Dual diagnosis in primary care. Detecting and treating both the addiction and mental illness

Implication of problematic substance use in poststroke depression: an hospital-based study

The prevalence of clinically defined problematic substance use among stroke patients is overlooked and its association with post-stroke depression (PSD) is unknown. Our aims were to: (1) estimate the proportion of stroke patients with a problematic substance use as defined by clinical screening scales; (2) determine the proportion of PSD at three months of follow-up; (3) explore if the baseline severity in substance use and its evolution are independent predictors of PSD. A cohort of first-ever non-severe stroke adult patients was screened at baseline and three months post-stroke using recommended cut-off scores of standardized scales for tobacco, alcohol and cannabis abuse. PSD was defined using the Center of Epidemiological Studies Depression scale score. Out of the 244 eligible patients, 74 (30.3%) presented a problematic substance use, including 21 (8.6%) polydrug abusers. Among these patients, the prevalence of PSD was 50.8%, including 29.5% of severe depression. The severity of tobacco dependence at baseline was found to double the risk (OR 1.59, 95% CI 1.05–2.43) of presenting a PSD, independently of previously reported risk factors. We found no significant evidence for an effect of the evolution in substance use at follow-up. Addictive disorders are part of the critical unmet needs that should be addressed in the management of PSD.

Self-Regulation in Dual Diagnosis: A Multi-Method Approach of Self-Awareness, Error-Monitoring and Emotional Distress

Introduction: Self-regulatory actions direct the achievement of life goals. Awareness of one's state is needed to adequately self-regulate one's life.

Methods: The self-regulatory actions of (cognitive/emotional) self-awareness and (error-)monitoring were assessed in patients with Dual Diagnosis and healthy controls. A multi-method approach was applied.

Results: Patients with Dual Diagnosis reported lower capacity to identify, verbalize and interpret emotions in a cognitive manner. Both groups reported experiencing arousal of emotions, but patients showed less cognitive elaboration on them and they reported more negatively labeled emotions. Patients with Dual Diagnosis signaled errors less adequately, but did not differ in the number of errors.

Discussion: The abundance of negative emotions may overwhelm patients and trigger substance use to handle this negativity. Especially because they do in fact experience the arousal of emotions, but they find it harder to timely identify, interpret and verbalize these emotions. Training self-awareness and emotion regulation may be beneficial.

Guidelines of the Brazilian Association of Studies on Alcohol and Other Drugs (ABEAD) for diagnosis and treatment of psychiatric comorbidity with alcohol and other substance and dependence

In recent years, several studies have been focused on the comorbidity of psychiatric disorders with alcohol and other substance dependence. In this context, the Brazilian Association of Studies on Alcohol and Other Drugs initiated a project to establish Brazilian Guidelines. The aim of this study was to review diagnostic and therapeutic criteria for the most prevalent psychiatric comorbidities. Randomized clinical trials, epidemiological studies, animal testing and other forms of research are reviewed herein. The main psychiatric comorbidities are investigated and data published in the literature are reviewed, based on guidelines adopted by other countries. Epidemiological aspects, diagnostic criteria, integrated treatment and the organization of specialized service, as well as details regarding psychotherapy and pharmacological treatment are discussed. The guidelines of the Brazilian Association of Studies on Alcohol and Other Drugs reinforce the importance of adequate diagnosis and treatment regarding alcoholic and drug dependent patients suffering of comorbid psychiatric disorders.

A Hybrid III stepped wedge cluster randomized trial testing an implementation strategy to facilitate the use of an evidence-based practice in VA Homeless Primary Care Treatment Programs

Background

Homeless veterans often have multiple health care and psychosocial needs, including assistance with access to housing and health care, as well as support for ongoing treatment engagement. The Department of Veterans Affairs (VA) developed specialized Homeless Patient Alignment Care Teams (HPACT) with the goal of offering an integrated, “one-stop program” to address housing and health care needs of homeless veterans. However, while 70% of HPACT’s veteran enrollees have co-occurring mental health and substance use disorders, HPACT does not have a uniform, embedded treatment protocol for this subpopulation. One wraparound intervention designed to address the needs of homeless veterans with co-occurring mental health and substance use disorders which is suitable to be integrated into HPACT clinic sites is the evidence-based practice called Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking-Veterans Edition, or MISSION-Vet. Despite the promise of MISSION-Vet within HPACT clinics, implementation of an evidence-based intervention within a busy program like HPACT can be difficult. The current study is being undertaken to identify an appropriate implementation strategy for MISSION-Vet within HPACT. The study will test the implementation platform called Facilitation and compared to implementation as usual (IU). The aims of this study are as follows: (1) Compare the extent to which IU or Facilitation strategies achieve fidelity to the MISSION-Vet intervention as delivered by HPACT homeless provider staff. (2) Compare the effects of Facilitation and IU strategies on the National HPACT Performance Measures. (3) Compare the effects of IU and Facilitation on the permanent housing status. (4) Identify and describe key stakeholders’ (patients, providers, staff) experiences with, and perspectives on, the barriers to, and facilitators of implementing MISSION.

