Opioid agonist therapy and mortality among First Nations and other residents with concurrent alcohol use disorder in British Columbia, Canada: A population-based cohort study.

BACKGROUND: Despite the prevalence of alcohol use among people with opioid use disorder (PWOUD) engaged in opioid agonist therapy (OAT), clinical care guidance for concurrent alcohol use disorder (AUD) and OUD is scarce. We assessed the prevalence and risk of mortality for concurrent AUD among PWOUD who accessed OAT in British Columbia (BC). METHODS: Data were obtained from six linked population-level health administrative datasets to identify PWOUD from January 1996 to March 2020. All-cause age and sex standardized mortality ratios (SMR) were calculated to determine the mortality risk by OAT status (on vs. discontinued), stratified by First Nations and other residents with concurrent AUD and OUD. Adjusted risk ratios compared the relative risk of mortality by AUD status (AUD detected vs. not) among First Nations and other residents. RESULTS: We identified 62,110 PWOUD who received OAT, including 6305 (10.2%) First Nations. OAT substantially lowered the SMR among First Nations (SMR=6.6, 95% CI: 5.4-8.1) and other residents (SMR=6.6; 95% CI: 6.2-7.0) with concurrent AUD and OUD, compared to those who discontinued (SMR=22.7, 95% CI: 20.4-25.1, SMR=17.5, 95% CI: 16.8-18.2 respectively). The risk of mortality was 1.9 (95% CI: 1.6-2.2) times higher for First Nations and 2.0 (95% CI: 1.8-2.2) times higher for other residents with concurrent OUD and AUD compared to those without an indication of AUD. CONCLUSIONS: The protective effect of OAT remained despite the presence of a concurrent AUD among both First Nations and other residents with OUD. Findings have implications for clinical care management of concurrent disorders.

Association of clozapine treatment and rate of methamphetamine or amphetamine relapses and abstinence among individuals with concurrent schizophrenia spectrum and amphetamine use disorder: A retrospective cohort study.

BACKGROUND: Preliminary evidence suggest clozapine is associated with more favorable impact on concurrent substance use disorder related outcomes in patients with concurrent schizophrenia spectrum disorders (SSD). At the same time, there is a dearth of evidence with regards to clozapine outcomes in the context of concurrent methamphetamine or amphetamine use disorder (MAUD). AIMS: To examine whether clozapine use decreases rate of methamphetamine or amphetamine (MA) relapses and increases the likelihood of maintaining abstinence from any MA use. METHODS: A descriptive-analytic retrospective cohort study was conducted on individuals with SSD-MAUD in an inpatient provincial treatment and rehabilitation center for concurrent disorders. Antipsychotic exposure was categorized as "on clozapine" or "on other antipsychotic(s)." Data were collected using electronic health records. Logistic regression was used to examine association of clozapine treatment with likelihood of complete abstinence from MA use for the duration of antipsychotic exposure. Negative binomial regression was used to examine association of clozapine treatment with rate of MA relapses for the duration of antipsychotic exposure. RESULTS: The majority of the 87 included patients were male. Ethnicity was diverse, with the largest groups self-identifying as Indigenous and European. Clozapine use was both associated with increased likelihood of maintaining abstinence from MA use (adjusted odds ratio (aOR) = 3.05, 95% confidence intervals (CI) = 1.15-8.1, p = 0.025), and decreased rate of MA relapses (aRR = 0.45, 95% CI = 0.25-0.82, p = 0.009) for the duration of antipsychotic exposure. Co-prescription of psychostimulants was associated with increased rate of MA relapses (aRR = 2.43, 95% CI = 1.16-5.10, p = 0.019). CONCLUSION(S): In this study, clozapine use compared with other antipsychotics in SSD was associated with improved outcomes related to severe concurrent MAUD. Co-prescription of psychostimulant medications was associated with a poor outcome.

Effects of clozapine treatment on the improvement of substance use disorders other than nicotine in individuals with schizophrenia spectrum disorders: A systematic review and meta-analysis.

