Dual mental health diagnoses predict the receipt of medication-assisted opioid treatment: Associations moderated by state Medicaid expansion status, race/ethnicity and gender, and year.

BACKGROUND: Mental health diagnoses (MHD) are common among those with opioid use disorders (OUD). Methadone/buprenorphine are effective medication-assisted treatment (MAT) strategies; however, treatment receipt is low among those with dual MHDs. Medicaid expansions have broadly increased access to OUD and mental health services over time, but MAT uptake may vary depending on multiple factors, including MHD status, state Medicaid expansion decisions, and race/ethnicity and gender. Examining clinical and policy approaches to promoting MAT uptake may improve services among marginalized groups. METHODS: MAT treatment discharges were identified using the Treatment Episodes Dataset-Discharges (TEDS-D; 2014-2017) (n = 1,400,808). We used multivariate logistic regression to model MAT receipt using interactions and adjusted for several potential confounders. RESULTS: Nearly one-third of OUD treatment discharges received MAT. Dual MHDs in both expansion and non-expansion states were positively associated with MAT uptake over time. Dual MHDs were negatively associated with MAT receipt only among American Indian/Alaska Native women residing in Medicaid expansion states (aOR = 0.58, 95 % CI = 0.52-0.66, p < 0.0001). CONCLUSION: Disparities in MAT utilization are nuanced and vary widely depending on dual MHD status, Medicaid expansion, and race/ethnicity/gender. Medicaid is beneficial but not a universal treatment panacea. Clinical decisions to initiate MAT are dependent on multiple factors and should be tailored to meet the needs of high-risk, historically disadvantaged clients.

Mental health problems among clients with substance use problems: a nationwide time-trend study.

PURPOSE: Mental health and substance use disorders are notable contributors to the global total burden of disease. On a population level, co-occurring mental health and substance use problems are estimated to account for 2-4%. In clinical samples, estimate is even higher. The aim of this study was to examine changes in recognized mental health problems (MHPs) and in the substance use profiles among clients with substance use problems in Finland. METHODS: Data concerning individuals with substance use entering Finnish social and health care services during 1 day were collected nationwide at three time-points in 2007, 2011, and 2015. Cross-tabulations and logistic regression were used for statistical analysis. RESULTS: Co-occurring MHPs and substance use problems were common: 56-60% of the clients with substance use problems were reported to have had MHPs between the years 2007 and 2015. The proportion of MHPs remained rather stable among them. Substance use profiles have changed: the proportion of illicit drug use among those who had MHPs has increased in health care services, social services, and substance use problem services. CONCLUSION: Co-occurring substance use and MHPs among clients with substance use problems are common, and substance use profile is shifting from using alcohol only towards illicit drug use. This may even bring along more challenges for the treatment system and should be considered in future service planning.

Prediction of psychiatric comorbidity on premature death in a cohort of patients with substance use disorders: a 42-year follow-up.

BACKGROUND: We need to better understand how the use of different substances and psychiatric comorbidity influence premature death generally and cause-specific death by overdose, intoxication and somatic disorders in people with substance use disorders. METHOD: A cohort of 1405 patients consecutively admitted to a Swedish detoxification unit for substance use disorders in 1970-1995 was followed-up for 42 years. Substances were identified by toxicological analyses. Mortality figures were obtained from a national registry. Causes of death were diagnosed by forensic autopsy in 594 patients deceased by 2012. Predictions were calculated by competing risks analysis. RESULTS: Forty-two per cent of the cohort died during follow-up; more men than women (46.3% vs 30.4%). The standardised mortality ratio (SMR) was calculated as the ratio of observed deaths in males and females in specific age groups in the cohort versus expected deaths in corresponding groups in the general population. SMR was 5.68 for men (CI 95%; 5.04-6.11) and 4.98 (CI 95%; 4.08-5.88) for women. The crude mortality rate (number of deaths divided by number of person observation years) was 2.28% for men and 1.87% for women. Opiates predicted increased risk of premature death while amphetamine and cannabis predicted lower risk. Comorbid psychiatric disorders were identified in 378 cases and personality disorders in 763 cases. Primary psychoses or mood/depression and anxiety disorders predicted a higher risk of premature mortality. Death by overdose was predicted by male gender, younger age at admission to substance treatment, opiate use, and comorbid depression and anxiety syndromes. Cannabis and amphetamine use predicted a lower risk of overdose. Death by intoxication was predicted by male gender, use of sedatives/hypnotics or alcohol/mixed substances, primary psychoses and depression/anxiety syndromes. Premature death by somatic disorder was predicted by male gender and alcohol/mixed abuse. CONCLUSION: Psychiatric comorbid disorders were important risk factors for premature drug-related death. Early identification of these factors may be life-saving in the treatment of patients with substance use disorders.

