Improving the treatment of patients with dual diagnosis in emergency departments.

Dual diagnosis involves the co-occurrence of severe mental illness and substance misuse. Recent guidance has sought to improve the initial identification of dual diagnosis and the ongoing management of patients with confirmed dual diagnoses. However, service provision between mental health teams and emergency departments (EDs) can be disjointed, resulting in suboptimal care. This article explores the care of patients who present at EDs with symptoms arising from a combination of severe mental illness and substance misuse. The author aims to alter the approach of multidisciplinary teams by applying change management theory, resulting in patients being treated by multiple healthcare disciplines in a more coordinated way. This will be demonstrated through a case study that follows a patient with dual diagnosis on the journey through an emergency department. Guidelines identifying best practice will be referred to and care failings in the patient's journey will be analysed. The author also provides an overview of how change management theory can be used to implement a new protocol for managing the treatment of patients with a dual diagnosis.

Evolución del estrés familiar en niños con trastorno por déficit de atención con hiperactividad / Evolution of stress in families of children with attention deficit hyperactivity disorder

Introducción: El objetivo del estudio fue analizar la evolución del estrés en las familias de niños o adolescentes que comienzan tratamiento psicofarmacológico, tras ser diagnosticados de un trastorno por déficit de atención con hiperactividad (TDAH), y la capacidad de detección de este cambio mediante el cuestionario Family Strain Index (FSI). Metodología: Cuarenta y ocho especialistas en psiquiatría infanto-juvenil o neuropediatría incluyeron 429 familias de niños diagnosticados de TDAH, representadas por el padre, la madre o el tutor del niño. En la visita basal, a los 2 y 4 meses, se evaluó la intensidad de los síntomas del TDAH mediante la escala de Conners abreviada, y el estrés familiar mediante el cuestionario FSI. Resultados: Se observó: a) mejoría en la puntuación global del FSI y en todas sus dimensiones (p<0,001); b) mejoría en la intensidad de los síntomas de hiperactividad (Conners, p<0,0001);c) una buena concordancia entre las 2 escalas, a los 2 meses (R-intraclase 0,825, p<0,0001) y a los 4 meses de seguimiento (R-intraclase 0,784, p<0,0001). El 97,9% de los niños (420) recibieron tratamiento con metilfenidato de liberación modificada. Conclusiones: Se observó una correlación significativa entre la evolución positiva de los síntomas de los niños con TDAH y la reducción del estrés familiar evaluado mediante el cuestionario FSI, tras la instauración del tratamiento psicofarmacológico. Este estudio demostró una gran sensibilidad al cambio de la situación clínica de los pacientes con TDAH evaluado a través del estrés producido sobre sus familias. Se recomienda el uso de este cuestionario como medida indirecta de la repercusión del trastorno sobre el entorno del niño con TDAH en términos de estrés familiar (AU)

Introduction. The objective of this study was to assess the evolution of stress in families of children and adolescents who start psychopharmacological treatment after being diagnosed with attention deficit hyperactivity disorder (ADHD), and the ability to detect this change using the FSI (Family Strain Index) questionnaire. Methodology: Forty eight (48) specialists in child-adolescent psychiatry or neuropediatrics included 429 families of children diagnosed with ADHD, represented by the father, mother or guardian of the child. In the baseline visit, and at two and four months, the intensity of the symptoms of ADHD was evaluated using the abbreviated Conners scale, and family stress was evaluated using the FSI questionnaire. Results: The following was observed: a) an improvement in the overall FSI score and in all its dimensions (P<.001); b) an improvement in the intensity of the symptoms of hyperactivity (Conners, P<.0001); c) good agreement between these two scales at two months (R-intraclass 0.825, P<.0001) and at four months of follow-up (R-intraclass 0.784, P<.0001). Ninety seven point nine percent (97.9%) of the children or adolescents (420) received treatment with modified-release methylphenidate. Conclusions: There was a significant relationship between the positive evolution of symptoms in children with ADHD and the reduction of family stress, as evaluated by the FSI questionnaire, after starting psychopharmacological treatment. This study showed a great sensitivity to change in the clinical situation of patients with ADHD, evaluated through the stress it produces on its families. It is recommended to use this questionnaire as an indirect measurement of the repercussions of the disorder on the environment of the child with ADHD in terms of family stress (AU)

Pensamiento constructivo como medida de inteligencia emocional en patología dual / No disponible

