A meta-review of literature reviews assessing the capacity of patients with severe mental disorders to make decisions about their healthcare.

BACKGROUND: Determining the mental capacity of psychiatric patients for making healthcare related decisions is crucial in clinical practice. This meta-review of review articles comprehensively examines the current evidence on the capacity of patients with a mental illness to make medical care decisions. METHODS: Systematic review of review articles following PRISMA recommendations. PubMed, Scopus, CINAHL and PsycInfo were electronically searched up to 31 January 2020. Free text searches and medical subject headings were combined to identify literature reviews and meta-analyses published in English, and summarising studies on the capacity of patients with serious mental illnesses to make healthcare and treatment related decisions, conducted in any clinical setting and with a quantitative synthesis of results. Publications were selected as per inclusion and exclusion criteria. The AMSTAR II tool was used to assess the quality of reviews. RESULTS: Eleven publications were reviewed. Variability on methods across studies makes it difficult to precisely estimate the prevalence of decision-making capacity in patients with mental disorders. Nonetheless, up to three-quarters of psychiatric patients, including individuals with serious illnesses such as schizophrenia or bipolar disorder may have capacity to make medical decisions in the context of their illness. Most evidence comes from studies conducted in the hospital setting; much less information exists on the healthcare decision making capacity of mental disorder patients while in the community. Stable psychiatric and non-psychiatric patients may have a similar capacity to make healthcare related decisions. Patients with a mental illness have capacity to judge risk-reward situations and to adequately decide about the important treatment outcomes. Different symptoms may impair different domains of the decisional capacity of psychotic patients. Decisional capacity impairments in psychotic patients are temporal, identifiable, and responsive to interventions directed towards simplifying information, encouraging training and shared decision making. The publications complied satisfactorily with the AMSTAR II critical domains. CONCLUSIONS: Whilst impairments in decision-making capacity may exist, most patients with a severe mental disorder, such as schizophrenia or bipolar disorder are able to make rational decisions about their healthcare. Best practice strategies should incorporate interventions to help mentally ill patients grow into the voluntary and safe use of medications.

Dual disorder: does expert clinical experience support the rationale for cariprazine use?

Comorbid substance use disorder (SUD) in patients with schizophrenia (dual disorder, DD) is a frequent occurrence in the psychiatric clinical practice and is positively associated with poorer outcomes. Despite a very high co-prevalence, clinical guidelines for SUD and severe mental illnesses tend to give limited consideration to co-existing disorders regarding diagnosis and management. This article is the result of a meeting held in February 2023 to discuss common challenges and best clinical practice initiatives for patients with schizophrenia and DD in different treatment settings. The authors identified issues in the clinical approach to DD in schizophrenia spectrum disorders and suggested the most suitable management based on their experience as a group of experts, identifying possible improvement areas. In conclusion, the panel recommends that individuals with DD should be cared for in a single center. Pharmacologic treatment in individuals with DD needing both control of symptoms related to schizophrenia spectrum disorders and substance withdrawal should ideally be based on using a non-sedative antipsychotic with anti-craving activity.

Clinical guideline for the treatment of dual pathology in the adult population.

Editorial del vol 28-1.

Gender differences in cocaine dependent patients: a 6 month follow-up study.

This 6-month follow-up study compared 64 men and 37 women hospitalized for cocaine dependence. Drug histories, sociodemographic characteristics, psychiatric diagnoses, and Addiction Severity Index (ASI) scores were compared during hospitalization; cocaine use and ASI scores were compared at 6 months. During hospitalization, women had significantly more severe family and social problems; men had more antisocial personality disorder. At follow-up, significantly more women had remained abstinent: family/social problem severity no longer differed. This replicates previous research showing better treatment outcome for cocaine dependent women. This may be related to specific characteristics of women who enter mixed-gender cocaine treatment programs.

The role of personality disorders on drug dependence treatment outcomes following inpatient detoxification.

