Drafting a dual diagnosis program: a tailored intervention for patients with complex clinical needs

Background: Clinical practice of mental health services changed in 1978 after the Basaglia Law was passed, and it is now characterized by usually voluntary treatments offered by community-based services. That broadened the interventions' focus from the single subject to their environment. Dual diagnosis is defined by WHO as «the co-occurrence in the same individual of a psychoactive substance use disorder and another psychiatric disorder¼. It is considered to be a "border territory" since entails networking between different medical services. Materials and methods: A literature search was performed in PubMed, Web of Science, Scopus and Google Scholar. Search terms were: "guidelines", "treatment", "comorbidity", "substance abuse", "alcohol", "dual-diagnosis", "psychiatric illness", "outpatient", "inpatient", "health care service", "clinical practice". National and regional regulations about health and addiction were screened too. Out of 598 titles, 31 studies were included in this article for their relevance on treatments and networking between services for dual diagnosis cases. Results: There are not any guidelines for clinical practice in the literature, neither there are any shared treatment strategies on a national level. Considering the autonomy that every regional health service has, several different courses of action are possible. Here there are reported the ones available. Conclusions: After discussing the weak points of the treatment options, we suggest the "Multidisciplinary Healthcare" model to best address the difficulties represented by dual diagnosis cases.

Dual diagnosis: an intriguing and actual nosographic issue too long neglected

Background: The term "dual diagnosis" (DD) has been used in clinical practice for years. However, there is confusion about these medical cases, which consist in the presence of both a psychiatric disorder and a substance abuse disorder (in this case, alcohol). There are evidences that in the alcohol use disorder (AUD) population, 50.3% of patients had a psychiatric comorbidity during their lifetime. Nevertheless, to these days there are not any thorough guidelines for the management of these patients. A precise nosography would prevent delay in diagnosis and treatment and all the self-evident negative outcomes of those delays. Materials and methods: A literature search was performed in PubMed, Web of Science, and Scopus, including studies published between 1980 and 2015. Search terms were: "guidelines", "treatment", "comorbidity", "substance abuse", "alcohol", "dual-diagnosis", "etiopathogenesis", "outpatient", "inpatient", "unit", "diagnosis". Out of 1045 titles, 43 studies were included in this article for their relevance on definition and nosography of DD. Results: Taking into account the state of art available in the literature, we contributed to clarify the definition of DD in the alcohol addiction field. Clinical data confirm high prevalence of DD, and allow to better describe and understand the complex relationship between alcohol dependence and other psychiatric diseases. Conclusions: We believe that a clear nosographic framework and a precise diagnostic process are essential for a timely management of every case, using specific guidelines to standardize and improve clinical practice. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which introduces dimensional approach, could be a useful tool to improve diagnostic accuracy.

Pharmacological treatment for dual diagnosis: a literature update and a proposal of intervention

Background: It has long been appreciated that alcohol use disorder (AUD) is associated with increased risk of psychiatric disorder. As well, people with history of mental disorder are more likely to develop lifetime AUD. Nevertheless, the treatment of dual diagnosis (DD) in alcohol addiction still remains a challenge. The efficacy of pharmacological treatment for these patients has been widely investigated with controversial results. Patients with untreated psychiatric disorder are at higher risk to return to drinking and tend to do so more quickly. The aim of this review was to collect clinical data for developing guidelines for the pharmacological treatment of psychiatric diseases in a population with AUD. Materials and methods: A literature review was conducted using the following databases: PubMed-NCBI, Cochrane database, Embase Web of Science, and Scopus, including studies published between 1980 and 2015. Search terms were: "guideline", "treatment", "comorbidity", "substance abuse", "alcohol", "dual-diagnosis", "antidepressant", "antipsychotic", "mood-stabilizer". Out of 1521 titles, 84 studies were included for their relevance on pharmacological treatment of psychiatric disorders in people with AUD. Results: Different drugs were collected in major pharmacological classes (antidepressant, mood-stabilizer, antipsychotic), in order to identify their proved efficacy for treating specific psychiatric disorder in the AUD population. Data were selected and verified for publications from randomized clinical trials, open-label trials and case reports. Conclusions: DD in alcohol dependence is a complex clinical entity, and its high prevalence is supported by epidemiological data. Pharmacological management of psychiatric disorders in patients with AUD remains partially anecdotal. Based on reviewed articles, we propose a classification of psychiatric medications for treatment of mental disorders comorbid with AUD, listed with evidence-based recommendations. More research is needed to obtain and collect clinical data, in order to organize and share evidence-based guidelines.