Introducción: El objetivo de este estudio es comparar el pensamiento constructivo, una medida de inteligencia emocional, entre una muestra clínica de pacientes adultos diagnosticados de patología dual y una muestra no clínica. Método: Mediante un diseño de investigación comparativo, una muestra no clínica de 835 sujetos se comparó con una muestra de 180 sujetos diagnosticados de patología dual: 78 con trastornos clínicos o del Eje I y102 con trastornos de la personalidad o del Eje II, según criterios DSM-IV-TR. Resultados: Los resultados indican un pensamiento constructivo superior en la muestra no clínica, así como un pensamiento destructivo superior en la muestra con patología dual. No se apreciaron diferencias entre trastornos clínicos y de personalidad. Conclusiones: La muestra clínica presenta un patrón destructivo o desadaptativo de afrontamiento en comparación con población no clínica, que en el caso de pacientes con trastornos de personalidad se ve incrementado por ilusiones, supersticiones y pensamientos esotéricos que contribuyen a su afrontamiento deficitario

Introduction: The objective of this study is to compare the constructive thinking, a measure of emotional intelligence, between a clinical sample of adult patients diagnosed with dual diagnosis and a non-clinical sample. Method: By means of a comparative design of investigation, a not clinical sample of 835 subjects was compared with a sample of 180 subjects diagnosed of dual diagnosis: 78 with clinical disorders or of the Axix I and 102 with disorders of the personality or of the Axis II, according to DSM-TR-IV. Results: The results indicate a constructive thinking greater than in the non-clinical sample, as well as a destructive thinking higher in the sample with dual diagnosis. There were no differences between clinical disorders and personality. Conclusions: The clinic sample presents a destructive pattern of coping or no adaptative compared with non-clinical population, which in the case of patients with personality disorders is increased by illusions and superstitions and esoteric thoughts that contribute to their coping deficit

The Dual Diagnosis Capability of Residential Addiction Treatment centres: priorities and confidence to improve capability following a review process.

INTRODUCTION AND AIMS: The Dual Diagnosis Capability of Addiction Treatment (DDCAT) index is used to assess the capacity of substance abuse services to work with individuals with co-occurring mental health problems. The current study aimed to: (i) examine the dual diagnosis capability of residential substance abuse programs in Australia; (ii) identify managers' perceptions regarding both priorities and confidence for change following the completion of the DDCAT; and (iii) to examine the usefulness of the DDCAT to residential substance abuse programs. DESIGN AND METHODS: The DDCAT was completed across 16 residential substance abuse units. An external researcher administered and scored the DDCAT. A Unit Manager from each site completed the Comorbidity Priorities and Confidence Survey following the completion of the DDCAT review. This survey examined the usefulness of the DDCAT, and the unit's priorities to improve its capability, and confidence to improve its DDCAT score. RESULTS: Across the services, program structure and staff training were the DDCAT domains that required the most improvement. While training was the highest endorsed priority area for improvement, program structure was the lowest priority. Overall the Unit Managers reported positive attitudes towards use of the DDCAT and were confident that their unit could improve their DDCAT scores. DISCUSSION AND CONCLUSIONS: DDCAT scores of Australian residential substance abuse programs are comparable with previous published results. However, there is still substantial work required to improve the capability of these programs. Future research should examine strategies to promote sustained improvements in the capability of residential substance abuse programs.

Measuring money mismanagement among dually diagnosed clients.

Clients dually diagnosed with psychiatric and substance abuse disorders may be adversely affected if they mismanage their Social Security or public support benefits. Assistance managing funds, including assignment of a representative payee, is available but there are no objective assessments of money mismanagement. In this study, a Structured Clinical Interview for Money Mismanagement was administered twice at 1-week intervals to 46 clients receiving disability payments and was compared with clinician's judgment that the client was incapable of managing funds, the frequent basis for payee assignment by the Social Security Administration and Veterans Affairs. Clinician's judgment and structured interview were concordant on 71% of capability judgments. The interview had high test-retest reliability and was correlated with self-reported money mismanagement and global assessment of functioning scale scores, but clinician judgment was not associated with these measures. Results suggest that the interview is sensitive in detecting money mismanagement and raises questions concerning the validity of clinicians' judgments.

How successful is the dual diagnosis good practice guide?