Standardized drug and alcohol questions at admission to an acute adult mental health unit: clarifying the burden of dual diagnoses across a five-year period.

OBJECTIVES: We aimed to report substance use across a five-year period in individuals admitted to an acute mental health unit, utilizing data from a routine clinical measure, diagnoses, and findings related to gender, ethnicity and the implementation of a new dual-diagnosis policy. METHODS: Data was extracted from the electronic records of 2118 individuals who had consecutive admissions to the acute inpatient unit. Analysis focused on demographic and diagnosis variables and the drug and alcohol question in the Health of the Nations Outcome Scale. RESULTS: Some 57.6% of the sample was in the at-risk drug and alcohol category. Male and indigenous inpatients were most at risk. More than 50% of patients with schizophrenia, anxiety and personality disorders were deemed at-risk. Following implementation of the dual-diagnosis policy, recorded primary and secondary substance use disorder (SUD) diagnoses significantly increased. CONCLUSIONS: The study replicated previous findings of a high proportion of patients with co-morbid drug and alcohol use. In this sample it seems likely that the dual-diagnosis policy and related activities increased the rate of SUD diagnoses recorded, although it is likely to still be under-reported.

Dual diagnosis of epilepsy and psychogenic nonepileptic seizures: Systematic review and meta-analysis of frequency, correlates, and outcomes.

Comorbid epilepsy and psychogenic nonepileptic seizures (PNES) represent a serious challenge for the clinicians. However, the frequency, associations, and outcomes of dual diagnosis of epilepsy and PNES are unclear. The aim of the review was to determine the frequency, correlates, and outcomes of a dual diagnosis. A systematic review of all published observational studies (from inception to Dec. 2016) was conducted to determine the frequency, correlates, and outcomes of dual diagnosis. We included studies of individuals of any age reporting a dual diagnosis of epilepsy and PNES. All observational study designs were included with the exception of case reports and case series with fewer than 10 participants. The mean frequency of epilepsy in patients with PNES across all studies was 22% (95% confidence intervals [CI] 20 to 25%, range: 0% to 90%) while the mean frequency of PNES in patients with epilepsy was 12% (95% CI 10 to 14%, range: 1% to 62%). High heterogeneity means that these pooled estimates should be viewed with caution. A number of correlates of dual diagnosis were reported. Some studies delineated differences in semiology of seizures in patients with dual diagnosis vs. PNES or epilepsy only. However, most of the correlates were inconclusive. Only a few studies examined outcome in patients with dual diagnosis. Dual diagnosis is common in clinical practice, especially among patients referred to specialized services, and requires careful diagnosis and management.

Addiction Vulnerability: Exploring Relationships Among Cigarette Smoking, Substance Misuse, and Early Psychosis.