BACKGROUND: Antipsychotic medications are the mainstay of treatment for schizophrenia and are associated with a reduction in psychiatric hospitalization and overall mortality. Some evidence suggest that antipsychotic medications might have a varying effect on the improvement of comorbid substance use disorders (SUDs), with clozapine showing more favorable outcomes. AIM: We systematically reviewed all available evidence on effects of clozapine on the improvement of SUDs other than nicotine. METHODS: Electronic searches of MEDLINE, Embase, PsycINFO, and CINHAL were conducted up to March 1, 2022. Studies of any methodological design involving two concepts: (1) clozapine and (2) SUD terms (excluding nicotine) were included. For SUD outcomes with three or more comparative studies with available raw data meta-analysis was performed. SUD outcomes not meeting criteria for meta-analysis were described qualitatively. Risk of bias was examined using "Downs and Black," and "Q-Coh" instruments. RESULTS: The majority of individuals in the included 31 studies were male and of European ancestry. Abstinence was the most common outcome. Most of the studies were of low-to-moderate quality, and none of the studies met all the quality criteria. Pooled findings from four observational studies in samples of patients with predominantly comorbid alcohol use disorder showed that clozapine treatment is associated with significantly higher odds of remaining abstinent. In addition clozapine was associated with decreased odds of psychiatric hospitalization in all but one observational study. CONCLUSIONS: Our systematic review and meta-analysis builds upon previous reviews, and it suggests the association of clozapine treatment with significantly higher odds of remaining abstinent from substance use and decreased likelihood of psychiatric hospitalization, compared with continuing treatment with other antipsychotic medications. Still, the validity of this association needs greater exploration and providing recommendations for the utility of clozapine in individuals without treatment-resistant psychosis and comorbid SUDs would be premature.

Key conditions for the successful implementation of evidence-based practice in concurrent disorder nursing care with the ECHO® model: Insights from a mixed-methods study.

Background: People with concurrent mental health and substance use disorders have complex biopsychosocial problems but risk not having their healthcare needs met. Nurses are positioned to meet these needs but often lack training in concurrent disorder management. Extension for Community Healthcare Outcomes (ECHO®, University of New Mexico Health Sciences Center, 2003) is a promising technology-enabled collaborative learning model used to implement evidence-based practice and build capacity among healthcare professionals in managing complex, chronic, health conditions. Objective: To understand how an ECHO program for concurrent disorder management impacts nurses' competency development and clinical practice and uncover key conditions for successful uptake and implementation. Design: A convergent mixed-methods design comprising a quantitative, uncontrolled before-and-after study and a qualitative study using interpretive description methodology. Setting and participants: An ECHO program for concurrent disorder management was implemented in 2018 at a quaternary academic hospital centre in metropolitan Western Canada. All 65 nurses who registered in the program between 2018 and 2020 were invited to participate in the study. Methods: Online surveys completed by the participating nurses (N = 28) were administered at baseline and six and 12 months following entry-to-program to measure changes in nurse-related outcomes. The survey data were analyzed using descriptive statistics and repeated measures analysis. Semi-structured interviews were conducted with a nurse subgroup (n = 10) to explore how they developed and implemented competencies and what factors influenced this process. Interview transcripts were analyzed using inductive thematic analysis. Using the Pillar Integration Process, we analyzed results from both methods to provide a richer understanding of the phenomena. Results: We identified six interrelated key conditions for successful uptake and implementation of evidence-based practice in concurrent disorder nursing care with ECHO: (1) Practice and validation opportunities; (2) Reciprocal and trusting relationships in an interprofessional education context; (3) Peer-to-peer experience sharing; (4) Collaboration with experts; (5) Reinforcement of positive attitudes towards one's professional role; and (6) Organizational support. Conclusions: Outcome measures, perspectives, and experiences collected over 12 months indicated that ECHO contributed to nurses' competency development and, under some conditions, to effective nursing practice changes. Given the challenges in implementing clinical guidelines in concurrent disorder nursing care, our results highlight the importance of understanding the key conditions for successful uptake and implementation. This informs approaches to optimally adapt implementation strategies to the needs and specificities of nurses to obtain impactful and sustainable results.