Evidence from the US shows that integrated treatment programmes for dually diagnosed patients are more successful than parallel treatment programmes. In the UK the Dual Diagnosis Good Practice Guide (DDGPG, 2002a), advocates a move towards an integrated system of care delivery. However, the paucity of evidence in the UK and the entrenched nature of the established mental health and addictions services means that current policy is derived from limited information and is struggling to address the process of change. By definition, dual diagnosis is a complex interaction between a range of mental health and substance misuse problems leading to difficulties in allocating appropriate skill mixes to teams. Ethical and legal issues in the mental health services cause conflict with the treatment concepts for substance misuse. The advent of the DDGPG is positive, but there is a clear need for further work in this area.

Defining dual diagnosis of mental illness and substance misuse: some methodological issues.

This paper discusses methodological issues arising in the initial stages of a larger epidemiological case-control study. Practitioners from both Generic Mental Health and Substance Misuse Services (n = 170) were asked to identify which of their clients, from a time-limited caseload (n = 2341), had comorbid mental health and substance misuse problems. Although practitioners were provided with a definition of 'singly diagnosed' and 'dually diagnosed', it became apparent that these definitions were applied pragmatically, depending on the nature of the client's primary problem and the agency they were presenting to. Issues raised include the time period in which a client was considered to have a concurrent mental health problem and substance misuse, how a 'mental health problem' was defined and whether a personality disorder should be categorized as a 'mental health problem'. There was also some disagreement about whether clients who were being treated primarily by Substance Misuse Services, but were also taking prescribed antidepressants, implicitly had a 'mental health problem'. We raise these methodological issues, as they have implications for determining the prevalence of 'dual diagnosis' and the subsequent provision of services.

The co-occurrence of psychiatric and substance use diagnoses in adolescents in different service systems: frequency, recognition, cost, and outcomes.

The frequency, severity, recognition, cost, and outcomes of adolescent substance use comorbidity were analyzed in the Fort Bragg Demonstration Project. Comorbidity was defined as the co-occurrence of substance use disorder (SUD) with other psychiatric diagnosis. The sample consisted of 428 adolescent clients whose providers' diagnoses were compared with research diagnoses. The project identified 59 clients (13.8%) with SUD, all with additional psychiatric diagnoses. Providers recognized only 21 of these 59 comorbid cases. The frequency and severity of comorbidity did not differ between service system samples, although recognition did. Comorbid clients had more behavior problems and more functioning impairment, and their average treatment cost ($29,057) was more than twice as high as that of noncomorbid clients ($13,067). Mental health outcomes were not influenced by type of service system, comorbid diagnosis, or treatment. Screening for and prevention of SUD are discussed as a potential cost-savings opportunity in mental health services.

Psychopathology: description and classification.

DSM-IV's strong empirical base has yielded an instrument with good to excellent reliability and improved validity. Diagnostic reliability depends on both the clarity and validity of diagnostic criteria and the changeability of disorders over time: The reliability of schizophrenic spectrum disorders, personality disorders, and some childhood and adolescent disorders remains problematic. Findings on diagnostic validity appear paradoxical: Attempts to validate schizophrenic spectrum disorders with neurobiological and genetic-familial validators have been only modestly successful, whereas the tripartite personality trait model has differentiated a range of depressive and anxiety disorders. Research on comorbidity has identified several highly comorbid disorders (substance-related disorders, personality disorders, depression, and anxiety) as well as some adverse consequences of comorbidity. The advantages of dimensional approaches to diagnosis have largely been demonstrated conceptually; ultimate conclusions about the strengths and weaknesses of dimensional and syndromal methods await substantial additional empirical research.

A review of comorbidity: major mental illness and problematic substance use.

OBJECTIVE: The aim of this paper is to critically review the literature on major mental illness and problematic substance use in order to provide clinicians and policy-makers with evidence to support proposed directions for management of the above. METHOD: The available literature was accessed using computerised databases and manual searching. RESULTS: The predominantly North American-based literature is largely descriptive. Those studies which attempt empirical evaluation are limited by methodological weaknesses which include small sample sizes, short follow-up periods, inadequate measurement of substance use, lack of experimental design, and treatment drift over time. However, there is consensus among most studies regarding prevalence rates and treatment. CONCLUSIONS: Problematic substance use is the most common comorbid condition among people with a major mental illness and is associated with poorer patient outcomes. There is evidence to suggest that the integration of mental health and drug and alcohol services will result in improved detection, assessment and management of comorbidity. Integration refers to the provision of comprehensive services by a single service with staff who are competent in both mental health and drug and alcohol skills. A tolerant, non-confrontational approach to substance use is most appropriate for people with a major mental illness. Treatment programs need to recognise the longitudinal nature of substance abuse and dependence. More research needs to be conducted in this field in order to establish guidelines for effective management.

