Concomitant Substance Abuse Research Articles

Intravenous Valproic Acid Add-On Therapy in Acute Agitation Adolescents With Suspected Substance Abuse: A Report of Six Cases.

The aim of this study was to test efficacy and safety of intravenous (IV) valproate for aggression in children and adolescents with mood or conduct disorder and concomitant substance abuse. Six patients received a 20 mg/kg dose of IV valproic acid as an add-on therapy to their standard therapy with second-generation antipsychotics and benzodiazepines. Agitation and general psychopathology were measured at baseline and after the first injection using the Modified Overt Aggression Scale, the Brief Psychiatric Rating Scale, and the Children's Global Assessment Scale. The findings suggested that in emergency psychiatry clinical settings, IV valproate was effective in reducing agitation and aggressive behaviors with a good tolerability profile and better treatment compliance.

Opioids in Cancer Pain: Right or Privilege?

Opioid analgesia is a mainstay of the treatment of cancer pain. Treatment of pain in patients with cancer with an ongoing substance abuse disorder can be difficult. We report the ethical challenges of treating a patient with cancer with a concomitant substance abuse disorder in an outpatient palliative care setting. We present an analysis of ethical considerations for the palliative care physician and strategies to aid in the successful treatment of such patients. We argue that there are select patients with cancer for whom exclusion from treatment with opioid therapy is warranted if their health is endangered by prescription of these medications.

Primary psychosis with comorbid drug abuse and drug-induced psychosis: Diagnostic and clinical evolution at follow up.

The study reports a follow-up assessment of 48 patients with concomitant drug abuse at the first admission for psychosis. We focused on the diagnostic distinction between primary psychosis with concomitant drug abuse and drug induced psychosis, to observe whether the diagnoses are stable over time and whether the clinical course significantly differs. The study examined 25 primary psychotic disorder with comorbid drug abuse and 23 drug-induced psychotic disorder patients. Diagnostic and psychopathological assessments were made at baseline and at follow-up. Mean follow-up period was 4.96 years. Patients with comorbid Drug Abuse exhibited higher scores in the item Unusual Content of Thought at baseline than drug-induced psychotic disorder patients: 5.48 vs 4.39 while the two patients groups did not differ in any of the BPRS items evaluated at follow-up. The primary psychosis with comorbid drug abuse and the substance induced psychosis groups were similar regarding diagnostic stability, and a diagnosis of schizophrenia at follow-up occurred similarly. There was no evidence that Drug Induced psychotic patients' symptoms tend to improve more after cessation of drug abuse. An earlier age of onset was found in primary psychotic patients, particularly for patients diagnosed as affected by schizophrenia at follow up. These results might reflect the uncertainty of the distinction between Primary and Drug Induced Psychosis and the difficulties in applying the DSM IV-TR criteria for diagnosing comorbid drug use disorders and psychotic disorders.

Mo1404 - High Prevalence of Concomitant Substance Abuse and Mental Health Disorders in an Urban Underserved FQHC-Based HCV Treatment Program

Mo1404 - High Prevalence of Concomitant Substance Abuse and Mental Health Disorders in an Urban Underserved FQHC-Based HCV Treatment Program

Immunogenicity and safety of a high-dose hepatitis B vaccine among patients receiving methadone maintenance treatment: A randomized, double-blinded, parallel-controlled trial

Background and aimsTo explore whether the immunization with high-dose (60μg) hepatitis B vaccines in patients receiving methadone maintenance treatment (MMT) could yield a superior protection against hepatitis B infection than did the standard dose (20μg). MethodsWe conducted a randomized, double-blinded, parallel-controlled trial in MMT patients. Patients with serologically negative hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (anti-HBs) were randomized in a ratio of 1:1 to receive three intramuscular injections of 20μg or 60μg recombinant hepatitis B vaccine at months 0, 1, and 6. Serum HBsAg and anti-HBs were measured at months 7 and 12 post-vaccination to assess the immunogenicity. ResultsA total of 196 MMT patients were randomized and 195 received at least one injection (98 and 97 in 20 and 60μg vaccine groups, respectively). The 60μg vaccine group showed a seroconversion of anti-HBs of 87.3%, high-level response rate of 56.3%, and GMC of 742.9mIU/mL at month 7. While these results were numerically higher than the 20μg group, a statistical difference was not found. HIV infection and concomitant drug abuse were negatively associated with the robust immune responses. 7.7% of MMT patients receiving at least one dose of vaccine reported solicited adverse reactions within 7days after vaccination, 2.6% reported unsolicited adverse reactions within 28days after vaccination. None of the MMT patients reported serious adverse events or became HBsAg positive during the follow-up. ConclusionsThe three-dose regimen of 60μg recombinant hepatitis B vaccine at months 0, 1, and 6 can yield a similar immunogenicity among MMT patients as compared to the 20μg vaccine.ClinicalTrials.gov identifier: NCT02991599

