Patients who use drugs during inpatient substance abuse treatment.

OBJECTIVE: Drug use by patients during inpatient substance abuse treatment is frequently a cause of premature hospital discharge. The authors examined the histories of patients who used drugs while in inpatient substance abuse treatment, the methods used to detect drug use, and the temporal relationship of drug use episodes. METHOD: The authors reviewed the charts of patients admitted consecutively to an inpatient substance abuse treatment unit between 1981 and 1988. Of 729 patients, 42 were found to have used drugs while receiving inpatient treatment. The diagnoses and clinical histories of these 42 patients were compared with those of all other patients. Methods of detection and circumstances of drug use were recorded, and drug use episodes were plotted on a time line that was examined for temporal clustering. RESULTS: Significantly more of the patients who used drugs during inpatient substance abuse treatment had primarily used heroin or methadone before treatment. Random urine screens, self-report, and staff observation together detected approximately 85% of the patients who used drugs during treatment. Episodes of drug use did cluster in time, but within clusters the hospital stays of the patients who used drugs did not necessarily overlap. CONCLUSIONS: Temporal clustering of drug use episodes may occur because drug use by one patient heralds drug availability and stimulates craving in other inpatients. Clinicians should be aware that one episode of drug use may be followed by others. Multiple detection methods, including random comprehensive urine screens, should be used to test for drug use on inpatient units.     

Treatment for co-occurring mental and substance use disorders in five state Medicaid programs

OBJECTIVES: This study described the locations and patterns of psychiatric and substance abuse treatment for Medicaid beneficiaries with co-occurring mental and substance use disorders in five states. METHODS: Medicaid beneficiaries aged 21 to 65 with psychiatric or substance use disorders were identified with claims and encounter records. Groups were further divided into those with and those without a diagnosed substance use disorder. Adjusted odds of treatment in community-based settings, inpatient facilities, emergency departments, and hospital outpatient departments were calculated. RESULTS: A total of 92,355 persons had a psychiatric disorder, 34,158 had a substance use disorder, and 14,256 had co-occurring psychiatric and substance use disorders. In all five states, beneficiaries with severe mental illness (schizophrenia, bipolar disorder, or major depression) and a substance use disorder had higher odds of inpatient, emergency department, and hospital-based outpatient psychiatric treatment, compared with those with severe mental illness alone. In four of five states, both severe and less severe mental illness and a co-occurring substance use disorder were associated with lower odds of community-based treatment compared with those with the respective mental illness alone. Compared with those with less severe mental illness alone, individuals with less severe psychiatric disorders and a co-occurring substance use disorder had higher odds of inpatient treatment in all states and of emergency department use in three of five states. Odds of inpatient and outpatient hospital use and emergency department use for substance abuse treatment were higher for persons with severe mental illness and a co-occurring substance use disorder in most states, compared with odds for those with a substance use disorder alone. CONCLUSIONS: Heavy inpatient and emergency department use by Medicaid beneficiaries with co-occurring substance use disorders is a consistent cross-state problem. Co-occurring disorders may decrease the likelihood of community-based treatment for those with less severe mental disorders and for those with severe mental illness, suggesting that policies focusing only on these settings may miss a significant proportion of people with these co-occurring disorders.     

Addiction in the elderly - an underestimated diagnosis in clinical practice?

According to several studies in the USA, alcohol abuse is common among elder people, particularly among those admitted to hospital. Corresponding data for Germany are lacking as yet. In this study, the frequency of addiction problems in the elderly admitted to hospital was investigated using the data from 1990 to 1998 of the psychiatric department at the General University Hospital of Lübeck, Germany. Furthermore, the documentations of all consultations in that period were reevaluated. The psychiatric consultation service covers two general hospitals providing inpatient treatment for about 200,000 inhabitants. Diagnoses were made according to the ICD-10 criteria. In 17.7% of the males older than 64 years and in 4.2% of the elderly females admitted to the psychiatric department, alcohol dependency was diagnosed, while 5.8% of the elderly patients showed substance abuse, most often of benzodiazepine. Among the patients visited in the psychiatric consultation service, 10.8% of the elderly males and 3.2% of the elderly females were alcohol addicts and 3.9% substance abusers. The frequency of alcohol-induced neuropsychiatric complications, particularly withdrawal delirium and amnestic syndrome, increased with age. Also, benzodiazepine withdrawal delirium most frequently occurred in older patients. These results underscore that, although the prevalence rate seems to be lower than among the younger population, in the elderly population substance abuse still is a relevant medical problem, since the rate of neuropsychiatric complications increased with age.     

