Dual disorder is a term applied to patients with an addictive disorder and other mental disorder. Epidemiological studies have established that dual disorders are an expectation rather than an ...exception. They are difficult to diagnose and treat and constitute a huge burden for both patients and their relatives and society. Current treatments are a combination of those needed to treat the addictive disorder with those focused on the co-occurring psychiatric disorder. Focusing specifically on schizophrenia, growing scientific evidence supports the existence of a shared vulnerability for substance use in these patients and those at risk. Various antipsychotics have been found to be useful in the treatment of psychotic symptoms and disorders; however, few effective treatments have been identified until now for substance use disorders in patients with dual schizophrenia. Partial agonism stands as a new pharmacological option available in recent years. Molecules with this kind of action may act as functional agonists or as antagonists, depending on the surrounding levels of the neurotransmitter. Studies have found their efficacy in schizophrenia, addiction, anxiety and depression. Certain partial agonist antipsychotics seem to have a role in the treatment of dual schizophrenia. That could be the case with cariprazine. Because of its higher affinity for dopaminergic D3 receptors compared to D2, a potential to prevent relapse to addiction, added to its antipsychotic efficacy, has been suggested. Here we briefly review current advances and future directions and introduce some personal insights into the role of partial agonists in co-occurring schizophrenia and substance use.
Abstract
The persistent difficulty in conceptualizing the relationship between addictive and other mental disorders stands out among the many challenges faced by the field of Psychiatry. The ...different philosophies and schools of thought about, and the sheer complexity of these highly prevalent clinical conditions make progress inherently difficult, not to mention the profusion of competing and sometimes contradictory terms that unnecessarily exacerbate the challenge. The lack of a standardized term adds confusion, fuels stigma, and contributes to a “wrong door syndrome” that captures the difficulty of not only diagnosing but also treating addictive and other mental disorders in an integrated manner. The World Association on Dual Disorders (WADD) proposes the adoption of the term “Dual Disorder” which, while still arbitrary, would help harmonize various clinical and research efforts by rallying around a single, more accurate, and less stigmatizing designation.
Objectives:
We aimed to evaluate a hepatitis C (HCV) micro-elimination program in 2 addiction centers among subjects with substance use disorders (SUD).
Methods:
The program was based on simplifying ...the diagnosis of HCV infections by avoiding referral to primary care for the diagnosis and performing the necessary tests at the point of care (ie, the addition center) and simplifying the patient pathway by directly referring patients to the specialized care for treatment. Descriptive and multivariate analyses are presented.
Results:
Of the 1497 subjects included in the program, 327 reported that they were anti-HCV-positive. Among the 1170 patients who were offered the HCV rapid antibody test, 180 (15.4%) did not perform the test. Performing the HCV rapid antibody test only contributed ten patients (3%) to the 337 who were anti-HCV-positive. A high proportion (147 out of 327 45%) of subjects who reported being anti-HCV-positive also reported that they had not been treated for HCV. Among the 67 subjects who were HCV-RNA-positive and were referred for treatment, 53 (79%) ultimately received and completed antiviral treatment. Unfortunately, we did not find any factors associated with not performing dry blood testing, and the factors associated with not performing the HCV rapid antibody test were difficult to interpret, and the model showed low goodness of fit.
Conclusions:
Our results suggest that a micro-elimination program focused on patients with SUD attending an addiction center is not effective for screening the presence of hepatitis C but is successful for linking patients with hepatitis C to antiviral treatment.
Several behaviors, including compulsive gambling, have been considered non-substance-related addictive disorders. Categorical mental disorders (e.g., DSM-5) are usually accompanied by very different ...symptomatic expressions (affective, behavioral, cognitive, substance abuse, personality traits). When these mental disorders occur with addictive disorders, either concomitantly or sequentially over the life span, this clinical condition is called a dual disorder. Gambling disorder (GD) has been associated with other categorical psychiatric diagnoses: attention deficit hyperactivity disorder, depression, bipolar disorder, social anxiety, schizophrenia, substance use disorder, antisocial personality disorder; and dimensional symptoms including higher impulsivity, poorer emotional wellbeing, cognitive distortion, psychosis, deficient self-regulation, suicide, poorer family environment, and greater mental distress. We are calling this clinical condition Gambling Dual Disorder. From a clinical perspective, it is clear that Gambling Dual Disorder is not the exception but rather the expectation, and this holds true not just for GD, but also for other mental disorders including other addictions. Mental disorders are viewed as biological disorders that involve brain circuits that implicate specific domains of cognition, emotion, and behavior. This narrative review presents the state of the art with respect to GD in order to address current matters from a dual disorder, precision psychiatry, and clinical neuroscience perspective, rather than the more subjective approach of symptomatology and clinical presentation. This review also presents Gambling Dual Disorder as a brain and neurodevelopmental disorder, including from the perspectives of evolutionary psychiatry, genetics, impulsivity as an endophenotype, the self-medication hypothesis, and sexual biological differences. The wide vision of the disease advances a paradigm shift, highlighting how GD and dual disorders should be conceptualized, diagnosed, and treated. Rethinking GD as part of a dual disorder is crucial for its appropriate conceptualization from the perspective of clinical neuroscience and precision psychiatry.