Perceptions of prevalence, consequences, and strategies for managing contraband substance use in an inpatient concurrent disorders program: A qualitative study of patient perspectives and survey of clinician perspectives.

Objective: Inpatient treatment programs for substance use disorders (SUDs) typically have an abstinence policy for patients, but unsanctioned substance use nonetheless takes place and can have significant negative clinical impacts. The current study sought to understand this problem from a patient perspective and to develop strategies for improved contraband substance management in an inpatient concurrent disorders sample. Methods: First, a qualitative study (n = 10; 60% female) was undertaken to ascertain perceived prevalence, impact, and patient-generated strategies. Second, an anonymous follow-up survey was conducted with unit staff clinicians to evaluate the suggested strategies. Results: Patients reported that contraband substance use was present and had significant negative consequences clinically. Recommendations from patients included more extensive urine drug screening, the use of drug-sniffing dogs, and direct contingencies for contraband use. Nineteen staff competed an anonymous follow-up questionnaire to evaluate the viability of these strategies, revealing variable perceptions of feasibility and effectiveness. Conclusion: These findings emphasize the adverse consequences of contraband substance use in addiction treatment programs and identify patient-preferred strategies for managing this challenge.

Enhancing nurses' capacity to provide concurrent mental health and substance use disorder care: A quasi-experimental intervention study.

BACKGROUND: Patients experiencing concurrent disorders (i.e., co-occurring mental health and substance use disorders) are prevalent in mental health settings and their health and social outcomes are often poor. This reflects persistent stigma as well as inadequate preparatory training or continuing education for healthcare professionals, including nurses. OBJECTIVE: To explore the impacts of the 1-day 'Enhancing Concurrent Disorder Care Intervention' on nurses' and student nurses' capacity to deliver care, grounded in current evidence, to patients with concurrent disorders in inpatient mental health settings. DESIGN: A Quasi-experimental intervention design was used with pre- and postt-test components, guided by the STROBE checklist for observational studies. SETTINGS: Five acute mental health units across two hospitals in British Columbia, Canada, as well as two schools of nursing representing students completing clinical practicum rotations within these settings. PARTICIPANTS: Seventy-six nurses (Registered Nurses and Registered Psychiatric Nurses) and student nurses practicing in inpatient mental health care. METHODS: This educational intervention was informed by a pilot study, which included content validation from international concurrent disorder experts, and further refined through collaborative processes with lived experience and nurse partners. Intervention impacts were examined using online surveys conducted prior to the intervention and within two weeks post-intervention. Surveys assessed knowledge and attitudes about concurrent disorders using a validated instrument and questions developed by the study team. Descriptive statistics alongside paired and independent t-tests and two-way ANOVAs were used to compare survey scores before and after the intervention. RESULTS: Findings indicate that the intervention was effective in improving participants' knowledge and attitudes toward patients with concurrent disorders across participant groups. CONCLUSIONS: Enhancing care and outcomes for patients with concurrent disorders is a global priority. Brief educational interventions aimed at nurses can provide an effective, low-barrier mechanism to address knowledge gaps that contribute to harmful care and adverse outcomes.

Medical Cannabis and Past-Year Cannabis Use Disorder Among Adult Recreational Users in the United States: Results From a Nationally Representative Sample.

