Luca Rovai

Dual diagnosis and chronology of illness in treatment-seeking Italian patients dependent on heroin.

ABSTRACT Although there are studies describing the prevalence of patients with drug addiction and dual diagnosis, there is a paucity of data regarding the progression from psychiatric disorders to drug addiction or vice versa. A total of 1,090 patients dependent on heroin were interviewed to examine the presence of dual diagnosis and the progression from psychiatric disorders to drug dependence or vice versa. A total of 574 patients met the criteria for a dual diagnosis. A total of 362 patients progressed from substance abuse disorders to psychiatric disorders (SUD-PR) and 144 patients progressed from psychiatric disorders to drug addiction (PSY-PR). SUD-PR patients are more frequently affected by mood disorders. PSY-PR patients were more frequently diagnosed as psychotic or affected by anxiety disorders. The authors’ findings suggest that the self-medication theory of dual diagnosis was relevant only for those with existing diagnoses of schizophrenia or anxiety disorders. When treating patients with a dual diagnosis, clinicians should ensure that the same attention is given to the treatment of drug dependence as it is to the treatment of comorbid psychiatric conditions.

Clinical presentations of substance abuse in bipolar heroin addicts at time of treatment entry

BackgroundStudies on the ‘self-medication hypothesis’ have focused on substance abuse as an attempt to alleviate emotional suffering.MethodsWe have investigated concomitant substances of abuse in 150 bipolar heroin addicts clustered according to their clinical presentation at treatment entry (depressive episode, hypomanic episode, manic episode and mixed episode). Bipolar heroin addicted patients were chosen because they tend to have a concomitant poly-substance abuse and because, as compared with patients suffering for other mental illnesses, they more clearly reveal a variety of identifiable affective states.ResultsPatients with a depressive episode more frequently used non-prescribed anxiolytic-hypnotics. They were found to use cocaine-amphetamines more frequently during a hypomanic episode, whereas the use of cannabis and cocaine-amphetamines occurred more frequently during a manic episode. The associated use of alcohol, cocaine-amphetamines and cannabinoids was more frequently encountered during a mixed episode. Limitations: apart from the difficulty in determining whether the substance use modifies the mood or the mood state determines the substance used, this is a report on a retrospective analysis, rather than a study specifically designed to elucidate the issue; in addition, no information was available on the temperament of our subjects. Assessments of the same subject in various clinical presentations would have provided a better level of information.ConclusionsBesides one expected result – the prominent use of CNS stimulants during a depressive phase of bipolar patients – this study supports the hypothesis that mood elation is a pleasurable, rewarding experience that, in bipolar patients, can be started or prolonged by means of CNS stimulant drugs. Stimulant use was, therefore, more prevalent during the ‘up’ rather than the ‘down’ phase of the illness.

Discriminant and convergent validity of TEMPS-A[P] correlation with MMPI and the emotional-affective state following a stressful situation

BACKGROUND The temperament evaluation of the Memphis, Pisa, Paris and San Diego questionnaire (TEMPS), in its rater-wise and its self-evaluation forms, has been designed to evaluate temperamental characteristics in clinical and non-clinical populations. The validation process is currently in progress in various countries. In order to improve this validation process we have extended the area of correlations of its self-evaluation form (TEMPS-A[P]) to MMPI, and to a special RS that allows assessment of the emotional-affective state following a stressful situation. METHODS In 693 candidates applying to become cadets in the Italian Air Force we have assessed the correlation between the TEMPS-A[P] and the MMPI validity and clinical scales, and administered an emotional-affective state questionnaire (EAS-RS) after they had gone through the stressful challenge of taking an academy entrance examination. RESULTS As regards MMPI validity scales, TEMPS-A[P] depressive candidates tend to report their symptoms sincerely. Hyperthymic candidates tend to give false answers so that others will see them in a good light. Cyclothymic and irritable candidates tend to exaggerate symptoms. As regards the MMPI clinical scales, a low level of linkage between affective temperaments and abnormal personality traits was found. As regards EAS-RS: hyperthymic temperament on one hand, and cyclothymic and depressive temperaments on the other, are characterized by counter-polar emotional states following the test; these are desirable in the first case and undesirable in the other two. CONCLUSIONS The convergent and discriminant validity of TEMPS-A[P] was confirmed. From a personalistic point of view, temperaments seem to belong to the realm of normality rather than to that of pathology, in line with their putative adaptive role.

