Socidrogalcohol Spanish national survey on prevalence and treatment of co-ocurrence of substance use disorder and other mental disorder Juan José Fernández Miranda Socidrogalcohol Board Spain

Background

SUD+OMD has been associated with: Although the co-occurrence of a substance use disorder (SUD) and other mental disorder (OMD) has been known for many years, only in the last two decades it has become a source of interest because high prevalence reported and negative influence such comorbidity has on prognosis of both disorders SUD+OMD has been associated with: poor health, higher suicidal risk, greater use of ER visits and psychiatric hospitalization, decreased treatment compliance, worse response to treatment with increased side effects and interactions, greater violent behavior, greater family instability, social exclusion and legal problems higher prevalence of HIV and hepatitis.

A number of studies report a high comorbidity between SUD and OMD, with a highly variable prevalence as studies have been conducted in heterogeneous populations (clinical, general populations) and using different methodologies. Prevalence of dual diagnosis is noticeably higher in treatment samples than in community samples. Population surveys have reported even rates around 50% for lifetime comorbidity. Alcohol is the most frequent substance of abuse among dual patients, followed by cannabis or cocaine. No psychopathology-substance related preference has been clearly shown.

SUD+OMD studies in Spain Arias F., et al. (2013). Estudio Madrid sobre prevalencia y caracteristicas de los pacientes con patologia dual en tratamiento en las redes de salud mental y de atencion al drogodependiente. Adicciones, l 25(1): 191-200. Arias et al. (2014). Bipolar disorders. Madrid study on the prevalence of dual disorders/pathology. J.Dual Diagn, 10 (2):68-78. EMCDDA (2015). Perspectives on drugs. Comorbidity of substance use and mental health disorders in Europe. Lisbon: EMCDDA. Fernández-Miranda, JJ et al. (2001). Influencia de los trastornos psiquiátricos en la efectividad de un programa de mantenimiento prolongado con metadona. Actas Españolas Psiquiatría 29 (4): 228-232. Gual, A. (2007). Dual diagnosis in Spain. Drug and Alcohol Review,26(1), 65–71. Pereiro, C et al(2013) Psychiatric comorbidity in patients from the addictive dsiorders assistance units in Galicia. The COPSIAD Study Sanchez-Pena, J.F., Alvarez-Cotoli, P., Rodriguez-Solano, J.J. (2012). Psychiatric disorders associated with alcoholism: 2 year follow-up of treatment. Actas Esp. Psiquiatr, 40(3): 129-135. Szermann, N et al (2012). Dual diagnosis ad suicide risk in spanish outpatient sample. Subs Use Misuse 47: 383-9.

Introduction

The effectiveness of existing programs to treat people with SUD+OMD in a specific and comprehensive manner has not been clearly shown. But it is clear that the treatments that reduce psychiatric symptoms also work in dual patients and the same for treatments that reduce substance abuse. In Spain, a relevant problem is a healthcare system traditionally organized into two parallel assistance services: mental health and addictions. Each service tends to give treatment priority to the disorder that has traditionally been within its scope, making patient’s improvement less likely.

Diagnose and treatment resources for people with SUD+OMD is an important challenge for National Health Service in Spain. There is a lack of registration and knowledge about people with dual diagnoses and of the different resources in which these patients are treated. And there is a need of additional efforts for harmonizing registry and therapeutic interventions . Socidrogalcohol has conducted a national survey of patients undergoing psychiatric or addiction treatment throughout Spain, taking advantage of its structure, with representation in all the Autonomous Communities and of all kind of health professionals.

Socidrogalcohol Spanish survey on prevalence and treatment of SUD and OMD Design

Method Epidemiological, observational, multicenter study with a large, randomized, representative sample of patients with addictive or other mental disorder throughout Spain. Health care professionals (physicians, psychiatrists, psychologists, …) seeing patients in: -mental health services (MHS): mental health units, day hospitals, psychiatric acute admission units, medium-stay rehabilitation units) -addiction treatment settings (ATS): detox. units, outpatient programs, day centers, therapeutic communities) completed a specific online questionnaire about substance use, diagnoses and treatment of patients attended on a scheduled day of the week during 4 weeks

It is expected that almost one hundred professionals will agree to participate in the study, recording data from more than 2000 patients, between 2017-2018. It is a representative sample of professionals and patients, and also of the different diagnoses made and of the resources and treatments provided. Prevalence of dual diagnoses in different treatment settings and medications used for addiction disorder and for the other mental disorder were recorded. We present preliminary data from 753 patients from 11 Autonomous Communities.