Importance of clinical diagnoses for comorbidity studies in substance use disorders

Many clinical and epidemiologic studies have shown a high frequency of co-occurrence of substance abuse and psychiatric disorders, with important consequences from health and social perspective. However, the identification of reliable and valid diagnosis of psychiatric comorbidity in substance abusers is problematic, mainly because the acute or chronic effects of substance abuse can mimic symptoms of many other mental disorders, making difficult to differentiate psychiatric symptoms that represent effects of acute or chronic substance use or withdrawal, of those that represent an independent disorder. While DSM-IIII-R and earlier nomenclatures were unclear in differentiating independent from other psychiatric disorders, DSM-IV and DSM-IV-TR provided clearer guidelines in diagnosing psychiatric disorders in heavy users of alcohol and drugs, providing three categories: "primary" psychiatric disorders, "substance-induced" disorders, and "expected effects" of the substances, meaning expected intoxication and/or withdrawal symptoms that should not be diagnosed as symptoms of a psychiatric disorder. The use of the "Psychiatric Research Interview for Substance and Mental Disorders (PRISM)", a structured interview developed to improve the diagnosis of co morbidity in drug abusers according DSM-IV, supplies new opportunities in the clinical research in this field.     

Factors associated with repeat suicide attempts among adolescents

OBJECTIVE: To determine potential risk factors associated with repeat suicide attempts among adolescents. METHOD: Retrospective medical record review of all patients aged 13-20 years who presented to the emergency department at an inner city tertiary hospital after attempted suicide between 1994 and 1996. Subjects were identified using the International Classification of Diseases (ICD-9) codes E950.0 to E959.9 for attempted suicide. Study variables included demographic parameters, chronic medical conditions/illnesses, psychiatric and substance abuse disorders, history of sexual abuse and previous and subsequent suicide attempts. Variables univariately associated with repetition at p < 0.25 were entered into a multiple regression analysis. RESULTS: Eighty seven per cent of patients presented with a drug overdose. Seventy-six per cent of all subjects attempted suicide in the context of a dispute or relationship break-up. At least one psychiatric disorder was present in 76% of subjects at the index attempt. The most frequently diagnosed disorders were depression (45.5%) and drug (34%) and alcohol abuse (27%). Variables predicting repetition within 12 months were drug (OR = 3.891, p = 0.02) and alcohol abuse (OR = 3.56, p = 0.05), non-affective psychotic disorders (OR = 3.81, p = 0.04), and chronic medical conditions/illness (OR = 3.29, p = 0.03). A history of sexual abuse was almost significant (OR = 3.03, p = 0.06). CONCLUSIONS: Adolescents most likely to re-attempt suicide with 12 months present with either substance abuse, non-affective psychotic disorders, chronic medical conditions, or a history of sexual abuse. All adolescents with a possible suicide attempt should receive a comprehensive mental health and psychosocial assessment. Closer scrutiny of the role of chronic illnesses and sexual abuse in both future research and clinical management is urged. A broad based, multidisciplinary intervention approach is recommended.     

Race and inpatient psychiatric diagnoses among elderly veterans

OBJECTIVE: Limited data exist on differential rates of psychiatric diagnoses between ethnocultural groups in the elderly population. The purpose of this study was to examine more closely the issue of race and rates of psychiatric diagnoses among elderly inpatients. METHODS: The national sample included 23,758 veterans age 60 or over admitted in 1994 to acute inpatient units in Department of Veterans Affairs (VA) hospitals. Psychiatric diagnosis determined inclusion in one of six diagnostic groups: cognitive, mood, psychotic, substance use, anxiety, and other disorders. The study also assessed rates of psychiatric diagnoses among patients admitted to psychiatric units only and by age group and treatment setting, such as the size of the hospital and whether it had an academic affiliation. RESULTS: Compared with elderly Hispanic and Caucasian patients, a significantly higher proportion of elderly African-American patients were diagnosed as having cognitive disorders and substance use disorders, and a significantly lower proportion were diagnosed as having mood and anxiety disorders. Hispanic and African-American patients had significantly higher rates of psychotic diagnoses than Caucasian patients. For all diagnoses except cognitive disorders, these differential rates were also found among patients admitted to psychiatric units only. Age and treatment setting appeared to moderate some of the differences in diagnostic rates, except for mood disorders. In every analysis performed, the rate of mood disorder diagnoses among elderly African-American patients was less than half the rate among elderly Caucasian patients. CONCLUSIONS: The findings suggest that elderly African-American veterans admitted to VA inpatient units have strikingly lower rates of mood disorder diagnoses. Future studies should examine the contribution of both patient and provider factors to these differences.     

