Dual diagnosis: 15 years of progress

Accepting multiple conditions in psychiatry: From comorbidity to multimorbidity

The concept of multimorbidity in psychiatry refers to the coexistence of multiple health conditions without conceptualizing a central disorder referring to a patient-centered approach that views every diagnosis equally. It emphasizes a shift from focusing on an index disorder to considering interrelated symptoms crucial in psychiatry due to frequent multimorbidity patterns. In clinical practice, multimorbidity guides patient-centered care helping to address the holistic needs of patients and challenging the organization of mental health care. In research, multimorbidity reshapes study outcomes and promotes the development of patient-reported outcome questionnaires, also posing ethical challenges and advocating for the inclusion of multimorbid patients in personalized interventions. Finally, multimorbidity in psychiatry has public health implications aligning with the socioecological systems perspective. This notion aims to improve prognosis, care, and health costs while impacting global mortality and challenging the conceptualization and organization of psychiatric care.

The role of co-occurring disorders in criminal recidivism and psychiatric recovery among adults with opioid use disorder and criminal-legal involvement: A statewide retrospective cohort study

INTRODUCTION

Individuals with opioid use disorder (OUD) in the criminal-legal system commonly present co-occurring mental health disorders. However, evidence-based treatment for high-risk populations such as those with co-occurring disorders is often unavailable within jails and prisons. Coordination of timely and affordable access to behavioral health treatment following incarceration is critical to address the multidimensional needs of people with co-occurring needs. However, the role of co-occurring disorders among adults with OUD and criminal-legal involvement who are accessing community-based treatment is understudied.

METHODS

This retrospective cohort study investigated community and recovery outcomes among 2039 adults with OUD and criminal-legal involvement enrolled in a statewide forensic treatment initiative between October 2015 to March 2018. Using court records and clinical data, we assessed the impact of co-occurring OUD and mental health disorders on criminal recidivism and psychiatric recovery and the moderating role of co-occurring disorders on the relationship between community-based treatment and these outcomes.

RESULTS

We found that 47 % of those with OUD also had an underlying mental health disorder. Co-occurring OUD and mental health disorders predicted higher rates of recidivism during the early stages of treatment. Furthermore, group and individual therapy services were associated with lower odds of recidivism. A co-occurring disorder was an important predictor of more severe behavioral health needs when exiting community-based services and did moderate the relationship between service utilization-specifically group therapy and substance use outpatient services-and psychiatric recovery (i.e., behavioral health needs at exit).

CONCLUSIONS

Co-occurring mental health disorders are highly prevalent among adults with OUD who have criminal-legal involvement, but it appears that they can benefit from social support services in the community. Given the multidimensional needs of this high-risk population, criminal-legal stakeholders and community-based clinicians must work in tandem to develop tailored treatment plans that give individuals with co-occurring OUD and mental health disorders the best chance for success post-incarceration rather than a siloed approach to overlapping disorders.

Opening up the black box of recovery processes in persons with complex mental health needs: a qualitative study of place-making dynamics in a low-threshold meeting place

Background

The recovery processes of persons with complex mental health needs take a slow and unpredictable course. Despite the fact that a number of essential building blocks of recovery in this population have been identified (e.g. social relationships, treatment, personal beliefs), the actual process of recovery in persons with complex mental health needs largely remains a black box. The aim of this study was to gain insight into how the recovery processes of persons with complex mental health needs take place, by applying a relational geographical approach and scrutinizing the place-making dynamics of one low-threshold meeting place in Belgium engaging with this group.

Methods

Data collection took place during the height of the COVID-19 pandemic by means of 11 in-depth interviews with different involved actors (service users, staff members, volunteers) and analyzed thematically.

Results

Results showed how the daily practice of the meeting place is continuously reproduced through place-making rituals that create an inclusive space of hospitality, are fueled by creative processes and form an indispensable counterweight for service users’ mental health needs.

Conclusions

To further open up the ‘black box’ of recovery in persons with complex mental health needs, it is vital to focus our analytic gaze onto recovery as a dynamic and relational practice.

What kind of science for dual diagnosis? A pragmatic examination of the enactive approach to psychiatry

The recommended treatment for dual diagnosis - the co-occurrence of substance use and another mental disorder - requires seamless integration of the involved disciplines and services. However, no integrative framework exists for communicating about dual diagnosis cases across disciplinary or sectoral boundaries. We examine if Enactive Psychiatry may bridge this theoretical gap. We evaluate the enactive approach through a two-step pragmatic lens: Firstly, by taking a historical perspective to describe more accurately how the theoretical gap within the field of dual diagnosis initially developed. Secondly, by applying the Enactive Psychiatry approach to data from a longitudinal study on the trajectory of cannabis use in psychosis disorders. By applying the theory rather than simply presenting it, we position ourselves better to evaluate whether it may assist the purpose of achieving a more expedient pragmatic “grip” on the field of dual diagnosis. In our discussion, we suggest that this may very well be the case. Finally, we consider the enactive approach as one of a small handful of new theories of mental disorders that draw on systems thinking and ecological psychology, and discuss whether they have the potential for a wider progressive problemshift within psychiatry. The case in favor of such potential, we argue, is less strong unless the role of complexity, similar to that seen within the dual diagnosis field, may be demonstrated for other fields of clinical practice.