Patients with alcohol-use disorders (AUDs) have a high prevalence of anxiety disorders (AnxDs). "Co-occurring disorders" refers to the coexistence of an AUD and/or drug related disorders with another ...non-addictive psychiatric disorder. The aim of this study was to assess the effectiveness of psychopharmacological treatments and psychotherapy in patients with AUD and AnxD and to propose recommendations for the treatment of patients with comorbid AnxDs and AUDs. Randomized clinical trials, meta-analyses, and clinical guidelines were retrieved from PubMed, Embase, and Cochrane databases. Paroxetine was found to be effective in social anxiety patients with alcohol dependence. Selective serotonin reuptake inhibitors (SSRIs), especially sertraline, showed effective results in posttraumatic stress disorder and in comorbid AnxD-AUD. However, SSRIs should be used with caution when patients are actively drinking because they may increase alcohol consumption. Buspirone, gabapentin, and pregabalin were found to be effective in comorbid AnxD-AUD. The treatment of dual AnxDs should start as early as possible. Since AUDs and AnxDs can reinforce each other, treatments targeting both pathologies can be effective. Women suffer from higher levels of stress and AnxDs than men, and they are also more vulnerable to maintaining alcohol consumption levels. Further research is needed in this comorbid patient population, including the study of different types of patients and gender perspectives.
Background:
Previous studies in Mexico undertaken at residential facilities for treating substance use disorders (SUDs) reported that the prevalence of Dual Disorders (DDs) is over 65%. DDs pose a ...major challenge for the Mexican health system, particularly for community-based residential care facilities for SUDs, due to the shortage of certified professionals to diagnose and treat these patients. Moreover, the lack of standardized algorithms for screening for and evaluating DDs to refer patients to specialized services (whether private or public) hinders timely care, delaying the start of integrated treatment. The use of new technologies provides a strategic opportunity for the timely detection of DDs through the development of standardized digital applications for the timely detection of DDs.
Objective:
To develop an app to screen for DDs, which will contribute to referral to specialized services in keeping with the level of severity of psychiatric and addictive symptomatology, and be suitable for use by community-based residential care facilities for SUDs.
Method:
The research project was implemented in two stages. Stage 1 involved obtaining the psychometric properties of the Dual Diagnosis Screening Interview (DDSI). Stage 2 consisted of two steps to test the
Beta
version of the app and the quality of version 1.0.
Results:
The DDS obtained sensitivity and specificity scores above 85%. The app and its algorithm to screen for and refer DDs proved to be efficient and easy to apply with satisfactory community acceptance.
Conclusion:
The app promises to be a useful screening tool at residential addiction treatment centers.
Aim
To evaluate the efficacy and impact of long-acting injectable (LAI) aripiprazole in patients with schizophrenia with a coexisting substance use disorder (SUD).
Patients and methods
A multicenter, ...observational, descriptive and retrospective study was conducted in patients with a DSM-5 diagnosis of schizophrenia who had a coexisting SUD and were treated with LAI-aripiprazole. Disease severity was evaluated with the Clinical Global Impression (CGI) severity scale for schizophrenia, daily functioning and disability were evaluated with the World Health Organisation Disability Assessment Scale (WHODAS-2.0), and the severity of the addiction was evaluated with the Severity of Dependence Scale (SDS).
Results
The sample included 40 patients. Overall, after 6 months of treatment with LAI-aripiprazole at a dose of 400 mg/4 weeks in 77.5% of the patients, we observed significant improvement in the psychopathological symptoms, with a reduction of over 30% in the scores of the five CGI-severity scales. The WHODAS-2.0 mean (standard deviation) score was also significantly reduced from 57.6 (8.2) to 42.3 (4.3) points (
p
< 0.001). Regarding SUDs, after 6 months of treatment, substance use was stopped in 5 of the 9 patients with cocaine use disorder and in 3 of the 16 patients with alcohol abuse disorder. A significant reduction in the severity of the dependence was observed only in the subgroups of participants with cocaine and alcohol use disorders.