Sample description N= 753 TOTAL ATS MHS Gender Age (years) C Status 77.7 % men 77.2 % men 81.3 % men Age (years) 44.2 (10.2) 43.7 (10.1) 47.6 (10.8) C Status 50.2 % single 25.4% divorced 22.7% married 51.4 % single 25.2% divorced 22.1% married 41.8 % single 26.4% divorced 27.5% married Convivence 35.5 %Orig fam 29 %Own fam 27 %Alone 35.8 %Orig fam 28.2%Own fam 27 % Alone 33 %Orig fam 34.1%Own fam 26.4 % Alone Working 30.3 % yes 42.8 % no 19 % retired 31.9 % yes 44.3 % no 16.9 % retired 18.7 % yes 31.9 % no 34.1 % retired

Socidrogalcohol Spanish survey on prevalence and treatment of SUD and OMD. Results

Substance use TOTAL ATS MHS Tobacco Alcohol Cannabis Cocaine BZDs 53 % 51.2% 65.9% Alcohol 40 % 39.3% 42.9% Cannabis 12.1 % 13.1% 4.4% Cocaine 11.2 % 12.2% 3.3% BZDs 2.4 % 2.6% 1.1% Opiates Prescibed: 4.6% Heroin: 2.5 % Prescibed: 5% Heroin: 2.9 % Prescibed: 2.2% Heroin: none

Substance multi use Tobacco+Alcohol 19.3 % Tobacco+Cannabis 6.8 % Cocaine+Alcohol 1.9 % Tobacco+Prescribed Opiates Cannabis+Alcohol 1.1 % Tobacco+Cocaine 1.2 % Tobacco+Alcohol+Cocaine 4 % Tobacco+Alcohol+Cocaine+Cannabis 2.5 % Tobacco+Prescribed Opiates+OH 1.5 %

Substance Use Disorder diagnoses ICD Disorder TOTAL ATS MHS F.10-Alcohol u.d. 45.9 % 46.1% 45.1% F.11-Opiates u.d. 18.5 % 20.2% 5.5% F.12-Cannabis u.d. 5 % 21.3% 14.3% F.13-Tranquilizers u.d. 4.8% 5.3% 1.1% F.14-Cocaine u.d. 27.9 % 30.1% 12.1% F.15-Stimulants u.d. 2.1% 2% 3.3% F.16-Hallucinogens u.d. 0.3% 0% F.17-Tobacco u.d. 25.5 % 19.5% 69.2% F.18- Solvents u.d. F.19-Multiple subst. u.d. 1.2 % 1.4%

Substance use disorders codiagnoses F.17-Tobacco+F.10-Alcohol 10.6 % F.17-Tobacco+F.12-Cannabis 3.7 % F.14-Cocaine+F.10-Alcohol 5.3 % F.12-Cannabis+F.10-Alcohol 1.1 % F.17-Tobacco+F.14-Cocaine 2.7 % F.17-Tobacco+F.19-Opiates 1.6 % F.11-Opiates+F.14-Cocaine 1.3 % F.10-Alcohol+F.14-Cocaine+F.12-Cannabis 4.2 % F.11-Opiates+F.12-cannabis+F.14-Cocaine 1.5 % F.10-Alcohol+F.12-Cannabis+F.17-Tobacco 1.1%

Another Mental Disorder diagnoses ICD Disorder TOTAL ATS MHS F.20-29. Psychosis 11.7% 10.3% 24.2% F.30-39. Affective 29.7% 30.5% F.40-49. Anxiety 16.6% 17.3% 12.1% F.60-69. Personality 22.6% 25.8% 8.7% F.00-99. Others 4.6% 35.8%

Number Mental Disorder diagnoses N# F 10-19 Dis TOTAL ATS MHS 1 41.8% 40.5% 46.2% 2 27.6% 26.0% 31.9% 3 11.3% 11% 12.1% N# non F 10-19 Dis 43.3% 39.6% 70.3% 14.7% 14.8% 14.3%

Medications prescribed TOTAL ATS MHS Mood stabilizers 16.1 % 15.3 % 22 % Interdictors 9.7 % 8.6 % 17.6 % Naltrexone/Nalmefene 0.3 % 0 % Benzodiacepines 44.4 % 43.8 % 49.5 % Antidepressants 39.6 % 38.8 % 45.1 % Antipsychotics 23.9 % 22.1 % 37.4 % Opiate agonists 17 % 18.7 % 4.4 %

Conclusions

Our study shows (poly)drug use and high prevalence of mental disorders in patients seen in ATS settings and SUD in patients seen in mental health. Substances commonly used were tobacco, alcohol and cannabis, with mainly two SUD diagnoses The most frequent non-SUD diagnose was affective disorder. The definition of dual diagnosis was met at the time of the study by more than 50% of patients These patients were more often diagnosed with multiple OMD disorders (different than SUDs) There is a lack of some SUD treatments for comorbid patients, especially for alcohol, and BZD overprescription.

The main strengths of this study are its sample size, the national wide and the variety of treatment settings and health services to avoid biases. A potential limitation of this study is the inclusion of cases, which was not uniformly done, and might have had implications on the sample collection. We used a descriptive approach and an inclusive definition of comorbidity. However, comparability with other studies is limited.

Further research is needed. This study also describes differences between SUD and OMD patients, which may imply diverse needs. Bearing all these in mind, we believe that the study provides us with valuable information on the real co-occurrence of addictive and other mental disorders in Spain and the treatment provided. We expect that it may reflect concurrent comorbidity in real practice conditions. Further research is needed.

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