Long-Term γ-Hydroxybutyric Acid (GHB) and Disulfiram Combination Therapy in GHB Treatment-Resistant Chronic Alcoholics

Leading Italian studies support the use of γ-hydroxybutyric acid (GHB), not only in the treatment of the alcohol withdrawal syndrome, but also in maintaining alcohol abstinence. GHB gives a better result than naltrexone and disulfiram in maintaining abstinence, and it has a better effect on craving than placebo or disulfiram. The problem is that about 30–40% of alcoholics are non-responders to GHB therapy. In our clinical practice, we speculate that by combining disulfiram with GHB treatment we may be able to achieve a kind of ‘antagonist’ effect by using the ‘psychological threat’ of disulfiram (adversative effect) while taking advantage of the anticraving effect of GHB, despite the limitation of its ‘non-blockade’ effect on alcohol. In this context, to improve the outcome in GHB long-term treated alcoholics, we added disulfiram to GHB in the management of GHB treatment-resistant alcoholics. In this study we compared retention in treatment of 52 patients who were treated with the GHB-disulfiram combination for up to six months, with retention for the same subjects considering their most recent unsuccessful outpatient long-term treatment with GHB only. An additional comparison was carried out on the days of complete abstention from alcohol. Thirty four patients (65.4%) successfully completed the protocol and were considered to be responders; 18 (34.6%) left the programme, and were considered to be non-responders. Considering the days of complete abstinence from alcohol, 36 patients stayed in treatment longer with the GHB-Disulfiram combination, 12 stayed for a shorter time and four for the same time. The results of this study seem to indicate a higher efficacy of the GHB-disulfiram association compared with GHB alone. Randomized controlled trials are now needed to verify this hypothesis.

TEMPS-A[p] temperament profile related to professional choice: A study in 1548 applicants to become a cadet officer in the Italian air force

BACKGROUND Temperaments have been described with respect to their adaptive roles. Thus, depressive traits seem to increase sensitivity to suffering, cyclothymic traits appear relevant to creativity, and hyperthymic traits have been implicated in territoriality and leadership and more generally in active pursuits. METHODS The temperaments of 1548 candidates applying to become a cadet officer in the Italian air force, who had taken the 2005 entrance examination, were compared with deviant and non-deviant peers. At a psychological level, we also compared those who had applied to become a cadet officer with other applicants who had failed in a previous entrance examination and with applicants who had passed or failed to pass the specific psychological entrance examination. RESULTS Applicants who took the entrance examination are more hyperthymic than their peers, regardless of any concurrent psychosocial deviance (i.e. drug addiction). The specificity of this correlation is confirmed by the fact that applicants who made a second attempt to pass the entrance examination after an initial failure were more hyperthymic than first-time applicants. Similarly, success in specific psychological admission tests is related to the same temperamental profiles, since those who prove to be psychologically fit are more hyperthymic. The inverse relationship emerges from an examination of other temperamental scales, which are better represented in controls (non-applicants), or other applicants making their first attempt at admission, or those who were excluded due to psychological flaws. CONCLUSION In the present study, extremely high scores on the hyperthymic scale combined with extremely low ones in the cyclothymic scale seem to correspond to the specific temperament profile and to the highest likelihood of success in those applying to become a cadet officer in the Italian air force.

Negative dimension in psychiatry. Amotivational syndrome as a paradigm of negative symptoms in substance abuse.

Negative symptoms, conceptualized as clinical manifestations of schizophrenia, and subsequently described in other psychiatric disorders, include the loss of normal arousal, drive and affective reactivity. In the field of substance abuse, an interesting analogy can be detected between negative symptoms, in their classical meaning, and the amotivational syndrome (AS), which has been described as a form of chronic cannabis intoxication. AS also shows a close resemblance to the reward deficiency syndrome (RDS) of alcoholics and stimulant abusers, and to the post-withdrawal syndrome (PWS) of detoxified heroin addicts. A variety of substances share a common tropism for the dopaminergic system, leading to a state of hypophoria, which seems to represent a common pathway for chronic substance abusers. In the light of these convergences, a common treatment principle for addictive disorders can be enunciated. This consists in resorting to pro-dopaminergic drugs, that are supposed to replace damaged functions and control craving, and in avoiding anti-dopaminergic drugs, that are expected to exacerbate craving and impede the reversal of the reward deficiency.

The long-term outcomes of heroin dependent-treatment-resistant patients with bipolar 1 comorbidity after admission to enhanced methadone maintenance.