OBJECTIVE: Smoking rates in adolescents at risk for psychosis are significantly greater than in those who are not at risk. Recent research suggests that cigarette smoking in adolescence may be a potential marker of transition to psychosis, although the exact relationship between the two remains unclear. Our aim was to examine whether tobacco smoking is a potential marker of transition to psychosis or subsequent episodes of psychosis, independently of other substance use, or alternatively whether smoking is essentially a general marker of later mental illness episodes. METHODS: This substudy was conducted as part of an audit of a specialized early psychosis community mental health service, the Psychological Assistance Service (PAS). A multilayered audit over 10 years (January 1997 to December 2007) of PAS presentations was conducted (N = 1997), which documented baseline sociodemographic and clinical characteristics and subsequent illness episodes and service usage. Among clients with baseline smoking status information (n = 421, mean age = 18.3 years), this study examined predictors of transition to or subsequent episodes of psychosis, substance misuse, and affective disorder. RESULTS: A recent psychosis episode at baseline and receiving ongoing treatment from PAS predicted transition to or subsequent psychosis episodes; however, baseline ultra-high-risk status was not predictive. In addition, baseline smoking/substance misuse status was a significant predictor, with smokers being twice as likely to experience a subsequent episode of psychosis, even after controlling for other baseline comorbidity. Baseline smoking status also independently predicted subsequent substance misuse episodes, but not subsequent affective disorder. Among clients experiencing post-PAS comorbid substance misuse and psychosis, the majority (80.3%) reported smoking at baseline. CONCLUSIONS: Smoking status at service presentation appeared to function as a general proxy for addiction vulnerability among young help seekers and thereby as a potential marker for the development of severe mental illness (including psychosis) and associated health problems. Routine evaluations of presenting problems need to incorporate comprehensive assessments of early substance misuse and tobacco smoking. Adjunctive lifestyle interventions promoting smoking cessation, physical health, and well-being need to be offered in conjunction with conventional mental health interventions tailored to key presenting problems, recovery, and psychological strengthening.

A systematic review of the prevalence of comorbid mental health disorders in people presenting for substance use treatment in Australia.

ISSUES: The aim of this paper was to conduct a systematic review of the prevalence of comorbid mental health conditions in people accessing treatment for substance use in Australia. APPROACH: A systematic review identified studies meeting the following eligibility criteria: reporting original data published in English; sample presenting for substance use treatment in Australia; assessing the prevalence of mental health and substance use conditions and reporting the percentage of participants with co-occurring mental health and substance use conditions. A narrative analysis was conducted because of the heterogeneity of methods used to assess key outcome variables and small number of studies assessing particular mental health outcomes. The abstracts of 1173 records were screened, and 59 full articles were assessed for eligibility. Eighteen studies were included in the review. KEY FINDINGS: Prevalence estimates of current mental disorders in substance use treatment clients varied (47 to 100%). Mood and anxiety disorders were particularly prevalent, with the prevalence of current depression ranging from 27 to 85% and current generalised anxiety disorder ranging from 1 to 75%. IMPLICATIONS: The high prevalence of mood and anxiety disorders in substance use treatment settings indicates a need for clinicians to screen and assess for these disorders as part of routine clinical care, and be familiar with evidence-based management and treatment strategies. CONCLUSION: Although further studies are required to determine the prevalence of the full range of mental health disorders in this population, these findings emphasise the high prevalence of comorbid mental disorders are among individuals accessing substance use treatment in Australia. [Kingston REF, Marel C, Mills KL. A systematic review of the prevalence of comorbid mental health disorders in people presenting for substance use treatment in Australia. Drug Alcohol Rev 2017;36:527-539].

Outcome of patients with dual diagnosis in secondary psychiatric care.

BACKGROUND: Dual diagnosis (DD) is a common co-morbidity of mental illness and substance use disorder (SUD) and patients with DD are prone to complications. Better knowledge on the outcome, mortality and management of patients with DD in usual secondary psychiatric care would help to inform improved treatment strategies in the future. AIMS: To explore the functional outcome and mortality of patients with DD receiving psychiatric treatment. To assess the recognition of substance use disorders (SUDs) in terms of diagnosis, and the associations of clinically diagnosed SUDs with treatment-related variables. METHODS: The sample of 330 patients was collected by screening all currently treated patients with the Alcohol Use Disorders Identification Test (AUDIT) and a question about other substances used. The inclusion criteria were AUDIT >7 and/or reported use of other substances during the preceding 12 months. The Global Assessment of Functioning scale was used to assess functional outcomes during a 2-year follow-up. Information concerning treatment and patient characteristics was collected retrospectively. RESULTS: Level of functioning remained stable among all study patients during follow-up. The mortality rate was not increased. Effective medication use was associated with improved functional outcomes. SUDs were underdiagnosed. A clinically diagnosed SUD seemed to have an impact on the regularity of appointments and the doses of prescribed medications. CONCLUSIONS: Given our results suggesting a stable level of functioning, patients with DD appear to be well managed within secondary psychiatric care. Attention should be paid to more precise diagnostics of SUDs and to effective use of medication.