Introduction: With the increasing number of cannabis users and more jurisdictions allowing medical cannabis, more evidence-based knowledge about the prevalence of cannabis use disorder (CUD) among medical users is greatly needed. Objectives: To examine and compare the prevalence and severity of CUD and the prevalence of different CUD criteria among two groups: those who combine recreational and medical use vs. those who exclusively use cannabis recreationally. To examine the association between CUD and sociodemographic characteristics, medical conditions, and psychiatric comorbidities between these two groups. Methods: The National Epidemiological Survey on Alcohol and Related Conditions III data were used, a US nationally representative in-person interview of 36,309 adults aged ≥18 years collected in 2012-2013. The statistical examination included proportion comparison hypothesis testing and linear regressions, all using complex survey design analysis procedures. Results: Recreational users who used cannabis also for medical purposes had a higher prevalence of CUD in general, as well as mild and moderate CUD than users who used cannabis only for recreational purposes. CUD is more prevalent in recreational, medical users with the following characteristics: young, male, non-white, living in the Midwest, using a greater amount of cannabis, having a concurrent mental disorder, and had CUD before the past year. Conclusion: Recreational, medical cannabis users have a higher likelihood of having CUD. Although the results should be taken with caution, given the lack of established validity of CUD among medical users, health care professionals who prescribe or recommend the use of cannabis for medical purposes should take this into consideration while evaluating the risks/benefits ratio of cannabis. They need to assess patients' recreational cannabis use, screen for CUD, and educate users about the possible complications caused by cannabis use.

The Utility of Research Domain Criteria in Diagnosis and Management of Dual Disorders: A Mini-Review.

The Research Domain Criteria (RDoC) initiative has been considered a comprehensive alternative classification framework for understanding neuropsychiatric ailments, as opposed to the longstanding, traditional DSM framework. Where the DSM categorizes neuropsychiatric disorders as each being distinct and diagnostically defined by the presence of specified symptoms, RDoC provides a multidimensional conceptualization of psychiatric disorders with neurobiological roots. By taking a multidimensional approach, RDoC overcomes two major constraints of the DSM framework: that is, that the DSM is categorical in its approach to psychiatric disorders to the point of understating the intersectionality between concomitant disorders, and that the DSM focuses mainly on clinical features. RDoC seems to better account for the intersection between dual disorders and considers a range of factors, from the more microscopic (e.g., genetics or molecular functions) to the more macroscopic (e.g., environmental influences). The multidimensional approach of RDoC is particularly appealing in the context of dual disorders. Dual disorders refers to a concurrent psychiatric disorder with an addiction disorder. RDoC accounts for the fact that there is often overlap in symptoms across and bidirectional influence between various disorders. However, to date, there is limited research into the clinical utility of RDoC, and less so in the context of the clinical management of dual disorders. In this Mini-Review, we discuss how RDoC differs from the DSM, what outcomes have been reported in utilizing RDoC clinically, the utility of RDoC for the diagnosis, management, and monitoring of psychopathology, and the limitations of RDoC as well as avenues for future research.

Critical Characteristics of Housing and Housing Supports for Individuals with Concurrent Traumatic Brain Injury and Mental Health and/or Substance Use Challenges: A Qualitative Study.

Traumatic brain injury (TBI) and mental health and/or substance use challenges (MHSU) are commonly co-occurring and prevalent in individuals experiencing homelessness; however, evidence suggests that systems of care are siloed and organized around clinical diagnoses. Research is needed to understand how housing and housing supports are provided to this complex and understudied group in the context of siloed service systems. This study aimed to describe critical characteristics of housing and housing supports for individuals with concurrent TBI and MHSU from the perspectives of service users with TBI and MHSU and housing service providers. Using basic qualitative description, in-depth interviews were conducted with 16 service users and 15 service providers. Data were analyzed using thematic analysis techniques. Themes capture core processes in finding and maintaining housing and the critical housing supports that enabled them: (1) overcoming structural barriers through service coordination, education and awareness raising, and partnerships and collaborations; and (2) enabling engagement in meaningful activity and social connection through creating opportunities, training and skills development, and design of home and neighborhood environments. Implications for practice, including the urgent need for formalized TBI and MHSU education, support for service providers, and potential interventions to further enable core housing processes are discussed.

Posttraumatic Stress Disorder Symptomatology and Substance Use in an Outpatient Concurrent Disorders Sample.

