Diagnosis Of Substance Misuse Research Articles

Child Sexual Abuse and Age at Onset of Psychotic Disorders: A Matched-cohort Study: L'âge d'apparition des troubles psychotiques chez les victimes d'agression sexuelle à l'enfance: Une étude prospective de cohortes appariées.

Victims of child sexual abuse (CSA) present with a higher risk of psychotic disorders. However, the developmental course of psychosis following CSA, such as the age at onset, remains unknown. This study aimed to determine whether the age at onset of psychotic disorders was influenced by sexual abuse, sex, and confounding factors (substance misuse, intellectual disability, and socioeconomic status). A prospective matched-cohort design was used, with administrative databases from a child protection agency (CPA) and a public health system. Children who received a substantiated report of CSA at the CPA and whose health data could be retrieved were selected (n = 882) and matched with children from the general population using their date of birth, sex, and geographical area. Survival analysis was performed to estimate the association between sexual abuse, sex, and confounding factors and the age at onset of psychotic disorders. Sexual abuse and substance misuse are significantly associated with the age at onset of psychotic disorders. In the sexually abused group, only substance misuse is associated with the age at onset of psychotic disorders, but this was not significant for the general population. These findings highlight the importance of prevention of psychotic disorders among sexually abused youth, especially those with a substance misuse diagnosis.

PRS1 BEYOND TOBACCO- THE SECONDARY IMPACT OF SUBSTANCE MISUSE IN CHRONIC LUNG DISEASE

Chronic lung disease, specifically COPD and asthma, impacts more than 500 million adults worldwide, and is associated with high healthcare spending and significant disease related morbidity. While the direct impact of substance use disorder is well documented, little is known about the indirect impact of substance misuse within this patient population. Utilizing administrative data, we quantified the secondary morbidity, mortality and healthcare utilization attributable to substance misuse in patients with chronic lung disease on a national scale. Utilizing the National Readmissions Database we identified patients with a diagnosis of COPD or asthma admitted to a hospital within the United States between 2012-2015. Within this patient subgroup, ICD-9/10-CM codes were utilized to determine the prevalence of substance misuse by drug class. Utilizing weighted regression analysis, morbidity, mortality and healthcare utilization differences between the two groups were identified. The impact of tobacco use, with or without associated substance misuse, was determined, and adjusted for in final analysis. 1,087,226 patients with an index admission for COPD or asthma were identified. Of these patients 4.01% had a documented diagnosis of substance misuse. Patients with documented substance misuse of any kind had an increased cost per index admission, with an increased risk of respiratory failure (OR: 1.44 (95%CI: 1.37, 1.52, p<0.001) and need for mechanical ventilation (OR 1.44 (95%CI: 1.37, 1.52 p <0.05). The additional index admission costs totaled $24 million for our cohort. Additionally substance misuse was associated with an increased risk of readmission. (OR 1.29 95%CI: 1.25, 1.33 p<0.001). Substance misuse is associated with an increase in healthcare utilization and healthcare cost in patients with chronic lung disease. Targeted substance misuse treatment in this patient population has the potential for significant cost savings to the healthcare system.

P129: The Calgary Stampede: effects on emergency and urgent care department utilization during a Canadian mass gathering

Introduction: The Calgary Stampede is a two-week mass gathering occurring annually in July. Clinicians have anecdotally noted increases in emergency department (ED) and urgent care (UC) visits, especially for complaints related to substance misuse and violence. Our objectives were: 1) to determine if there is an increase in overall visits to EDs and UCs during the Stampede, and 2) to determine if there are increases in presentations related to trauma, violence, or intoxication. Methods: This observational study used prospectively collected administrative data from five EDs and two UCs in Calgary. For the years 2013 to 2016, daily average data during Stampede dates were compared to the data from the 21 days immediately preceding and following the event. Dates were selected to incorporate a similar proportion of weekends and weekdays in the Stampede and non-Stampede periods. The primary outcome was daily average ED and UC utilization. Secondary outcomes included time of arrival, utilization by demographic groups, complaint category at triage, or International Statistical Classification of Diseases, 10th revision (ICD-10) diagnosis. Results: The study period included 263 380 individual ED and UC visits (34 492 Stampede and 228 888 non-Stampede visits). Daily average ED and UC visits increased by 2.1% (p&amp;lt;0.0001) during the Stampede period. Increases in utilization were identified in specific subgroups: male, ambulance arrival, and nighttime arrival between 2000 and 0400 (all p&amp;lt;0.05). The Stampede period saw a marked increase in CTAS 1 visits (16.2%, p&amp;lt;0.01), triage complaints of lacerations (12.4%, p&amp;lt;0.0001) and blunt trauma (19.4%, p&amp;lt;0.0001), and the ICD-10 diagnosis of substance misuse (23.9%, p=0.01). Visits triaged to the minor treatment areas increased by 9.5% (p&amp;lt;0.0001), again most markedly at night (15.3%, p&amp;lt;0.0001).No differences were detected for triage complaints of altered level of consciousness, sexual assault, head or neck injury, limb injury, or social problems. Conclusion: The Calgary Stampede provokes appreciable changes in overall ED and UC utilization, with marked increases in nighttime visits, visits by men, trauma or substance abuse-related complaints, and minor treatment visits. This data may be useful in manpower planning to ensure optimal patient flow and service delivery during mass gatherings.

