.4% for anxiety within the past 12 months. Among current (past 30 days) substance use, it was reported that alcohol (69.3%), cannabis (17.9%) and tobacco (11%) were the most common. There was a significant association between depression and current tobacco use (OR =1.36, 95% CI: 1.22-1.52, P<0.001) and current cannabis use (OR =1.17, 95% CI: 1.05-1.31, P<0.001). There was also a gender-specific association between anxiety and female alcohol users (OR =1.41, 95% CI: 1.24-1.62, P<0.001).

CONCLUSION

The results of this study found significant associations between depression, tobacco use and cannabis use, and anxiety and alcohol use among post-secondary students. These conditions should be screened concurrently for improved outcomes among this vulnerable population.

A Biomarker to Differentiate between Primary and Cocaine-Induced Major Depression in Cocaine Use Disorder: The Role of Platelet IRAS/Nischarin (I1-Imidazoline Receptor)

The association of cocaine use disorder (CUD) and comorbid major depressive disorder (MDD; CUD/MDD) is characterized by high prevalence and poor treatment outcomes. CUD/MDD may be primary (primary MDD) or cocaine-induced (CUD-induced MDD). Specific biomarkers are needed to improve diagnoses and therapeutic approaches in this dual pathology. Platelet biomarkers [5-HT2A receptor and imidazoline receptor antisera selected (IRAS)/nischarin] were assessed by Western blot in subjects with CUD and primary MDD (n = 16) or CUD-induced MDD (n = 9; antidepressant free, AD-; antidepressant treated, AD+) and controls (n = 10) at basal level and/or after acute tryptophan depletion (ATD). Basal platelet 5-HT2A receptor (monomer) was reduced in comorbid CUD/MDD subjects (all patients: 43%) compared to healthy controls, and this down-regulation was independent of AD medication (decreases in AD-: 47%, and in AD+: 40%). No basal differences were found for IRAS/nischarin contents in AD+ and AD- comorbid CUD/MDD subjects. The comparison of IRAS/nischarin in the different subject groups during/after ATD showed opposite modulations (i.e., increases and decreases) in response to low plasma tryptophan levels with significant differences discriminating between the subgroups of CUD with primary MDD and CUD-induced MDD. These specific alterations suggested that platelet IRAS/nischarin might be useful as a biomarker to discriminate between primary and CUD-induced MDD in this dual pathology.

Prevalence of Antipsychotic-Treated Patients in a Cohort of Adult Addicted Patients

PURPOSE

The objective of this cross-sectional study was to describe and estimate the prevalence of antipsychotics (AP) in a cohort of addicted patients, and to compare the profiles of addictive patients receiving AP or not.

METHODS

We included all adult patients seen at the addiction care center of Montpellier University Hospital, between January 1, 2015, and March 31, 2015. Demographic, clinical, and therapeutic data were collected from the patients' medical records.

RESULTS

During the study period, 415 patients were included, with a mean age of 38 ± 10 years. They were mostly men (73.3%), French (54.9%), and unemployed (61.8%). Among the study population, 93 patients (patients treated with AP [trAP], 22.4%) were treated by 111 different AP, mainly cyamemazine (29.0% of treated patients), aripiprazole (20.4%), olanzapine (17.2%), and quetiapine (16.1%), mostly in monotherapy (80.6%) and by oral route (93.2% of AP). Psychiatric history was more frequent in trAP than in those without AP (untrAP) (55.9% vs 35.4% respectively; P < 0.001). Professional activity tended to be less frequent in patients with AP (25.3% vs 38.9%, P = 0.08).When compared with untrAP, trAP consumed more amphetamine (10.8% vs 4.4%; P = 0.02) and tended to consume less opiates (7.5% vs 14.9%; P = 0.06); the consumptions of cannabis (43.0% vs 35.7%; P = 0.20) and cocaine (22.6% vs 16.8%; P = 0.20) were not statistically different.Opiate maintenance therapy was reported in 63.7% of trAP and 68.4% of untrAP (P = 0.41): it consisted of methadone (trAP, 60.3% vs untrAP, 56.5%) and buprenorphine (trAP, 39.7% vs untrAP, 43.5%).

CONCLUSIONS

The concomitant management of psychiatric and substance use disorders in the same center may explain the high prevalence of trAP in this study. Cannabis and psychostimulants may have been used in these patients as self-medication for mental disease-related symptoms or adverse effects of APs.

Evaluation of plasma cytokines in patients with cocaine use disorders in abstinence identifies transforming growth factor alpha (TGFα) as a potential biomarker of consumption and dual diagnosis

BACKGROUND

Cocaine use disorder (CUD) is a complex health condition, especially when it is accompanied by comorbid psychiatric disorders (dual diagnosis). Dual diagnosis is associated with difficulties in the stratification and treatment of patients. One of the major challenges in clinical practice of addiction psychiatry is the lack of objective biological markers that indicate the degree of consumption, severity of addiction, level of toxicity and response to treatment in patients with CUD. These potential biomarkers would be fundamental players in the diagnosis, stratification, prognosis and therapeutic orientation in addiction. Due to growing evidence of the involvement of the immune system in addiction and psychiatric disorders, we tested the hypothesis that patients with CUD in abstinence might have altered circulating levels of signaling proteins related to systemic inflammation.