THU-200 - High prevalence of concomitant substance abuse and mental health disorders in an urban underserved FQHC-based hepatitis C virus treatment program

THU-200 - High prevalence of concomitant substance abuse and mental health disorders in an urban underserved FQHC-based hepatitis C virus treatment program

Smoking-Related Home Oxygen Burn Injuries: Continued Cause for Alarm

Background: Home oxygen therapy is a mainstay of treatment for patients with various cardiopulmonary diseases. In spite of warnings against smoking while using home oxygen, many patients sustain burn injuries. Objectives: We aimed to quantify the morbidity and mortality of such patients admitted to our regional burn unit over a 6-year period. Methods: A retrospective chart review of all patients admitted to a regional burn center from 2008 through 2013 was completed. Admitted patients sustaining burns secondary to smoking while using home oxygen therapy were selected as the study population to determine morbidity. Results: Fifty-five subjects were admitted to the burn unit for smoking-related home oxygen injuries. The age range was 40-84 years. Almost all subjects were on home oxygen for chronic obstructive pulmonary disease (96%). Seventy-two percent of burns involved <5% of the total body surface area, 51% of patients were intubated, and of those 33% had evidence of inhalation injury. The hospital mortality rate was 14.5%. The mean length of hospital stay was 8.6 days, and 54.5% were discharged to a nursing home or another advanced facility. Finally, concomitant substance abuse was found in 27%, and a previous history of injury from smoking while on home oxygen was discovered in 14.5%. Conclusions: This single-center analysis is one of the largest describing burn injuries stemming from smoking while using home oxygen therapy. We identified the morbidity and mortality associated with these injuries. Ongoing education and careful consideration of prescribing home oxygen therapy for known smokers is highly encouraged.

Participating in mobility: People with schizophrenia driving motorized vehicles

Participation of people with schizophrenia in individual mobility is an important aspect of inclusion according to the UN convention of human rights of persons with disabilities. However, driving motorized vehicles can be dangerous due to positive, negative, and cognitive symptoms, side effects of antipsychotic drugs and concomitant substance abuse. The objective of this study was to explore the patterns of individual mobility in a representative patient population, to determine predictors for active use of motorized vehicles, and to compare the results with data of the general population in the respective region. We interviewed N=150 participants with schizophrenia or schizoaffective disorder, 66 in-patients and 84 out-patients, in different types of out-patient services. A questionnaire developed for this purpose was used in interviews. 64% of the participants had a driving licence, 32% had driven a motorized vehicle in the past year, 31% owned a car, 2% a motor bike. The driving licence had been withdrawn from 24.7% of participants, 32.7% reported having been involved in a road accident. Participants drove considerably less in time and distances than the general population. Significant variables determining the chance of active use of motorized vehicles in a logistic regression model were Global Assessment of Functioning (GAF) (OR 1.04 per each point), number of previous admissions (OR 0.52 per admission), and history of driving under alcohol or drugs (OR 0.18).

An Interprofessional Model of Care for the Pregnant Woman with Complex Psychiatric Illness