Undertreatment of human immunodeficiency virus in psychiatric inpatients: a cross-sectional study of seroprevalence and associated factors.

BackgroundThe aims of this study were to evaluate the prevalence of HIV and its associated demographic and clinical factors among psychiatric inpatients of a general hospital.MethodsThis was a single-center, observational, cross-sectional study that included patients consecutively admitted to our unit aged 16 years or older and with no relevant cognitive problems. The patients were evaluated using a semistructured interview and an appropriate test for HIV infection.ResultsOf the 637 patients who were screened, 546 (86%) who consented to participate were included in the analyses. Twenty-five (4.6%, 95% confidence interval [CI] 3.0–6.8) patients were HIV-positive. The prevalence was higher among patients with substance misuse (17.4%, 95% CI 9.7–28.8). All except one of the 25 patients knew of their seropositive condition prior to participation in the study. Only 14 (56%) of the 25 seropositive patients had previously received pharmacological treatment for their infection. According to the multiple logistic regression analysis, the likelihood of HIV infection was lower in patients with higher levels of education and higher among patients who were single, had history of intravenous drug use, and had an HIV-positive partner, particularly if they did not use condoms. Among the patients with HIV infection, 18 (72%) had a history of suicide attempts compared with 181 (34.7%) of the patients without HIV infection (relative risk 2.1, 95% CI 1.6–2.7; P<0.001).ConclusionHIV infection is highly prevalent in patients admitted to a psychiatric unit, especially those with a diagnosis of substance misuse. Seropositive patients show very poor treatment adherence. The risk of suicide seems to be very high in this population. Implementing interventions to reduce the suicide risk and improve adherence to antiretroviral therapy and psychotropic medications seems crucial.

Frequent Emergency Department Use Among Released Prisoners With Human Immunodeficiency Virus: Characterization Including a Novel Multimorbidity Index

The objective was to characterize the medical, social, and psychiatric correlates of frequent emergency department (ED) use among released prisoners with human immunodeficiency virus (HIV). Data on all ED visits by 151 released prisoners with HIV on antiretroviral therapy (ART) were prospectively collected for 12 months. Correlates of frequent ED use, defined as having two or more ED visits postrelease, were described using univariate and multivariate models and generated medical, psychiatric, and social multimorbidity indices. Forty-four (29%) of the 151 participants were defined as frequent ED users, accounting for 81% of the 227 ED visits. Frequent ED users were more likely than infrequent or nonusers to be female; have chronic medical illnesses that included seizures, asthma, and migraines; and have worse physical health-related quality of life (HRQoL). In multivariate Poisson regression models, frequent ED use was associated with lower physical HRQoL (odds ratio [OR] = 0.95, p = 0.02) and having not had prerelease discharge planning (OR = 3.16, p = 0.04). Frequent ED use was positively correlated with increasing psychiatric multimorbidity index values. Among released prisoners with HIV, frequent ED use is driven primarily by extensive comorbid medical and psychiatric illness. Frequent ED users were also less likely to have received prerelease discharge planning, suggesting missed opportunities for seamless linkages to care.

Temperature-related deaths in people with psychosis, dementia and substance misuse

Climate change is expected to have significant effects on human health, partly through an increase in extreme events such as heatwaves. People with mental illness may be at particular risk. To estimate risk conferred by high ambient temperature on patients with psychosis, dementia and substance misuse. We applied time-series regression analysis to data from a nationally representative primary care cohort study. Relative risk of death per 1°C increase in temperature was calculated above a threshold. Patients with mental illness showed an overall increase in risk of death of 4.9% (95% CI 2.0-7.8) per 1°C increase in temperature above the 93rd percentile of the annual temperature distribution. Younger patients and those with a primary diagnosis of substance misuse demonstrated greatest mortality risk. The increased risk of death during hot weather in patients with psychosis, dementia and substance misuse has implications for public health strategies during heatwaves.