Cognitive impairment in the co-occurrence of alcohol dependence and major depression: neuropsychological assessment and event-related potentials analyses

To evaluate the putative detrimental effect of Major Depressive Disorder (MDD) on the cognitive impairment associated with Alcohol Dependence (AD), we contrasted the neuropsychological profile and behavioral responses of AD subjects, MDD individuals, and in those with a co-occurring AD-MDD diagnosis (DD). Patients and healthy subjects completed a comprehensive neuropsychological battery and were recorded for P200, P300, and N450 event-related potentials during memory and Stroop tasks. AD subjects exhibited a generalized detrimental neuropsychological performance; in contrast, in MDD individuals, impairment was limited to discrete domains. Notably, the deficits were distinctive in DD cases. A P200 increased amplitude in MDD, a decrease in P300 amplitude in AD, and increased latency of P300 in DD patients were the overt electrophysiological abnormalities identified. Dual patients also exhibited a distinct pattern of behavioral responses, particularly apparent during high-demand cognitive tasks. Specific ERP adjustments were associated with the short-term fluoxetine treatment in DD and MDD subjects; the SSRI also improved altered baseline performance in learning and cognitive flexibility in DD subjects. In conclusion, the neuropsychological and behavioral alterations detected in the co-occurrence of AD-MDD did not seem to be merely the sum of the negative contributions of the independent disorders.

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Dual diagnosis (DD) patients exhibited a distinctive pattern of cognitive impairments compared to single diagnosis subjects.

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The ERP alterations identified were not shared among affected groups.

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Dual patients exhibited idiosyncratic behavioral responses.

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Impaired executive functions in DD subjects improved with SSRI medication.

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Neuropsychological and behavioral alterations are not explained as the sum of negative contributions of individual diagnosis.

Cannabis Use and Mental Illness: Understanding Circuit Dysfunction Through Preclinical Models

Patients with a serious mental illness often use cannabis at higher rates than the general population and are also often diagnosed with cannabis use disorder. Clinical studies reveal a strong association between the psychoactive effects of cannabis and the symptoms of serious mental illnesses. Although some studies purport that cannabis may treat mental illnesses, others have highlighted the negative consequences of use for patients with a mental illness and for otherwise healthy users. As epidemiological and clinical studies are unable to directly infer causality or examine neurobiology through circuit manipulation, preclinical animal models remain a valuable resource for examining the causal effects of cannabis. This is especially true considering the diversity of constituents in the cannabis plant contributing to its effects. In this mini-review, we provide an updated perspective on the preclinical evidence of shared neurobiological mechanisms underpinning the dual diagnosis of cannabis use disorder and a serious mental illness. We present studies of cannabinoid exposure in otherwise healthy rodents, as well as rodent models of schizophrenia, depression, and bipolar disorder, and the resulting impact on electrophysiological indices of neural circuit activity. We propose a consolidated neural circuit-based understanding of the preclinical evidence to generate new hypotheses and identify novel therapeutic targets.

"En la Lucha": Strategies to Improve HIV Care for Puerto Ricans with Opioids Use Disorders

BACKGROUND

Clínica Bienestar is a comprehensive HIV primary care clinic for Spanish-speaking Latinx with opioids use disorders (OUD). This article describes the barriers and trajectories to HIV viral suppression for Puerto Ricans with a transnational profile and dual diagnoses (HIV and OUD), and the strategies applied to increase retention in care.

METHODS

Case study methodology was used to select two patient life histories that illustrate the most common pathways to success in reducing HIV viral load to undetectable and achieving OUD long-term recovery.

RESULTS AND DISCUSSION

Patients' major challenges included: (1) Persistent migrating while seeking substance use treatment services with limited or no support from their sending and hosting communities; (2) Intersectional stigmas; (3) Untreated trauma; (4) Language and cultural barriers. Clínica Bienestar's service model included ten strategies to retain patients in care (e.g., Case management to identify cases with high social isolation), six emerged as central to addressing transnational challenges.

Relational recovery in co-occurring conditions: a qualitative study of first-person experiences

Purpose

The purpose of this paper is to explore and describe first-person experiences of relational recovery in co-occurring mental health and substance use conditions.

Design/methodology/approach

Within a phenomenological and collaborative approach, in-depth individual interviews with eight persons with co-occurring conditions were analysed using systematic text condensation.

Findings

Participants described interpersonal relationships as both supporting and hindering recovery in fundamental ways. Four categories of experiences of relational recovery were described as follows: choosing one’s child; living with loneliness and a painful past; sacrificing everything for one’s partner; and regaining trust and support.

Originality/value

This paper provides an enhanced understanding of how interpersonal relationships may be experienced by persons who live with co-occurring conditions. The results generally support an understanding of recovery as a relational process.

Factors associated with the successful completion of a substance rehabilitation programme at a psychiatric training hospital

Background

Comorbid psychiatric and substance use disorders are common and present several treatment challenges.

Aim

The aim of this study was to determine which patient and substance factors are associated with the completion of a substance rehabilitation programme in psychiatric inpatients.

Setting

The study was conducted at the Substance Rehabilitation Unit (SRU) at Weskoppies Hospital, a psychiatric training hospital in South Africa, which offers a 6-week programme at the hospital for psychiatric inpatients.

Methods

This descriptive, retrospective hospital-based study was carried out comparing completers and non-completers of the SRU programme with respect to patient and substance factors. All patients accepted into the SRU during 2013–2014 were included (n = 119). Data were collected over a year (2016–2017) from the clinical files, SRU referral forms, SRU attendance register, hospital computerised demographic records, nursing notes and administration files using a data collection sheet designed by the researchers for this study. Comparison between completers and non-completers was performed using Chi-Square or Fisher’s Exact tests.

