Substance use disorder and posttraumatic stress disorder comorbidity: Addiction and psychiatric treatment rates.

This study compares substance use disorder (SUD) patients with and without a comorbid diagnosis of posttraumatic stress disorder (PTSD) on their use of addiction and psychiatric services over the 6-month period before an inpatient substance abuse admission. Compared with non-PTSD patients, PTSD patients had a greater number of hospital overnights for addiction treatment. Given no significant between-groups differences on any substance use indexes, PTSD patients apparently overuse costly inpatient addiction services. Despite their greater rates of psychiatric comorbidity, PTSD patients did not receive treatment for psychiatric problems at greater rates than did non-PTSD patients. Among PTSD patients, use of PTSD treatment was low. Assessment of psychiatric comorbidity and referral to treatment targeting co-occurring PTSD and other disorders are suggested as possible ways to reduce the high treatment costs associated with SUD-PTSD comorbidity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Dual diagnosis: a review of etiological theories

The etiology of the high prevalence of substance use disorders in patients with severe mental illness (schizophrenia or bipolar disorder) is unclear. We review the evidence of different theories of increased comorbidity, organized according to four general models: common factor models, secondary substance use disorder models, secondary psychiatric disorder models, and bidirectional models. Among common factor models, evidence suggests that antisocial personality disorder accounts for some increased comorbidity. Among secondary substance use disorder models, there is support for the supersensitivity model, which posits that biological vulnerability of psychiatric disorders results in sensitivity to small amounts of alcohol and drugs, leading to substance use disorders. There is minimal support for the self-medication model, but the accumulation of multiple risk factors related to mental illness, including dysphoria, may increase the risk of substance use disorder. Secondary psychiatric disorder models remain to be convincingly demonstrated. Bidirectional models have not been systematically examined. Further clarification of etiologic factors, including the identification of subtypes of dual diagnosis, may have implications for developing more effective prevention efforts and treatment.     

Pre- and postsynaptic neurotoxic effects of dopamine demonstrated by intrastriatal injection

The coexistence of psychiatric and substance abuse problems within the same patient occurs with significant frequency. These patients present serious challenges to a health care system which has traditionally treated mental health and substance abuse in separate venues, with differing and sometimes contradictory treatment modalities. Few studies exist on the treatment of the "dual diagnosis" patient utilizing an integrated approach, where both problems are addressed by the same staff on a single inpatient ward. We describe such a program in which dual diagnosis patients on one ward are separated into two different treatment tracks based upon the severity of their psychiatric illness. Follow-up measures at 3 months after discharge are compared for patients from each treatment track, with no significant difference found for the five outcome variables studied. This suggests that chronically mentally ill inpatients may benefit from integration of attention to their substance abuse problems with psychiatric treatment.     

The trauma patient: open hospital choice?

Mental-health service utilization among elderly people has been shown to be low relative to younger age groups. This study was done to determine the current proportion of elderly persons served in a university-affiliated psychiatry outpatient clinic, and to better characterize elderly patients who receive specialized mental-health care in this setting. The proportion of visits from elderly patients (aged 60 and over) was found to be 16%. Demographic and clinical characteristics of a sample of 140 consecutive geriatric patients evaluated at the clinic were obtained. The data revealed that the patients had a mean age of 74.7+/-7.5 (SD) years, and were mostly female (72.1%) and white (78.6%). Surprisingly, the age distribution was found to be bell shaped, with a small upper tail. The three most prevalent psychiatric diagnoses were depression (56.4%), dementia (35.7%), and substance use disorder (20%). Overall, 59.3% of geriatric patients had a history of prior psychiatric treatment. Females were significantly more likely than males to have a psychiatric history (69.3% vs. 33.3%, P = .0001). Among patients with a psychiatric history, females were more likely to have a current diagnosis of major depression (P = .0006), while males were more likely to have a current substance use disorder (P = .03). The prevalence of dementia increased with each successive decade above 60, while the occurrence of bipolar and adjustment disorders was confined to younger geriatric patients. Elderly patients receiving psychiatric treatment in the clinic thus formed a heterogeneous group. Gender, age, and presence of a psychiatric history were all associated with differences in prevalence and distribution of various mental disorders in this geriatric psychiatry outpatient clinic.     