Design

Type III Hybrid modified stepped wedge implementation comparing IU to Facilitation across seven HPACT teams in three sites in the greater Los Angeles VA system. This is a cluster randomized trial.

Discussion

Integrating MISSION-Vet within HPACT has the potential to improve the health of thousands of veterans, but it is crucial to implement the intervention appropriately in order for it to succeed. The lessons learned in this protocol could assist with a larger roll-out of MISSION within HPACT. This protocol is registered with clinicaltrials.gov and was assigned the number NCT 02942979.

Unraveling Executive Functioning in Dual Diagnosis

In mental health, the term dual-diagnosis is used for the co-occurrence of Substance Use Disorder (SUD) with another mental disorder. These co-occurring disorders can have a shared cause, and can cause/intensify each other’s expression. Forming a threat to health and society, dual-diagnosis is associated with relapses in addiction-related behavior and a destructive lifestyle. This is due to a persistent failure to control impulses and the maintaining of inadequate self-regulatory behavior in daily life. Thus, several aspects of executive functioning like inhibitory, shifting and updating processes seem impaired in dual-diagnosis. Executive (dys-)function is currently even seen as a shared underlying key component of most mental disorders. However, the number of studies on diverse aspects of executive functioning in dual-diagnosis is limited. In the present review, a systematic overview of various aspects of executive functioning in dual-diagnosis is presented, striving for a prototypical profile of patients with dual-diagnosis. Looking at empirical results, inhibitory and shifting processes appear to be impaired for SUD combined with schizophrenia, bipolar disorder or cluster B personality disorders. Studies involving updating process tasks for dual-diagnosis were limited. More research that zooms in to the full diversity of these executive functions is needed in order to strengthen these findings. Detailed insight in the profile of strengths and weaknesses that underlies one’s behavior and is related to diagnostic classifications, can lead to tailor-made assessment and indications for treatment, pointing out which aspects need attention and/or training in one’s self-regulative abilities.

A cluster randomized Hybrid Type III trial testing an implementation support strategy to facilitate the use of an evidence-based practice in VA homeless programs

BACKGROUND

The Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program is one of the largest initiatives to end Veteran homelessness. However, mental health and substance use disorders continue to reduce client stability and impede program success. HUD-VASH programs do not consistently employ evidence-based practices that address co-occurring mental health and substance use disorders. This paper presents a study protocol to evaluate the implementation of an evidence-based, co-occurring disorder treatment called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking-Veterans Edition (MISSION-Vet) in HUD-VASH using an implementation strategy called Getting To Outcomes (GTO).

METHODS/DESIGN

In three large VA Medical Centers, this Hybrid Type III trial will randomize case managers and their clients by HUD-VASH sub-teams to receive either MISSION-Vet Implementation as Usual (IU-standard training and access to the MISSION-Vet treatment manuals) or MISSION-Vet implementation augmented by GTO. In addition to testing GTO, effectiveness of the treatment (MISSION-Vet) will be assessed using existing Veteran-level data from the HUD-VASH data monitoring system. This project will compare GTO and IU case managers and their clients on the following variables: (1) fidelity to the MISSION-Vet intervention; (2) proportion of time the Veteran is housed; (3) mental health, substance use, and functional outcomes among Veterans; and (4) factors key to the successful deployment of a new treatment as specified by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model.

DISCUSSION

This project is an important step for developing an implementation strategy to increase adoption of evidence-based practice use in VA homeless programs, and to further examine efficacy of MISSION-Vet in HUD-VASH. This project has important implications for program managers, policy makers, and researchers within the homelessness field. VA Central IRB approval for this study was granted in October 2011. The three sites were trained on MISSION-Vet and GTO in the first half of 2013. The first GTO planning meetings began after training occurred, between January 2013 and November 2013, across the three sites. The data collection-via a fidelity measure embedded into the VA Computerized Patient Record System-began as each site initiated MISSION-Vet, between April 2013 and January 2014.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01430741.