Results

The SRU accepted 119 patients from January 2013 to December 2014. The majority of the sample were involuntary patients (n = 39), 30–49 years old (n = 57), male (n = 89), unmarried (n = 112), never having received a disability grant (n = 27), unemployed (n = 96) and with a Grade 8–11 education (n = 49). Substance-induced psychotic disorders (n = 39), schizophrenia (n = 29) and bipolar disorders (n = 22) were found to be common. Frequent medical comorbidities included head injury (n = 27), cardiovascular disease (n = 18) and HIV reactivity (n = 7). Cannabis (n = 98), alcohol (n = 94) and nicotine (n = 90) were the most frequently used substances. Level of education (p = 0.004), disability grant status (p = 0.004), Nyaope use (p = 0.001) and nicotine use (p = 0.049) were statistically seen to be significantly associated with completion. Psychiatric diagnoses and general medical comorbidity were not associated with completion.

Conclusions

This study has yielded several results in areas that have not yet been well researched in South Africa. Risk factors for non-completion may include lower levels of education, being on a disability grant and using Nyaope or nicotine, but may vary in different settings. Future research should focus on identifying further factors that may affect completion of substance rehabilitation in psychiatric inpatients, the role of disability grants in patients with co-occurring disorders and the effect of Nyaope and nicotine use on treatment outcomes in this population. Effective and accessible interventions to assist vulnerable patients also need to be identified.

The Penrose Effect and its acceleration by the war on drugs: a crisis of untranslated neuroscience and untreated addiction and mental illness

In 1939, British psychiatrist Lionel Penrose described an inverse relationship between mental health treatment infrastructure and criminal incarcerations. This relationship, later termed the 'Penrose Effect', has proven remarkably predictive of modern trends which have manifested as reciprocal components, referred to as 'deinstitutionalization' and 'mass incarceration'. In this review, we consider how a third dynamic-the criminalization of addiction via the 'War on Drugs', although unanticipated by Penrose, has likely amplified the Penrose Effect over the last 30 years, with devastating social, economic, and healthcare consequences. We discuss how synergy been the Penrose Effect and the War on Drugs has been mediated by, and reflects, a fundamental neurobiological connection between the brain diseases of mental illness and addiction. This neuroscience of dual diagnosis, also not anticipated by Penrose, is still not being adequately translated into improving clinical training, practice, or research, to treat patients across the mental illness-addictions comorbidity spectrum. This failure in translation, and the ongoing fragmentation and collapse of behavioral healthcare, has worsened the epidemic of untreated mental illness and addictions, while driving unsustainable government investment into mass incarceration and high-cost medical care that profits too exclusively on injuries and multi-organ diseases resulting from untreated addictions. Reversing the fragmentation and decline of behavioral healthcare with decisive action to co-integrate mental health and addiction training, care, and research-may be key to ending criminalization of mental illness and addiction, and refocusing the healthcare system on keeping the population healthy at the lowest possible cost.

Challenges in working with patients with dual diagnosis

Purpose

Studies have shown that mental health professionals find working with patients with dual diagnosis challenging, and the purpose of this paper is to examine some of these challenges.

Design/methodology/approach

In total, 85 mental health professionals from 8 different mental health centres in Denmark were interviewed. The data analysis was inspired by a grounded theory approach.

Findings

Different challenges in the dual diagnosis treatment were identified and they suggested that the focus of treatment was mainly on the mental illness rather than the substance use disorder. The single focus of the treatment made it challenging to treat patients with dual diagnosis sufficiently. While several studies explain the single focus by inadequate competencies among professionals, the present study suggests that the single focus is also explained by the way that the treatment is organised. For instance, standardized treatment packages and insufficient guidelines on substance abuse treatment make it challenging to treat patients with dual diagnosis.

Originality/value

This paper suggests that a more flexible, and a longer period of, treatment, together with more sufficient guidelines on dual diagnosis treatment and a more formalized collaboration with the substance abuse treatment centres, will make it a less challenging issue to treat patients with dual diagnosis.

The associations of poor psychiatric well-being among incarcerated men with injecting drug use histories in Victoria, Australia

BACKGROUND

Dual substance dependence and psychiatric and psychological morbidities are overrepresented in prison populations and associated with reoffending. In the context of an increasing prison population in Australia, investigating the needs of vulnerable people in prison with a dual diagnosis can help inform in-prison screening and treatment and improve prison and community service integration and continuation of care. In this study we quantified psychiatric well-being in a sample of people in prison with a history of injecting drug use in Victoria, Australia, and identified factors associated with this outcome.

METHODS AND RESULTS

Data for this paper come from baseline interviews undertaken in the weeks prior to release as part of a prospective cohort study of incarcerated men who reported regular injecting drug use prior to their current sentence. Eligible participants completed a researcher-administered structured questionnaire that canvassed a range of issues. Psychiatric well-being was assessed using the 12-item General Health Questionnaire (GHQ-12) and potential correlates were included based on a review of the literature. Of the 317 men included for analyses, 139 were classified as experiencing current poor psychiatric well-being. In the multivariate model using modified logistic regression, history of suicide attempt (aOR = 1.36, 95%CI 1.03-1.78), two or more medical conditions (aOR = 1.87, 95%CI 1.30-2.67) and use of crystal methamphetamine in the week prior to their current sentence (aOR = 1.52, 95%CI 1.05-2.22) were statistically significantly associated with current poor psychiatric well-being.

CONCLUSIONS

Comprehensively addressing the health-related needs for this vulnerable population will require a multidisciplinary approach and enhancing opportunities to screen and triage people in prison for mental health and other potential co-occurring health issues will provide opportunities to better address individual health needs and reoffending risk.

