Mohammed T. Abou-Saleh

The effectiveness of behavioural interventions in the primary prevention of Hepatitis C amongst injecting drug users: a randomised controlled trial and lessons learned

AimTo develop and evaluate the comparative effectiveness of behavioural interventions of enhanced prevention counselling (EPC) and simple educational counselling (SEC) in reducing hepatitis C viral (HCV) infection in sero-negative injecting drug users (IDU).DesignRandomised controlled trial (RCT) of EPC intervention in comparison with simple educational counselling (SEC).Setting SpecialisedDrug services in London and Surrey, United Kingdom.Participants and MeasurementsNinety five IDUs were recruited and randomised to receive EPC (n = 43) or SEC (n = 52). Subjects were assessed at baseline using the Addiction Severity Index (ASI), the Injecting Risk Questionnaire (IRQ), and Drug Injecting Confidence Questionnaire (DICQ). The primary outcome was measured by the rate of sero-conversion at 6 months and 12 months from baseline and by the ASI, IRQ and DICQ at 6 months from baseline. Hepatitis C testing was undertaken by the innovative test of the dried blood spot (DBS) test which increased the rate of testing by 4 fold compared to routine blood testing.Findings SeventyEighty two subjects (82%) out of the 95 recruited were followed up at 6 months and 62 (65%) were followed up at 12 months. On the primary outcome measure of the rate of seroconversion, 8 out of 62 patients followed-up at twelve months seroconverted, three in the EPC group and five in the SEC group, indicating incidence rates of 9.1 per 100 person years for the EPC group, 17.2 per 100 person years for the SEC group, and 12.9 per 100 person years for the cohort as a whole. Analysis of the secondary outcome measures on alcohol use, risk behaviour, psychological measures, quality of life, showed no significant differences between the EPC and the SEC groups. However, there were significant changes on a number of measures from baseline values indicating positive change for both groups.ConclusionWe were not able to prove the efficacy of EPC in comparison with SEC in the prevention of hepatitis C in IDUs. This was related to low recruitment and retention rates of the participants. Moreover there was a low adherence rate to EPC. The study provided the benefits of developing and introducing behavioural interventions of the EPC and SEC and the DBS screening for Hepatitis C. Moreover the main lessons learnt were that piloting of a new intervention is a crucial first step before conducting pragmatic RCTs of psychological interventions in the field of addiction; that an infrastructure and culture for psychosocial interventions is needed to enable applied research in the service environment, and research funding is needed for enabling the recruitment of dedicated trained therapists for the delivery of these interventions.

Risky decision-making predicts short-term outcome of community but not residential treatment for opiate addiction. Implications for case management.

BACKGROUND Opiate addiction is associated with decision-making deficits and we previously showed that the extent of these impairments predicts aspects of treatment outcome. Here we aimed to establish whether measures of decision-making performance might be used to inform placement matching. METHODS Two groups of opiate dependent individuals, one receiving treatment in a community setting (n=48) and one in a residential setting (n=32) were administered computerised tests of decision-making, impulsivity and planning shortly after the beginning of treatment, to be followed up three months into each programme. RESULTS In the community sample, performance on the decision-making tasks at initial assessment predicted abstinence from illicit drugs at follow-up. In contrast, in the residential sample there was no relationship between decision-making and clinical outcome. CONCLUSIONS Intact decision-making processes appear to be necessary for upholding a resolve to avoid taking drugs in a community setting, but the importance of these mechanisms may be attenuated in a residential treatment setting. The results support the placement matching hypothesis, suggesting that individuals with more prominent decision-making deficits may particularly benefit from treatment in a residential setting and from the inclusion of aspects of cognitive rehabilitation in their treatment programme.

The prevalence and burden of psychiatric disorders in primary health care visits in Qatar: Too little time?