OBJECTIVE The aim of this study was to compare the long-term outcomes of treatment-resistant bipolar 1 heroin addicts with peers who were without DSM-IV axis I psychiatric comorbidity (dual diagnosis). METHOD 104 Heroin-dependent patients (TRHD), who also met criteria for treatment resistance - 41 of them with DSM-IV-R criteria for Bipolar 1 Disorder (BIP1-TRHD) and 63 without DSM-IV-R axis I psychiatric comorbidity (NDD-TRHD) - were monitored prospectively (3 years on average, min. 0.5, max. 8) along a Methadone Maintenance Treatment Programme (MMTP). RESULTS The rates for survival-in-treatment were 44% for NDD-TRHD patients and 58% for BIP1-TRHD patients (p=0.062). After 3 years of treatment such rates tended to become progressively more stable. BIP1-TRHD patients showed better outcome results than NDD-TRHD patients regarding CGI severity (p<0.001) and DSM-IV GAF (p<0.001). No differences were found regarding urinalyses for morphine between groups during the observational period. Bipolar 1 patients needed a higher methadone dosage in the stabilization phase, but this difference was not statistically significant. LIMITATIONS The observational nature of the protocol, the impossibility of evaluating a follow-up in the case of the patients who dropped out, and the multiple interference caused by interindividual variability, the clinical setting and the temporary use of adjunctive medications. CONCLUSIONS Contrary to expectations, treatment-resistant patients with bipolar 1 disorder psychiatric comorbidity showed a better long-term outcome than treatment-resistant patients without psychiatric comorbidity.

Symptomatological features of patients with and without ecstasy use during their first psychotic episode

Background: Ecstasy use is generally chosen by adolescents and young adults for its entactogenic properties (the production of feelings of empathy, love, and emotional closeness to others.) Despite this desired and frequently realized outcome, Ecstasy use has often resulted in the genesis of psychotic symptoms and aggressive behaviors, particularly after chronic and/or intensive use. Methods: To explore the negative consequences of Ecstasy use and to examine the aggressive nature oftentimes seen in many Ecstasy users we employed a case-control study model. We compared, by means of validated psychometric tests, the psychopathological symptoms (BPRS), the aggressiveness (OAS) and the social adjustment (DSM-GAF) of psychotic patients with (n = 23) and without (n = 46) recent user of Ecstasy, during their first psychotic episode and hospitalization. All 23 Ecstasy users were Ecstasy users only. Results: Almost all of the psychotic symptoms were of similar severity in both groups. Blunted affect was milder in users than in non-users, whereas hostility and aggressive behavior was significantly more severe in users than in non-users. Conclusions: psychosis with a high level of aggressiveness and violence constitutes an important ‘side-effect’ that surely runs counter to the expected entactogenic action of Ecstasy. At a patient psycho-educational level, this study suggests that the use of Ecstasy may be counterproductive with respect to user expectations.

TEMPS-A[P] temperament profile related to professional choice. Differences between applicants to become a cadet officer in the Italian Air Force or Navy

BACKGROUND Temperament appears to be a factor involved in professional attitudes. The most impressive findings are those on the importance of cyclothymia in art and of hyperthymia in leadership. AIM In this study we raise the issue of whether the relationship between hyperthymic temperament and the choice of a military career, previously reported among Italian Air Force applicants, can be extended to another military service such as the Italian Navy. METHODS We compared temperaments between those who had applied to become a cadet officer in the Italian Air Force or in the Italian Navy, with special reference to gender differences and the ability of the two types of applicants to pass the psychiatric examination for admission that we had recently assessed in the Italian Air Force. RESULTS Hyperthymic traits were well represented in both these armed services. Navy applicants differed from air-force applicants in obtaining higher depressive, cyclothymic and irritable scores. Navy applicants who passed the psychiatric entrance examination (PEE) showed the same incidence of hyperthymic temperament as their Air Force counterparts, but higher depressive, cyclothymic and irritable scores. Considering gender, among Air Force applicants depressive traits were better represented in males; conversely, among Navy applicants they were better represented in females. If we consider gender together with PEE results, the highest hyperthymic scores were more frequently found among males who passed and females who failed to pass the PEE. On the other hand, a greater number of cyclothymic traits were found in females who passed and males who failed to pass the PEE. CONCLUSIONS It was confirmed that hyperthymic temperament represents the temperamental profile of those who aim to become a cadet officer in the Italian armed forces. This study further supports the idea that hyperthymic traits bring distinct advantages in a professional field, such as a military career, which is closely related to leadership.

Correlations Between Awareness of Illness (Insight) and History of Addiction in Heroin-Addicted Patients

In a group of 1066 heroin addicts, who were seeking treatment for opioid agonist treatment, we looked for differences in historical, demographic, and clinical characteristics, between patients with different levels of awareness of illness (insight). The results showed that, in the cohort studied, a majority of subjects lacked insight into their heroin-use behavior. Compared with the impaired-insight group, those who possessed insight into their illness showed significantly greater awareness of past social, somatic, and psychopathological impairments, and had a greater number of past treatment-seeking events for heroin addiction. In contrast with other psychiatric illnesses, the presence of awareness appears to be related to the passing of time and to the worsening of the illness. Methodologies to improve the insight of patients should, therefore, be targeted more directly on patients early in their history of heroin dependence, because the risk of lack of insight is greatest during this period.