Service innovations

One of the challenges for services in the UK has been how best to meet the needs of those people who experience severe mental health problems and use drugs and alcohol problematically. It is now well-documented in the international literature that the coexistence of severe mental health and substance misuse problems are common (e.g. Regier et al, 1990; Krausz et al, 1996; Menezes et al, 1996; Fowler et al, 1998; Mueser et al, 2000; Graham et al, 2001) and often correlated with a number of adverse outcomes (Smith & Hucker, 1994; Johnson, 1997; Mueser et al, 2000). Integrated treatment approaches developed in the USA for this client group (e.g. Drake & Wallach, 2000; Drake et al, 2001), and although they offer much food for thought and some direction, they could not be wholly imported and implemented in the UK because of significant differences in the contextual factors that guide service provision in the two countries. The challenge in the UK has been to develop effective services that fit with the unique community-based treatment approaches for substance misuse problems and mental health that have developed and historically offered separately and in parallel.

Service innovations

One of the challenges for services in the UK has been how best to meet the needs of those people who experience severe mental health problems and use drugs and alcohol problematically. It is now well-documented in the international literature that the coexistence of severe mental health and substance misuse problems are common (e.g. Regier et al, 1990; Krausz et al, 1996; Menezes et al, 1996; Fowler et al, 1998; Mueser et al, 2000; Graham et al, 2001) and often correlated with a number of adverse outcomes (Smith & Hucker, 1994; Johnson, 1997; Mueser et al, 2000). Integrated treatment approaches developed in the USA for this client group (e.g. Drake & Wallach, 2000; Drake et al, 2001), and although they offer much food for thought and some direction, they could not be wholly imported and implemented in the UK because of significant differences in the contextual factors that guide service provision in the two countries. The challenge in the UK has been to develop effective services that fit with the unique community-based treatment approaches for substance misuse problems and mental health that have developed and historically offered separately and in parallel.

Patterns of Substance Abuse in Offenders With Schizophrenia- Illness-Related or Criminal Life-Style?

Objective: The impact of substance abuse on violent behavior in patients suffering from schizophrenia is well-known. However, the association between the pattern of substance abuse and certain aspects of criminal behavior like the severity of offense, the previous history of violence and the age at onset of the criminal career is still unclear. Method: To assess the relationship between substance abuse, schizophrenia and violent behavior we examined healthy non-offenders; healthy offenders; non-offenders suffering from schizophrenia; and offenders suffering from schizophrenia, with respect to different patterns of substance abuse (none, alcohol only, illicit drugs only, and multiple substances). Results: Healthy offenders as well as offenders and non-offenders suffering from schizophrenia are characterized by increased rates of alcohol and illicit drug abuse. Especially multiple substance abuse appears to lower the threshold of aggression and illegal behavior. This effect is more pronounced in subjects suffering from schizophrenia. In both offender groups the abuse of psychoactive substances is associated with an earlier onset of the criminal career, but has no impact on the severity of the offenses. Conclusion: Our results point to the need for a differentiated view on the contribution of substance abuse to the criminality of subjects suffering from schizophrenia.

The Concept of Recovery as Experienced by Persons with Dual Diagnosis: A Systematic Review of Qualitative Research From a First-Person Perspective

OBJECTIVES

In recent years, the concept of recovery has gained ground in the treatment of persons with dual diagnosis. Recovery refers to living a meaningful life despite limitations caused by mental illness and substance use disorders. It also implies that support for persons with dual diagnosis should be organized according to the personal needs and wishes of its users. Therefore, it is important to gain insight into the aspects that persons with dual diagnosis deem important for their recovery process. This systematic review aims to summarize existing qualitative research on the meaning of recovery from the perspective of persons with dual diagnosis.

METHODS

A literature search was conducted following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for systematic reviews in the following databases: Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Medline, Embase, and Web of Science.

RESULTS

Sixteen studies using a qualitative research design were retained in which four overarching themes could be identified. The first theme focused on feeling supported by family and peers and being able to participate in the community. The second theme focuses on the need for a holistic and individualized treatment approach, seeing the persons "behind the symptoms." The third theme that emerged was having personal beliefs, such as fostering feelings of hope, building a new sense of identity, gaining ownership over one's life, and finding support in spirituality. The last theme identified was the importance of meaningful activities that structure one's life and give one motivation to carry on.

CONCLUSIONS

In this review, the participants pleaded for "flexibility" in mental health care, i.e., an approach that allows for both successes and failures. However, in order to come to a more comprehensive theoretical model of recovery in persons with dual diagnosis, future research is necessary to gain insight into the underlying mechanisms of recovery processes.

A Qualitative Study of Barriers to Care for People With Co-Occurring Disorders

The present qualitative study used face-to-face and telephone interviews with service providers in the Tampere area in Finland to describe the provider viewpoint on barriers to care for people with co-occurring disorders. The core barrier concerns the definition and understanding of the problems: client and professional perspectives often differ, and both can be out of step with what the care system actually proposes. Professionals need to take into account contexts with potentially multiple barriers to care. Providers in each local area should examine possible barriers and find solutions together, integrating the client perspective at each step in the process.

Co-occurring Mental Disorders in Substance Abuse Treatment: the Current Health Care Situation in Germany

Aim of this study was to investigate the current health care situation for patients with co-occurring mental disorders in addiction treatment. Therefore, data from the German Substance Abuse Treatment System (N = 194,406) was analysed with regard to the prevalence of comorbid mental disorders, treatment characteristics and outcomes of patients with comorbid psychiatric diagnosis. In outpatient setting, the prevalence of comorbid diagnoses was considerably lower (4.6%) than in inpatient setting (50.7%), but mood and anxiety disorders were the most prevalent additional diagnoses in both settings. In the treatment of patients with these comorbid disorders, we found higher rates of complementary internal and external (psychiatric) treatment, more co-operations and referrals after treatment, and positive treatment process outcomes. Findings indicate that the knowledge of an additional diagnosis influences the health care provision of affected patients and can therefore be seen as the essential precondition for providing adequate and comprehensive treatment. This highlights the importance of a sufficient consideration and diagnostic assessment of mental disorders in addiction treatment to further improve the health care situation of comorbid patients.