Overlap of clusters of psychiatric symptoms among clients of a comprehensive addiction treatment service.

This article describes the prevalence and overlap of psychiatric symptoms among 2,784 clients of the outpatient programs at a comprehensive addictions treatment facility. The psychiatric symptoms were assessed by a computer-based questionnaire, and the analysis focused on the overlap of symptom clusters (multimorbidity) and their relation to selected intake variables known to be predictors of treatment outcome. Of all clients, 27.4% scored positive for 1, 18.9% for 2, and 22.3% for 3 or more clusters, the most frequent being depression, anxiety, and history of conduct disorder. Multimorbidity was significantly correlated with female gender, unemployment, less social support, cannabis problems, fewer legal problems, and increased treatment engagement. Clients with more substance use disorders presented more psychiatric symptoms. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Reducing HIV-Risk Behavior Among Adults Receiving Outpatient Psychiatric Treatment: Results From a Randomized Controlled Trial.

This study investigated the efficacy of a 10-session, HIV-risk-reduction intervention with 221 women and 187 men receiving outpatient psychiatric care for a mental illness. Patients were randomly assigned to the HIV intervention, a structurally equivalent substance use reduction (SUR) intervention, or standard care; they were assessed pre- and postintervention and at 3- and 6-month follow-ups. Patients receiving the HIV-risk-reduction intervention reported less unprotected sex, fewer casual sex partners, fewer new sexually transmitted infections, more safer sex communications, improved HIV knowledge, more positive condom attitudes, stronger condom use intentions, and improved behavioral skills relative to patients in the SUR and control conditions. Patients receiving the SUR intervention reported fewer total and casual sex partners compared with control patients. Exploratory analyses suggested that female patients and patients diagnosed with a major depressive disorder were more likely to benefit from the HIV-risk-reduction intervention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Performance in occupational therapy as a predictor of successful prevocational training

Scores on three subtests of the Minnesota Follow-up Scale (MFS) were related to client outcomes in a prevocational training program in a study of 26 clients who were referred from an adult psychiatric day treatment unit. The results of the study agreed with a prediction that successful performance in occupational therapy in the day treatment unit, as measured by subtest 1, would be significantly related to successful client outcomes. the results regarding predictions for two other subtests were less conclusive because clients received high scores. Age and sex distributions showed that the younger male clients were most likely to be referred for prevocational training. The staff of the prevocational training program accepted the results of the study and also agreed that performance in occupational therapy (in the day treatment unit) should receive greater recognition by staff members as an important indicator of work potential when evaluating clients for referral to a vocational training program. It is planned to continue the use of the MFS in the day treatment unit as an aid for evaluating clients for referral purposes. Scores will continue to be related to client outcomes in the prevocational training program. Further study is also planned concerning the relationship of age and sex and sources to which clients are discharged or referred from the day treatment unit.     

Psychiatric treatment in jail: an experiment in health-care delivery

The author discusses the source of referral, psychiatric diagnosis, and treatment of 539 inmates who were referred for psychiatric treatment in two metropolitan jails. Almost one-third of the patients were evaluated within 24 hours of their being booked into jail. Manifestly disordered and violent behavior accounted for 50 per cent of the referrals; almost half the patients were diagnosed as schizophrenic or manic. The author emphasizes the importance of a close working relationship with the custody staff to facilitate identifying inmates who need psychiatric treatment.     

Industrial action by nurses: the Italian situation

The objective of this pilot study is to describe the use of a Social Security representative payee program as a clinical intervention integrated into long-term, dual-disorder treatment of severely mentally ill outpatients with comorbid drug/alcohol disorders. Compared with non-payees, patients selected to be payee participants were more likely to be male, have a diagnosis of schizophrenia, have a history of high inpatient utilization, and have higher current ratings of psychiatric symptoms, substance use, and functional disability. Despite these higher severity ratings, which usually predict poor outpatient compliance and higher rate of adverse outcomes, the payee participants attended about twice the number of outpatient service sessions as non-payees and were no more likely to be currently homeless, hospitalized, or incarcerated. The payee intervention is described, and ethical and research issues are discussed.     