The case for chronic disease management for addiction

Chronic disease (care) management (CDM) is a patient-centered model of care that involves longitudinal care delivery; integrated, and coordinated primary medical and specialty care; patient and clinician education; explicit evidence-based care plans; and expert care availability. The model, incorporating mental health and specialty addiction care, holds promise for improving care for patients with substance dependence who often receive no care or fragmented ineffective care. We describe a CDM model for substance dependence and discuss a conceptual framework, the extensive current evidence for component elements, and a promising strategy to reorganize primary and specialty health care to facilitate access for people with substance dependence. The CDM model goes beyond integrated case management by a professional, colocation of services, and integrated medical and addiction care-elements that individually can improve outcomes. Supporting evidence is presented that: 1) substance dependence is a chronic disease requiring longitudinal care, although most patients with addictions receive no treatment (eg, detoxification only) or short-term interventions, and 2) for other chronic diseases requiring longitudinal care (eg, diabetes, congestive heart failure), CDM has been proven effective.

Screening and brief intervention for unhealthy drug use in primary care settings: randomized clinical trials are needed

The efficacy of screening and brief intervention (SBI) for drug use in primary care patients is largely unknown. Because of this lack of evidence, US professional organizations do not recommend it. Yet, a strong theoretical case can be made for drug SBI. Drug use is common and associated with numerous health consequences, patients usually do not seek help for drug abuse and dependence, and SBI has proven efficacy for unhealthy alcohol use. On the other hand, the diversity of drugs of abuse and the high prevalence of abuse and dependence among those who use them raise concerns that drug SBI may have limited or no efficacy. Federal efforts to disseminate SBI for drug use are underway, and reimbursement codes to compensate clinicians for these activities have been developed. However, the discrepancies between science and policy developments underscore the need for evidence-based research regarding the efficacy of SBI for drug use. This article discusses the rationale for drug SBI and existing research on its potential to improve drug-use outcomes and makes the argument that randomized controlled trials to determine its efficacy are urgently needed to bridge the gap between research, policy, and clinical practice.

Mental health of adolescents who abuse psychoactive substances in Enugu, Nigeria - a cross-sectional study

BACKGROUND

Association between psychiatric morbidity and substance abuse among adolescent has been reported. However prevalence and pattern of such dysfunctions are unknown in our environment.

AIMS

To determine the prevalence of psychosocial dysfunction and depressive symptoms among adolescents who abuse substance and also note the influence of socio-demographic factors and type of substance on the pattern of dysfunction.

METHOD

A cross-sectional study was carried out among 900 adolescents selected from 29 secondary schools in Enugu metropolis. A multi-stage sampling procedure was used to select the students. The student drug use questionnaire was used to screen respondents for substance abuse. Those who were abusing substance and matched controls (non substance abusers) were assessed for psychiatric symptoms using the 35-item Paediatric Symptom Checklist (PSC) and the Zung Self-rating Depression Scale (SDS). Social classification was done using the parental educational attainment and occupation.

RESULT

A total of 290 students were current substance abusers. The substances most commonly abused were alcohol (31.6%), cola nitida (kola nut) (20.7%) and coffee (15.7%). Using the PSC scale, 70 (24.1%) subjects compared to 29 (10.7%) of the controls had scores in the morbidity range of >or= 28 for psychosocial dysfunction. This was statistically significant (chi(2) = 17.57 p = 0.001). Fifty-four subjects (18.6%) had scores in the morbidity range of >or= 50 for depressive symptoms using the Zung SDS compared to 21 (7.7%) of controls. This was statistically significant (chi(2) = 14.43, p = 0.001). Prevalence of dysfunction was not significantly related to age in both subjects and controls (chi(2) = 4.62, p = 0.010, chi(2) = 4.8, p = 0.10 respectively). Also using both scales, there was no significant relationship between psychosocial dysfunction and gender or social class in both subjects and control. The prevalence of dysfunction using both scales was significantly higher in multiple abusers compared to single abusers. Subjects abusing alcohol scored more on both scales compared to those abusing other substances.

CONCLUSION

Prevalence of psychosocial dysfunction is higher in adolescents abusing substance compare to controls. The prevalence of psychiatric morbidity was not related to the age, gender or social classes in the study population.We advocate periodic screening of our adolescents for drug abuse regular evaluation of such group for possible psychopathology.