Severe mental illness and addictions: assessment considerations.

This article provides a selective overview of the empirical literature on substance use assessment for persons with severe mental illness. We organize the review around key questions related to three assessment goals. With regard to screening, we address what screening tools are appropriate for use in psychiatric settings, and what methodological concerns arise regarding their use in these contexts. With regard to diagnosis, we discuss why diagnosing comorbid disorders is difficult and how clinicians can enhance the reliability and validity of their diagnoses. With regard to the related goals of treatment planning and outcome evaluation, we consider what are appropriate outcome measures, and how assessment information can assist in treatment planning. Finally, we outline three promising directions for future research: (a) evaluating the psychometric properties of established substance-related measures in persons with severe mental illness, (b) identifying the conditions under which self-report information is more or less accurate, and (c) improving the population relevance of substance assessment instruments.

Course and treatment of patients with both substance use and posttraumatic stress disorders.

Posttraumatic stress disorder (PTSD) is a common co-occurring diagnosis in patients with substance use disorders (SUDs). Despite the documented prevalence of this particular "dual diagnosis," relatively little is known about effective treatment for SUD-PTSD patients. This article reviews empirical research on the course and treatment of SUD-PTSD comorbidity and highlights clinically relevant findings. Based on this review, the following is noted: PTSD is highly prevalent in SUD patients, consistently associated with poorer SUD treatment outcomes, and related to distinct barriers to treatment. Specific treatment practices are recommended for substance abuse treatment providers: (a) All patients should be carefully screened and evaluated for trauma and PTSD; (b) referrals should be provided for concurrent treatment of SUD-PTSD, if available, or for psychological counseling with the recommendation that trauma/PTSD be addressed; and (c) increased intensity of SUD treatment should be offered in conjunction with referrals for family treatment and self-help group participation.

Reliability of self-reported antisocial personality disorder symptoms among substance abusers.

It is estimated that from 20 to 60% of substance abusers meet criteria for Antisocial Personality Disorder (APD). An accurate and reliable diagnosis is important because persons meeting criteria for APD, by the nature of their disorder, are less likely to change behaviors and more likely to relapse to both substance abuse and high risk behaviors. To understand more about the reliability of the disorder and symptoms of APD, the Diagnostic Interview Schedule Version III-R (DIS) was administered to 453 substance abusers ascertained from treatment programs and from the general population (St Louis Epidemiological Catchment Area (ECA) follow-up study). Estimates of the 1 week, test-retest reliability for the childhood conduct disorder criterion, the adult antisocial behavior criterion, and APD diagnosis fell in the good agreement range, as measured by kappa. The internal consistency of these DIS symptoms was adequate to acceptable. Individual DIS criteria designed to measure childhood conduct disorder ranged from fair to good for most items; reliability was slightly higher for the adult antisocial behavior symptom items. Finally, self-reported 'liars' were no more unreliable in their reports of their behaviors than 'non-liars'.

Antisocial behavioral syndromes among residential drug abuse treatment clients.

We compared residential addictions treatment clients meeting full criteria for antisocial personality disorder (ASPD+) with those reporting syndromal levels of antisocial behavior only in adulthood (AABS+) on demographics, antisocial symptomatology, drug history, axis I comorbidity and characteristics of index treatment episode. We examined these issues in the sample as a whole, as well as separately in male and female respondents. Among both men and women, ASPD+ initiated their antisocial behavior earlier, met more ASPD criteria and endorsed more violent symptoms, than AABS+. Male ASPD+ also met criteria for more lifetime axis I diagnoses and reported more years of drug involvement than male AABS+. Trends were observed toward poorer retention in treatment among ASPD+ than among AABS+ participants of both genders randomized to a planned duration of 180 days, but retention did not differ between ASPD+ and AABS+ randomized to a planned duration of 90 days. Our findings, which replicate and extend previously published results, carry potential implications for treatment programming and for the nosology of ASPD.

Prediction of 7 months methadone maintenance treatment response by four measures of antisociality.