Poster Presentation Background Caring for a severely ill, suicidal pregnant woman with a history of concomitant drug abuse and violence is uncommon. When caring for such women and their families, diversions from standards of care may occur. Thus, to mitigate the potential challenges for such a woman, an interprofessional approach to care was developed to ensure not only optimal care for the woman and her fetus, but also to provide a safe, therapeutic, working environment for staff. Case In this case, the woman was a homeless, multiparous, 39‐year‐old with a history of drug abuse, severe depression, multiple suicide attempts, and violence. Her obstetric history was significant for a previous term vaginal delivery. She arrived by ambulance at 23 weeks gestation to an obstetric triage setting with bleeding following cocaine use. She admitted the desire to kill herself during this stay. Immediate consultation was obtained from psychiatry, social work, and obstetrics. After a brief in‐patient stay, the woman was discharged to a homeless shelter and given prescriptions for psychiatric medications. As the pregnancy progressed, the woman's mental health deteriorated and violent, psychotic behavior was exhibited. Risk management, hospital security, ethics, and the obstetric care team met to develop a comprehensive plan. These meetings occurred throughout the pregnancy and included updates on condition, delivery, and postpartum planning. The decision to commit the woman involuntarily was made. The woman was scheduled for a term induction of labor and the interprofessional care plan was utilized throughout her stay. She had a normal vaginal delivery and provided skin‐to‐skin care for her healthy infant. A petition was filed for a child abuse and neglect form at the time of birth, which meant the woman would not have custody of the infant. The woman was eventually discharged to her psychiatric facility, and the infant was discharged to care of the maternal grandmother. Discharge to outpatient care occurred at 2 weeks postpartum. A follow up report was obtained of the woman's suicide shortly thereafter. Conclusion Utilizing concepts of ethical and moral care coupled with interprofessional coordination can minimize maternal and neonatal morbidity and provide a safe environment for the woman, family, and the care team. This case illustrates the need for early postpartum follow‐up for women with depression.

Assessment of Substance Abuse On the Course of Somatic Pathology in Patients with Schizophrenia.

Purpose Assess the impact of chemical dependency for a somatic pathology in patients with schizophrenia. Methods During one year, 440 patients admitted to the emergency multi somatic hospital were examined. Inclusion criteria were: age older than 18 years; the presence of “dual” diagnosis; the appropriate category is F2 and F1 ICD-10. Results Patients suffering from schizophrenia spectrum disorders, is 2.0% of all incoming patients in the multi somatic hospital. Almost half of these patients (47.7%) have a concomitant diagnosis of addiction (harmful use or dependence on the different types of substances). A somatic pathologies among patients with schizophrenia who abuse substances is represented by different disorders. Poisoning occurred most frequently (29.3%), slightly less frequent in burns (22.3%) and head injuries (20.3%). Infections were observed in 15.9% of patients, mostly were is socially significant transfusion transmitted infections and tuberculosis. Cardiovascular disease, diabetes, and pathology of the gastrointestinal tract occurred less frequently. Patients with schizophrenia spectrum disorders in conjunction with the substance dependencies often come to the hospital unconscious, significantly longer being treated in the hospital compared with patients with schizophrenia without concomitant substance abuse disorders (low bed/day 12.1 vs 7,2; p Conclusion Substance abuse in patients with schizophrenia spectrum disorders increases the risk of somatic disorders and degrades during somatic disorders.

Subdural Empyema Complicating Bacterial Meningitis: A Challenging Diagnosis in a Patient with Polysubstance Abuse.

Subdural empyema (SDE) and cerebrovascular accident (CVA) are uncommon life-threatening complications of bacterial meningitis, which require urgent neurosurgical intervention to prevent adverse outcomes. Clinicians must be vigilant of the onset of focal neurologic deficits or seizure activity to establish the diagnosis of SDE. Streptococcus pneumoniae accounts for <1% of pyogenic brain abscesses. This case describes a presentation of community acquired pneumococcal pneumonia in which the diagnosis of SDE with vasculitis induced CVA was confounded by concomitant substance abuse and sedation.

No Demonstrable Relationship Was Found between Alcohol Dependence and Concomitant Drug Abuse amongst Detainees in Police Custody in West Yorkshire, England

The behavioural effects of alcohol and drug abuse may lead to arrest by the police. Individuals who abuse one substance may be at risk of developing multiple drug dependencies. Using the forensic records, data were collected on 50 successive subjects detained in police custodies across West Yorkshire, England who had gave history of alcohol addiction to a single practitioner. The degree of correlation between alcohol dependency and illicit drug usage was assessed by calculating the Spearman’s Rank coefficient. Thirty three subjects in this study did not use any illicit drugs. There was no correlation between alcohol dependency and concomitant drug abuse in this group. Spearman’s coefficient was statistically insignificant (p = 0.230). Kruskal’s Gamma, which is used for comparing ordinal data, also failed to show a significant link between the alcohol and drug group (p = 0.185). As the degree of alcohol dependency increased, co-use of other drugs decreased. Conversely as the use of stronger drugs increased, co-use with alcohol and other drugs increased. Alcohol dependency is a distinct disorder. Once alcoholism had set in, the use of other drugs falls. The forensic behavioural patterns linked alcohol with “violent disorder” and Class A drug abuse with “organised crime”. This study does not support the contention that most alcohol dependent individuals will also abuse illicit drugs.