METHODS

The study was designed as a cross-sectional study of CUD treatment-seeking patients. These patients were recruited from outpatient programs in the province of Malaga (Spain). The study was performed with a total of 160 white Caucasian subjects, who were divided into the following groups: patients diagnosed with CUD in abstinence (N = 79, cocaine group) and matched control subjects (N = 81, control group). Participants were clinically evaluated with the diagnostic interview PRISM according to the DSM-IV-TR, and blood samples were collected for the determination of chemokine C-C motif ligand 11 (CCL11, eotaxin-1), interferon gamma (IFNγ), interleukin-4 (IL-4), interleukin-8 (IL-8), interleukin-17α (IL-17α), macrophage inflammatory protein 1α (MIP-1α) and transforming growth factor α (TGFα) levels in the plasma. Clinical and biochemical data were analyzed in order to find relationships between variables.

RESULTS

While 57% of patients with CUD were diagnosed with dual diagnosis, approximately 73% of patients had other substance use disorders. Cocaine patients displayed greater cocaine symptom severity when they were diagnosed with psychiatric comorbidity. Regarding inflammatory factors, we observed significantly lower plasma levels of IL-17α (p < 0.001), MIP-1α (p < 0.001) and TGFα (p < 0.05) in the cocaine group compared with the levels in the control group. Finally, there was a significant primary effect of dual diagnosis on the plasma concentrations of TGFα (p < 0.05) in the cocaine group, and these levels were lower in patients with dual diagnoses.

DISCUSSION

IL-17α, MIP-1α and TGFα levels are different between the cocaine and control groups, and TGFα levels facilitate the identification of patients with dual diagnosis. Because TGFα reduction is associated with enhanced responses to cocaine in preclinical models, we propose TGFα as a potential biomarker of complex CUD in humans.

The association of psychiatric comorbidity with treatment completion among clients admitted to substance use treatment programs in a U.S. national sample

BACKGROUND

Psychiatric disorders are highly comorbid with substance use disorders and play an important role in their course and recovery. However, the impact of comorbidity on treatment outcomes has not been examined in a U.S. national sample. This study explores the impact of psychiatric comorbidity on treatment completion among individuals admitted to publicly funded substance use treatment facilities across the United States.

METHODS

Using data on first-time treatment episodes in the U.S. from the Treatment Episode Dataset-Discharges (TEDS-D) for the years 2009-2011, logistic regression was used to assess the association between psychiatric comorbidity and treatment non-completion, and Cox proportional hazards regression was used to assess the association between comorbidity and rate of attrition. Analyses were performed for all substances together and then stratified by primary substance of abuse (alcohol, cannabis, stimulants, or opioids).

RESULTS

Of 856,385 client treatment episodes included in our analysis, 28% had a psychiatric comorbidity and 38% did not complete treatment. After adjusting for socio-demographic and treatment characteristics, clients with psychiatric comorbidity had higher odds of not completing treatment relative to those without comorbidity [OR=1.28 (1.27-1.29)], and had an earlier time to attrition [HR=1.14 (1.13-1.15)]. Psychiatric comorbidity was most strongly associated with treatment non-completion and rate of attrition in those admitted primarily for alcohol [OR=1.37 (1.34-1.39); HR=1.19 (1.17-1.21), respectively].

CONCLUSIONS

Individuals with psychiatric comorbidities receiving treatment for substance use disorders face unique challenges that impact their ability to complete treatment. The findings call for further efforts to integrate treatment for psychiatric comorbidities in substance use treatment settings.

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

Introduction

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

Psychosis After Switch in Opioid Maintenance Agonist and Risperidone-Induced Pisa Syndrome: Two Critical Incidents in Dual Diagnosis Treatment

BACKGROUND AND AIMS

Dual diagnosis commonly occurs among patients with an opioid use disorder. Treatment is ideally performed in an integrated fashion. We present a case that illustrates the complex and challenging psychiatric and medical therapy of such patients in the light of the literature.

CASE DESCRIPTION

We report on a 56-year-old patient with schizophrenia and opioid dependence who experienced both risperidone-induced Pisa syndrome and, 3 years later, acute psychosis after switching the opioid substitution medication from methadone to slow-release oral morphine due to QT prolongation.

CONCLUSIONS

With the current availability of a diversity of substitution opioids in Switzerland (methadone, buprenorphine, diacetylmorphine, sustained-release oral morphine), studies on differential effectiveness of these agents in opioid-dependent subpopulations with selective comorbidity profiles are desirable. The same is true for further investigation of the involvement of the opioid receptor system in schizophrenia. In clinical practice, any alteration of opioid medication in patients with dual diagnosis and a history of schizophrenia should be accompanied by close observation for psychotic symptoms.