Background: Psychiatric disorders including anxiety, depression, somatization, obsessive compulsive, and bipolar disorders are recognized as causing the biggest burden of disease worldwide. Aim: In this study, we aimed to assess the prevalence and burden of common mental disorders at Primary Health Care Centers (PHCC) using the World Health Organization Composite International Diagnostic Interview (WHO-CIDI) in the Qatari population, aged 18–65 who attended Primary Health Care (PHC) settings. Design: A prospective cross-sectional study conducted during November 2011 to October 2012. Setting: Primary Health Care Centers of the Supreme Council of Health, Qatar. Subjects: A total of 2,000 Qatari subjects aged 18–65 years were approached; 1475 (73.3%) agreed to participate. Methods: Prevalence and severity of International Classification of Disease-10 disorders were assessed with the WHO-CIDI (Version 3.0). Results: Of the 1475 participants, 830 (56.3%) were females and 645 (43.7%) was males. One-third were aged 35–49 years 558 (37.8%). The three most common disorders were major depression disorders (18.31%), any anxiety disorders (17.3%), any mood disorders (16.95%), followed by separation anxiety disorders (15.25%), personality disorder (14.1%). In the present study, prevalence in women was significantly higher than men for the most common psychiatric disorders, specifically generalized anxiety disorder, panic disorder, social phobia, specific phobias, obsessive compulsive disorders, posttraumatic disorder, somatization, major depressive disorder, bipolar disorder, dysthymia, and oppositional defiant disorder. Of the total 20% had only one psychiatric diagnosis and 12% had two disorders, 9.7% respondents with three diagnoses, and finally 4.3% of respondents had four or more diagnoses. Conclusion: One-fifth of all adults who attended the PHCC (20%) had at least one psychiatric diagnosis. The CIDI is a useful instrument for psychiatric diagnosis in community settings such as PHC clinics, clinical research and intervention studies. There is an urgent need to not only assess prevalence, but also risk factors, burden, treatment gaps and outcomes to obtain evidence for policy making.

Hepatitis C Testing in Drug Users Using the Dried Blood Spot Test and the Uptake of an Innovative Self-administered DBS Test

Background:Hepatitis C viral (HCV) infection is a common occurrence in drug users attributed to injecting drug use. HCV is treatable with the availability of effective antiviral medication. However, studies have shown low uptake of hepatitis C routine blood testing and hence little access to treatment for drug users with HCV. There is therefore need to develop alternative methods of HCV testing. The dried blood spot (DBS) test provides this alternative method to increase detection rates and improve access to treatment. Objectives:To assess the effect of providing testing for HCV using the DBS at community drug services including nonstatutory drug services and in prison; to determine pathways of care for drug users with HCV; to examine the uptake of offering injecting drug uses, the option of obtaining a DBS sample themselves at their place of residence as an innovative way of delivering testing in the community. Methods:The present study recruited groups of drug users attending national health care, nonstatutory (needle exchange scheme) community services, and those detained in prison. Participants were offered the DBS including an innovative self-administered DBS to enable them to take responsibility for their health and to self-manage risk behavior for hepatitis C. Results:There were high rates of HCV infection in all these settings, and the use of DBS resulted in an increased uptake of HCV testing including the self-administered DBS on the second testing occasion. Moreover its provision has enabled the development of care pathways into treatment for those with HCV. Conclusions:The DBS test for HCV is an effective alternative method with many advantages over conventional blood testing method. Its use in health care settings increased uptake of testing and access to treatment. The self-administered DBS is an innovative method that enables drug users to take responsibility for self-management and maintaining their health and safety.

Developing a service for people with dual diagnosis

Background: Comorbid severe mental illness and substance misuse occur in 15% of patients attending community mental health teams. Although these patients have poorer outcomes than those without comorbidity, historically they have been inadequately provided for by existing addiction and mental health services. Development: In Richmond, UK, a new service was developed for people with dual diagnosis without extra staffing or financial resources. The model comprised three components: a link worker from the community drug and alcohol team who works with individual mental health teams to offer advice and attend multidisciplinary meetings; a five-day training in dual diagnosis for staff; and a protocol for joint working of patients by both mental health and substance misuse teams. Discussion: The major issue in implementing the model was engaging staff, but overall referral pathways between teams have improved. In addition, the majority of dual diagnosis patients attend joint appointments, and 80 members of staf...

Screening for mental problems in people presenting with hypertension and comorbidities.

The authors provided good guidance on the complexities of managing hypertension with associated chronic comorbid physical conditions, such as kidney disease, diabetes, chronic obstructive pulmonary disease (COPD), and heart failure.1 However, they did not mention the mental health problems that are often seen in these people …

Detecting Antibodies to Hepatitis C in Injecting Drug Users: A Comparative Study Between Saliva, Serum, and Dried Blood Spot Tests

Background:Injecting drug use is associated with high rates of hepatitis C. This has been attributed to the sharing of equipment used in injecting. Testing for hepatitis C viral (HCV) infection using routine blood has proved to be problematic, and hence the need to develop alternative methods of HCV testing has arisen. Objectives:To study the utility of saliva for HCV antibody testing in comparison with the use of blood obtained by routine blood sampling or using the dried blood spot (DBS) test in the context of a randomized controlled trial of the effectiveness of primary prevention of hepatitis C in injecting drug users (IDUs). Methods:IDUs attending drug services were screened for HCV antibodies using saliva or blood including DBS. Results:There was poor acceptability of a routine blood test for HCV. Introducing the DBS was associated with a 4.6-fold increase in HCV testing. A total of 241 unique patients provided 323 DBS and/or saliva samples. The prevalence of HCV antibodies ranged from 19.7% to 52.9% (mean 26.8%) in IDUs. The prevalence of HCV infection detected by saliva was 28.5% compared with 27.6% detected by blood (DBS). In 51 IDUs who were HCV seronegative and were tested for a second time by DBS, 4 were antibody positive indicating an incidence of 8 per 100 person-years. Conclusions:Testing for HCV infection using saliva although feasible has lower sensitivity (90.4%) and lower specificity (95.1%) compared with blood samples including DBS. This study introduced the DBS to screen for HCV in clinical settings. The use of DBS removes a key obstacle for testing for HCV and is recommended for routine use in health settings and for large-scale community-based surveys of the prevalence and incidence of HCV in drug users.