Positive psychology constructs as predictors of depression in retirees

This study investigated whether five positive psychological constructs (self-efficacy, gratitude, grit, hope and optimism) had a combined effect on levels of depression. The co-occurrence of these psychological factors, defined as an example of covitality, was examined in relation to predicting lower levels of depression. Participants were 278 retirees living in Brisbane, Australia. Each participant completed either an online or hard-copy self-report, related to positive psychological functioning. A standard multiple regression found that self-efficacy, grit, optimism and hope were individually all significant predictors of depression (small effect sizes); however, the combinatorial relation of all these four factors with depression was substantial (R2 = 0.34; large effect size). Gratitude was not a significant predictor. While no causality can be inferred from this cross-sectional study, having a combination of positive psychological factors might have an effect on levels of depression in retirement.

Meeting the Treatment Needs of Multiply Diagnosed Consumers

Recent research demonstrates that approximately 10 million people in the United States have been diagnosed with at least one co-occurring mental health disorder and substance abuse disorder in any given year (Substance Abuse & Mental Health Services Administration National Advisory Council, 1997). Emerging awareness by clinicians, substance abuse counselors, and researchers has subsequently awakened the treatment community to the needs of consumers who are afflicted with co-occurring problems. One panel of the Los Angeles County-wide conference “Common Ground, Common Language, Common Goals: Bringing Substance Abuse Research and Practice Together” (held in April 2001) focused on the prevalence and treatment of co-occurring disorders. This article outlines the discussion and findings of this panel on the numerous treatment needs of consumers with multiple diagnoses and the converging and conflicting treatment models that have been developed for them.

Complex Recovery: Understanding the Lives of Formerly Homeless Adults with Complex Needs

OBJECTIVE

This report examines mental health recovery in a population neglected in the literature--formerly homeless adults with serious mental illness and co-occurring substance abuse. The term 'complex recovery' is used to examine the onset and impact of various types of adversity over the life course.

METHOD

Burawoy's extended case method was conducted on in-depth interviews with 74 formerly homeless adults living in housing programs in New York City. Data included verbatim transcripts, interviewer feedback forms, and case summaries.

RESULTS

Seven themes emerged: the longstanding influence of poverty, childhood hardship, social support and network depletion, substance abuse and recovery, unequal impact of gender differences, experiences of incarceration and fragmented service system. Structural as well as individual factors were found to comprise complex recovery.

CONCLUSIONS

Complex recovery, which situates mental health recovery amidst homelessness and other forms of adversity, has implications for policies and practices designed to assist this vulnerable population.

Node-link mapping, an asset?

Purpose

– The purpose of this paper is to evaluate the use of node-link mapping (NLM) on the effectiveness of a structured treatment for dual diagnosis for men living in a low-secure environment.

Design/methodology/approach

– In total, 15 participants were recruited and randomly allocated to one of two conditions. The control group, treatment as usual (TAU) or the treatment group, TAU with NLM. Outcome measures used were: a qualitative evaluation form, The Alcohol and Illegal Drugs Decisional Balance Scale and the Brief Situational Confidence Questionnaire.

Findings

– Results indicate no statistically significant difference for either group on the pre- and post-treatment outcome measures used. Qualitative data indicated that those using NLM reported the intervention as useful and instructive more often.

Research limitations/implications

– The results gained were only a snapshot of the intervention straight after treatment and did not take into account any long-term benefits of therapy such as substance use relapse rates. The outcome measures used may not have been properly understood by all respondents, or reflect practical change. The NLM tool may not have been used as confidently as TAU. The TAU condition needs to be reviewed to improve effectiveness, and NLM to be included to improve the accessibility. A study comparing other outcome tools needs to be completed. Training for staff using NLM may require coaching.

Originality/value

– This paper has a high/low originality. It highlights a number of advantages to NLM when comparing this to TAU.

Evans A, Achara-Abrahams I, White W. Beyond co-occurring disorders to behavioral health integration

Purpose

– Despite the high prevalence of co-occurring disorders and the need for systems of care to integrate mental health and addiction services, integration remains a challenge. The purpose of this paper is to address this challenge by focussing on shared processes of recovery.

Design/methodology/approach

– After reviewing commonalities between mental health and substance use recovery, integration of treatment with recovery supports under the rubric of a “recovery-oriented system of care” is described. Philadelphia's Department of Behavioral Health and Intellectual disAbility Services is then used as an example to illustrate strategies for achieving two forms of integration: mental health and addiction and treatment and recovery supports.

Findings

– Viewed through the lens of people with mental health and addiction challenges, the services and supports that promote recovery are very similar. One of the common themes that emerged was the need for these services to go beyond helping people manage their symptoms or achieve abstinence, to also helping them to rebuild their lives in their communities. In addition to co-location and increased collaboration, service providers must possess common values, a consistent approach, and a shared vision for the people they serve.

Practical implications

– Systems need to find innovative and effective ways to integrate recovery support services with treatment and other interventions, hopefully transforming existing services in the process.

Originality/value

– In the process of developing a truly integrated behavioral health system, a shared vision across all sectors of the system must shift away from the field's historical focus on illness and problems to a new focus on strengths and possibilities.

Gender differences in prevalence and correlates of antisocial personality disorder among heroin dependent users in compulsory isolation treatment in China

BACKGROUND

Little is known about gender difference in correlates of antisocial personality disorder (ASPD) among drug users.

OBJECTIVE

To detect gender difference in correlates of ASPD in a Chinese heroin dependent sample.