Trends in dual diagnosis of severe mental illness and substance use disorders, 1996-2010, Israel.

OBJECTIVES: (1) To examine the trends in the incidence of dual diagnosis (DD) of severe mental illness and substance-related disorders among inpatients in Israel, and (2) the demographic and clinical correlates of DD patients. METHOD: Using data from the National Psychiatric Case Register, we identified 56,774 inpatients aged 15-64 whose first psychiatric hospitalization occurred between 1996 and 2010. We compared the characteristics of inpatients having DD with drugs, alcohol or drug/alcohol abuse with those with mental disorder only. RESULTS: Over the period, DD with drugs decreased from 8.2% in 1996 to 6% in 2010; DD with alcohol increased from 3% to 4% and DD with drugs/alcohol from 2% to 4%. DD with drugs was highest, whereas DD with alcohol was lowest for the youngest age- group in 1996 but increased to the same as other age-groups in 2006-2010. Male gender, a previous suicide attempt, compulsory hospitalizations and marital status were positive predictors for all DD. Immigrant status was a positive predictor of DD with alcohol, but the opposite for DD with drugs; being Jewish and psychotic diagnosis was a positive predictor of DD with drugs, but negative for DD with alcohol. CONCLUSIONS: Over the study period, DD with drugs has decreased among young patients, although it is still higher than among older groups. However, DD with alcohol or drugs/alcohol has increased in the younger group. The clinical-demographic profile of DD patients was similar to that from the relevant literature, except for immigrant status that was negatively associated with DD with drugs.

[Deaths in a Tunisian psychiatric hospital: an eleven-year retrospective study]. / La mortalité à l'hôpital psychiatrique de Tunis : étude rétrospective sur 11ans.

BACKGROUND: Mortality in patients in psychiatric hospitals is reported to be two to three times as high as in the general population. In Tunisia, we do not have any figures on mortality and causes of death in psychiatric inpatients. AIM: The aim of our study was to assess the mortality rate in a psychiatric hospital in comparison to the mortality rate in the general population, to determine the patients' profile, and to identify the causes and risk factors for these deaths. METHODS: We performed a retrospective, descriptive and comparative study. We examined the records of all patients who died during their stay in the different wards of psychiatry at the Razi Hospital in Tunis. We also scrutinized reports of autopsies in the Forensic Medicine unit at Charles-Nicolle Hospital in Tunis over a period of eleven years from January 1st, 2000 to December 31st, 2010. We conducted a descriptive study to calculate the standardized mortality ratio (SMR) aiming to highlight any existing excess mortality among the psychiatric inpatients compared to the general population. This ratio was obtained by dividing the observed number of deaths by the expected number of deaths. In the analytical study, our sample was compared to a control population made-up of randomly selected living patients among those admitted to the Razi hospital in 2010. This study allowed us to investigate the risk factors for premature mortality in psychiatric inpatients. RESULTS: The average rate of mortality was two deaths per 1000 inpatients per year. Twenty-four percent (24%) of deaths involved institutionalized patients. Compared to the general population, premature mortality was noted among patients aged less than 40 (SMR=1.9). The older the patients were, the closer to 1 the SMR was. The average age at death was 51.38 years; 65% of patients were male, 60% had a low socio-economic level, 54% had a comorbid medical condition. Forty-two percent (42%) of deceased patients were diagnosed with schizophrenia with the paranoid form being the most prevalent (44%), 13% had bipolar disorder, 22% had psycho-organic disorders (mental retardation, dementia, delirium). Antipsychotics were the most prescribed psychotropic drugs. High doses were used. Forty percent of cases (40%) consisted of sudden deaths. A cause for death was identified in 80% of cases. In 92% of cases, the death was classified as being "natural". Main causes were respiratory (26%) and cardiovascular (9%). Accidental causes accounted for 8% of deaths. In 20% of cases, the cause remained undetermined. Three factors were identified as independent predictors of mortality among mental patients: age at death (OR=3.9 among patients older than 40), psychiatric diagnosis (OR=2.9 among patients with psychotic or mood disorders compared to other diagnoses) and combination of antipsychotic drugs (OR=6.09 in patients receiving more than two antipsychotics). DISCUSSION: Young psychiatric inpatients seem to be at high risk of premature death: the SMR in our study was 1.9. It ranged between 2.15 and 6.55 in other similar studies. This increased risk mainly concerns non-natural deaths. The leading natural cause of death in our population was represented by thromboembolic accidents. Such a high thromboembolic risk may be explained by the mental illness itself, by physical restraint as well as by antipsychotic treatment. Diagnosing medical conditions in psychiatric patients is often a daunting task: history of the patient is sometimes unreliable and clinical features might be modified by psychotropic agents. Patient-related risk factors for premature death include poor socio-economic level, access-to-care difficulties, positive family and personal history of mental and/or medical disorders, smoking, substance abuse, unhealthy diet and lack of physical activity. Moreover, iatrogenic effects of psychotropic drugs (combination of antipsychotics was more common in deceased patients than in controls) and inadequate medical care in psychiatric hospitals (lack of ECG devices, in particular) partly account for such a high mortality. CONCLUSION: Identifying risk factors for deaths in psychiatric hospitals highlights needed changes in psychiatric management strategies taking into account the patient's characteristics as well as the drugs' safety profile. Further studies with larger samples are needed to better highlight risk factors for premature death in psychiatric inpatients. Identifying such risk factors is necessary to develop efficient preventive strategies.