OBJECTIVE: Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) present a complex and often severe clinical presentation within a concurrent disorders context. The objective of this study was to examine associations between PTSD symptoms and SUD outcomes to better understand the clinical phenomenon of comorbid PTSD and SUD. Multivariate statistical methods were used to test the hypothesis that elevated PTSD symptoms, both at the level of global severity and specific PTSD symptom clusters, are associated with greater substance use and related problems. METHODS: Data were collected from an intake assessment battery within a specialized concurrent disorders outpatient service in Hamilton, ON. The sample comprised 326 participants (mean age = 37.19, 45.4% female). Structural equation models examined associations between PTSD and alcohol, cannabis, and substance use frequency and problems, controlling for age and sex. Alcohol was ultimately dropped from the model due to non-significant bivariate associations. RESULTS: Higher global PTSD symptomatology was significantly associated with higher cannabis and other substance use frequency and related problems. Analyses using PTSD cluster scores showed higher scores for alterations in arousal were positively associated with cannabis-related problems, drug-related problems, and cannabis and other substance use frequency. Avoidance was significantly associated with cannabis frequency and cannabis-related problems. In general, effect sizes were small in magnitude, accounting for between 9% and 25% of variance. CONCLUSION: Significant cluster-level associations indicate the importance of specific PTSD symptoms (hyperarousal, avoidance) in relation to substance use when identifying therapeutic targets among individuals presenting with comorbid PTSD-SUD. This multivariate approach provides a higher resolution and potentially more clinically informative representation of the complex clinical presentation of PTSD and SUD in a concurrent disorder population and could guide the development of more effective treatment paths.

Schizoaffective Disorder and Concurrent Rhabdomyolysis.

The authors present a unique case of schizoaffective disorder exacerbation, complicated by substance misuse, rhabdomyolysis, and acute renal injury. The patient had been recently released from jail and was not on any psychiatric medications aside. His family reported bizarre behavior involving the patient spending a significant amount of time in an outdoor hot tub exposed to extreme heat, which the patient justified as necessary to protect him from snakes. The patient was diagnosed with severe dehydration and rhabdomyolysis, both of which were managed by the primary care team in a hospital setting with specialist input from the psychiatry and renal departments. The patient exhibited paranoid ideations toward the medical team and at times was agitated and combative. Resolution of this distrust was pivotal to successful treatment and was made possible through trilateral communication between the patient, the police officers, and medical staff.

Changes in Loss Sensitivity During Treatment in Concurrent Disorders Inpatients: A Computational Model Approach to Assessing Risky Decision-Making.

BACKGROUND: Recent studies have employed computational modeling to characterize deficits in aspects of decision-making not otherwise detected using traditional behavioral task outcomes. While prospect utility-based modeling has shown to differentiate decision-making patterns between users of different drugs, its relevance in the context of treatment has yet to be examined. This study investigated model-based decision-making as it relates to treatment outcome in inpatients with co-occurring mental health and substance use disorders. METHODS: 50 patients (Mage = 38.5, SD = 11.4; 16F) completed the Cambridge Gambling Task (CGT) within 2 weeks of admission (baseline) and 6 months into treatment (follow-up), and 50 controls (Mage = 31.9, SD = 10.0; 25F) completed CGT under a single outpatient session. We evaluated 4 traditional CGT outputs and 5 decisional processes derived from the Cumulative Model. Psychiatric diagnoses and discharge data were retrieved from patient health records. RESULTS: Groups were similar in age, sex, and premorbid IQ. Differences in years of education were included as covariates across all group comparisons. All patients had ≥1 mental health diagnosis, with 80% having >1 substance use disorder. On the CGT, patients showed greater Deliberation Time and Delay Aversion than controls. Estimated model parameters revealed higher Delayed Reward Discounting, and lower Probability Distortion and Loss Sensitivity in patients relative to controls. From baseline to follow-up, patients (n = 24) showed a decrease in model-derived Loss Sensitivity and Color Choice Bias. Lastly, poorer Quality of Decision-Making and Choice Consistency, and greater Color Choice Bias independently predicted higher likelihood of treatment dropout, while none were significant in relation to treatment length of stay. CONCLUSION: This is the first study to assess a computational model of decision-making in the context of treatment for concurrent disorders. Patients were more impulsive and slower to deliberate choice than controls. While both traditional and computational outcomes predicted treatment adherence in patients, findings suggest computational methods are able to capture treatment-sensitive aspects of decision-making not accessible via traditional methods. Further research is needed to confirm findings as well as investigate the relationship between model-based decision-making and post-treatment outcomes.