METHODS

Structured interviews were conducted among 882 heroin dependent users in two compulsory isolation settings in Changsha, China. Descriptive statistics were employed to report sample characteristics by gender. Bivariate relationships were examined between co-occurring ASPD and variables measuring demographic, drug use, and psychiatric co-morbidities. Multivariate logistic regressions with stepwise forward method were conducted to determine independent predictors for co-occurring ASPD. All analyses examining correlates of co-occurring ASPD were conducted for the total, the male and the female participants respectively to detect both the common and the unique correlates of ASPD by gender.

RESULTS

Of the total participants, 41.4% (54.2% of males and 15.4% of females) met the DSM-IV criteria of ASPD. For male participants, lower educational level, unemployment, unmarried, younger age at first heroin use, previous history of compulsory treatment, larger amounts of heroin used per day and poly-drug abuse during past month before admission, as well as psychiatric co-morbidities of lifetime major depressive disorder and borderline personality disorder were independent predictors for co-occurring ASPD; while for female participants, only three variables: younger age at first heroin use, paranoid personality disorder and borderline personality disorder were independent predictors for co-occurring ASPD.

CONCLUSIONS

Gender differences in prevalence and correlates of ASPD among heroin dependent users were detected. The findings highlight a need for gender-specific interventions.

The Burnaby treatment center for mental health and addiction, a novel integrated treatment program for patients with addiction and concurrent disorders: results from a program evaluation

Background

Patients with addictions and concurrent disorders constitute the most underserved population in the system of care. There are numerous reasons why this population has so much difficulty accessing services, including behavioural issues, criminal engagement, and non-compliance with outpatient services. To improve services to this population which is marked by multiple morbidities, high mortality and insufficient access to health care, the government of British Columbia, Canada developed a program for people with both substance use disorder and one or more mental disorders who have not benefited from previous therapies.

Method

In July 2008, the Burnaby Treatment Centre for Mental Health and Addiction (BCMHA), a specialized and integrated tertiary care facility, was opened. The current article provides a description of the treatment program and a clinical profile of the population.

Results

The target population is being served, at intake clients present with high rates of psychopathology, childhood and adult trauma, and substance use.

Conclusion

While preliminary, these results indicate, that the novel approach of the Burnaby Centre may constitute a new path towards providing effective recovery for this population.

Characterizing the longitudinal patterns of substance use among individuals diagnosed with serious mental illness after psychiatric hospitalization

AIM

To characterize longitudinal patterns of substance use across a large sample of psychiatric patients discharged from inpatient admission, followed for 1-year post-hospitalization.

DESIGN

Prospective cohort study.

SETTING

Kansas City, MO, USA; Pittsburgh, PA, USA; Worcester, MA, USA.

PARTICIPANTS

Eight hundred and one schizophrenia-spectrum (n = 204), bipolar (n = 137) and depressive disorder (n = 460) patients from the MacArthur Violence Risk Assessment Study.

MEASUREMENTS

Symptoms, functioning, drug/alcohol use assessed by the Brief Psychiatric Rating Scale, the Global Assessment of Functioning, and substance use interviews.

FINDINGS

Patients used alcohol (67.0%; n = 540) and cannabis (30.0%; n = 237) more frequently than other substances up to 30 days before admission, and those with depressive and schizophrenia-spectrum used heroin more than individuals with bipolar (P = 0.023). Post-hospitalization, patients using alcohol (B = -0.15, P < 0.001) and cannabis (B = -0.27, P < 0.001) decreased, but patterns varied across diagnosis and genders. Patients using cannabis decreased at greater rates in depressive and schizophrenia-spectrum compared with bipolar (all P < 0.05), and more men used alcohol (B = 0.76, P < 0.001) and cannabis (B = 1.56, P < 0.001) than women. Cannabis (B = 1.65, P < 0.001) and alcohol (B = 1.04, P = 0.002) were associated with higher symptomatology; cannabis (B = -2.33, P < 0.001) and alcohol (B = -1.45, P = 0.012) were associated with lower functioning.

CONCLUSIONS

Substance use is frequent and associated with poor recovery in patients with serious mental illness recently discharged from psychiatric hospitalization. Addiction treatments personalized by diagnosis and gender may be effective for improving outcomes in people with serious mental illness.

The Addiction Psychiatrist as Dual Diagnosis Physician: A Profession in Great Need and Greatly Needed

Addiction is the number one cause of premature illness and death in the U.S., especially among people with mental illness. Yet American medicine lacks sufficient workforce capacity, expertise, training, infrastructure, and research to support treatment for people with co-occurring addictions and mental illness. This essay argues that the addiction psychiatrist is essential in dual diagnosis care.

The relationship between medication-related problems and behavioural health condition among patients served by a health care for the homeless centre

Objectives

To evaluate the association between behavioural health conditions and the presence of a medication-related problem (MRP) and the association between the type of MRP and the presence of a dual diagnosis.

Methods

We used an existing database from a behavioural health clinic for homeless persons. Logistic regression was used to assess the relationship between the type of behavioural health condition and MRP presence, and whether the type of MRP varied with the presence of a dual diagnosis.

Key findings

A total of 426 patients were eligible. The majority were black (61%) and women (53%). Patients were 44.7 ± 10.2 years old, taking 3.4 ± 2.4 medications and had 2.3 ± 0.9 behavioural health conditions. The majority (53%) had a dual diagnosis, 44% had depression, 30% had a bipolar disorder, 26% had a personality disorder and 12% had an anxiety disorder. Bipolar [odds ratio (OR) 4.0, 95% confidence interval (CI) 1.8–8.9] and anxiety disorders (OR 3.1, CI 1.0–9.2) and a dual diagnosis (OR 2.1, CI 1.2–3.8) were independently associated with the presence of an MRP. Patients with a dual diagnosis were more likely to have ineffective drug therapy (OR 1.7, CI 1.1–2.8) and less likely to have an adverse effect (OR 0.5, CI 0.3–0.9).