Drug use disorders and post-traumatic stress disorder over 25 adult years: role of psychopathology in relational networks.

BACKGROUND: In traumatized populations, drug use disorders and post-traumatic stress disorder (PTSD) persist for many years. Relational factors that mediate this persistence have rarely been systematically examined. Our aim is to examine the relative effects of psychopathology in familial and non-familial networks on the persistence of both disorders over adulthood. METHODS: We utilized longitudinal data from an epidemiologically ascertained sample of male Vietnam veterans (n=642). Measures included DSM-IV drug use disorders, other psychiatric disorders, network problem history and time-varying marital and employment characteristics. Longitudinal measures of veterans' psychopathology and social functioning were retrospectively obtained for each year over a 25 year period. We used generalized estimating equations (GEE) to estimate the relative effects of network problems on veteran's drug use disorders and PTSD after adjusting for covariates. RESULTS: Veterans' mean age was 47 years in 1996. Prevalence of illicit drug disorders declined from 29.8% in 1972 to 8.3% in 1996, but PTSD remained at 11.7% from 13.2% in 1972. While 17.0% of veterans reported a familial drug use problem, 24.9% reported a non-familial drug use problem. In full GEE models, a non-familial drug problem was a significant predictor of illicit drug use disorders over 25 years (OR=2.21, CI=1.59-3.09), while both familial depression (OR=1.69, CI=1.07-2.68) and non-familial drinking problem (OR=1.66, CI=1.08-2.54) were significant predictors of PTSD over 25 years. CONCLUSIONS: Familial and non-familial problems in networks differentially affect the persistence of drug use disorders and PTSD in traumatized male adults.

Contribution of psychiatric illness and substance abuse to 30-day readmission risk.

BACKGROUND: Little is known about the contribution of psychiatric illness to medical 30-day readmission risk. OBJECTIVE: To determine the independent contribution of psychiatric illness and substance abuse to all-cause and potentially avoidable 30-day readmissions in medical patients. DESIGN: Retrospective cohort study. SETTING: Patients discharged from the medicine services at a large teaching hospital from July 1, 2009 to June 30, 2010. MEASUREMENTS: The main outcome of interest was 30-day all-cause and potentially avoidable readmissions; the latter determined by a validated algorithm (SQLape) in both bivariate and multivariate analysis. Readmissions were captured at 3 hospitals where the majority of these patients are readmitted. RESULTS: Of 6987 discharged patients, 1260 were readmitted within 30 days (18.0%); 388 readmissions were potentially avoidable (5.6%). In multivariate analysis, 2 or more prescribed outpatient psychiatric medications (odds ratio [OR]: 1.1, 95% confidence interval [CI]: 1.01-1.20) or any prescription of anxiolytics (OR: 1.16, 95% CI: 1.00-1.35) were associated with increased all-cause readmissions, whereas discharge diagnoses of anxiety (OR: 0.82, 95% CI: 0.68-0.99) or substance abuse (OR: 0.80, 96% CI: 0.65-0.99) were associated with fewer all-cause readmissions. These findings were not replicated as predictors of potentially avoidable readmissions; rather, patients with discharge diagnoses of depression (OR: 1.49, 95% CI: 1.09-2.04) and schizophrenia (OR: 2.63, 95% CI: 1.13-6.13) were at highest risk. CONCLUSIONS: Our data suggest that patients treated during a hospitalization for depression and for schizophrenia are at higher risk for potentially avoidable 30-day readmissions, whereas those prescribed more psychiatric medications as outpatients are at increased risk for all-cause readmissions. These populations may represent fruitful targets for interventions to reduce readmission risk.

