Carmen Barral

Psychiatric comorbidities in opioid-dependent patients undergoing a replacement therapy programme in Spain: The PROTEUS study

Opioid-dependent patients show a high rate of psychiatric comorbidities. The prevalence and characteristics of patients with dual diagnosis have not been well established in Spanish opioid agonist treatment (OAT) programmes. Thus, 621 opioid-dependent patients enrolled in OAT programmes were assessed, using the EuropASI questionnaire, for psychiatric comorbidities, which were detected in 67% of patients (anxiety 53%, mood disorders 48%, sleep disorders 41%, substance-related disorders 36%). In addition, compared with patients without a dual diagnosis, patients with dual pathology were significantly older, used benzodiazepines and cannabis in significantly greater percentages, and showed significantly more frequent infectious and non-infectious comorbidities, worse overall working status, a lower proportion of drivers and higher levels of severity regarding medical, employment, alcohol, legal, family and psychological issues. Therefore, the data showed a very high prevalence of psychiatric comorbidity in opioid-dependent patients receiving OAT in Spain and several problems frequently associated with patients with dual diagnosis. Physicians treating opioid-dependent patients should be aware of these facts to correctly identify and manage patients with a dual diagnosis.

Neuroticism and impulsivity: Their hierarchical organization in the personality characterization of drug-dependent patients from a decision tree learning perspective

OBJECTIVE Neuroticism and impulsivity are the personality variables most consistently associated with drug-dependent patients. To date, no data mining procedures have been applied to explore the differential role of personality variables in this population. METHODS The personality profile of 336 drug-dependent patients was compared with that of a sample of community participants in the context of a decision tree learning approach using the Alternative Five Factor Model. The resulting discriminant model was cross-validated. RESULTS Neuroticism and impulsivity were the most relevant variables in the resulting model, but their association appeared to be hierarchically organized. In the personality characterization of these patients, neuroticism became the main discriminant dimension, whereas impulsivity played a differential role, explained by means of an interaction effect. Decision tree learning models appear to be a heuristic theoretical and empirical approximation to the study of relevant variables, such as personality traits, in drug-dependency research.

Serum Brain-Derived Neurotrophic Factor Levels and Cocaine-Induced Transient Psychotic Symptoms

Background: Cocaine-induced psychosis (CIP) is among the most serious adverse effects of cocaine. Reduced serum brain-derived neurotrophic factor (BDNF) levels have been reported in schizophrenia and psychosis; however, studies assessing the involvement of BDNF in CIP are lacking. Methods: A total of 22 cocaine-dependent patients (aged 33.65 ± 6.85) who had never experienced psychotic symptoms under the influence of cocaine (non-CIP) and 18 patients (aged 34.18 ± 8.54) with a history of CIP completed a 2-week detoxification program in an inpatient facility. Two serum samples were collected from each patient at baseline and at the end of the protocol. Demographic, consumption and clinical data were recorded for all patients. A paired group of healthy controls was also included. Results: At the beginning of the detoxification treatment, serum BDNF levels were similar in both the non-CIP and the CIP groups. During early abstinence, the non-CIP group exhibited a significant increase in serum BDNF levels (p = 0.030), whereas the CIP group exhibited a decrease. Improvements in depression (Beck Depression Inventory, BDI, p = 0.003) and withdrawal symptoms (Cocaine Selective Severity Assessment, CSSA, p = 0.013) show a significant positive correlation with serum BDNF levels in the non-CIP group, whereas no correlation between the same variables was found in the CIP group. Conclusions: This study suggests that BDNF plays a role in the transient psychotic symptoms associated with cocaine consumption. In the non-CIP group, the increase in serum BDNF appears to be driven by the effects of chronic cocaine consumption and withdrawal. In contrast, patients with CIP share some of the neurotrophic deficiencies that characterize schizophrenia and psychosis.

Confirmatory Factor Analysis of Borderline Personality Disorder symptoms based on two different interviews: The Structured Clinical Interview for DSM-IV Axis II Disorder and the Revised Diagnostic Interview for Borderlines

The diagnostic criteria for Borderline Personality Disorder (BPD) are heterogeneous, and include an admixture of personality traits, behaviours, and symptoms. The BPD DSM factor structure has been extensively studied, even though results are not consistent. In this study we performed a confirmatory factor analysis (CFA) to compare the five-factor model reported by Oldham, a three-factor model, and a unidimensional model of BPD diagnosis criteria. This study validates the findings of previous studies by performing a CFA with the DSM-IV BPD criteria and information derived from the DIB-R. A sample of 338 patients referred to our outpatient BPD program participated in the study. Results of the CFA support both the hypothesized unidimensional and the three-factor models, whereas the five-factor model was not confirmed. However, the three-factor model fits better than the unidimensional model. Thus, although the DSM-IV BPD criteria conceptualize BPD as a unidimensional structure, our results give support to the idea that the three-factor model could offer a better approach to further improve the current treatment of BPD, as well as lead to a better understanding of its ethiopathogenesis and comorbidity analysis.