Leveraging Nurses to Improve Care for Patients with Concurrent Disorders in Inpatient Mental Health Settings: A Scoping Review.

Objective: Several challenges have been identified for patients with concurrent disorders and the providers that care for them, contributing to a pressing need for interventions to improve outcomes, particularly within inpatient mental health settings. Methods: A systematic search of peer-reviewed literature was conducted using four online databases: CINAHL, MEDLINE (Ovid), PsycInfo and Web of Science. Articles were selected based on inclusion criteria and additional articles were identified through hand searches. Study details were charted and qualitative synthesis was conducted. Results: Thirty two articles met inclusion criteria. A substantial focus within the literature was education, with higher levels of education shown to improve healthcare provider attitudes and practices. Within this overarching focus, four themes were identified: 1) education as an intervention to improve attitudes and increase confidence and knowledge; 2) strategies to support practice change, including interventions aimed at clinical leaders and methods to address substance use among inpatients; 3) frameworks to guide care; and 4) opportunities to expand nursing scope of practice. Conclusions: Given the substantial evidence indicating that education improves nurses' knowledge, attitudes and practices, there is great promise in expanding educational intervention opportunities for nurses to improve care and outcomes for patients with concurrent disorders-a priority patient population.

Living With Dual Diagnosis and Homelessness: Marginalized Within a Marginalized Group.

Objective: Concurrent mental and substance use disorders or dual diagnosis are highly prevalent among individuals experiencing homelessness. Studies have indicated that dual diagnosis leads to poorer health outcomes and higher health service utilization among those affected. This study aims to estimate the prevalence of dual diagnoses among homeless populations in British Columbia (BC), Canada, and understand their characteristics and specific factors associated with dual diagnoses. Methods: The BC Health of the Homeless Survey is a cross-sectional study involving the homeless population of three cities in BC. The survey assessed addiction and concurrent disorders with standardized interviews-the Mini-International Neuropsychiatric Interview Plus, the Maudsley Addiction Profile, and the Brief Symptom Inventory-in a sample of 500 individuals who are homeless living in shelters or on the street. We characterized individuals after categorizing them into four groups: those without any current mental disorder, those with substance use disorders only, those with mental disorders only, and those with concurrent substance use and mental disorders. Focusing on the concurrent disorder group, we completed a multivariate analysis comparing individuals with dual diagnosis to those without concurrent disorders. Results: Consistent with previous studies, we found that individuals with dual diagnoses report more severe physical and psychological symptoms. Among the homeless, they were more likely to be Aboriginal and younger and more likely to not make it into a shelter. They also reported substantially more difficulties in getting the health care service that they need. Conclusions: Within this marginalized group, individuals with dual diagnosis were more likely to be from groups considered to be more vulnerable with more complex needs. They were having more problems accessing even basic support, such as shelters and health care. Without a systematic approach in providing appropriate care to individuals with dual diagnosis, the most vulnerable clients are not only the ones likely to suffer the most but also the ones having the most problems meeting their basic needs.

Models of Concurrent Disorder Service: Policy, Coordination, and Access to Care.

Background: Societal capacity to address the service needs of persons with concurrent mental health and substance-use disorders has historically been challenging given a traditionally siloed approach to mental health and substance-use care. As different approaches to care for persons with concurrent disorders emerge, a limited understanding of current models prevails. The goal of this paper is to explore these challenges along with promising models of coordinated care across Canadian provinces. Materials and methods: A scoping review of policies, service coordination and access issues was undertaken involving a review of the formal and gray literature from 2000 to 2018. The scoping review was triangulated by an analysis of provincial auditor general reports. Results: Models of concurrent disorders service were found to have evolved unevenly. Challenges related to the implementation of models of collaborative care and local networks that foster service coordination and policy accountability were found to inhibit integrated care. Conclusion: Emergent models of coordinated care were found to include collaborative care, regional networks with centralized access to care, clinical information-sharing, cross-training, improved scope of care to include psychologists and alignment of physician incentives with patient needs to better support patient care.