Trends in rates of mental illness in homicide perpetrators.

BACKGROUND: The rise in homicides by those with serious mental illness is of concern, although this increase may not be continuing. AIMS: To examine rates of mental illness among homicide perpetrators. METHOD: A national consecutive case series of homicide perpetrators in England and Wales from 1997 to 2006. Rates of mental disorder were based on data from psychiatric reports, contact with psychiatric services, diminished responsibility verdict and hospital disposal. RESULTS: Of the 5884 homicides notified to the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness between 1997 and 2006, the number of homicide perpetrators with schizophrenia increased at a rate of 4% per year, those with psychotic symptoms at the time of the offence increased by 6% per year. The number of verdicts of diminished responsibility decreased but no change was found in the number of perpetrators receiving a hospital order disposal. The likeliest explanation for the rise in homicide by people with psychosis is the misuse of drugs and/or alcohol, which our data show increased at a similar magnitude to homicides by those with psychotic symptoms. However, we are unable to demonstrate a causal association. Although the Poisson regression provides evidence of an upward trend in homicide by people with serious mental illness between 1997 and 2006, the number of homicides fell in the final 2 years of data collection, so these findings should be treated with caution. CONCLUSIONS: There appears to be a concomitant increase in drug misuse over the period, which may account for this rise in homicide. However, an increase in the number of people in contact with mental health services may suggest that access to mental health services is improving. Previous studies have used court verdicts such as diminished responsibility as a proxy measure of mental disorder. Our data indicate that this does not reflect accurately the prevalence of mental disorder in this population.

A retrospective review of trends and clinical characteristics of methamphetamine-related acute psychiatric admissions in a South African context.

OBJECTIVE: Epidemiological studies indicate that methamphetamine (MA) abuse poses a major challenge to health in the Western Cape. The objectives of this study were to retrospectively assess the trends, clinical characteristics and treatment demand of MA-related admissions to a psychiatric ward in this region. METHOD: The clinical records of patients admitted to an acute psychiatric admission ward at Tygerberg Hospital from 1 January 2002 to 30 June 2002 and 1 January 2006 to 30 June 2006, were retrospectively reviewed. Admission numbers including those of adolescent and adult substance users were compared for both study periods. Study samples comparing demographic profile, admission status, length of stay, psychopathology, treatment requirements and referral pattern to other disciplines between MA users and non-users were collected for the 2006 period. RESULTS: There was a significant (p <0.01) increase in adolescent substance user admissions between the study periods. A significant (p <0.01) increase in adolescent and adult MA user admissions was also noted. MA users were significantly (p = 0.04) younger than non-MA users, whilst the former presented mainly with psychotic features associated with aggression, requiring involuntary admission of an average of 8 weeks. MA users required significantly (p = 0.007) more benzodiazepines compared to non-MA users. CONCLUSION: Although MA use is relatively recent to the Western Cape, its adverse psychiatric effects and consequences have become a major challenge. These effects in both adolescent and adult patient populations and the associated impact on psychiatric services demand urgent intervention strategies as well as prospective study.

Influence of personality disorder features on social functioning in substance-abusing women five years after compulsive residential treatment.