Zero-order correlational and simultaneous regression analyses were performed to ascertain the comparative validity of four measures of antisociality for predicting the initial 7 months treatment response of 193 male methadone maintenance (MM) patients. Predictor variables were the number of childhood conduct disorder (CD) behaviors, number of adult antisocial personality disorder (A-APD) behaviors, the revised Psychopathy Checklist (PCL-R) score and the revised California Psychological Inventory-Socialization (CPI-So) scale score. The outcome measures were completion/noncompletion of 7 months of treatment, percent positive during-treatment of cocaine, opiate and benzodiazepine urine toxicologies, and change from baseline to 7 months follow-up in seven Addiction severity index (ASI) composite scores (CSs). All four measures of antisociality were significantly correlated with treatment noncompletion, although only the PCL-R score was significant in the predictor model. The PCL-R predicted more positive cocaine urines. At the individual level, both PCL-R and CPI-So were associated with more positive benzodiazepine urines, but neither contributed a significant amount of variance when both were entered in the model. None of the predictors were significantly associated with self reported improvement in the CSs. The PCL-R and CPI-So were more successful in predicting outcomes than the two behavior-based measures.

Substance use among patients with a psychotic disorder in a psychiatric emergency room.

OBJECTIVE: This study used laboratory tests to identify current drug and alcohol users among psychotic patients seeking treatment in an urban psychiatric emergency room. Rates of clinician-suspected use and self-reported use were compared, as were treatment and disposition of users and nonusers. METHODS: Logistic regression modeling was used to identify factors that differentiated current substance users from nonusers in a sample of 112 psychotic patients. RESULTS: Laboratory analyses revealed that 24 of the 112 psychotic patients (21 percent) had used alcohol or an illegal substance before visiting the emergency room. Younger age, male gender, African-American ethnicity, clinician-suspected substance use, and presentation in the emergency room between 7 p.m. and 7 a.m. were associated with a higher likelihood of positive results on the urine test. Only five of the patients who had positive results (21 percent) self-reported substance use. Clinicians suspected that 59 patients (53 percent) were under the influence; however, only 17 of those suspected (29 percent) had positive laboratory results. Patients with positive laboratory results required more intense care in the psychiatric emergency room and were more often hospitalized. CONCLUSIONS: Some demographic and clinical factors were associated with concurrent substance use among psychotic patients in the emergency room. Clinicians' suspicions of use in this sample of psychotic patients lacked specificity due to the fact that potential use was suspected in a large number of cases for which laboratory results were negative. In contrast, self-reported use was uncommon among patients with positive results. Because neither clinician judgment nor patient self-report meaningfully predicts current substance use, routine urine drug screens may be appropriate.

Problems in the recognition and treatment of patients with dual diagnoses.

BACKGROUND: This study was to find if the dually diagnosed in a teaching psychiatric hospital were being adequately identified and treated. METHOD: The records of 200 adult inpatients were reviewed for psychiatric diagnoses, the presence of a history of substance abuse, and the kinds of treatment rendered those patients. RESULTS: Forty-three percent of the patients admitted were found to have a history of substance abuse, but 31.4% of these had a history of substance abuse in the record without a formal diagnosis. Major depression (26.6%) and schizophrenia (18.7%) were the most frequent diagnoses. Half of the patients received no documented treatment for substance abuse. The most common intervention was education by the nursing staff. CONCLUSIONS: There is a clear need for better recognition and treatment of the dually diagnosed patient.

The effect of psychiatric symptoms on the recognition of alcohol disorders in primary care patients.

OBJECTIVE: To determine factors related to physician recognition of alcohol abuse in a primary clinic, specifically factors associated with psychiatric illness. METHOD: Using a cross-sectional study design, we conducted a comprehensive chart review of an existing study sample. A total of 321 systematically sampled patients completed a patient interview. One-hundred-and-one patients scored one or more on the CAGE screening questionnaire for alcohol abuse and were eligible for the medical chart review, which assessed sociodemographic variables, psychiatric and medical diagnoses, alcohol and other substance use, laboratory tests results, and number of patient contacts. RESULTS: 35 percent of the CAGE positive sample had a history of a psychiatric disorder documented in the chart, and an additional 17 percent had symptoms consistent with possible underlying psychopathology. Using multiple logistic regression analysis, the presence of documented psychiatric disorders was not found to be significantly associated with physician recognition (odds ratio = 1.7, 95% confidence interval, 0.5-5.8), relative to patients without these disorders. However, patients who reported psychiatric complaints were significantly more likely to have been recognized by their physicians as having a probable alcohol disorder (odds ratio = 4.4, 95% confidence interval, 1.2-16.2), relative to those without such complaints. Other factors found to be associated with recognition are discussed. CONCLUSIONS: The evidence indicates that a large proportion of alcohol disorders go unrecognized by physicians, however it does not appear that this is due to the misclassification of alcoholism as other psychiatric disorders or symptoms. Additional studies with objective assessment of psychiatric status will be helpful in further investigating this question.