Dual diagnosis vs. triple diagnosis in HIV: A comparative study to evaluate the differences in psychopathology and suicidal risk in HIV positive male subjects

IntroductionThe problem of triple diagnosis of HIV, substance abuse and psychiatric disorders is a complex one with difficult solutions. HIV disease progression is affected by substance use as well as psychiatric illness burden due to both direct as well as indirect factors. Continuing substance abuse with poor drug adherence coexists with psychiatric disorders leading to increased morbidity and mortality. MethodA total of 100 HIV positive subjects comprising of two groups each having 50 subjects with and without substance abuse were assessed using detailed history, mental state examination, WHO schedule for clinical assessment in neuropsychiatry (SCAN 2.0) and Beck's Scale for Suicidal Ideation (BSS). Statistical analysis used Chi-Square test, Fischer's exact test, Student's t-test, Pearson's correlation coefficient, univariate and multiple regression analysis, univariate and multiple logistic regression analysis. p-Value<0.05 was considered to denote statistical significance. ResultsSubjects with substance use disorder had higher rates of psychiatric morbidity (52% vs. 24%, 95% CI=0.5200, p<0.05). The rate of antiretroviral therapy default was almost double in subjects with substance abuse, as compared to subjects without substance use. Suicidal risk was significantly increased (p<0.05) in subjects with co-morbid medical disorders but substance abuse did not increase the risk. ConclusionSubstance abuse inflicts a much greater burden on HIV positive individuals as compared to subjects without substance use. Concomitant substance abuse resulted in significantly increased duration of illness and psychiatric morbidity.

Editorial Commentary: A Tale of 2 Realities: What Are the Challenges and Solutions to Improving Engagement in HIV Care?

“It was the best of times, it was the worstof times . . . we had everything before us,we had nothing before us....” [1]. Inshort, the period Charles Dickens de-scribed is reminiscent of the current stateof the human immunodeficiency virus(HIV) epidemic in the United States andthroughout the world. There is now con-crete evidence that, as never before, weare in the “best of times” for the HIVepi-demic. Over the past 2 decades, dramaticimprovements in HIV treatment have ledto significant declines in HIV-relatedmortality in the United States, from apeak of 50876 deaths in 1995 to 8369 in2010 [2].Globally, the scale-up of antire-troviral therapy (ART) has led to similarreductions in mortality [3]. Finally, therecognition that suppression of HIV rep-lication to below the limit of detectionwith ART reduces the risk of HIV trans-mission by nearly 100% [4] provides aroadmap to effective control of the epi-demic. However, approximately 20% ofAmericans and close to 50% of the globalpopulation who are infected with HIV donot know their status. Moreover, themajority of those diagnosed with HIVare not engaged in care [5]. Despite datademonstrating that “treatment is preven-tion,” there continue to be about 50000new infections per year in the UnitedStates and >2 million globally with evi-dence of increasing incidence amongmen who have sex with men in thiscountry, suggesting that enormous chal-lenges remain ahead and that it may benaive or at least premature to be talkingabout the “End of AIDS” [6]. In fact, thismay be the “worst of times” for ultimateepidemic control.In an article by Mugavero et al, pub-lished in this issue of Clinical InfectiousDiseases [7], the authors review thecurrent state of engagement in care inthe United States, propose existingevidence-based interventions to improvecare outcomes, and call for increasing theresearch agenda to study strategies toimprove linkage, engagement, and reten-tion in care. There is a wide array ofreasons why some HIV-infected patientsare not effectively linked or retained intocare, ranging from untreated depressionto unstable living conditions, to stigma,to active substance abuse. Because theUS epidemic disproportionately affectspeople of color, structural issues, such asperceived racism and medical mistrust ofhealthcare providers, may also impairoptimal linkage and retention in care.There is an increasing array of evidence-based interventions that can result inimproved clinical outcomes, rangingfrom case management that links peopleinto care after diagnosis [8], to improvedscreening for the diagnosis and treatmentof concomitant mental health and sub-stance abuse conditions [9], to the useof peer health system navigators thatassist patients to efficiently access neededservices [10].The Mugavero paper is particularlytimely as we are currently at a criticaljuncture in healthcare in the UnitedStates that may create a perfect storm forpatients with HIV. At a time of increas-ing hope, we are also facing a healthcaresystem with decreasing resources. In thecurrent fiscal environment, the congres-sional sequestration has already impactedmany programs through its automatic5.1% cuts in funding, translating intoabout 424000 fewer HIV tests that theCenters for Disease Control and Preven-tion can provide to health departmentsandcommunity-basedorganizationscom-pared to prior years and 7400 peoplenotbeingabletoaccessantiretroviralmed-ication through the federal AIDS DrugAssistance Program. Medicaid expansion,critical forprovidingcare for those most atneed as part of the Affordable Care Act(ACA), is opposed by governors and/orlegislatures in some of the most affectedstates in the southern United States [ 11].These are only a few examples of theimpact of sequestration. Furthermore,although full implementation of the ACA

