Training physicians to treat substance use disorders

The importance of training physicians to effectively assess and manage substance use disorders has become increasingly recognized. Studies highlighting the effort to enhance curricula are described and common practices identified. Preferable curricula incorporate interactive teaching methods along with experiential and didactic components. Addiction specialists serve an important role in training programs designed for medical students and residents (ie, role models) and practicing physicians (ie, clinical support). Further integration of online training into current programs may expand and enhance training opportunities.     

Cognitive and Cognitive-Behavioral Therapy for substance abuse disorders

This article describes the current status of Cognitive and Behavioral Therapy as well Relapse Prevention and Coping Skill approaches applied in drug abuse treatments. The objective is show a review about theories and technique used by Cognitive Therapy and others approaches derived that, specifically Relapse Prevention and Coping Skill Treatments. Cognitive and Behavioral Therapy, Coping Skill, and Relapse Prevention are a short-time, goal-oriented and structured treatments. Thus, they assume a posture directive and active. We pointed out some difference between the theories about Cognitive Therapy, Relapse Prevention and Coping Skill. The Cognitive Therapy accentuated the focus in patients thought, feeling and circumstances that get in a dysfunctional behavioral. Relapse Prevention and Coping Skill are based in behavioral theories besides of the Cognitive. We, finally, look forward to introduce the lasted scientific finding to helpful the general psychiatric to improve the assistance in drug abuse treatment.     

How to diagnose and treat limb apraxia

Apraxia is a disorder of higher motor cognition. Deficits in imitating abstract and symbolic gestures as well as deficits in appropriate tool use are common apraxic symptoms which, importantly, cannot be explained by primary sensorimotor deficits alone. In spite of the relevance of apraxia for neurorehabilitation and the individual stroke patient's prognosis, apraxia is to date still too rarely diagnosed and treated. In this review the currently published assessments for the diagnosis of apraxia are evaluated. Based on this, an apraxia screening instrument as well as a diagnostic test for clinical use are recommended. In addition, different published approaches to the therapy for apraxia are described. Although current evidence is scarce, the gesture training suggested by Smania and co-workers can be recommended as a therapy for apraxia, because its effects were shown to extend to activities of daily living and to persist for at least two months after completion of the training. This review aims at directing the clinician's attention to the importance of apraxia. Moreover, it provides the interested reader with instruments for a reliable diagnosis and effective treatment of apraxia. These are also important prerequisites for further research into the neurobiological mechanisms underlying apraxia and the development of new therapy strategies leading to an evidence-based effective treatment of apraxia.     

Youth with substance abuse and comorbid mental health disorders

Patients with co-occurring disorders (CODs) have a substance use disorder (SUD) and at least one other mental health diagnosis. Many patients with a non-SUD mental health diagnosis also have an SUD, whereas most patients with SUDs have other co-occurring psychiatric disorders. Recognition is growing regarding the importance of identifying and treating CODs. This article reviews the magnitude of CODs, theories by which CODs develop, treatment options for CODs (including psychotherapeutic and psychopharmacologic interventions), current treatment initiatives for CODs, and ways to prevent CODs. Although research on CODs is providing direction and hope for treatment, many more questions than answers remain regarding these challenging conditions.     

Comorbidity of substance abuse with other psychiatric disorders

Substance abuse is a frequent comorbid condition with other psychiatric disorders including schizophrenia and depression. These disorders may share a common substrate at the neurotransmitter or neurocircuit level. One candidate is hypofunction of the glutamate system. Several lines of evidence suggest that N-methyl-D-aspartate (NMDA) receptors may hypofunction in schizophrenia. Thus, NMDA receptor antagonists are schizophrenogenic; postmortem and imaging results point to reduced NMDA receptor function in schizophrenic brains; a number of genes that have been linked to schizophrenia code for proteins that influence NMDA function; and there is preliminary evidence that pro-NMDA drugs may be therapeutic in the treatment of schizophrenia. One of the most effective therapeutics for the treatment of substance abuse in schizophrenic people is clozapine, and clozapine may act at the glycine modulatory site to enhance NMDA receptor function. This preliminary line of evidence may link schizophrenia and drug abuse to a common neurochemical base, subnormal NMDA receptor function. People with schizophrenia and drug abusers similarly show deficits in tasks known to be sensitive to ventromedial prefrontal cortical damage, and both groups show decreased activation in the ventral striatum during reward anticipation in functional magnetic resonance imaging studies. These observations implicate common prefrontal cortical-striatal circuits and their modulation by hippocampal projections in schizophrenia and substance abuse. Withdrawal from substance abuse and depression both have been linked to changes in the function of several neurotransmitters including serotonin, dopamine and glutamate. These findings suggest possible common substrates and novel therapeutic approaches. Further studies are needed to fully characterize the neurocircuits and transmitters involved in various psychiatric disorders and their possible common elements in comorbid drug abuse.     