Comorbidity and "self-medication"

Comorbidity is the rule rather than the exception for substance use disorders, especially when they involve drugs other than alcohol. A common reaction of physicians to comorbidity is to attribute the substance use of addicted people to "self-medicating" with drugs of abuse. When an individual uses an abused drug nonmedically, he or she is seeking brain reward, not treatment. To confuse this drug-using behavior with treatment is to misunderstand addictive behavior and to encourage a false sense that the primary clinical task is to lower the dysphoria associated with the comorbid condition in order to stop the nonmedical drug use. Even the most effective treatment of comorbid disorders is unlikely to halt the addictive drug use. The best way to handle comorbidity (e.g., depression and alcoholism) is to consider each of the comorbid conditions to be a separate and serious illness deserving of effective and specific treatment and not to consider one to be a "symptom" of the other. While it is desirable to treat all comorbid conditions using the best practices for the treatment of that condition it is not reasonable to assume that one of the comorbid disorders is secondary to the other and therefore that treatment of the "secondary" disorder is irrelevant or unnecessary.

Primary care management of patients with co-occurring disorders

Primary care physicians (PCPs) often provide the first line of care for the vast number of United States adults—∼30% at any given time—with either a psychiatric or a substance use disorder, or both. The widespread prevalence of this comorbidity bears reiterating: During the same 12-month period, 20% of national survey respondents with a substance use disorder (SUD) had at least one mood disorder, and 17% had at least one anxiety disorder. Conversely, at least one SUD was found among 20% of respondents with a mood disorder and 15% of those with an anxiety disorder. However, because PCPs are often not aware of or alerted to these problems, it would seem advisable that patients presenting with either a psychiatric or an alcohol use disorder should be evaluated for both conditions. Establishing the presence of co-occurring disorders may be difficult, but it is necessary for appropriate and realistic treatment planning.

Medications Development for the Treatment of Nicotine Dependence in Individuals with Schizophrenia

The development of medications for the treatment of nicotine dependence in patients with schizophrenia is a public health priority due to its high prevalence rates, devastating medical consequences, and difficulty to treat. It has been hypothesized that the high prevalence of nicotine dependence among patients with schizophrenia may be due to a shared neurobiological vulnerability. This shared vulnerability has been evidenced in reports showing that nicotine improves neuropsychological deficits associated with schizophrenia such as in the P50 evoked auditory potentials, spatial working memory, and attention. The common pathophysiologic pathways of smoking and schizophrenia may serve as the basis for the pharmacological evaluation of medications for the treatment of these concurrent disorders. Currently, little research of medications for the treatment of this comorbidity has been conducted. Studies have evaluated the efficacy of smoking cessation medications in patients with schizophrenia. These include the nicotine replacement therapy (patch, nasal spray) and sustained release bupropion. Others have evaluated the anti-smoking effect of medications (e.g., clozapine, haloperidol) used for the treatment of schizophrenia. In both cases, the results have not been conclusive. Newer smoking cessation approaches such as varenicline, selegiline, rimonabant, and nicotine vaccine, among others, have yet to be tested in this population. The purpose of this article is to review the results of the studies conducted to date and propose some potential pharmacotherapies based on the current knowledge of the pathophysiology of both disorders.

Well-being, psychosocial factors, and side-effects among heroin-dependent inpatients after detoxification using buprenorphine versus clonidine

Previous studies comparing buprenorphine and clonidine provided little information about subjective factors associated with the effective management of opioid withdrawal. This study sought to compare detoxification programs using these medications with regard to side-effects and related distress, general well-being, perceived self-efficacy and social support. A total of 200 treatment-seeking heroin-dependent patients, aged 18-50, were randomly assigned to buprenorphine or clonidine inpatient withdrawal treatments over 10days followed by 11days of relapse prevention measures. A semi-structured interview and a battery of self-rating scales assessing parameters of the interest were administered to the patients who completed the 10-day detoxification protocol with buprenorphine (n=90) and clonidine (n=50). Chi-square statistics and analysis of covariance were performed to examine between-group differences. Compared with patients treated with clonidine, patients who received buprenorphine developed significantly less side-effects and related distress, and had higher senses of well-being, self-efficacy and social support. The findings suggest that buprenorphine is preferable for inpatient detoxification due to its side-effects profile and positive effects on well-being and psychosocial variables. These early benefits of buprenorphine could enable consequent maintenance treatment.

Diretrizes da Associação Brasileira de Estudos do Álcool e outras Drogas (ABEAD) para o diagnóstico e tratamento de comorbidades psiquiátricas e dependência de álcool e outras substâncias

O diagnóstico e tratamento de comorbidade psiquiátrica e dependência de álcool e outras substâncias tem sido objeto de inúmeros estudos nos últimos anos. A Associação Brasileira de Estudos do Álcool e Outras Drogas desenvolveu o projeto Diretrizes. Este trabalho visa o desenvolvimento de critérios diagnósticos e terapêuticos atualizados para as comorbidades psiquiátricas mais prevalentes. Ensaios clínicos randomizados, estudos epidemiológicos, com animais e outros estudos são revisados. As principais comorbidades psiquiátricas são estudadas e os dados de literatura resumidos, tendo como referência diretrizes adotadas em outros países. São abordados aspectos epidemiológicos, critérios diagnósticos, tratamento integrado e organização de serviço especializado, assim como especificidades do tratamento psicoterápico e farmacológico. As Diretrizes da Associação Brasileira de Estudos do Álcool e Outras Drogas reforçam a importância da abordagem adequada do dependente químico portador de comorbidade psiquiátrica.