Cocaine/"crack" dependence among psychiatric inpatients

The authors studied 40 cocaine-dependent subjects admitted to psychiatric inpatient wards of a metropolitan hospital because of general psychiatric symptoms. The results indicate that the predominant form of cocaine administration (88%) was freebasing "crack." DSM-III-R cluster B personality disorders (N = 17) and schizophrenia (N = 13) constituted the diagnoses for 75% of the sample. Compared to the schizophrenic patients in this cohort, the patients with cluster B personality disorders used cocaine in greater quantities and more frequently and began abuse of the drug at an earlier age. The escalation in urban areas of psychiatric hospitalizations attributed to use of crack may be largely related to psychiatric symptoms in cocaine-dependent patients with personality disorders as well as cocaine-induced psychopathology in schizophrenic patients.     

Differences between early-phase primary psychotic disorders with concurrent substance use and substance-induced psychoses

CONTEXT: The distinction between a substance-induced psychosis and a primary psychotic disorder that co-occurs with the use of alcohol or other drugs is critical for understanding illness course and planning appropriate treatment, yet there has been little study and evaluation of the differences between these 2 diagnostic groups. OBJECTIVE: To identify key demographic, family, and clinical differences in substance-induced psychosis and primary psychotic disorders diagnosed according to DSM-IV criteria using a research diagnostic instrument for psychiatric and substance use comorbidity. DESIGN: Data on demographic, family, and clinical factors were gathered at baseline as part of a 3-year longitudinal study of early-phase psychosis and substance use comorbidity in New York, NY. SETTING: Psychiatric emergency department admissions. PARTICIPANTS: The study is based on a referred sample of 400 subjects interviewed at baseline. Participants had at least 1 psychotic symptom assessed during administration of the research protocol, had used alcohol and/or other drugs within the past 30 days, and had no psychiatric inpatient history before the past 6 months. Subject race included 43.5% black, 42.0% Hispanic, and 14.5% white or other. MAIN OUTCOME MEASURE: Psychotic disorders defined by the DSM-IV. RESULTS: Overall, 169 (44%) were diagnosed as having substance-induced psychosis and 217 (56%), as having primary psychosis. Significant differences were observed in all 3 domains. Multivariate analysis using logistic regression identified the following 3 key predictors as being greater in the substance-induced group: parental substance abuse (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.00-2.85), a diagnosis of dependence on any drug (OR, 9.41; 95% CI, 5.26-16.85), and visual hallucinations (OR, 2.13; 95% CI, 1.10-4.13). The key predictor of total positive and negative symptom score was greater in the primary psychosis group (OR, 0.96; 95% CI, 0.94-0.97). CONCLUSIONS: Differences in demographic, family, and clinical domains confirm substance-induced and primary psychotic disorders as distinct entities. Key predictors could help emergency clinicians to correctly classify early-phase psychotic disorders that co-occur with substance use.     

Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study.

OBJECTIVE: The study examined the association between fidelity of programs to the assertive community treatment model and client outcomes in dual disorders programs. METHODS: Assertive community treatment programs in the New Hampshire dual disorders study were classified as low-fidelity programs (three programs) or high-fidelity programs (four programs) based on extensive longitudinal process data. The study included 87 clients with a dual diagnosis of severe mental illness and a comorbid substance use disorder. Sixty-one clients were in the high-fidelity programs, and 26 were in the low-fidelity programs. Client outcomes were examined in the domains of substance abuse, housing, psychiatric symptoms, functional status, and quality of life, based on interviews conducted every six months for three years. RESULTS: Clients in the high-fidelity assertive community treatment programs showed greater reductions in alcohol and drug use and attained higher rates of remission from substance use disorders than clients in the low-fidelity programs. Clients in high-fidelity programs had higher rates of retention in treatment and fewer hospital admissions than those in low-fidelity programs. No differences between groups were found in length of hospital stays and other residential measures, psychiatric symptoms, family and social relations, satisfaction with services, and overall life satisfaction. CONCLUSIONS: Faithful implementation of, and adherence to, the assertive community treatment model for persons with dual disorders was associated with superior outcomes in the substance use domain. The findings underscore the value of measures of model fidelity, and they suggest that local modifications of the assertive community treatment model or failure to comply with it may jeopardize program success.     