Treatment Resistant Depression: A Roadmap for Effective Care

Back to table of contents Previous article Next article Book ReviewsFull AccessTreatment Resistant Depression: A Roadmap for Effective CareElizabeth A. Jensen, M.D., Ph.D.Elizabeth A. JensenSearch for more papers by this author, M.D., Ph.D.Published Online:1 Aug 2012https://doi.org/10.1176/appi.ps.20120p837AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Treatment Resistant Depression: A Roadmap for Effective CareGredenJohn F.M.D.RibaMichelle B.M.D., M.S. and McInnisMelvin G.M.D.; Washington, D.C., American Psychiatric Publishing, 2011, 364 pages, $69The book Treatment Resistant Depression: A Roadmap for Effective Care was edited by three experts from the University of Michigan's Comprehensive Depression Center. It aims to summarize and educate on recent advances in treatment-resistant depression. In many ways, it is a continuation of Treatment of Recurrent Depression, edited by Greden in 2001. Both books call for advancements in research to address the disability and cost burdens associated with depression, particularly over the course of a lifetime of intermittently treated symptoms. Treatment-resistant depression is defined as “failure to achieve remission after two evidence-based antidepressant treatment courses known to have been of acceptable dose and duration.” The book suggests that rapid recognition and assertive treatment earlier in the disease, rather than later, are critical in managing depressive symptoms. There is a focus on chronicity of illness and on self-management of depressive symptoms.Several authors with years of expertise in treating mood disorders contribute chapters on various topics, including pharmacotherapy for depression, psychotherapy for depression, approaches to sleep hygiene, nutrition, concomitant substance abuse, and medical comorbidities. Treatment-resistant depression is examined in multiple populations, with separate chapters devoted to adolescents, college students, pregnant women, and the geriatric population. Each chapter is written by a different set of authors with different styles, leading to a mosaic of topics. For the most part, the book maintains its focus in proposing multiple treatment modalities in different populations. However, the chapter on the medical care model for bipolar disorder is discontinuous with the treatment-resistant depression theme and would have been better placed in a separate volume.Given that the authors originate from the University of Michigan, a strong research university and authority on electroconvulsive therapy (ECT), there is a heavy focus on evidence-based medicine guided by research, as well as a chapter containing detailed information on the use of ECT and neuromodulation to treat depression. There is a well-written chapter on psychotherapy, but in the context of the book as a whole, this approach is underemphasized. There is an interesting and informative chapter on the role of peer support and community resources for individuals suffering from depression and a concise and easily understandable chapter focusing on the genetics of mood disorders—an important area of development in depression research. The book is well referenced and has a comprehensive and organized index.The book is complete and accurate; however, it is rather dry and not stimulating to read. Instead of feeling motivated to use these treatment algorithms, I quietly filed away the information and looked forward to the next vignette. The case vignettes are very enlightening, and I would have liked to see more of these. The Key Clinical Concepts sections are useful summaries and may be all a busy clinician has time to read. Overall, I am glad to have the material as a reference and will remember various points to benefit the patients I treat.This book would be most useful to psychiatrists, psychiatric residents, and medical students. More specific information on therapy would make the book more useful to psychologists, social workers, and other therapists. For consumers of mental health care and legislators, this book may not be a good starting place to understand this complicated, debilitating, and multifactorial set of illnesses. A more patient-centered book with more illustrations, first-person accounts from patients, and details about how individuals utilized their roadmap toward achieving health would be more appropriate for this audience. Graphics in each chapter depicting individuals with treatment-resistant depression would have breathed life into the information presented.In summary, this volume is a good start for addressing the dearth of information available on treatment-resistant depression. It is well referenced and complete and contains summaries of critical research studies. It will be helpful for psychiatrists and psychiatrists in training. In the next edition, the inclusion of more illustrations and a more patient-centered approach could greatly expand the audience who would benefit from this highly informative book.Dr. Jensen is a fourth-year psychiatry resident at Tulane University, New Orleans, Louisiana.The reviewer reports no competing interests. FiguresReferencesCited byDetailsCited byNone Volume 63Issue 8 August 2012Pages 837-837 Metrics PDF download History Published online 1 August 2012 Published in print 1 August 2012