1,000 forensic outpatients: a descriptive study

The case notes and court reports of 1,000 consecutive outpatient referrals to a regional forensic outpatient service were studied retrospectively. Socio-demographic, psychiatric and forensic information was collected. The sample was predominantly male, Caucasian and relatively young in comparison with a general psychiatric population. The commonest source of referral was from defense solicitors and the commonest reason for referral was for a court report. A wide range of diagnoses and offences were noted. A number of differences were found in the frequency of gender, ethnicity and diagnosis according to the source of, and reason for, referral.     

Use of health services for anxiety disorders: a multisite study in Quebec

OBJECTIVE: We investigated patient characteristics and use of services for anxiety disorders among patients seeking care from participating clinicians at 7 anxiety clinics in Quebec: 3 general hospital clinics, 3 psychologist-run clinics, and one psychiatric hospital clinic. METHODS: Persons eligible for the study were those who were visiting the clinics for the first time, had a current diagnosis of an anxiety disorder, and could communicate in French or English. Subjects recruited through advertisements were excluded. Data, collected by a self-administered questionnaire, included demographics, treatment history, use of services for anxiety, and the Beck Anxiety Inventory (BAI). RESULTS: The sample comprised 235 subjects: 146 seen at 3 general hospital clinics, 54 at 3 psychologist-run clinics, and 35 at a psychiatric hospital clinic. There were statistically significant differences by clinic type in the prevalence of specific anxiety diagnoses, BAI score, referral source, antidepressant use, and use of services. High-intensity use (10 or more consultations during the previous year) was reported by 23.4% of the sample for medical services and 19.6% for mental health services. Multiple logistic regression identified variables associated with high-intensity use of medical services (higher BAI score, 1 to 4 years since first sought treatment, and less than 12 years of education) and high-intensity use of mental health services (clinic type, obsessive-compulsive disorder [OCD], and 5 or more years since first sought treatment). CONCLUSIONS: The patient populations seen at different types of anxiety clinics differ in several respects, including referral source, previous treatment, and severity of symptoms. Regardless of type of clinic, patients with a longer time since they first sought treatment use more services, particularly mental health services. Those with less education use more medical services than those with greater education.     

Coping and the decision to hospitalize in emergency psychiatry

This study was done to clarify whether and in what way a patient's coping repertoire can be linked to the disposition decision in a psychiatric emergency service. For 1 year, all consultations (N = 1439) of a psychiatric emergency service were documented in a detailed questionnaire covering sociodemographic and diagnostic data as well as information about the disposition decision. Depending on disposition, three groups were identified: outpatients (N = 530), inpatients (N = 481), and a nonintervention group (N = 428). In addition, over a 5-month period, patients were requested to fill in the "Bernese Coping Modes" questionnaire. Thus, a sample of 28 patients undergoing outpatient crisis intervention and 28 patients referred to inpatient treatment was obtained. Statistical analysis included Chi square-test, t-test, Mann-Whitney U-test, and logistic regression analysis. Assessment of coping repertoire contributed more than the diagnosis to the decision to hospitalize. Outpatients have a larger coping repertoire (t = 3.48, p = 0.001) than inpatients and show higher values in "acceptance-stoicism," "dissimulation," "tackling," "giving meaning," "altruism," "optimism," and "relativizing." Logistic regression revealed relativizing, altruism, and optimism as being most important. Self-referral to emergency psychiatry was also correlated with outpatient treatment. Other criteria such as being without work, living alone, history of previous hospitalization, and the diagnosis of a psychotic or mood disorder were significantly correlated with referral to inpatient treatment. More attention should be paid to patients' coping repertoires in emergency services when deciding about the need for inpatient treatment.     

Pellucid marginal corneal degeneration 12 years after penetrating keratoplasty for keratoconus

Historically the divisions between the mental health and substance abuse fields have been so deep that attempts to provide coordinated treatment across service sectors for people with dual diagnoses of psychiatric disorder and substance use disorder have failed. The authors describe a program in Maine designed to develop collaboratives, or communities of providers, who work together to offer coordinated mental health and substance abuse treatment and support. Surveys of provider agencies in one collaborative conducted one year and two years after the collaborative was established showed an increase in interagency referrals, joint assessments of clients, and jointly sponsored training and client services.     