Homeless people at disadvantage in mental health services

OBJECTIVE: The aims of this study are threefold: to depict characteristics of homeless at discharge from a psychiatric hospital; to describe the utilisation of inpatient care and treatment measures during hospitalisation; and to analyse to what extent psychiatric disorders and clinical variables contribute to the risk for homelessness at discharge. METHODS: Based on case register data we analysed all 28,204 people consecutively referred in 1996-2001 to psychiatric hospitals of a well-defined catchment area in Switzerland. RESULTS: 1% (N=269) of all admissions were homeless at discharge (mean age: 32.0 years; women: 27.9 %). Compared to other psychiatric inpatients, we found among the homeless more males, more people with younger age and lower education. Regarding treatment measures during the inpatient stay, homeless received less often psychopharmacotherapy, ergotherapy and physiotherapy, but more vocational training, occupational therapy and support by social workers. There was no difference between homeless and others regarding compulsory medication or seclusion. Homeless had a shorter length of inpatient stay. Risk factors for being homeless at discharge were: being homeless at admission, not living in a relationship, having a multiple substance abuse or a dual diagnosis, low clinical improvement during inpatient treatment and discharge against medical advice. DISCUSSION: To prevent homelessness at discharge, it is important to consider all independent contributors, i. e. the living situation before admission, health care inequalities during inpatient treatment (care received, low clinical improvement, discharge planning) and psychopathology.     

Psychiatric disorders in substance-abusing adolescent inpatients: a pilot study.

In a pilot study of 226 adolescents entering inpatient treatment because of a primary substance use disorder, 82% met DSM-III-R criteria for an Axis I psychiatric disorder. Of this population, 74% had two or more psychiatric disorders. Mood disorders were found in 61%, conduct disorders in 54%, and anxiety disorders in 43%. Substance induced organic mental disorders were found in 16%. The data argue strongly for the simultaneous evaluation of both substance use and psychiatric disorders in this type of adolescent population. The pilot study also demonstrates the relative frequency of dually diagnosed subgroups. The authors propose that the dual diagnosis subgrouping may have specific treatment implications involving a combined psychiatric and substance abuse treatment approach.     

Axis II comorbidity in substance abusers

OBJECTIVE: To assess the complex relationship between substance abuse and personality disorders, the authors determined the prevalence of personality disorders in a group of middle-class substance abusers and compared the subjects who had personality disorders with those who did not. METHOD: The subjects were drawn from patients consecutively admitted to an inpatient substance abuse program in a private psychiatric hospital; they were the first 100 who agreed to participate. Substance dependence was diagnosed according to DSM-III-R, and the patients were assessed with the Structured Clinical Interview for DSM-III-R Personality Disorders, Alcohol Use Inventory, MMPI, Health and Daily Living Form, Shipley Institute of Living Scale, and measures of chemical use and life satisfaction. RESULTS: Of the 100 substance abusers, 57 had personality disorders. These patients differed significantly from the 43 patients without personality disorders in several ways: they had greater involvement with illegal drugs, had different patterns of alcohol use, had greater psychopathology, were less satisfied with their lives, and were more impulsive, isolated, and depressed. CONCLUSIONS: Because of the marked differences between the substance abusers with and without personality disorders, a uniform approach to substance abuse treatment may be inadequate.     

Race, psychiatric diagnosis, and mental health care utilization in older patients.