Pharmacotherapy of alcohol use disorders

Therapeutic interventions to treat alcoholism have increased in number, including several pharmacotherapies. Aspects of epidemiology, gender, and psychiatric comorbidity as well as a brief overview of neurobiology are presented as an introduction. The medications used clinically for the treatment of alcoholism, disulfiram and naltrexone, approved by the Food and Drug Administration in the United States for the treatment of alcoholism and acamprosate, a medication used extensively in Europe that is currently being evaluated in the United States, are reviewed in detail. An overview of the serotonergic agents is also provided. Finally, future directions, including new medications and some clinical strategies that show promise but are not yet used extensively clinically, are mentioned.

Patient and program factors in obtaining supportive services in DATOS

This study examined patient and program factors that influenced the receipt of scheduled supportive services in the Drug Abuse Treatment Outcome Studies (DATOS). Patients (N = 2,932) in 21 long-term residential (LTR) programs, 27 outpatient methadone treatment (OMT), and 25 outpatient drug-free programs were interviewed at admission and at 3 months during treatment. A hierarchical regression analysis was used to examine the relationship between patient-level and program-level factors associated with receiving supportive services in seven categories (medical, psychological, family, legal, educational, vocational, and financial). LTR patients received more services on average than outpatients (especially OMT), but patients overall received few services in the first 3 months of treatment. The patient-level likelihood of receiving services was related to being female and to having higher problem severity at intake. At the program level, outpatient clientele with higher problem severity received more services if they entered a program whose other enrolled patients were less troubled on average.

Medical complications of bulimia nervosa

Bulimia nervosa (BN) is a prevalent illness. There are multiple different medical complications that impact the overall treatment plan and prognosis of these patients. Practitioners should be alert for medical complications that are a direct result of the mode of purging behavior utilized by the bulimic patient. The treatment will proceed most smoothly if the primary care physician and the mental health professional work collaboratively and have clear and frequent communication.

Problem substance use among depressed patients in managed primary care

This study identifies characteristics associated with problem substance use among 1,187 patients with either depressive symptoms (44%) or depressive disorders (56%) in primary care clinics of six managed care organizations. Sedative misuse (reported by 14% of all patients) was associated with greater wealth, social phobia, and misuse of prescription opioids. Cannabis use (11%) was associated with younger age, male gender, single marital status, white ethnicity, less education, recurrent depression, agoraphobia, and hazardous alcohol use. Hazardous drinking (11%) was significantly associated with younger age, male gender, single marital status, and cannabis use. Greater understanding of substance use problems in primary care patients with depressive symptoms and disorders may aid efforts to more quickly identify, educate, and provide services for those in need.

Pharmacologic treatment of heroin-dependent patients

Patients with heroin dependence frequently present to internists and other physicians for heroin-related medical, psychiatric, and behavioral health problems and often seek help with reducing their heroin use. Thus, physicians should be familiar with the identification and diagnosis of heroin dependence in their patients and be able to initiate treatment of heroin dependence both directly and by referral. Recent research has provided much information concerning effective pharmacologically based treatment approaches for managing opioid withdrawal and helping patients to remain abstinent Methadone maintenance and newer approaches using L-alpha acetylmethadol and buprenorphine seem to be particularly effective in promoting relapse prevention. Although these treatments are currently provided in special drug treatment settings, recent and ongoing research indicates that the physician's office may be an effective alternative site for these treatments.

Eating disorders in adolescents and young adults

Eating disorders are relatively common and frequently result in medical signs and symptoms. Armed with an appreciation of the protean manifestations of these complex health problems as well as an appreciation of the biopsychosocial approach needed to help the adolescent or young adult woman recover, the primary care physician is in an excellent position to have a therapeutic role in the recovery from these chronic conditions. By recognizing the medical aspects of eating disorders, the oversimplified viewpoint of considering them as purely psychiatric disorders can be avoided. Open and consistent communication with patients, with a focus on health rather than dysfunction and mental illness, facilitates the acceptance of a comprehensive approach in which the internist, dietitian, and mental health provider all have a role.