Conclusions

Patients with bipolar or anxiety disorders and/or a dual diagnosis may benefit from a pharmacist intervention to address MRPs. Pharmacists can make recommendations to improve the effectiveness of patients' medication therapy and help to resolve adverse effects.

Treatment of dual diagnosis disorders

PURPOSE OF REVIEW

Treatment of dual diagnosis [co-occurrence of a substance use disorder (SUD) in patients with mental illness] poses several challenges for mental health professionals. This article seeks to review the recent advances in dual diagnosis treatment with respect to pharmacotherapy and psychosocial approaches.

RECENT FINDINGS

Atypical antipsychotics are commonly used for comorbid schizophrenia and SUD. Whereas there is no difference between risperidone and olanzapine, clozapine appears to have a distinct advantage in reducing psychotic symptoms as well as substance abuse (including smoking). There is emerging evidence that quetiapine is beneficial in dually diagnosed patients, particularly using alcohol, cocaine and amphetamine. A combination of naltrexone and sertraline was found to be effective in patients with depressive disorder and alcohol dependence. Effectiveness of atomoxetine is yet to be established in patients with comorbid adult attention-deficit/hyperactivity disorder with respect to decrease in substance abuse. Integrated intervention is the choice of treatment for patients with dual diagnosis.

SUMMARY

In spite of the high association between substance use and psychiatric disorders, there is a surprising paucity of studies related to treatment and outcome. A few well-designed studies have been recently published and more studies of this nature are required in order to address the challenges posed in the treatment of dual disorders.

"Thank you God": religion and recovery from dual diagnosis among low-income African Americans

People with lived experience of dual diagnosis face specific challenges in that they have struggled with both severe mental illness and substance use disorder simultaneously. I conducted a 6-year ethnographic study with poor African Americans with lived experience of dual diagnosis in Washington, DC, to assess barriers and facilitators to recovery. In this paper, I analyze the relationship between religion and recovery. I set out to answer two research questions: (a) What is the self-identified role of religious commitment and activity in participants' recovery from dual diagnosis? (b) What (if any) religious activities, notions, and resources are positively harnessed to enhance recovery? I found high levels of Christian religiosity among participants. Participants perceived their ongoing recovery as a process reliant upon (a) an intimate and personal relationship with God, and (b) engagement in certain core private religious activities, most notably prayer, reading of scripture, and listening to religiously inspired radio, television, or music. Participants' religiosity was underpinned by a Pauline theology of transformation and reconciliation. Psychiatric services serving an African American clientele with lived experience of dual diagnosis may increase effectiveness by better harnessing client religiosity to assist recovery.

Substance use disorder among people with first-episode psychosis: a systematic review of course and treatment

OBJECTIVE

People experiencing a first episode of psychosis frequently have co-occurring substance use disorders, usually involving alcohol and cannabis, which put them at risk for prolonged psychosis, psychotic relapse, and other adverse outcomes. Yet few studies of first-episode psychosis have addressed the course of substance use disorders and the response to specialized substance abuse treatments.

METHODS

The authors searched MEDLINE, PsycINFO, and other medical databases for English-language articles published between 1990 and 2009. Included studies addressed two research questions. First, do some clients become abstinent after a first episode of psychosis without specialized substance abuse treatments? Second, for clients who continue to use substances after a first episode of psychosis, does the addition of specialized substance abuse treatment enhance outcomes?

RESULTS

Nine studies without specialized substance abuse treatment and five with specialized substance abuse treatment assessed the course of substance use (primarily cannabis and alcohol) after a first episode of psychosis. Many clients (approximately half) became abstinent or significantly reduced their alcohol and drug use after a first episode of psychosis. The few available studies of specialized substance abuse treatments did not find better rates of abstinence or reduction.

CONCLUSIONS

Experience, education, treatment, or other factors led many clients to curtail their substance use disorders after a first episode of psychosis. Specialized interventions for others need to be developed and tested.

Mentally ill offenders in prison: the Belgian case

According to the EUPRIS-study on mental health in prisons (2007), available data on mental disorders in prison are scarce. Therefore, this study aims at summarizing and discussing the available knowledge on incarcerated mentally ill offenders concerning: (1) the screening and assessment for detecting mental health; (2) the psychiatric expertise in order to evaluate the mental status; and (3) the development and provision of forensic psychiatric treatment and care. These findings will be applied to the current situation in Belgium, which is a particularly interesting case. Belgium is currently facing difficulties concerning a large population of interned mentally ill offenders residing in correctional establishments. Implications with regard to the penal code, general or mental health legislation, screening, assessment, and treatment could deliver interesting viewpoints on how this problem could be tackled more effectively. Therefore, the findings will be discussed with reference to the international scientific and policy debate, focusing on ethical implications.

Predictors of Depressive Symptomatology in Family Caregivers of Women With Substance Use Disorders or Co-Occurring Substance Use and Mental Disorders

This study utilized a stress-process model to examine the impact of having a female family member with substance use or co-occurring substance use and mental disorders on family caregivers' depressive symptomatology. Participants were 82 women receiving substance abuse treatment and the family member providing the most social support for each woman. Greater caregiver depressive symptomatology was predicted by greater care recipient emotional problems, less care recipient social support, and poor caregiver health. Implications of findings for treatment and future research are discussed.