AIMS: The present 6 month follow-up study was conducted to investigate the possible influence of comorbid personality disorders on drug treatment, as well as associated psychopathology and HIV-related risk behaviors outcomes. SUBJECTS AND METHODS: Data were collected initially from a consecutive sample of 74 patients with a diagnosis of opiate abuse or dependence, admitted for inpatient detoxification. RESULT: During intake, 80.9% of patients reported at least one HIV-related risk behavior in the previous 6 months. Not using condoms during sexual intercourse was the most common and the only risk behavior that showed a statistically significant reduction over the follow-up period. A total of 58.1% of subjects had at least one personality disorder (PD). Borderline PD was the most prevalent. However, antisocial PD was the only PD that influenced substance use outcomes. The presence of this diagnosis increased the chance of worse opiate use outcomes, but decreased likelihood of not using condoms. Patients with low obsessive-compulsive PD dimensional scores showed a significant increase in the number of risk behaviors. However, these influences were only seen at the 3-month follow-up assessment. CONCLUSIONS: These results suggest that personality disorders need to be considered when planning effective interventions for opiate dependent individuals and when preparing and evaluating HIV risk-reduction interventions, particularly for the more severe substance dependent patients.

Bipolar disorder associated to substance use disorders (dual diagnosis). Systematic review of the scientific evidence and expert consensus.

The present work focuses on the so-called dual diagnosis (DD): bipolar disorder (BD) associated with substance use disorders (SUD). Although the psychiatrists who treat patients with BD and physicians in charge of patients with SUD frequently find this association with DD, unfortunately there are few scientific works that have studied this association. The Spanish Working Group on Bipolar Disorders in Dual Diagnosis reviewed the published material using a Medline search and selected the most relevant articles. Following this, the Work Group developed an expert consensus in DD and finally, a survey was performed among a group of experts in this disorder to cover the areas that were not fully addressed by the scientific evidence or in those areas in which the Work Group was unable to reach a consensus. We conclude that, in view of the above, establishment of a consensus is a valid tool to complement the current scientific evidence.

The significance of a coexisting opioid use disorder in cocaine dependence: an empirical study.

This study was undertaken to compare cocaine-dependent patients with and without an opioid use disorder, in an effort to identify important clinical similarities and differences between the two groups. Ninety patients hospitalized for cocaine dependence were divided according to whether or not they had a coexisting opioid use disorder; 32 patients (35.6%) had an opioid diagnosis and 58 (64.4%) did not. The groups were compared on substance use histories, psychopathology, severity of drug-related problems, and 3-months cocaine use outcome. Patients with an opioid diagnosis had more current major depression, antisocial personality disorder, and other substance use disorders. They also had higher medical and drug scores on the Addiction Severity Index, and longer cocaine use histories. Nonetheless, 3-month cocaine use outcome was similar for both groups. Interestingly, patients with an opioid diagnosis engaged in more treatment during the follow-up period. Cocaine-dependent patients with a coexisting opioid use disorder may thus constitute a subgroup with worse prognostic characteristics, for whom differential treatments may improve outcome.

[Depression and cognitive deterioration: a transversal study of comorbidity]. / Depresión y deterioro cognitivo: un estudio transversal de comorbilidad.

This cross-sectional study investigates the relation between a broad category of cognitive impairment and depression in a sample of 654 subjects aged 65 or over. This sample represents 74% of all subjects of that age living in a defined electoral district in North London, UK. The presence of depression and cognitive impairment was ascertained by interviewing all subjects with Short-CARE. Information was collected also for a variety of socto-demographic factors, level of social support and variables of functional limitation (i.e., impairment, disability and handicap). We found a cross-sectional association between depression and cognitive impairment (OR = 3.3; 95% CI: 2.1-3.1). However, when the analysis was adjusted for potential confounders using stratified analysis and logistic regression, we found that variables of functional limitation (especially disability and handicap) acted as confounders of the above association. This confounding effect did not differ significantly across sexes in our study.