Adjunctive pregabalin in partial responders with major depressive disorder and residual anxiety.

BACKGROUND: Anxiety symptoms in depression result often in treatment resistance, residual symptoms, and persistent functional impairment. OBJECTIVE: To assess the effectiveness and safety of adjunctive pregabalin to antidepressants for residual anxiety in patients with major depressive disorder (MDD). METHODS: A retrospective chart review was conducted to identify partial responders among patients with MDD with residual anxiety. Twenty such patients (age, 58.4 ± 11.2 years; 15 women; baseline Hamilton Depression Rating Scale [HDRS], 17.1 ± 3.5) who received adjunctive pregabalin for residual anxiety were included. Antidepressants augmented were the selective serotonin reuptake inhibitors (n = 12), mirtazapine (n = 2), and selective serotonin-norepinephrine reuptake inhibitors (n = 6). RESULTS: Twenty patients received at least 4 weeks of pregabalin treatment after 8 weeks of antidepressant therapy. At week 1 (9 weeks after initiating treatment), pregabalin was prescribed at a mean ± SD dose of 71.2 ± 31.7 mg, and the mean maximum pregabalin dose prescribed was 156.2 ± 76.5 mg (range, 75-300 mg). At week 8, there were 13 responders (13/20 [65%]), and 7 of these 13 patients achieved remission (HDRS17 < 8). There were significant decreases in HDRS scores (13.5 ± 3.1 vs 9.1 ± 2.9, P < 0.000), and HDRS anxiety/somatization subscale scores (6.3 ± 2 to 3.6 ± 1.7, P < 0.000). Adverse effects included somnolence (n = 7), weight gain (n = 3), dizziness (n = 4), dry mouth (n = 6), edema (n = 3), blurred vision (n = 3), difficulty with concentration/attention (n = 8), headache (n = 6), and diarrhea (n = 5). CONCLUSIONS: The results suggest a possible augmentation role for pregabalin when used in conjunction with conventional antidepressants for residual anxiety in MDD.

Treatment with ß-blockers and incidence of post-traumatic stress disorder after cardiac surgery: a prospective observational study.

OBJECTIVE: The aim was to investigate perioperative factors associated with the development of post-traumatic stress disorder (PTSD) in patients who underwent cardiac surgery. DESIGN: Prospective observational study. SETTING: Single academic center. PARTICIPANTS: One hundred twenty-eight consecutive patients scheduled for elective cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: Patients were interviewed within the surgical unit 1 to 3 days before cardiac surgery. MEASUREMENTS AND MAIN RESULTS: Six months after surgery, participants were mailed the modified version of the Posttraumatic Stress Symptom Inventory 10. Of the 71 patients who completed the questionnaire and mailed it back at follow-up, 14 (19.7%) received a diagnosis of PTSD. Seven of 13 female patients who were not treated with ß-blockers received a diagnosis of PTSD compared with 0 of 12 who were treated with ß-blockers (p = 0.005, Fisher exact test). In a general linear model, including sex and ß-blocker treatment as predictors, the Posttraumatic Stress Symptom Inventory 10 score was significantly predicted by ß-blockade (F = 4.74, p = 0.033), with a significant interaction between sex and ß-blockade (F = 9.72, p = 0.003). CONCLUSIONS: These findings suggest that the use of ß-blockers might be protective against the development of PTSD in women after cardiac surgery.

[Stress vulnerability and night eating syndrome in the general population]. / Vulnerabilità allo stress e night eating syndrome nella popolazione generale.

AIM: Night Eating Syndrome (NES) is an eating disorder characterized by the clinical features of morning anorexia, evening hyperphagia, and insomnia with awakenings followed by nocturnal food ingestion. The core clinical feature appears to be a delay in the circadian timing of food intake. Energy intake is reduced in the first half of the day and greatly increased in the second half. In particular, NES is clinically relevant because of its association with obesity. The aim of the present study was to determine the vulnerability to develop NES in the general population and to investigate the hypothesized role of acute and chronic stress in the pathogenesis of dysfunctional eating behaviors. METHODS: The Night Eating Questionnaire (NEQ) and the Stress Vulnerability Scale (SVS) have been administered to 531 adults attending the Department of Science of Health at the University of L'Aquila. Socio-demographic and anthropometric features were collected through a specific questionnaire. RESULTS: 9.3% of patients reported evening hyperphagia, while 2.7% reported nocturnal food ingestion. A negative relationship was instead found between NEQ scores and SVS "lack of social support" subscale. CONCLUSIONS: The study confirms the strong association between perceived stress, altered eating behaviors and obesity.