QTc prolongation: is clozapine safe? Study of 82 cases before and after clozapine treatment

The most feared cardiological consequence of clozapine is sudden cardiac death. A potential marker of it is QTc interval (QTc) prolongation. This study aimed to determine the prevalence of QTc prolongation in patients before and after 18 weeks of clozapine treatment and to detect predictors of QTc prolongation. Patients undergoing treatment with clozapine who had been given an electrocardiogram prior to the treatment and had their electrocardiogram, serum clozapine and norclozapine levels taken on the 18th week were selected. Exclusion criteria were thioridazine, pimozide, diuretics or beta-blocker treatment, electrolytic alteration, heart diseases and substance misuse diagnosis. Prolonged QTc was defined as >450 ms in men and >470 ms in women. No significant differences were detected in prevalence of prolonged QTc or mean QTc before and after 18 weeks of clozapine treatment (p = 0.15, p = 0.32, respectively). Age, heart rate at 18th week and QTc prior to clozapine treatment had significant effects on QTc at follow-up. Prolonged QTc during previous treatment and heart rate >95 beats/min at 18 weeks were found to be predictors of QTc prolongation. No significant differences were detected in prevalence of QTc prolongation or mean QTc among patients before and after 18 weeks on clozapine.

Pressures to adhere to treatment (‘leverage’) in English mental healthcare

Coercion has usually been equated with legal detention. Non-statutory pressures to adhere to treatment, 'leverage', have been identified as widespread in US public mental healthcare. It is not clear if this is so outside the USA. To measure rates of different non-statutory pressures in distinct clinical populations in England, to test their associations with patient characteristics and compare them with US rates. Data were collected by a structured interview conducted by independent researchers supplemented by data extraction from case notes. We recruited a sample of 417 participants from four differing clinical populations. Lifetime experience of leverage was reported in 35% of the sample, 63% in substance misusers, 33% and 30% in the psychosis samples and 15% in the non-psychosis sample. Leverage was associated with repeated hospitalisations, substance misuse diagnosis and lower insight as measured by the Insight and Treatment Attitudes Questionnaire. Housing leverage was the most frequent form (24%). Levels were markedly lower than those reported in the USA. Non-statutory pressure to adhere to treatment (leverage) is common in English mental healthcare but has received little clinical or research attention. Urgent attention is needed to understand its variation and place in community practice.

An audit of incomplete involuntary admissions to an approved Irish centre.

With the implementation of the Mental Health Act 2001 (M HA 2001) in November 2006, there was an expectation of reduction in the overall involuntary admission rate, particularly as those with a sole diagnosis of substance misuse were specifically excluded from the definition of mental disorder. The aim of this audit cycle was to ascertain this rate and to audit the process of the referral, transfer, assessment and subsequent management of the patients whose admission orders were not completed by the consultant psychiatrists (CPs) following referral for involuntary admission to an approved centre. In addition, the authors wished to ascertain if the recommendations of Audit 2003 were implemented. The Audit 2003 analysed all Temporary Patient Reception Orders sent to an approved centre in the year 2003 but whose admission orders were not completed by the CP. A protocol was drawn up to elicit information. The Re-Audit in 2008 used the same protocol. The duration of the Re-Audit was 01.11.06-31.10.07. The results were analysed using SPSS 12. There is no change in the involuntary referral rate to the approved centre in Longford/Westmeath since the new legislation was enacted. The CP continues to refuse to make an order in one in three cases. Patients with a sole diagnosis of alcohol misuse continue to be referred for involuntary admission but are now presenting sober on admission. There also appears to be an increased rate of incorrectly filled forms by GPs. This audit indicates a need for more training for GPs and Gardai in the MHA 2001 and filling of forms.

Risk of death during and after opiate substitution treatment in primary care: prospective observational study in UK General Practice Research Database

Objective To investigate the effect of opiate substitution treatment at the beginning and end of treatment and according to duration of treatment.Design Prospective cohort study.Setting UK General Practice Research DatabaseParticipants...

Do valerian teabags improve subjective sleep quality for male remand prisoners with a dual diagnosis?

Insomnia is a problem commonly identified by remand prisoners who also have a concurrent dual diagnosis of substance misuse and mental health problems. Historically, sleep problems in prison have been treated with either hypnotics or benzodiazepines but these cause adverse side effects and are often misused. Valerian teabags were introduced in 2004 but their efficacy was untested within the prison setting. The aim of this study was to establish whether Valerian teabags improve subjective sleep quality for men with sleep disturbance and dual diagnosis in a remand prison setting within a 14‐day period. The findings show that herbal alternatives appear to improve sleep quality for prisoners with complex needs.