Association between insight, cognitive insight, positive symptoms and violence in patients with schizophrenia

Background: Violence is a significant clinical and public concern and is a frequent occurrence in patients with schizophrenia. The relationship between insight and violence remains controversial. In addition, there is a lack of research on insight, cognitive insight, demographic and psychopathologic variables in violent versus nonviolent schizophrenia patients. Aim: We aimed to compare insight, cognitive insight, psychopathological and demographic variables in violent and nonviolent subjects suffering from schizophrenia. In addition, we aimed to determine the demographic and clinical predictors of violent behaviour in patients with schizophrenia. Method: We recruited 133 schizophrenic patients without concomitant substance abuse or axis II disorder. Diagnoses were based on the SCID-I and SCID-II. Violent behaviours were assessed using the Overt Aggression Scale. Insight and cognitive insight were assessed with the Scale to Assess Unawareness of Mental Disorder and the Beck Cognitive Insight Scale, respectively. Results: We compared 47 patients with violent schizophrenia with 86 nonviolent patients. Non-violent patients had more severe depression, lower scores on positive symptoms, better clinical insight, more self-reflectivity and higher R-C index scores than did violent patients. In addition, history of violence, lower self-reflectiveness, worse clinical insight and delusion severity were significant predictors of violence in schizophrenia. Conclusion: The present study suggests that the inclusion of insight and cognitive insight may increase the prediction of violence in this population. In addition, clinicians should consider using non-pharmacological techniques that are based on cognitive behaviour therapy and enhance insight, particularly cognitive insight, among patients with schizophrenia who exhibit violent behaviour.

Birth Outcomes Following Self‐Inflicted Poisoning During Pregnancy, California, 2000 to 2004

To describe birth outcomes following intentional acute poisoning during pregnancy. California Linked Vital Statistics-Patient Discharge Database, 2000 to 2004. Pregnant women age 15 to 44, who had a singleton live birth or fetal death that occurred between gestational ages 20 and 42 weeks who were discharged from the hospital for an intentional poisoning were compared to pregnant women discharged from the hospital for any nonpoisoning diagnosis. Intentional acute poisoning hospital discharges were identifed by the presence of an ICD-9-CM E-Codes E950-E952 (suicide, attempted suicide and self-inflicted injuries specified as intentional.) Through a retrospective cohort design, birth outcomes including low birth weight; preterm birth; fetal, neonatal, and infant death; and congenital anomalies were identified by the presence of ICD-9-CM diagnosis codes or by notation in the dataset. There were 430 hospital discharges for an intentional poisoning during pregnancy documented in the dataset (rate=25.87/100,000 person years). The rate of intentional poisoning was greatest in the first weeks of gestation and declined with increasing gestational age. Analgesics, antipyretics, and antirheumatics were most commonly implicated. Adverse birth outcomes associated with intentional poisoning included preterm birth (odds ratio [OR]=1.34; 95% Confidence Interval [CI] [1.01, 1.77]), low birth weight (OR=1.49; 95% CI [1.04, 2.12]), and circulatory system congenital anomalies (OR=2.17; 95% CI [1.02, 4.59]). Intentional acute poisoning during pregnancy was associated with several adverse birth outcomes; however, these relationships may be confounded by concomitant maternal substance abuse.