Co-morbidity in the Severely Mentally Ill: Cardiometabolic Risk Factors, Prevention and Intervention

Co-morbidity represents one of the greatest challenges for twenty-first-century medicine. A high prevalence of co-morbidity in the severely mentally ill (SMI) has been well established leading to a significant impact on quality of life, life expectancy and premature death by 15–20 years. The major recognised contributor to excess death is cardiovascular disease.

Schizophrenia and co-morbid obsessive - compulsive disorder: Clinical characteristics

BACKGROUND Psychiatric co-morbidity is a common condition, partly due to the overlap of symptoms in the categorical diagnosis of mental disorders. The co-occurrence of schizophrenia (SZ) and obsessive compulsive disorder (OCD) is a common and challenging co-morbid condition. Also, the relationship between SZ and OCD remains unclear. AIM The aim of this study was to describe the co-morbidity of obsessive-compulsive disorder (OCD) among schizophrenia (SZ) patients and compare clinical characteristics of schizophrenia patients with versus without comorbid OCD. SUBJECTS AND METHODS A cohort-study was carried out on 396 patients enrolled between November 2011 to June 2014 at the Department of Psychiatry, Rumeilah Hospital in Qatar. We employed the WHO Composite International Diagnostic Interview (WHO-CIDI), and Structured clinical interview for DSM-5 (SCID-5) for diagnoses, the Yale-Brown Obsessive Compulsive Scale Symptom Checklist for scoring OCD. Patients were grouped in SZ patients with and without comorbid OCD (SZ-OCD vs SZ). RESULTS 396 subjects were interviewed. Age of SZ-OCD patients was 42.69 ± 14.33 (years old) whereas SZ patients without OCD ranged 41.59 ± 13.59 years old. There were statistically significant differences in clinical characteristics between SZ with and without OCD : age (p = 0.010), BMI (body mass index; p = 0.011), education (p = 0.033), employment (p = 0.019), cigarette smoking (p = 0.039), sheesha smoking (p = 0.008), and prevalence of consanguinity (p = 0.043). In particular, the rate of consanguinity in the current generation was 31.8% [95% CI = 29.1-34.7]. Also, there were statistically significant differences at Hamilton Depression score, General Health Score, Clinical Global Impression- Score, duration of illnesses, and Global Assessment of Functioning (p < 0.001). The results show that anxious, mood and psychotic dimensions rated higher among SZ - OCD ones than SZ only patients. CONCLUSION This study confirms that SZ-OCD is a common co-morbidity and prevalence of SZ OCD is higher among patients reporting a degree of consanguinity. Even if this condition is under-recognized in clinical practice, it may significantly change SZ presentation and outcome since psychopathological dimensions report higher scores in the co-morbidity sample.

Comorbid obsessive-compulsive disorder and bipolar disorder in a highly endogamous population: which came first?

ABSTRACT Co-occurrence of bipolar disorder (BD) and obsessive compulsive disorder (OCD) is a common and difficult comorbid condition to manage. The aim of this study was to determine the prevalence of comorbidity with OCD among BD patients in a highly endogamous population. A cohort study was carried out on 396 patients enrolled between November 2011 and October 2013. Patients were grouped in BD patients with OCD (BD-OCD) and BD patients without OCD, rated for mania and depression and scored for OCD morbidity. We found significant differences in level of education (p = 0.022), occupation status (p = 0.025), household income, (p = 0.049), cigarette smoking (p = 0.038), sheesha smoking (narghile, water pipe, hookah or hubble bubble smoking) (p = 0.007) and prevalence of consanguinity (p = 0.036) among these groups. Number of hospitalizations and Young Mania Rating Scale score were not different among BD patients with or without OCD, whereas there were significant differences in Ham-D score, Clinical Global Impression for bipolar disorder Score, duration of illnesses and Global Assessment of Functioning. Also, specific phobia, somatization, depression, mania, any mood disorder, oppositional defiant disorder, Attention Deficit Hyperactivity Disorder and personality disorder were more common in BD than OCD–BD group. This study confirms that BD-OCD is a common comorbidity, largely under-recognized in clinical practice, which may significantly change BD presentation and outcome.