Conclusion
Our study suggests that once-monthly LAI-aripiprazole retains its antipsychotic efficacy in patients with schizophrenia and a coexisting SUD and could be useful for the management of cocaine or alcohol use disorders in this population.
The objective was to quantify the prevalence of dual diagnosis and to evaluate the characteristics of these patients from community mental health and substance misuse services in Madrid. The sample ...consisted of 837 outpatients from Madrid, 208 from mental health services and 629 from substance misuse services. We used the Mini International Neuropsychiatric Interview (MINI) and Personality Disorder Questionnaire (PDQ4+) to evaluate disorders from axis I and II. It was considered that 517 (61.8%) patients had dual pathology (current diagnoses of axis I or II disorders and an addictive disorder): 36,1% in mental health services and 70,3% in substance misuse services. There were fewer males amongst the dual patients and it was also found that they had a worse employment situation, along with higher figures of alcohol and cannabis dependence than addicts without dual diagnoses (n=194). When comparing them with patients with mental disorder diagnoses only, excluding substance use disorder (n=126), there were differences in all socio-demographic characteristics analyzed, and dual patients were associated with diagnoses of bipolar disorder, agoraphobia, generalized anxiety disorder, post-traumatic stress disorder, and had more suicide risk and different personality disorders. Thus, dual pathology is higher in patients who are in treatment and have differential characteristics (higher suicide risk, worse employment situation) that suggest greater severity that could be of help in the planning of care resource policies for these patients.
This study explored the clinical importance of latent impulsivity subtypes within a sample of individuals with substance use disorders (SUDs) and high rates of co-occurring disorders (CODs) receiving ...residential treatment, aiming to assess the heterogeneity of the associations between SUDs and CODs across such impulsivity subtypes. The abbreviated Barratt impulsiveness scale was used to assess motor and cognitive (attentional and nonplanning) impulsivity, a structured interview for diagnosis of SUD and CODs, and other clinimetric measures for severity of substance use. Latent class analysis was conducted to extract subgroups of impulsivity subtypes and Poisson regression to analyze effects of interactions of classes by CODs on severity of substance use. 568 participants were evaluated. Results featured a four-class model as the best-fitted solution: overall high impulsivity (OHI); overall low impulsivity; high cognitive-low motor impulsivity; and moderate cognitive-low motor impulsivity (MC-LMI). OHI and MC-LMI concentrated on most of the individuals with CODs, and individuals within OHI and MC-LMI showed more severity of substance use. The expression of this severity relative to the impulsivity subtypes was modified by their interaction with internalizing and externalizing CODs in very heterogeneous ways. Our findings suggest that knowing either the presence of trait-based subtypes or CODs in individuals with SUDs is not enough to characterize clinical outcomes, and that the analysis of interactions between psychiatric categories and behavioral traits is necessary to better understand the expressions of psychiatric disorders.
Objective: Addiction co-occurs with distinct pathological personality traits, other psychiatric disorders or symptoms and cognitive impairment, which are known as dual disorders or co-occurring ...disorders. This symptomatic high concurrency suggests that both conditions are in some ways causally linked. Research is ongoing to identify distinctive neurobehavioral mechanisms and endophenotypes that predispose individuals to compulsive drug use and other mental disorders. Research is also providing new revelations about the diverse effects of substances on individuals, including differences according to sex. Today we know that the same substance may give rise to different behavioral, affective, cognitive, and sensory effects across different individuals. Methods: This state-of the art review tends to address the concept of precision psychiatry and dual disorders. The PubMed database was searched for the last 15 years to identify those articles that reported neurobiological perspectives on dual disorders, addiction and other mental disorders, precision medicine, and precision psychiatry. Results: There has been considerable progress made in recent years in relation to the study of addiction and dual disorders. The concept of dual disorders attempts to capture not only the persistence of substance use and substance seeking but also the evident vulnerability of specific subpopulations to switch from controlled to compulsive drug use. Precision medicine is focused on identifying this individual vulnerability to illness as much as the individual response to treatment. Psychiatry is fully committed to this goal. Regarding addiction, essential precision medicine advances will be possible if concerted efforts are made in the discovery of biological variations and environmental factors that contribute to individual vulnerability to addictive disorders and dual disorders, together with the identification of moderators of treatment response. Conclusions: Here we survey the discoveries, future research directions, and translational relevance of the concept of precision psychiatry for dual disorders. The review may offer new perspectives on this issue and highlight a new way to see and to think about dual disorders.
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