Autistic-like traits and their association with mental health problems in two nationwide twin cohorts of children and adults

Autistic-like traits (ALTs), that is restrictions in intuitive social interaction, communication and flexibility of interests and behaviors, were studied in two population-based Swedish twin studies, one in children and one in adults: (1) to examine whether the variability in ALTs is a meaningful risk factor for concomitant attention deficit hyperactivity disorder (ADHD), anxiety, conduct problems, depression and substance abuse, and (2) to assess whether common genetic and environmental susceptibilities can help to explain co-existence of ALTs and traits associated with such concomitant problems. Two nationwide twin cohorts from Sweden (consisting of 11 222 children and 18 349 adults) were assessed by DSM-based symptom algorithms for autism. The twins were divided into six groups based on their degree of ALTs and the risk for concomitant mental health problems was calculated for each group. Genetic and environmental susceptibilities common to ALTs and the other problem types were examined using bivariate twin modeling. In both cohorts, even the lowest degree of ALTs increased the risk for all other types of mental health problems, and these risk estimates increased monotonically with the number of ALTs. For all conditions, common genetic and environmental factors could be discerned. Overall, the phenotypic correlation between ALTs and the traits examined were less pronounced in adulthood than in childhood and less affected by genetic compared with environmental factors. Even low-grade ALTs are relevant to clinical psychiatry as they increase the risk for several heterotypical mental health problems. The association is influenced partly by common genetic and environmental susceptibilities. Attention to co-existing ALTs is warranted in research on a wide range of mental disorders.

Predictors of medication nonadherence and hospitalization in Medicaid patients with bipolar I disorder given long-acting or oral antipsychotics

Purpose:To assess rates and predictors of medication nonadherence and hospitalization among patients with bipolar I disorder.Methods:This was a retrospective cohort analysis of Medicaid patients who were aged ≥18 years, had ≥1 inpatient or ≥2 outpatient medical claims indicating bipolar I disorder (ICD-9-CM codes 296.0x–296.1x, 296.4x–296.7x), and filled ≥1 prescription for antipsychotic medication between January 1, 2004, and December 31, 2006. Patients were followed for 1 year from the date of first (index) antipsychotic prescription. Patients were required to be continuously eligible for Medicaid without dual Medicare eligibility from 1 year before (baseline) through 1 year after (follow-up) index, and were required to receive ≥1 additional antipsychotic during follow-up. Descriptive statistics and predictors of medication nonadherence (medication possession ratio <0.8) and hospitalization were generated.Results:A total of 9410 patients met study eligibility criteria with a mean age of 38 years; 74% were female and 75% were white. Approximately 31% and 57% had baseline diagnoses of substance abuse and other psychiatric conditions, respectively. During follow-up, roughly 60% of patients were nonadherent and 40% of patients were hospitalized for any reason (37% psychiatric-related). Multivariate analysis showed that new antipsychotic starts, younger patients, those with a baseline concomitant substance abuse diagnosis, those taking a baseline antidepressant, and those with a baseline psychiatric hospitalization had significantly higher risk of nonadherence. Baseline psychiatric hospitalization, baseline substance abuse or other psychosis diagnosis, baseline use of an anxiolytic, anticholinergic, or anticonvulsant, and nonadherence to therapy in the follow-up period were significant predictors of increased risk of hospitalization.Limitations:This analysis did not attempt to evaluate the complex relationships among treatment type, adherence, hospitalization, and other variables.Conclusions:Study results showed that the risk of nonadherence is relatively high and confirmed that nonadherence is associated with a greater risk of hospitalization.

Quetiapine Combined With Amisulpride in Schizophrenic Patients With Insufficient Responses to Quetiapine Monotherapy

Treatment resistance often leads to combinations of second-generation antipsychotics. Well-designed trials evaluated add-on strategies involving clozapine, but also olanzapine and quetiapine (QTP) have pharmacodynamic properties that render supplementation with high-affinity antidopaminergic second-generation antipsychotics, for example, amisulpride (AMS), reasonable. We report on 6 cases with partial response of psychotic positive symptoms to QTP despite sufficient dosage (mean, 783 mg/d) and serum levels (mean, 405 μg/L). Concomitant drug abuse and interfering pharmacological changes were excluded. The add-on of AMS in a mean dose of 466.7 mg/d (serum level, 132.1 μg/L) over a period of 8.3 weeks facilitated significant improvements of treatment-resistant psychotic symptoms. The Positive and Negative Syndrome Scale scores decreased from 94 to 54, whereas the Scale for the Assessment of Negative Symptoms and the Calgary Depression Scale for Schizophrenia significantly improved. Despite an increase in the mean body weight from 77.2 to 82.9 kg and an increase in prolactin levels from 43 to 163 μg/L, the observed general tolerance was good. The combination of AMS with QTP might be a successful strategy in individuals only partially responsive to quetiapine, but risks and benefits should be further evaluated in controlled clinical trials.