What makes alcohol-dependent individuals early in abstinence crave for alcohol: exposure to the drink, images of drinking, or remembrance of drinks past?

Craving is a major factor in addiction, predicting poorer outcome to treatment To improve our understanding of craving for alcohol, we have compared in the laboratory the effects of inducing craving for alcohol by exposure to the sight and the smell of an alcoholic beverage, imagery of craving scripts, and recall of autobiographical memories of craving. We used subjective measures of craving, together with autonomic measures, in 14 abstinent alcohol-dependent individuals in the first month after detoxification. All subjects reported a significant increase in ratings of urges after exposure to alcoholic drinks, following the imagery of craving and after recalling autobiographical memories of craving. Physiological measures have shown that craving imagery as well as memory induction were equally effective as exposure to alcoholic drinks in modestly increasing autonomic arousal (indicated by systolic blood pressure). Our preliminary findings support the existing evidence in nicotine and opiate dependence that images and memories are as effective as in vivo exposure in eliciting craving for drugs.

[Pharmacological treatment of substance dependence from a neuroscientific perspective (II): alcohol, benzodiazepines and nicotine]. / Tratamiento farmacológico de la dependencia de sustancias desde una perspectiva neurocientífica (II): alcohol, benzodiacepinas y nicotina.

The second part of this review deals with those neuroscientific aspects specific to the development and maintenance of dependence of three substances, two legal drugs (alcohol and tobacco) and a group of medications with abuse potential, benzodiazepines. Based on this context, the different pharmacological treatments of alcohol dependence, both related to detoxification and dehabituation, are discussed first. Treatment of the benzodiazepine withdrawal syndrome, together with the most outstanding aspects in the recent literature on relapse prevention, are reviewed. The publications on the treatment of nicotine dependence, both on replacement therapies and on bupropion, are analyzed. Finally, a critical reflection of the sources used to conduct this two-part review is done.

[Heroin prescribing: Is there scientific evidence of its efficacy for the treatment of its dependence?]. / Prescripción médica de heroína: existe evidencia científica de su eficacia en el tratamiento de la dependencia de la misma?

It is in the United Kingdom where medical prescription of opiates has been more widely used. Although these practice had been increasing until the sixties, several factors caused a decreased since then, so that it is currently 1.6% of all maintenance programmes, becoming methadone prescription more important. Mainly through studies conducted in Switzerland, the debate over the appropriateness of this practice. In such studies, it appears that heroin prescription supports important improvements in the patients outcome, as it is associated with better retention rates, a reduction in abuse of illicit substances, and improvements in patients health and social aspects. However, methodological limitations of these studies and ambiguous results of studies carried out in other countries, make it difficult to determine the effectiveness or efficacy of this pharmacotherapy, so that more studies are needed to scientifically justify this practice.

[Pharmacological treatment of substance dependence from a neuroscientific perspective (I): opiates and cocaine]. / Tratamiento farmacológico de la dependencia de sustancias desde una perspectiva neurocientífica (I): opiáceos y cocaína.

In this review paper it is intended to analyze the most recent publications on pharmacological treatment of drug dependences from a neuroscientific perspective. It has been divided into two parts, the first one focuses on the treatment of illegal substance dependence, specifically opiates and cocaine; and the second part deals with the pharmacological treatments of three substances, two legal drugs such as alcohol and tobacco, and a group of medications with abuse potential, benzodiazepines. In this first part the neuroscientific aspects (genetic, neurochemistry, circuits involved, neuroimaging and neuropsychological deficits) relevant to understanding the pharmacological treatment of the main drug addictions are summarized. The pharmacotherapies of opiate dependence, both for detoxification and for dehabituation, are then discussed. Finally, the main medications that have been proposed to treat cocaine dependence are also reviewed.