Comorbidity of substance abuse and other psychiatric disorders in adolescents

Psychopathology coexisting with substance abuse in adolescents is often encountered in a variety of clinical settings. Research findings suggest a major role for substance use in the etiology and prognosis of psychiatric disorders such as affective disorders, conduct disorder and antisocial personality disorder, attention-deficit hyperactivity disorder, and anxiety disorders. Psychiatric disorders also appear to have an important role in the etiology of and vulnerability to substance use problems in adolescents. Although the comorbidity of substance abuse and other psychiatric disorders in adolescents is recognized as an important factor in the treatment of adolescents, further research is needed to establish its prevalence, genetics, and clinical implications.     

Treatment of patients with psychiatric and psychoactive substance abuse disorders

The treatment of individuals with coexisting psychoactive substance abuse and severe psychiatric disorders requires an integration of principles from the mental health and chemical dependency fields. The authors outline a conceptual model for treating dually diagnosed patients that consists of four treatment phases--engagement, persuasion, active (or primary) treatment, and relapse prevention. The components of these phases include case management, group therapy, psychopharmacology, toxicologic screening, detoxification, family involvement, and participation in self-help groups. Due to the high morbidity and mortality associated with dual diagnoses, the authors encourage the development, implementation, and scientific evaluation of integrated treatment models targeted toward this population.     

Training non-neurologists to diagnose epilepsy

PurposeNarrowing the epilepsy treatment gap in the world's poorest countries is one of the greatest challenges that the epilepsy community faces. The reliable diagnosis of epilepsy is the first step in this. In well-off countries, doctors, often neurologists, carry this out but this is unrealistic in the developing world where there are often no neurologists, particularly in the rural areas where most people live. Other health professionals therefore need to acquire the skills to diagnose epilepsy.MethodA trainee doctor and a nurse accompanied an experienced neurologist on epilepsy camps in Nepal. Answers to a defined set of about 50 questions were obtained from each patient. The two participants made the diagnosis, of epilepsy or not epilepsy, independently of each other and of the neurologist. Their diagnoses were then compared with those of the neurologist who then explained the reasons for his diagnosis.ResultsAgreement between each participant and the neurologist increased from about 50% at the start to over 90% after 20 patients. In one of the participants a high level of agreement was maintained 12 months later.ConclusionIt is possible to train non-neurologists to diagnose epilepsy like a neurologist after exposure to only 20 patients in the company of that neurologist. This is a way in which experienced neurologists can help narrow the treatment gap in poorer parts of the world.     

Individual vulnerability to substance abuse and affective disorders: Role of early environmental influences

One of the most important questions raised by modern psychiatry and experimental psychopathology is the origin of mental diseases. More concisely, clinical and experimental neurosciences are increasingly concerned with the factors that render one individual more vulnerable than another to a given pathological outcome. Animal models are now available to understand the sources of individual differences for specific phenotypes prone to behavioral disadaptations. Over the last 10 years, we have explored the consequences of environmental perinatal maniqulations in the rat. We have shown that prenatal stress is at the origin of a wide range of physiological and behavioral aberrances such as alterations in the activity of the hormonal stress axis, increased vulnerability to drug of abuse, emotional liability, cognitive impairments and predisposition to pathological aging. Taken together, these abnormalities define a bio-behavioral syndrome. Furthermore, the cognitive disabilities observed in prenatally-stressed rats were recently related to an alteration of neurogenesis in the dentate gyrus, thus confirming the impact of early life events on brain morphology. A second model (handling model) has also been developed in which pups are briefly separated from their mothers during early postnatal life. In contrast with prenatallystressed animals, handled rats exhibited a reduced emotion response when confronted with novel situations and were protected against age-induced impairments of both the hormonal stress axis and cognitive functions.     

Outpatient treatment of patients with substance abuse and coexisting psychiatric disorders

Thirty-two patients with coexisting substance abuse and other psychiatric disorders were treated in a unique outpatient pilot program that used techniques drawn from both psychiatric and substance abuse treatment. Eleven patients remained in treatment for 3 or more months, and seven completed a year or more of treatment. Severity of associated psychiatric illness did not affect retention in treatment. Drug-abusing patients and those with personality disorders dropped out quickly; patients with a history of reliable outpatient treatment involvement tended to remain in treatment. Treatment retention was associated with reduced hospital utilization. The authors suggest guidelines for management of patients with coexisting substance abuse and other psychiatric disorders.     