To evaluate the impact of race on mental health care utilization among older patients within given clinical psychiatric diagnoses, the authors examined a retrospective sample of 23,718 elderly veterans treated in Department of Veterans Affairs inpatient facilities in 1994. Significant racial differences in mental health care utilization found over a subsequent 2-year period were related to outpatient (but not inpatient) care; for instance: 1) African American patients with psychotic disorders had significantly fewer outpatient psychiatric visits; and 2) African American patients with substance abuse disorders had significantly more psychiatric visits than Caucasian patients in their respective groups. Although inpatient utilization appeared to be similar among races, findings related to outpatient utilization may be associated with such factors as compliance, treatment efficacy, access to health care, or possible clinician bias.     

Diagnostic characteristics of inpatients in a Western African psychiatric hospital

Little is known about psychiatric patients and psychiatric service delivery in non-Western developing countries. Therefore, this naturalistic pilot study aimed at analysing and describing the patient population treated in the Tanka Tanka Psychiatric Hospital, the mental health inpatient facility of The Gambia. Most patients were male and exhibited a wide age range of over 40 years. There were also indicators that the hospital population consisted of two distinguished groups: a large group of chronically ill patients and a smaller group of psychiatric patients with very acute symptoms. Psychotic/mood disorders and substance dependence/abuse were the most common diagnoses. In many patients problematic cannabis use was prevalent. Such research can contribute to better understand the needs of psychiatric patients, and help to develop continuously improved service delivery and optimise therapeutic options.     

Heavy cannabis users seeking treatment

AIMS: The aim of this study was to estimate the prevalence of psychiatric disorders among 1439 heavy cannabis users seeking treatment for abuse problems in Denmark. DESIGN: Using two different registers, we compared cannabis users with 9122 abusers of other substances. FINDINGS: (1). Cannabis users were younger and more often males, but otherwise demographic data suggested that the group was as marginalized as users of hard drugs. (2). Additional abuse of other substances was common. (3). Even though cannabis users were generally young, 27.5% had at some point been inpatients at psychiatric hospitals with disorders unrelated to psychoactive substance abuse. (4). Cannabis users had significantly raised levels of depression (p < 0.001) and personality disorders (p < 0.0001) compared with users of other drugs, while the prevalence of schizophrenia was marginally raised (p < 0.05). The results were obtained after adjustment for age, gender and secondary abuse. Analyses were made using logistic regression methods. CONCLUSION: Co-morbid psychiatric disorders are common among heavy cannabis users seeking treatment. Some psychiatric disorders occur more frequently in this group compared with users of other substances.     

Integrated services for treatment of schizophrenic substance abusers: Demographics,symptoms, and substance abuse patterns

We have previously described a model of outpatient integrated treatment for patients with comorbid psychoactive substance use disorders and schizophrenia (PSUD/S)(1). Here we review relevant literature on comorbidity and outline the rationale for integrated services. Further, we describe results from 3 related studies: First, we document the approximate incidence of PSUD among a heterogeneous group of 602 schizophrenic inpatient admissions to our hospital. Second, we describe in greater detail the psychiatric symptoms and patterns of substance abuse among a subsample of 106 inpatients with PSUD/S, contrasting them with 112 patients with PSUD and mixed psychotic disorders, but who are not schizophrenic. Third, we present a prospective research project and describe a sample of 30 patients with PSUD/S, detailing demographic characteristics, psychiatric symptoms and substance abuse history. Attention is given to current issues in the differential diagnosis of patients with PSUD/S using standardized instruments.     

Assessment and treatment of mood disorders in the context of substance abuse

Recognition and management of mood symptoms in individuals using alcohol and/or other drugs represent a daily challenge for clinicians in both inpatient and outpatient treatment settings. Diagnosis of underlying mood disorders in the context of ongoing substance abuse requires careful collection of psychiatric history, and is often critical for optimal treatment planning and outcomes. Failure to recognize major depression or bipolar disorders in these patients can result in increased relapse rates, recurrence of mood episodes, and elevated risk of completed suicide. Over the past decade, epidemiologic research has clarified the prevalence of comorbid mood disorders in substance-dependent individuals, overturning previous assumptions that depression in these patients is simply an artifact of intoxication and/or withdrawal, therefore requiring no treatment. However, our understanding of the bidirectional relationships between mood and substance use disorders in terms of their course(s) of illness and prognoses remains limited. Like-wise, strikingly little treatment research exists to guide clinical decision making in co-occurring mood and substance use disorders, given their high prevalence and public health burden. Here we overview what is known and the salient gaps of knowledge where data might enhance diagnosis and treatment of these complicated patients.