A Review of Integrated Care for Concurrent Disorders: Cost Effectiveness and Clinical Outcomes.

Objective: The recognition of concurrent disorders (combined mental health and substance use disorders) has increased substantially over the last three decades, leading to greater numbers of people with these diagnoses and a subsequent greater financial burden on the health care system, yet establishing effective modes of management remains a challenge. Further, there is little evidence on which to base recommendations for a particular mode of health service delivery. This paper will further summarize the existing treatment models for a comprehensive overview. The objectives of this study are to determine whether existing service models are effective in treating combined mental health and substance use disorders and to examine whether an integrated model of service delivery should be recommended to policy makers. The following two research questions are the focus of this paper: (1) Are the existing service models effective at treating mental health and substance use disorders? (2) How are existing service models effective at treating mental health and substance use disorders? Methods: We used various databases to systematically review the effectiveness of service delivery models to treat concurrent disorders. Models were considered effective if they are found to be cost-effective and significantly improve clinical and social outcomes. Results: This systematic review revealed that integrated models of care are more effective than conventional, nonintegrated models. Integrated models demonstrated superiority to standard care models through reductions in substance use disorders and improvement of mental health in patients who had diagnoses of concurrent disorders. Our meta-analysis revealed similar findings, indicating that the integrated model is more cost-effective than standard care. Conclusions: Given the limited number of studies in relation to service delivery for concurrent disorders, it is too early to make a strong evidence-based recommendation to policy makers and service providers as to the superiority of one approach over the others. However, the available evidence suggests that integrated care models for concurrent disorders are the most effective models for patient care. More research is needed, especially around the translation of research findings to policy development and, vice versa, around the translation from the policy level to the patients' level.

Gambling-related cognitive distortions mediate the relationship between depression and disordered gambling severity.

BACKGROUND AND OBJECTIVES: Symptoms of depression are highly prevalent among individuals with gambling disorder, and severity of depression is associated with severity of gambling problem. Yet, little is known about the psychological mechanisms by which symptoms of depression lead to greater gambling severity. In this study, we tested whether cognitive distortions represent one such mechanism, as cognitive distortions are key characteristics in both depression and gambling disorder and have been shown to be associated with gambling severity. METHODS: A mediation model was tested among 345 treatment-seeking individuals with gambling disorder in Sao Paulo, Brazil. The diagnosis of gambling disorder was made using semi-structured clinical interviews and participants completed psychometrically sound self-report measures of depression symptoms (Beck Depression Inventory-I), gambling-related cognitive distortions (Gamblers' Beliefs Questionnaire), and gambling severity (Gambling Symptom Assessment Scale). RESULTS: As hypothesized, increased symptoms of depression were significantly associated with both increased disordered gambling severity and increased gambling-related cognitive distortions. Further, gambling-related cognitive distortions predicted greater disordered gambling severity when controlling for depression symptomology. Results from the bootstrapping method indicated that the relationship between symptoms of depression and increased disordered gambling severity is mediated by gambling-related cognitive distortions. CONCLUSIONS: Consistent with our predictions, gambling-related cognitive distortions mediated the relationship between depression symptoms and gambling severity among a sample of treatment-seeking disordered gamblers. These results suggest that cognitive distortions may be a key intervention target for the treatment of concurrent depression and gambling disorder.

Outcomes of an integrated care pathway for concurrent major depressive and alcohol use disorders: a multisite prospective cohort study.