BACKGROUND: Personality disorders (PD) are related to negative outcome in substance abuse treatment, and in the general population, personality disorders are related to negative outcome in overall functioning. Little is known about the impact of PD on adjustment following substance abuse treatment. METHODS: A cohort of 132 women was followed for 5 years after their index treatment episode in compulsory treatment. During treatment, patients were assessed with the SCID-II. At follow-up, patients were administered a timeline follow-back interview covering their functioning, including employment status over the years, and linked with hospital and criminal justice registers. RESULTS: The impact of PD on functioning varied substantially between disorders and outcome domains. Conduct disorder alone was associated with criminal justice involvement, and conduct disorder and avoidant PD features were associated with unemployment. Dependent PD and obsessive-compulsive personality disorder features were positively associated with employment. Borderline PD features were associated with hospital admissions. DISCUSSION: We discuss how strategies associated with various PDs may foster or hinder social adjustment in general and employment patterns in particular.

Secular trends in first hospitalizations for major mood disorders with comorbid substance use.

In the past half-century, the incidence of major mood disorders reportedly has risen, and onset age, diminished. Substance-use disorders (SUDs) are commonly comorbid with mood disorders and may influence their course and outcome. Since secular relationships of these disorders remain unknown, we evaluated medical records of 421 patients (233 men, 188 women) at first-lifetime admissions for major depression, mania or mixed bipolar episodes at a public hospital in Italy during 1978-2002, updated diagnoses to DSM-IV criteria, and compared selected factors between subjects with vs. without SUDs, seeking evidence of secular trends in SUDs in association with early mood disorders. SUD was diagnosed in 122 patients (29.0%). SUD risk was greatest in young males. Relative risk (RR) of diagnostic association with SUDs ranked: mixed states (RR 1.80), mania (RR 1.06), depression (RR 0.55). Annual rates of comorbid SUD and mood disorders increased continuously over the 25-yr epoch for all substances (r=0.640, p<0.001). Age at onset of illness and at first hospitalization (averaging 36 yr and 38 yr) were unrelated to year of hospitalization in this relatively brief sampling, but patients with SUD were younger at onset and admission, overall. Clinical Global Impression (CGI) ratings of illness severity at hospitalization and discharge were stable across years. These findings indicate a secular increase of comorbid SUD among first admissions for mood disorder, especially in young males, with a parallel increase in the proportion of bipolar disorder diagnoses over the past quarter of a century.

Divalproex sodium in the treatment of adults with bipolar disorder.

Divalproex sodium (Depakote, Abbott Laboratories) is an anticonvulsant with well-established efficacy in the treatment of bipolar I disorder, manic or mixed episode. Over the past 10 years, an increased number of studies indicate that divalproex has a broad spectrum of activity in the treatment of bipolar depression and rapid cycling, psychotic symptoms, impulsive aggression and post-traumatic stress disorder. Newer formulations of divalproex, namely the extended-release formulation, are now available. The improved tolerability and convenience of the once-daily extended-release formulation has a significant potential to improve patient compliance and thus, clinical and functional outcomes. The use of divalproex in the treatment of bipolar and other related psychiatric disorders is reviewed.

Psychiatric comorbidity, continuing care and mutual help as predictors of five-year remission from substance use disorders.

OBJECTIVE: In a cohort of 2,595 male patients in VA intensive treatment programs for substance use disorders (SUD), we tested whether psychiatric comorbidity, outpatient care and mutual help group attendance during the first two follow-up years predicted remission status at Year 5, controlling for covariates. METHOD: Logistic regression modeling of longitudinal data was used to test the hypotheses. RESULTS: Dual diagnosis patients were less likely to be in remission at Year 5 than SUD-only patients. Outpatient care was at best only weakly related to Year 5 remission status. By contrast, mutual help involvement substantially improved the chances of substance use remission at Year 5 for both SUD-only and dual diagnosis patients. Mutual help involvement did not, however, offset the poorer prognosis for dual diagnosis patients. CONCLUSIONS: Because mutual help groups specifically targeted to individuals with comorbid substance use and psychiatric disorders are currently rare, further research is recommended to investigate whether they are more effective than standard SUD mutual help groups in facilitating the recovery of persons with dual diagnoses.