Clinical differences between cocaine-induced psychotic disorder and psychotic symptoms in cocaine-dependent patients

The aim of this study is to compare the clinical characteristics of three groups of patients in treatment for cocaine dependence: patients without any psychotic symptoms (NS), patients with transient psychotic symptoms (PS) and patients with cocaine-induced psychotic disorder (CIPD). An observational and retrospective study of 150 cocaine-dependent patients undergoing treatment in the Drug Unit of the Psychiatry Department of University Hospital Vall d׳Hebron in Barcelona (Spain) using these three groups, NS, PS and CIPD, was performed. All patients were evaluated with the PRISM interview. ANOVA, χ2 tests and multivariate multinomial regression analysis were used to perform statistical analyses. Seven patients with a primary psychotic disorder were discharged. Forty-six patients (32.1%) did not report any psychotic symptoms. Ninety-seven patients (67.9%) presented with a history of any cocaine-induced psychotic symptom and were considered as the cocaine-induced psychotic (CIP) group. Among them, 39 (27.3%) were included in the PS group and 58 (40.6%) were included in the CIPD group. A history of imprisonment was found significantly more frequently in the PS group than in the NS group. The distribution of age at onset of dependence, lifetime cannabis abuse or dependence and imprisonment were significantly different between the NS and CIPD groups. We conclude that in cocaine-dependent patients, clinicians should be advised about the risk of development of psychotic symptoms. The presence of some psychotic symptoms could increase the potential risks of disturbing behaviours.

Effectiveness of combined individual and group dialectical behavior therapy compared to only individual dialectical behavior therapy: a preliminary study.

Dialectical behavior therapy (DBT) is an effective therapy. However, treating borderline personality disorder (BPD) patients with standard DBT can be problematic in some institutions due to logistical or cost limitations. The aim of this preliminary study is to examine the efficacy of Individual DBT in 37 BPD patients, compared with Combined individual/Group DBT in 14 BPD patients. Outcome measures included suicide attempts, self-harm behaviors, and visits to emergency departments. These variables were examined at pretreatment, 12 months/end of treatment, and at an 18-month follow-up. In addition, dropout rates were examined. Significant improvements on the outcome measures were observed across both versions of DBT treatment, particularly at the 18-month follow-up assessment. No significant differences were observed between Individual DBT and Combined individual/Group DBT on any of the posttreatment evaluations. An individual version of DBT may be an effective and less costly option for BPD treatment. Larger controlled trials are needed to confirm the results.

Cocaine-Induced Psychosis and Impulsivity in Cocaine-Dependent Patients

Cocaine-dependent patients have high impulsiveness. Cocaine-induced psychosis is common among cocaine-dependent patients. Different risk factors associated with cocaine-induced psychosis have been reported. The aim of this study is to analyze the relationship between psychotic symptoms in cocaine-dependent patients and impulsivity and mental disorders characterized by impulsivity. This descriptive study included 287 outpatients with cocaine dependence according to the DSM-IV-TR criteria. The Structured Clinical Interview for DSM-IV Axis I and II, the Barratt Impulsiveness Scale, and a specific questionnaire on the presence of cocaine-induced psychosis were used to assess patients. Symptoms were observed in 59.9% of the study population. Total and cognitive impulsiveness scores obtained from the Barratt Impulsiveness Scale were significantly higher in patients with cocaine-induced psychosis. Individuals from this group reported more overdose incidents, initiated more treatments during their lifetime, and had a significantly greater prevalence of attention deficit hyperactivity disorder. Patients with cocaine-induced psychosis have a greater degree of impulsivity and a higher prevalence of attention deficit hyperactivity disorder. Thus, if these disorders are observed in cocaine-dependent participants, the presence of psychotic symptoms should be evaluated to prevent further occurrence and their consequences.