Consultant psychiatrists' experiences and attitudes following the introduction of the Mental Health Act 2001: a national survey.

This study explored the attitudes and experiences of consultant psychiatrists regarding the Mental Health Act 2001. A postal survey was distributed to all consultant psychiatrists (n=238) in the Republic of Ireland. All specialties were included except Child and Adolescent Psychiatry. A response rate of 70% was achieved. Care of involuntarily admitted patients has improved according to 32%, but 48% found that the care of voluntary patients has deteriorated. Sixty-nine per cent of consultant psychiatrists acknowledge that involuntarily admitted patients are being changed to voluntary early to avoid a tribunal, and 21 % believe it occurs in over 40% of cases. Fourteen per cent of consultant psychiatrists have re-admitted a patient involuntarily immediately after a tribunal revoked the original Involuntary Order. Junior doctors' training by consultant psychiatrists has been reduced in 57% of placements as a result of the increased demands of the MHA 2001. Eighty-seven per cent report an increase in their on call service workload but only 23% report a sufficient increase in the number of consultants within their service. While 78% agree that patients should not be admitted involuntarily solely on the grounds that the person is suffering from a personality disorder, 58% feel that there is a risk in such patients not being involuntarily admitted in situations in which it is clinically necessary. Fifty-six per cent feel that there is a similar risk in patients with a diagnosis of substance misuse. Resources required to implement the Mental Health Act 2001 have not been sufficient leading to poorer quality of service and negatively affecting NCHDs training.

The use of the repertory grid technique to examine staff beliefs about clients with dual diagnosis

This paper reports a study exploring how individual psychiatric staff construes clients with psychosis who misuse substances. A dual diagnosis of substance misuse is common in clients with psychosis. Previous studies have suggested that psychiatric staff feel ill-equipped to work with these clients, and hold negative views of them, affecting client care and recovery. Understanding staff attitudes can inform training and practice. Twelve psychiatric nursing staff working in an inpatient service for adults with enduring mental health difficulties in England were interviewed. Using a repertory grid technique, staff were asked to describe clients and acquaintances who did and did not misuse substances, themselves and colleagues. All staff made critical judgements of some clients, particularly clients with dual diagnosis, but were less judgemental towards acquaintances who misused substances. Staff who used fewer dimensions to construe people appeared to make a clear distinction between clients and non-clients. This distinction was not apparent for staff with more cognitively complex construct systems. Specific factors that could be implicated in the organization of individuals' construct systems included personal experience of services as a carer; these staff made less distinction between clients and non-clients. Further training is needed for staff working with clients with a dual diagnosis. Training packages need to consider the personal experiences and views of staff. Reducing the boundaries between staff and clients might enable staff to better understand the actions of clients and improve client care.

P01-290 Clinical and demographic characteristics and bipolarity features in treatment-resistant depression - preliminary results from polish TRES-DEP study

Aim:The Polish multicenter Treatment Resistant Depression Project (TRES-DEP) has aimed to study a number of demographic, clinical and psychometric characteristics comparing patients with treatment-resistant (TR) and treatment non-resistant depression (TNR). Fifty patients with TR depression (group 1) and 50 patients with TNR depression (group 2) were included in this preliminary analysis.Method:Treatment-resistant depression was recognized on account of lack of significant improvement following at least two adequate courses of antidepressant treatment. The exclusion criteria were treatment with mood stabilizers, diagnosis of substance misuse, dementia or severe somatic disease. The presence of bipolarity features was assessed by Polish version of Mood Disorder Questionnaire (MDQ).Results:Significantly more patients with TR depression compared with TNR had family history of mental disorders, especially alcohol dependence (24% vs 8%, p=0,03), had more previous depressive episodes (8.5±5.0 vs 5.1±3.8; p=0.001), and reported shorter time from the last hospitalization (14.8±26.5 vs 41.9±71.1 months, p&lt; 0.005). Patients from group 1 significantly more frequently fulfilled MDQ criteria for bipolarity than patients from group 2 (44% vs 12%, p&lt; 0.001). Among TR patients, MDQ-positive compared with MDQ-negative more frequently reported treatment nonadherence (41% vs 18%, p=0.055), suicidal attempts (41% vs 18%, p=0.055) and inadequate remission (100% vs 21%; p&lt; 0.05).Conclusion:Our preliminary results point to clinical differences between patients with TR and TNR depression, including higher scores on bipolarity scale in TR. The features of bipolarity may be an important reason for non-response during antidepressant treatment of depression and worse clinical course and outcome.