Ventral and dorsal striatal dopamine efflux and behavior in rats with simple vs. co-morbid histories of cocaine sensitization and neonatal ventral hippocampal lesions

RATIONAL

Exposing animal models of mental illness to addictive drugs provides an approach to understanding the neural etiology of dual diagnosis disorders. Previous studies have shown that neonatal ventral hippocampal lesions (NVHL) in rats produce features of both schizophrenia and addiction vulnerability.

OBJECTIVE

This study investigated ventral and dorsal striatal dopamine (DA) efflux in NVHL rats combined with behavioral sensitization to cocaine.

METHODS

Adult NVHL vs. SHAM-operated rats underwent a 5-day injection series of cocaine (15 mg/kg/day) vs. saline. One week later, rats were cannulated in nucleus accumbens SHELL, CORE, or caudate-putamen. Another week later, in vivo microdialysis sampled DA during locomotor testing in which a single cocaine injection (15 mg/kg) was delivered.

RESULTS

NVHLs and cocaine history significantly increased behavioral activation approximately 2-fold over SHAM-saline history rats. DA efflux curves corresponded time dependently with the cocaine injection and locomotor curves and varied significantly by striatal region: Baseline DA levels increased 5-fold while cocaine-stimulated DA efflux decreased by half across a ventral to dorsal striatal gradient. However, NVHLs, prior cocaine history, and individual differences in behavior were not underpinned by differential DA efflux overall or within any striatal region.

CONCLUSION

Differences in ventral/dorsal striatal DA efflux are not present in and are not required for producing differential levels of acute cocaine-induced behavioral activation in NVHLs with and without a behaviorally sensitizing cocaine history. These findings suggest other neurotransmitter systems, and alterations in striatal network function post-synaptic to DA transmission are more important to understanding the interactive effects of addictive drugs and mental illness.

Dual diagnosis in a Dublin tertiary addiction centre - A cross-sectional study

OBJECTIVES

To address the relative dearth of information relating to the prevalence of psychiatric co-morbidity among attenders of community addiction facilities.

METHODS

We carried out a cross-sectional study of clients attending a Dublin-based tertiary addiction centre to assess the rates of psychiatric co-morbidity, determine the demographic and clinical variables and evaluate the level of contact with allied medical care especially primary care and community psychiatric services. Information was sourced from available patient records.

RESULTS

Forty-three per cent of the clients (n = 59), attending the service were found to have a chart diagnosis of psychiatric disorder. Only 15% of these were in contact with community psychiatric services.

CONCLUSIONS

This high rate of psychiatric co-morbidity has implications in terms of funding, training and service delivery.

Co-occurring psychiatric and substance use disorders among male detainees in Italy

This paper presents data on the prevalence of co-occurring substance use and psychiatric disorders among newly imprisoned males in Italy. Interviewers conducted semi-structured clinical interviews with n=302 male detainees seven days after their admission to the prison of Perugia from August 2005 through July 2006. Over half of male detainees (54.3%) had either a substance use disorder or another psychiatric disorder. One of every five detainees (20.9%) had comorbid substance use and psychiatric disorders. Compared to detainees with psychiatric disorder only, substance use disorder only, or no disorder, detainees with comorbid substance use and psychiatric disorders were significantly more likely to have severe impairment in the areas of employment, substance abuse, family and social functioning, and psychiatric symptoms. Findings underscore the need for careful diagnostic screening at intake, access to treatment during detention, and an effective transition to services at the time of release.

Dual diagnosis and psychosocial interventions--introduction and commentary

Treatment of patients with concurrent mental illness and substance abuse represents a challenge to the traditional treatment systems. This article gives: 1) an introduction of the concept and frequency of dual diagnosis (DD), 2) a presentation and discussion of the latest guidelines on DD treatment, 3) status on the current situation in the DD field in Denmark, and 4) potentials for future research. The article is based on systematic examination of evidence-based research and popularized latest guidelines on DD treatment. Methodologically, both treatment and research is challenged by the diversity in DD combinations. Although integrated treatment with the inclusion of cognitive-behavioural therapy, motivational interviewing and family intervention in DD treatment show promising results, it remains to establish which treatment programme is the most qualified in improving mental health and reducing substance use. A future priority is the development of DD treatment that targets specific co-morbid combinations and treatment needs.

The neonatal ventral hippocampal lesion as a heuristic neurodevelopmental model of schizophrenia

Traditionally, animal models of schizophrenia were predominantly pharmacological constructs focused on phenomena linked to dopamine and glutamate neurotransmitter systems, and were created by direct perturbations of these systems. A number of developmental models were subsequently generated that allowed testing of hypotheses about the origin of the disease, mimicked a wider array of clinical and neurobiological features of schizophrenia, and opened new avenues for developing novel treatment strategies. The most thoroughly characterized (approximately 100 primary research articles) is the neonatal ventral hippocampal lesion (NVHL) model, which is the subject of this review. We highlight its advantages and limitations, and how it may offer clues about the extent to which positive, negative, cognitive, and other aspects of schizophrenia, including addiction vulnerability, represent inter-related pathophysiological mechanisms.

EEG biofeedback as a treatment for substance use disorders: review, rating of efficacy, and recommendations for further research

Electroencephalographic (EEG) biofeedback has been employed in substance use disorder (SUD) over the last three decades. The SUD is a complex series of disorders with frequent comorbidities and EEG abnormalities of several types. EEG biofeedback has been employed in conjunction with other therapies and may be useful in enhancing certain outcomes of therapy. Based on published clinical studies and employing efficacy criteria adapted by the Association for Applied Psychophysiology and Biofeedback and the International Society for Neurofeedback and Research, alpha theta training-either alone for alcoholism or in combination with beta training for stimulant and mixed substance abuse and combined with residential treatment programs, is probably efficacious. Considerations of further research design taking these factors into account are discussed and descriptions of contemporary research are given.