Increasing treatment adherence among outpatients with depression and cocaine dependence: results of a pilot study

OBJECTIVE: This pilot study examined the effect of a modified motivational therapy intervention on outpatient treatment adherence and completion for patients with comorbid depressive disorder and cocaine dependence. METHOD: Depressed cocaine patients, stabilized with antidepressant medications on an inpatient psychiatric unit, were consecutively assigned on discharge to motivational therapy (N = 11) or treatment-as-usual (N = 12) during the first month of outpatient care. Patients were compared on treatment adherence and completion and on 1-year rehospitalization rates. RESULTS: Motivational therapy patients attended significantly more treatment sessions during month 1, completed 30 and 90 days of outpatient care at higher rates, and experienced fewer psychiatric rehospitalizations and days in the hospital during the first year from entry into outpatient treatment. CONCLUSIONS: An outpatient program combining individual and group motivational therapy sessions holds promise for improving treatment adherence and completion among depressed patients with cocaine dependence.     

Comparative effects of increased extracellular potassium and pacing frequency on the class III activities of methanesulfonanilide IKr blockers dofetilide, D-sotalol, E-4031, and MK-499

In order to analyze whether the referral system and nature of care exert any effect on the characteristics of patients, subjects aged 60 or above attending three medical centers on the Hong Kong Island between August and December 1990 were studied with respect to their age, sex, and psychiatric diagnosis. Psychiatric diagnoses were made in 98% of subjects at the psychogeriatric assessment service (PAC) (predominantly chronic organic brain syndrome), in 79.6% at the university psychiatric unit (mainly acute psychiatric problems, substance abuse, and deliberate self-harm), and in 20% at the general outpatient clinic (largely sleep and anxiety-related disorders). There was overrepresentation of the very old (above 80) and underutilization of counseling service at PAC. In Hong Kong, the psychogeriatric needs of the very old and of those with minor emotional disturbances associated with aging, retirement, and bereavement deserve reassessment.     

Determinants of suicidal ideation: the role of substance use disorders

BACKGROUND: This study tested the hypothesis that the amount of psychoactive substance consumed (frequency and/or quantity), life problems resulting from this use, and a DSM-IV diagnosis of substance abuse/dependence are independent risk factors associated with increased suicidal ideation in a population of psychiatric inpatients with major depressive disorder. METHOD: 891 hospitalized patients with a primary diagnosis of nonpsychotic major depressive disorder (MDD) received a standardized, psychiatrist-administered assessment battery. To examine the relationship between admission suicidality and demographic, psychiatric history, and admission variables, chi-square analyses were used for categorical data and one-way ANOVAs were used for continuous indices. Stepwise hierarchical multiple regression analyses were performed to determine the set of variables that was independently related to admission suicidality level. RESULTS: There was general agreement between our findings and previous literature in regard to the association between severity of Axis I diagnosis, depressed mood, hopelessness, male gender, unemployment, involuntary treatment, and alcohol/drug problems and higher suicidal ideation. In our sample of hospitalized patients with unipolar major depressive disorder, higher current drug and/or alcohol dependency and high current use of alcohol or other substances of abuse were independently associated with higher levels of suicidal ideation. CONCLUSION: This association with higher suicidal ideation lends support to the importance of treating patients for both alcohol/drug problems and depression in an effort to decrease their risk for future suicide. We hope that our findings will improve the care that patients with dual diagnoses receive.     

Smoking Among Psychiatric Outpatients: Relationship to Substance Use, Diagnosis, and Illness Severity.