Dual Diagnosis Resource Needs in Spain: A National Survey of Professionals

Objective: Since provision of integrated services for patients with dual pathology or dual disorders (coexistence of an addictive disorder and another mental health disorder) is an important challenge in mental health, this study assessed health care professionals’ perceptions and knowledge of the current state of specific resources for patients with dual pathology in Spain. Methods: We conducted a national survey of health care professionals seeing patients with dual pathology in treatment facilities throughout Spain. Participants completed a specific online questionnaire about the needs of and available resources for patients with dual pathology. Results: A total of 659 professionals, mostly psychologists (n = 286, 43.4%) or psychiatrists (n = 217, 32.9%), participated in the study. Nearly all participants who responded to these items reported that specific resources for dual pathology were needed (n = 592/635, 93.2%); 76.7% (n = 487) identified intermediate resources, 68.8% (n = 437) acute detoxification units, and 64.6% (n = 410) medium-stay rehabilitation units as particularly necessary. In the opinion of 54.0% of respondents (n = 343), integrated mental health and addiction treatment services were available. Of the participants who answered these items, only a small proportion (n = 162/605, 26.8%) reported that there were appropriate outpatient programs for dual pathology, 30.4% (n = 184/605) specific hospitalization units, 16.9% (n = 99/587) subacute inpatient units, 34.2% (n = 201/587) outpatient intermediate resources, 15.5% (n = 91/587) day hospitals, and 21.5% (n = 126/587) day centers. Conversely, 62.5% (n = 378/587) of participants reported a greater presence of specific detoxification/withdrawal units, 47.3% (n = 286/587) psychiatric acute admission units, and 41.9% (n = 246/587) therapeutic communities. In the professionals’ opinion, the presence of specialty programs was low; 11.6% of respondents (n = 68/587) reported that vocational programs and 16.7% (n = 98/587) reported that occupational rehabilitation programs were available. Employee turnover was common: 51.9% of respondents (n = 314/605) stated that employee turnover was occasional to frequent. Conclusions: According to the professionals surveyed, specific health care resources for the management of dual pathology are currently insufficient, underlining the need for additional efforts and strategies for treating individuals with comorbid disorders.

Neuroticism associated with cocaine-induced psychosis in cocaine-dependent patients: a cross-sectional observational study.

Background Cocaine consumption can induce transient psychotic symptoms, which has been correlated with more severe addiction and aggressive behavior. However, little is known about the nature of the relationship between personality traits and psychotic symptoms in cocaine-dependent patients. This study examined the relationship between neuroticism and cocaine-induced psychosis. Methods A total of 231 cocaine-dependent patients seeking treatment were recruited to the study. Personality was evaluated by the Zuckerman-Kuhlman Personality Questionnaire. Cocaine-induced psychosis questionnaire, SCID-I, and SCID-II were used to evaluate comorbidity and clinical characteristics. Data analysis was performed in three steps: descriptive, bivariate, and multivariate analyses. Results Cocaine-induced psychosis was reported in 65.4% of the patients and some personality disorder in 46.8%. Two personality dimensions (Neuroticism-Anxiety and Aggression-Hostility) presented a significant effect on the risk of experiencing psychotic symptoms (t(229) = 2.69, p = 0.008; t(229) = 2.06, p = 0.004), and patients with psychotic symptoms showed higher scores in both variables. On the multivariate analysis, only Neuroticism remained as a significant personality factor independently associated with psychotic symptoms (Wald = 7.44, p<0.05, OR = 1.08, CI 95% 1.02–1.16) after controlling for age, gender and number of consumption substances. Conclusions An association between high neuroticism scores and presence of psychotic symptoms induced by cocaine has been found, independently of other consumption variables. Personality dimensions should be evaluated in cocaine-dependent patients in order to detect high scores of neuroticism and warn patients about the risk of developing cocaine-induced psychotic symptoms.

Observational study on medications prescribed to dual-diagnosis outpatients.

Objectives:To quantify the number of medications used for treating psychiatric and addictive disorders in a cohort of dual diagnosis with substance dependence outpatients and report the most frequent pharmacological groups used. Methods:A descriptive, cross-sectional study was conducted. Demographic data, Axis I comorbidity diagnosis with substance dependence, and the medications prescribed were recorded. Diagnosis was assessed by the Structured Clinical Interview for DSM-IV (SCID). Results:One hundred seven patients (mean age 37.7 years; SD = 10.2 years) were evaluated (76.6% men). On average, patients took 4.0 (SD = 1.8) medications. The pharmacological groups prescribed were antipsychotics (69.2%) followed by antidepressants (65.4%), antiepileptics (58.9%), anxiolytics (37.4%), alcohol-aversive drugs (15.9%), methadone (15.9%), lithium (3.7%), and naltrexone (2.8%). Older patients (>45 years old) were found to have a higher number of prescribed medications. Patients diagnosed with a dual psychotic disorder were prescribed a larger number of pharmacological agents (mean = 4.4; SD = 2.1) than patients with a mood disorder (mean = 3.7; SD = 1.3) or an anxiety disorder (mean = 2.9; SD = 1.2), K = 10.5, P = 0.005. Conclusions:Because polypharmacy is frequent in patients with mental illness and a co-occurring substance use disorder, specialized approaches need to be developed.