Physical Health and Dual Diagnosis.

The physical health of people with mental illness may be neglected for a variety of reasons. This paper looks at the common physical health problems experienced by people with a dual diagnosis of substance misuse and serious mental illness, and suggests ways of assessing and managing them.

Service uptake in a sample of substance misuse and community mental health service clients: A case control study

Background: The difficulties in engaging and treating individuals with comorbid psychiatric problems and substance misuse has been acknowledged as a growing problem likely to have implications for treatment.Aims: This study compared service use in clients with single and comorbid diagnoses from Adult Mental Health (AMH) and Drug and Alcohol services (DAS).Methods: A retrospective matched case-control study of a sample of service users of a mental health Trust in East Anglia drawn across AMH (n = 400) and DAS (n = 190). Odds ratios were estimated and used to test for differences in client groups with respect to uptake of community services, formal and informal in-patient services, “out-of-hours” services and engagement with statutory services.Results: Marked differences were observed in terms of service use between clients of AMH who had a single diagnosis of severe, chronic or recurrent psychiatric problems and clients of AMH who had additional substance misuse problems. Differences were less pronounced between clients of DAS who had a single diagnosis of substance misuse and clients of DAS who had substance misuse and psychiatric problems.Conclusions: Different patterns of service uptake were observed between singly diagnosed and comorbid AMH clients. There was a lack of differences in patterns of service uptake in singly diagnosed and comorbid DAS clients. Substance misuse could be a factor influencing service uptake rather than comorbidity per se.

Are we meeting the psychological needs of heterosexual men with HIV disease? A retrospective case controlled study of referrals to a psychological medicine unit in London, UK

This study set out to ascertain what proportion of HIV-positive heterosexual men cared for at a central London teaching hospital HIV medical unit, were referred to the Psychological Medicine Unit, and to compare those HIV-positive male heterosexual patients with age and sex matched HIV-positive gay male controls. Hospital and Psychological Medicine Unit databases were interrogated to identify relevant patients seen during the period between February 1992 and December 2002. Furthermore, 50 heterosexual patients, who had been referred to the Psychological Medicine Unit, were matched for age and date of referral, with one gay male HIV-positive control patient. Demographic and illness data was gathered for the subjects and controls. Data was collected on 50 subjects in each group. The main findings of the study were: (1) that heterosexual men with HIV are almost three times less likely to be referred for specialist mental health care than HIV-positive gay men; (2) that heterosexual men with HIV disease, who were referred to the Psychological Medicine Unit, were less likely to be from a white ethnic background compared to gay men; (3) were less likely to be given a diagnosis of a depressive illness; but (4) were more likely to have a substance misuse diagnosis. Gay male patients who are HIV-positive are more likely to experience difficulties with sexual dysfunction, and receive a formal psychiatric diagnosis. The implications of the findings are discussed.

Dual diagnosis of substance misuse and psychiatric disorders: a U.S.–U.K. perspective

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Substance misuse and mental health: an overview

Patients with dual diagnosis of substance misuse and mental health problems present many challenges for nurses, as their complex needs make them difficult to manage and treat. The author provides an overview of the nature and extent of the problem and a framework for nursing interventions.

Prevalence and severity of substance misuse among referrals to a local forensic service

Substance misuse is frequently present alongside mental illness and personality disorder, complicating all aspects of management. We describe self-reported levels of substance misuse in referrals to a forensic psychiatry service, to establish degrees of dependency and co-morbidity with other diagnostic categories and to report the implications for treatment. There were 146 (70%) of 209 consecutive referrals who completed a semi-structured questionnaire, including the Alcohol Use Disorders Identification Test (AUDIT), Severity of Alcohol Dependency Questionnaire (SADQ), Alcohol Problem Questionnaire (APQ) and, for frequent users of opiates or stimulants, the Severity of Dependence Scales (SDS). Psychiatric diagnoses were made from clinical assessment using the International Classification of Diseases (World Health Organization, 1992). ICD-10 diagnoses of substance misuse were found in 83 (57%) subjects. A combination of mental illness and a substance misuse diagnosis was found in 54 (37%). The subgroup accepted into forensic psychiatric services was found to have higher levels of co-morbidity, although levels of dependency were low. Forensic services need expertise in assessing drugrelated morbidity; in motivational interviewing and other techniques for encouraging change; and in consolidating recovery.