Consulting for substance abuse: mental disorders among adolescents and their parents

Studies conducted outside of Scandinavia indicate that most adolescents with substance misuse problems suffer from co-morbid mental disorders. The present study assessed the mental health of adolescents seeking help for substance misuse problems in a large Swedish city. Parents' mental health was also examined. The sample included 97 girls with their 90 mothers and 52 fathers, and 81 boys with their 72 mothers and 37 fathers. The adolescents completed a diagnostic interview, either the Kiddie-SADs or the Structured Clinical Interview for DSM-IV (SCID) depending on their age. Their parents underwent diagnostic interviews with the SCID. Ninety per cent of the girls and 81% of the boys met criteria for at least one disorder other than substance misuse, and on average, they suffered from three other disorders, most of which had onset before substance misuse began. Almost 80% of the mothers and 67% of the fathers met criteria for at least one mental disorder other than alcohol and drug-related disorders. The findings concur with those reported from studies conducted in North America. The results suggest that in Sweden mental disorders are not being identified and effectively treated among some children and young adolescents who subsequently abuse alcohol and/or illicit drugs. Adolescents who consult for substance abuse problems require assessments and treatment by mental health professionals.     

Decision making in adolescents with behavior disorders and adults with substance abuse

OBJECTIVE: The study assessed the validity of the Gambling Task as a test of decision-making ability in adolescents and examined whether adolescents with behavior disorders, who are at risk for substance abuse, have deficits in decision making similar to those exhibited by adults with substance abuse. METHOD: Performance on the Gambling Task in two testing sessions separated by 1 week was assessed in 64 12-14-year-old adolescents (31 healthy, 33 with externalizing behavior disorders) and 52 adults (22 healthy, 30 with substance abuse). RESULTS: The healthy adolescents and the healthy adults had similar performance on the Gambling Task. Adolescents with behavior disorders performed more poorly than healthy adolescents, but only in the second testing session. In adults, overall Gambling Task performance did not differ between the healthy and substance abuse groups at either testing session, indicating no difference in learning of decision-making strategies between groups. However, adults with substance abuse performed more poorly than healthy adults during an early stage of the task, when participants presumably begin to understand the rewards and penalties involved in the task but are not yet sure of the actual risk of incurring penalities. CONCLUSIONS: The Gambling Task can be used with adolescents. Testing with the Gambling Task revealed a deficit in decision making in adolescents with behavior disorders, who are at risk for substance abuse. This deficit may represent a vulnerability factor for the development of substance abuse.     

Training child and adolescent psychiatrists to be culturally competent

The changing face of the United States urges the field of child and adolescent psychiatry toward more culturally sensitive care. This article gives a comprehensive review of the history of cultural education, empirical findings that speak to its need, and the challenges that may be faced in the conception and implementation of a cultural competency curriculum. The American Academy of Child and Adolescent Psychiatry's model curriculum is presented to help child and adolescent residency programs design one that is specific to their resources and needs.     

Switching outpatients with bipolar or schizoaffective disorders and substance abuse from their current antipsychotic to aripiprazole

OBJECTIVE: Substance abuse is extremely common in patients with bipolar disorders, although minimal data are available on the treatment of this important clinical population. Aripiprazole is an atypical antipsychotic that is approved for the treatment of mania and that has a novel mechanism of action, acting as a dopamine-2 receptor partial agonist, thereby increasing dopamine release in some parts of the brain and decreasing dopa-mine release in other brain regions. Dopamine release is implicated in substance use, and both dopaminergic agonists and antagonists have been examined for the treatment of substance abuse. To our knowledge, dopa-mine receptor partial agonists have not been investigated for treatment of substance abuse in humans. METHOD: Twenty antipsychotic-treated patients with bipolar or schizoaffective disorder and current substance abuse were switched to open-label aripipra-zole using an overlap and taper method. At baseline, diagnoses were confirmed using the Mini-International Neuropsychiatric Interview based on DSM-IV criteria. Psychiatric symptoms, side effects, and substance use and craving were assessed over 12 weeks. Psychiatric symptoms were assessed with the Hamilton Rating Scale for Depression (HAM-D), Young Mania Rating Scale (YMRS), and Brief Psychiatric Rating Scale (BPRS). Substance craving was assessed with visual analogue scales, and side effects were monitored using the Abnormal Involuntary Movement Scale, Simpson-Angus Scale, Barnes Akathisia Scale, and patient report. Study enrollment was from April 2003 to February 2004. RESULTS: Significant baseline-to-exit improvement in HAM-D (p = .002), YMRS (p = .021), and BPRS (p = .000) scores were observed without a significant change in antipsychotic-induced side effect scales. In 17 participants with current alcohol dependence, significant reductions in dollars spent on alcohol (p = .042) and alcohol craving (p = .003) were found. In 9 participants with cocaine-related disorders, significant reductions in cocaine craving (p = .014), but not use, were found. CONCLUSION: A change to aripiprazole was associated with symptomatic improvement. Limitations of the study include a small sample size, high attrition, and an open-label design. Controlled trials in dual-diagnosis patients are needed to confirm these findings.