BACKGROUND: In 2013, an Integrated Care Pathway (ICP) for concurrent Major Depressive (MDD) and Alcohol Use (AUD) Disorders was developed at the Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada. The ICP was further implemented at 8 other clinical sites across Ontario (the DA VINCI Project) in 2015-2017. The goal of this study was to systematically describe and analyze the main clinical outcomes of the project. METHODS: Data on a non-randomized cohort of patients receiving ICP-based treatment were collected prospectively at nine clinical sites in a variety of clinical settings. STATISTICAL METHODS: descriptive statistics, t-test, chi-square, ANOVA, generalized linear models. RESULTS: Two hundred forty-six patients were enrolled, 58.8% males, mean age was 45.6 years, 170 patients received treatment at academic health centres (AHC), 49 - at community hospitals (CH) and 27 - in family health teams (FHT). There were no major differences in anamnestic parameters and depression severity between the three settings, but there were differences in baseline drinking patterns between subgroups (F = 4.271, df = 2, p = 0.015). Overall completion rate was 70.7% with no significant variation between settings (χ2 = 3.35, df = 2, p = 0.19). Treatment duration in AHC was the longest, and completion rates were the highest. There was a statistically significant and clinically meaningful reduction in the number of drinking days per week (1.81, t = 8.78, p < 0.001). The cohort overall demonstrated significant and meaningful reduction in severity of cravings (Penn Alcohol Craving Scale: 4.42, t = 8.63, p < 0.001) and depressive symptoms (Quick Inventory of Depressive Symptomatology: 4.25, t = 11.26, p < 0.001). While some of the baseline patient characteristics and treatment parameters varied between the settings, the variation in clinical outcomes was mostly insignificant, though clinical improvement was more pronounced in academic setting and with individual therapy. CONCLUSIONS: The study demonstrated that ICP is a feasible and effective treatment for concurrent AUD and MDD that delivers meaningful clinical improvement in a variety of settings. A randomized controlled study is needed to properly compare the treatment outcomes between ICP model and treatment as usual and to further explore the role of various factors on treatment outcomes.

Cannabis use, other substance use, and co-occurring mental health concerns among youth presenting for substance use treatment services: Sex and age differences.

Cannabis use among youth is of significant concern given the potential negative health impacts on young people. This study describes the mental health characteristics, cannabis use, and substance use profiles of youth aged 14 to 24 years seen at the Youth Addiction and Concurrent Disorders Service at the Centre for Addiction and Mental Health, through an age and gender lens. Almost all participating youth indicated lifetime cannabis use. Substance use and mental health profiles among those indicating a history of cannabis use differed along sex and age. Male youth were more likely to use cannabis more frequently, while female youth were more likely to use greater variety of substances and display more co-occurring mental health problems. Adolescent problematic substance use tended to co-occur with externalizing problems whereas problematic young adult substance use tended to co-occur with internalizing problems. Implications for the integrated, coordinated care of substance use and mental health concerns, with attention to the unique needs of subgroups of youth, are discussed.

Helping concerned family members of individuals with substance use and concurrent disorders: An evaluation of a family member-oriented treatment program.

There is a growing body of research demonstrating that families of individuals with substance use and concurrent disorders (SUCD) experience a wide range of biopsychosocial problems that significantly impedes their quality of life and health. However, there has been a relative lack of treatment programs primarily focused on improving the well-being and quality of life of these family members. The current study assessed the efficacy of such a program at reducing stress, increasing perceived social support from family and friends, and increasing general, dyadic, and self-rated family functioning within these concerned family members. A sample of 125 family members of individuals with SUCDs was recruited, of which 97 participated in the treatment program and 28 were used as the comparison group. Results indicated that the treatment program significantly reduced stress, increased perceived social support from family and friends, and increased general, dyadic and self-rated family functioning. A perceived personal benefits questionnaire demonstrated that participants had a better understanding of SUCDs, better coping capabilities in regard to emotional difficulties, adopted stronger coping methods, participated in more leisure activities, and improved their relationship with the individual with a SUCD. The results of the current study further demonstrate the need to implement more of these family-member oriented psycho-educational treatment programs.