To understand the elevated smoking rates among psychiatric patients, the authors investigated whether psychiatric diagnosis, illness severity, and other substance use predicted smoking status in a diverse sample (N=2,774) of psychiatric outpatients. Results indicated that 61% smoked daily and that 18% smoked heavily. Smoking was related to psychiatric diagnosis and illness severity as well as caffeine consumption and substance abuse. Diagnoses of bipolar disorder, schizoaffective disorder, and schizophrenia were independently related to smoking status, an association that was most pronounced among persons treated at clinics serving more impaired patients. Thus, diagnosis and illness severity contribute to elevated smoking rates, even after controlling for other substance use. Cessation programs are needed to reduce tobacco use in this vulnerable population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predictors and outcome of discharge against medical advice from the psychiatric units of a general hospital

OBJECTIVE: The study examined predictors of discharge against medical advice (AMA) and outcomes of psychiatric patients with AMA discharges, as measured by poorer symptom ratings at discharge and higher rates of rehospitalization. METHODS: A total of 195 patients discharged AMA from general hospital psychiatric units were compared retrospectively with 2,230 regularly discharged patients. AMA status was defined as signing out against medical advice, being absent without leave, or being administratively discharged. All patients received standardized assessments within 24 hours of admission and at discharge. Demographic characteristics, psychiatric history, DSA-IV psychiatric and substance use diagnoses, and scores on an expanded 32-item version of the Psychiatric Symptom Assessment Scale were compared. RESULTS: The groups did not differ in primary psychiatric diagnoses. Patients discharged AMA were significantly less likely to be Caucasian or to be functionally impaired due to physical illness. They were more likely to live alone, have a substance use diagnosis, use more psychoactive substances, and have more previous hospitalizations. Patients discharged AMA had significantly shorter lengths of stay, higher rehospitalization rates, and more severe symptoms at discharge, even when length of stay was taken into account. The differences between the groups in male gender and young age were better accounted for by a greater likelihood of substance abuse in these groups. CONCLUSIONS: The results suggest a profile of patients who may be discharged AMA. Such patients have worse outcomes and are more likely to be high utilizers of inpatient resources. Aggressive identification of patients likely to be discharged AMA and early discharge planning for appropriate outpatient treatment are recommended.     

Comorbid dysthymia and substance disorder: treatment history and cost

OBJECTIVE: The purpose of this study was to determine the treatment history and cost of previous treatment among patients with comorbid substance-related disorder and dysthymia, as compared to patients with substance-related disorder only. METHOD: Retrospective data were obtained regarding past treatment. Treatment cost was calculated on the basis of the 1996 cost of various treatment modalities. The setting was alcohol-drug programs located within departments of psychiatry in two centers. A total of 642 patients were assessed, of whom 39 had substance-related disorder and dysthymia and 308 had substance-related disorder only (the remaining patients had other comorbid conditions). Data collection instruments included an interview-based questionnaire regarding previous psychiatric and substance abuse treatment. Current cost of treatment in various settings was assessed on the basis of a survey of facilities used by patients in this area. RESULTS: Patients with substance-related disorder and dysthymia had received more substance-related disorder treatment in 18 of 20 measures. Patients with substance-related disorder and dysthymia used 4.7 times more substance-related disorder treatment dollars than patients with substance-related disorder only, although their demographic characteristics were similar. Past self-help activities and pharmacotherapy were remarkably similar for both groups. Although substance-related disorder treatment differed considerably between the two groups of patients, other types of psychiatric treatment (i.e., non-substance-related treatment) did not differ between the two groups. CONCLUSIONS: Patients with substance-related disorder and dysthymia are referred to (or seek) substance-related disorder treatment more often than patients with substance-related disorder only but are referred to (or seek) non-substance-related psychiatric treatment no more often than patients with substance-related disorder only. The cost of previous substance-related disorder treatment was several times higher for the patients with substance-related disorder and dysthymia.     

Gender differences in homeless persons with schizophrenia and substance abuse

The purpose of this study was to test the generalizability of previous research on gender differences between men and women with co-occurring schizophrenia and substance abuse. One hundred eight patients with schizophrenia or schizo-affective disorder involved in a study of treatment for homeless persons were interviewed for information regarding substance use, social functioning and support, comorbid disorders, victimization, medical illness, and legal troubles. We found that women had more children and were more socially connected than men. Women also had higher rates of sexual and physical victimization, comorbid anxiety and depression, and medical illness than men. We conclude that homeless women with dual disorders, like women with substance use disorders in the general population, have distinct characteristics, vulnerabilities, and treatment needs compared with men. In addition to comprehensive treatment of psychiatric and substance use disorders, gender-specific services should be developed, including prevention and treatment of victimization and related problems as well as help with accessing medical services.